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Daily Medical Update
Toxic kidney injury
Friday, October 02, 2026
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🔬 Practice-Changing Findings
Evidence from RCTs and meta-analyses published in the
last 12 months.
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British journal of clinical pharmacology (2025) - Systematic Review and Meta-Analysis
Key Findings
- The triple combination of a diuretic, a renin-angiotensin-aldosterone system inhibitor, and an NSAID was associated with higher AKI risk (OR 2.01, 95% CI 1.30-3.10).
- No significant increase in all-cause mortality was observed among exposed patients.
📋 Practice Implication: Avoid or closely justify this drug combination, with renal function and volume status review before prescribing and during periods of acute illness.
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Lancet (London, England) (2025) - Randomized Controlled Trial
Key Findings
- Moderate or severe AKI occurred in 14.4% of intervention patients versus 22.3% with usual care (OR 0.57, 95% CI 0.40-0.79; number needed to treat 12).
- The preventive strategy did not increase adverse-event rates compared with usual care.
📋 Practice Implication: For high-risk major-surgery patients, a coordinated perioperative bundle covering hemodynamics, volume, glycemia, and nephrotoxin avoidance can reduce clinically important AKI without an apparent safety penalty.
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International journal of clinical pharmacy (2025) - Systematic Review and Meta-Analysis
Key Findings
- The pooled AKI incidence among adults exposed to polypharmacy was 18% (95% CI 2%-45%).
- Higher medication burden, cardiovascular drug combinations, nephrotoxic agents, pre-existing renal impairment, frailty, and intensive-care exposure were associated with increased AKI risk.
📋 Practice Implication: Use medication reconciliation and risk-adjusted deprescribing to focus renal-protection efforts on patients whose medication burden is compounded by frailty, CKD, or acute-care exposure.
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Jornal brasileiro de nefrologia (2026) - Systematic Review and Meta-Analysis
Key Findings
- Switching from tenofovir disoproxil fumarate to tenofovir alafenamide fumarate produced significant improvements in glomerular filtration rate.
- Across 10 randomized trials involving 1,179 patients with CKD, the analysis supported an improved and safer renal profile for tenofovir alafenamide, particularly during long-term treatment.
📋 Practice Implication: In HBV patients with CKD or ongoing renal risk, discuss tenofovir alafenamide as a kidney-sparing alternative while maintaining antiviral treatment goals.
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Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer (2025) - Systematic Review and Meta-Analysis
Key Findings
- Two small placebo-controlled trials suggested approximately 15%-20% absolute reductions in severe AKI with mannitol, whereas a furosemide-controlled trial showed no clear difference.
- Results for overall AKI and renal-function outcomes were inconsistent, and no consistent increase was seen in electrolyte or hematologic toxicities.
📋 Practice Implication: Do not adopt routine mannitol nephroprotection for cisplatin on this evidence; the apparent severe-AKI benefit remains hypothesis-generating and requires larger trials.
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Summary
Recent evidence highlights preventable medication-related and perioperative causes of acute kidney injury, including the doubled risk associated with the diuretic–RAAS inhibitor–NSAID combination and the burden of polypharmacy. A biomarker-guided perioperative prevention bundle reduced moderate or severe AKI, while switching from tenofovir disoproxil fumarate to tenofovir alafenamide improved kidney function; evidence for routine mannitol prophylaxis during cisplatin therapy remains insufficient.
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