Contemporary considerations for nephrotoxin stewardship: Estimating kidney function and use of novel biomarkers

Drug-associated acute kidney injury (D-AKI) constitutes approximately 19%–26% of all acute kidney injury (AKI) cases in hospitalized patients. Notably, there is often a deficiency in optimal drug management after D-AKI diagnosis, with only about half of the patients experiencing discontinuation of nephrotoxins and one-fifth avoiding further nephrotoxin administration. Nephrotoxin stewardship involves the application of coordinated care management strategies to ensure the safe utilization of nephrotoxins and renally eliminated medications. The purpose of this paper is to review nephrotoxin stewardship strategies and highlight contemporary considerations for estimating kidney function and the use of novel biomarkers as part of the stewardship program. The Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) 2021 serum creatinine formula is now recommended for estimating kidney function for adults in most clinical situations in the United States. It is time to reevaluate how healthcare professionals think of estimating kidney function for drug dosing with the use of the non-indexed, race-free, CKDEPI 2021 equation. In addition, widespread use of serum cystatin C (CysC) is anticipated so estimated glomerular filtration rate equations that incorporate serum CysC will need to be further evaluated for drug dosing recommendations and how the use of serum CysC can complement serum creatinine-based equations. Lastly, novel kidney stress/damage biomarkers should be viewed as a piece of a complex scenario of D-AKI prediction, diagnosis, and prognosis and should be interpreted along with other diagnostic criteria in relation to the clinical condition of the patient. These contemporary considerations for drug dosing and D-AKI management are important components of nephrotoxin stewardship.