Q: A 62-year-old patient with a past history of hypertension (HTN) and Diabetes Mellitus (DM) is admitted to the ICU with severe community-acquired pneumonia (CAP) and septic shock. Patient required intubation, and in the next 48 hours, went into Acute Kidney Injury (AKI). Which of his following medications should be discontinued? - select one
A) Angiotensin-converting enzyme (ACE) inhibitors
B) Sodium-glucose cotransporter 2 (SGLT2) inhibitors
C) Both A and B
Answer: C
In case of severe illness and AKI, all nephrotoxic meds, like nonsteroidal anti-inflammatory drugs (NSAIDs), should be stopped. Many of these patients are usually on ACE inhibitors, ARBs, and SGLT2 inhibitors - they all should be stopped.
SGLT2 inhibitors are relatively new agents, and there remains limited understanding about their role. Although they have shown to reduce the rate of AKI, once AKI and severe hemodynamic instability ensues they should be stopped. To date, the scientific evidence is mixed, and the jury is still out on this!
ACE inhibitors and ARBs, as well as SGLT2 inhibitors, alter the kidney's ability to autoregulate blood flow during AKI and reduce kidney perfusion. This results in exacerbation of hemodynamically mediated AKI. It is rarely appreciated that if ACE inhibitors or ARBs are discontinued in hospital-acquired AKI within the first 48 hours of admission, there is an overall statistically significant 30-day mortality. The only exception is scleroderma renal crisis.
A few other harmful drugs in AKI that should be stopped are metformin and gabapentin. All renally excreted drugs should be dose-adjusted.
#nephrology
#pharmacology
#endocrinology
References:
1. Nie S, Li Y, Sun Y, et al. Discontinuation of Renin-Angiotensin System Inhibitors during Acute Kidney Injury Episode and All-Cause Mortality: Target Trial Emulation Studies. J Am Soc Nephrol 2025; 36:2410.
2. Nakao Y, Mori M, Mori Y, Bonventre JV. SGLT2 inhibitors and acute kidney injury. Nephrol Dial Transplant. 2026 Jan 30;41(2):243-254. doi: 10.1093/ndt/gfaf132. PMID: 40736512; PMCID: PMC12855603.
3. Dong Z, Mo W, Ling Z, Hou L, Deng T. Efficacy of SGLT2 inhibitors on acute kidney injury in patients with chronic kidney disease, cardiovascular disease, and type 2 diabetes: A meta-analysis. J Natl Med Assoc. 2025 Dec;117(6):458-469. doi: 10.1016/j.jnma.2025.08.110. Epub 2025 Sep 16. PMID: 40962701.
