Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

medication related

1st line – discontinue triggering medication

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ACUTE
|
medication related
1st line – 

discontinue triggering medication

Over 250 triggering medications are known.[10]​ Common causes include antibiotics (particularly beta-lactams), non-steroidal anti-inflammatory drugs (NSAIDs), proton-pump inhibitors, immune checkpoint inhibitors, H2 antagonists (e.g., cimetidine, ranitidine), diuretics, allopurinol, phenytoin, mesalazine, and warfarin.

Many patients will have resolution of acute kidney injury and a progressive return of kidney function when the medication is discontinued.

If the patient is taking several known triggering medications, all medications should be switched to drugs from a different class.

Plus – supportive care

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ACUTE
|
medication related
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

All patients should have serum electrolytes, urea, and creatinine monitored daily during the acute episode.

Careful attention should be paid to fluid and electrolyte balance. Sodium and volume restriction may be required, along with limitation of potassium and phosphorus intake.

Consider – diuretic

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ACUTE
|
medication related
Consider – 

diuretic

Additional treatment recommended for SOME patients in selected patient group

Diuretics are used primarily for the treatment of fluid retention. Loop diuretics are generally effective.

If a diuretic is suspected as the trigger, a diuretic from a different class should be used.

Primary options

furosemide: 40-100 mg intravenously every 8-12 hours, maximum 600 mg/day

Secondary options

torasemide: 20-200 mg intravenously once daily

OR

bumetanide: 0.5 to 1 mg intravenously every 2-3 hours, maximum 10 mg/day

OR

metolazone: 5-20 mg orally once daily

Consider – oral corticosteroid

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ACUTE
|
medication related
Consider – 

oral corticosteroid

Additional treatment recommended for SOME patients in selected patient group

Corticosteroid therapy has been suggested to improve the rate and extent of renal recovery, although data are from observational studies and are conflicting.[28]​[33]​ Routine use has not been confirmed in randomised trials.​​​​​

A short course of prednisolone should be considered in most patients unless corticosteroid therapy is contraindicated.

Most patients respond in the first 2 weeks of treatment. The dose can be tapered as the creatinine returns towards baseline for a total of 1 to 1.5 months' treatment.

Primary options

prednisolone: 40-60 mg orally once daily for 2 weeks, then taper gradually for a total of 1 to 1.5 months

Consider – dialysis

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ACUTE
|
medication related
Consider – 

dialysis

Additional treatment recommended for SOME patients in selected patient group

Supportive dialysis is indicated in acute kidney injury if the patient has severe symptoms, or severe fluid balance or metabolic derangement that is not responding to medical therapy.

chronic inflammatory disease related

1st line – oral corticosteroid

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ACUTE
|
chronic inflammatory disease related
1st line – 

oral corticosteroid

Corticosteroids are the preferred therapy for interstitial nephritis associated with Sjogren syndrome, sarcoidosis, IgG4-related syndrome, systemic lupus erythematosus, and tubulo-interstitial nephritis with uveitis (TINU) syndrome.[14]​[28]​

Corticosteroid therapy has been suggested to improve the rate and extent of renal recovery, although long-term outcome is generally unchanged. Routine use has not been confirmed in randomised trials.[9][29][30][31][32]

A short course of prednisone should be attempted in most patients unless corticosteroid therapy is contraindicated.

AIN due to autoimmune conditions usually requires longer duration of treatment than drug-induced AIN. Most patients respond in the first 2 weeks of treatment. The dose can be tapered as the creatinine returns towards baseline for a total of 2 to 3 months' treatment.

Primary options

prednisolone: 40-60 mg orally once daily for 2 weeks, then taper gradually over 2-3 months

Plus – supportive care

Back
ACUTE
|
chronic inflammatory disease related
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

All patients should have serum electrolytes, urea, and creatinine monitored daily during the acute episode.

Careful attention should be paid to fluid and electrolyte balance. Sodium and volume restriction may be required, along with limitation of potassium and phosphorus intake.

Consider – diuretic

Back
ACUTE
|
chronic inflammatory disease related
Consider – 

diuretic

Additional treatment recommended for SOME patients in selected patient group

Diuretics are used primarily for the treatment of fluid retention. Loop diuretics are generally effective.

If a diuretic is suspected as the trigger, a diuretic from a different class should be used.

Primary options

furosemide: 40-100 mg intravenously every 8-12 hours, maximum 600 mg/day

Secondary options

torasemide: 20-200 mg intravenously once daily

OR

bumetanide: 0.5 to 1 mg intravenously every 2-3 hours, maximum 10 mg/day

OR

metolazone: 5-20 mg orally once daily

Consider – dialysis

Back
ACUTE
|
chronic inflammatory disease related
Consider – 

dialysis

Additional treatment recommended for SOME patients in selected patient group

Supportive dialysis is indicated in acute kidney injury if the patient has severe symptoms, or severe fluid balance or metabolic derangement that is not responding to medical therapy.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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