Managing Drug-Induced Nephrotoxicity

About

➀ Read and Learn

The following course content

Introduction   

When hearing the phrase drug-induced nephrotoxicity, what comes to mind? What do you think of when a client who is receiving medications that have the possibility of nephrotoxicity? If you’re a nurse, you’ve definitely heard about several prescription medications, especially about possible side effects and interactions within the body. Maybe even before nursing school, you might have seen people with complications of medications or people with kidney complications. Presently, clients seek guidance and information on various health topics from nurses. The information in this course will serve as a valuable resource for nurses of all specialties, education levels, and backgrounds to learn more about managing drug-induced nephrotoxicity.  

Definition 

Drug-induced nephrotoxicity is a complication as a result of a client using a medication or substance with the possible side effect of nephrotoxicity. Nephrotoxicity occurs when the kidneys are not functioning to their baseline level, causing complications at the microvascular and macrovascular level for the client. Sometimes, drug-induced nephrotoxicity can occur over time if a client is consistently receiving a medication with the possibility of renal complications. Other times, a client might receive a few doses of a medication in a short period of time and also have drug-induced nephrotoxicity.  

While drug-induced nephrotoxicity is most well-studied in prescription medications, there are also substances in nature, such as certain mushrooms, that can cause nephrotoxic side effects as a result of their metabolism in the body. There are several prescriptions and over the counter (OTC) medications, such as antibiotics, pain medications, and more. In addition, while clients with pre-existing renal impairment are the most likely to experience drug-induced nephrotoxicity, it is important to note that any client who is taking a medication that can impair the function of the kidney is at risk for drug-induced nephrotoxicity (1,2,3). 

Drug-induced nephrotoxicity can be measured by examining the client, obtaining renal health lab values, collecting a urine sample, performing lab imaging, and conducting a detailed client assessment. Common renal lab values to assess for include glomerular filtration rate (GFR), creatinine levels, BUN levels, cystatin C, and albumin. A urine sample can also be very insightful to determine if there are immediate or possible renal complications. Temperature, heart rate, blood pressure, skin texture, level of consciousness, and the ability for the client to urinate on their own are important to monitor as well.  

While lab imaging, such as an ultrasound, can help with visualizing possible drug-induced nephrotoxicity, often times, initial blood work, a urine sample, and general assessment are first line management options. It is also important to note that several cases of drug-induced nephrotoxicity do not always occur in inpatient settings, such as a hospital or long-term care facility. Several initial cases of suspected nephrotoxicity occur during routine exams at primary care offices, highlighting the importance of primary care, client education, and client care transfer as appropriate (1,2,3,4).  

In fact, drug-induced nephrotoxicity is not a novel health complication. For decades, the American health care system has seen millions of cases of drug-induced nephrotoxicity as a result of clients with compromised renal health, medication overdose and mismanagement, inadequate client education, and other structural barriers to accessing and receiving health care. As the aging population increases, one of the biggest predictors of drug-induced nephrotoxicity is age, especially as several geriatric clients have co-existing health conditions that already compromise their renal health. Truly, many clients with drug-induced nephrotoxicity might display more extreme symptoms, such as blood in urine, inability to stand because of pain, or comatose state. However, many clients remain at risk of drug-induced nephrotoxicity and have no symptoms, leaving them in a precarious situation of accessing health care when it is often at a critical stage for their health.  

Clients of several varied health histories, ages, and with unique health needs take medications with the possible side effect of nephrotoxicity daily. For instance, a client with diabetes cellulitis Type II and hypertension might be on a low-dose ACE inhibitor medication for several years and start showing signs of drug-induced nephrotoxicity. Another client can be in the ICU receiving vancomycin for a few days and develop signs of drug-induced nephrotoxicity because of their body’s inability to excrete the medication appropriately (1,2,3,4,5).  

Because drug-induced nephrotoxicity can be found in a variety of health care settings, such as such as in oncology nursing wards, rheumatology clinics, and ICUs, nurses need to be aware of early recognition and management of this complication. Initially, if drug-induced nephrotoxicity is suspected, stopping the medication with nephrotoxicity as a side effect is the first priority action. After that is complete, assessing and managing the client from there, along with the provider’s orders, is essential. With the increase of technology, telehealth, home health nurses, and remote client monitoring, thousands of clients receive take possible nephrotoxic-inducing medications at home, leaving many nurses in outpatient settings at the forefront of care and management of possible drug-induced nephrotoxicity (1,2,3,4,5,6,7).   

Because possible nephrotoxic medications can be used for short or long durations (as little as a few days to a lifetime), nursing care and client monitoring must be followed to ensure that clients are receiving appropriate fluid intake and nutrition, tolerating the medication well, urinating independently and regularly, and showing improvements in health and quality of life. Because there are several types of nephrotoxic medications, administration routes, doses, frequencies, concentrations, and durations, it is important to consider all these factors when managing drug-induced nephrotoxicity.  

A client’s clinical condition, response to medication and therapy, age, insurance, health status, and other factors determine the need and length for prescription therapy and management from drug-induced nephrotoxicity. Because of each client’s situation, it is important to make sure they are aware of the possibility of drug-induced nephrotoxicity and be educated on the risks for your clients (1,2,3,4,5,6,8).  

Prevalence 

The exact prevalence of drug-induced nephrotoxicity is not known, as several cases of drug-induced nephrotoxicity have been misdiagnosed, left untreated, or left unnoticed during client care. As a result, there have been more studies and discussions in renal health regarding classification for medications that can cause nephrotoxicity and more stringent criterium for drug-induced nephrotoxicity. That said, there is still much debate on the exact diagnosis of drug-induced nephrotoxicity compared to other renal health complications, such as if the drug-induced nephrotoxicity occurred before a client’s end-stage renal disease or if the drug-induced nephrotoxicity further induced a renal complication, such as acute kidney injury.  

In general, it is estimated that there are thousands of cases of drug-induced nephrotoxicity in the United States and more worldwide with cases expected to increase as a result of the aging population, more people taking possible nephrotoxic medications, and more people living with possible pre-existing renal impairment (1,2,4,5,6,9,10).  

It is estimated that at least a million adults have either tried or currently use some type of medication with the possibility of nephrotoxicity. Medications with the possibility of nephrotoxicity is also used by all age groups, from neonatal to pediatric and geriatric populations. Even pregnant people use possible nephrotoxic medications during their pregnancy. As a result, for many clients, the role of caregivers, such as a parent or spouse, who can assist with monitoring a client’s condition, can be helpful as well.  

In general, most acute care settings, hospitals, rehabilitation care centers, and long-term care facilities have protocols in place to monitor, manage, and document drug-induced nephrotoxicity. However, documentation, protocols, and treatment options can vary significantly, which can also cause discrepancies in true prevalence of drug-induced nephrotoxicity in various inpatient and outpatient settings (1,2,4,5,6,8,9).  

Causes 

Clients can experience drug-induced nephrotoxicity for a variety of reasons, such as an extensive or prolonged exposure to a nephrotoxic medication, pre-existing renal impairment, or a combination of both. Nephrotoxic medications administered too quickly, at a significantly larger than anticipated concentration, or in conjunction with other nephrotoxic medications can also trigger drug-induced nephrotoxicity. Clients with renal impairment, such as renal complications from diabetes mellitus, chronic alcoholism, end-stage renal disease, or acute kidney injury (AKI), are at an increased risk of drug-induced nephrotoxicity. That said, even people without any renal impairment can be at risk of drug-induced nephrotoxicity as a result of the way the medication interacts with the client’s renal system. In particular, some infections, such as COVID-19, can cause drug metabolism and renal health to be altered, possibly triggering drug-induced nephrotoxicity as well. Also, many people have undiagnosed and unmanaged renal impairment as a result of delayed access to care, leading to clients possibly using OTC medications that could be nephrotoxic without knowledge to the client (1,14,15,16,17,19).  

For instance, a client with lower back pain might take an OTC ibuprofen, a non-steroidal anti-inflammatory drug (NSAID). While ibuprofen is OTC, it has the possibility of nephrotoxicity for several clients, such as those with renal impairment. This same client also has a history of binge drinking after work, smoking a pack of cigarettes a day, and family history of diabetes, all of which are risk factors for renal impairment. This client decides to take several tablets of ibuprofen a day for a week, hoping to make their back pain resolve. Now, they are in severe pain, have headaches that will not go away, and having trouble urinating, thinking about going to the doctor for the first time in five years. This is just one example of how nephrotoxicity can emerge in outpatient settings.  

While nephrotoxicity is often detected early in inpatient settings, outpatient settings also have their fair share of seeing clients with possible drug-induced nephrotoxicity. While many factors can influence drug-induced nephrotoxicity, such as client health, medication pharmacokinetics and pharmacodynamics, exact causation is often something of speculation and left to examination and assessment by health care workers. As a result, education on renal health, drug metabolism, and drug-drug interactions are extremely important in client health education and promotion (1,2,4,5). 

Nephrotoxic Drugs  

There are several Food and Drug Administration (FDA) approved medications that have possible side effects of nephrotoxicity. NSAIDs, a popular OTC pain reliever, is a common drug class with possible nephrotoxicity. Commonly known NSAIDs are ibuprofen, aspirin, and naproxen. Another common drug class is ACE inhibitors, a prescription class of medications that block the production of angiotensin II in the renal system to lower blood pressure. Commonly known ACE inhibitors are lisinopril and benazepril. Another common drug class of medications with the possibility of nephrotoxicity is angiotensin-receptor blockers (ARBs), such as valsartan and losartan; these medications are also used to lower blood pressure. Cyclosporine is an immunomodulating medication that can affect renal function. Proton pump inhibitors, such as omeprazole, can also affect kidney health.  

Antibiotics, such as glycopeptides, aminoglycosides, beta-lactams, and fluoroquinolones, also have the possibility of nephrotoxicity. Commonly known antibiotics that are documented to be related to nephrotoxicity include vancomycin, gentamicin, and penicillin. In fact, it is estimated that over half of AKIs in hospitals can be related to a drug-induced nephrotoxicity. This is not a comprehensive list of all medications that can induce nephrotoxicity. As more medications emerge on the market, it is important to take a detailed health history and to be up to date on new medications as they emerge.  

It is also important to take a detailed medication and physical health history prior to administering medications to reduce the likelihood of drug-induced nephrotoxicity. Consider your client needs, allergies, facility protocols, client condition, medication history, and overall client progress when assessing for drug-induced nephrotoxicity (1,2,4,5,6,7,8,10,19). 

How and Where Are Possible Drugs that can Induce Nephrotoxicity Used? 

As mentioned above, drugs that can induce nephrotoxicity are found in inpatient and outpatient settings. People can overdose from OTC medications that can trigger nephrotoxic outcomes. People can also be receiving an IV infusion of an antibiotic in the emergency room and experience an AKI. Many medications that can induce nephrotoxicity can be taken by pill, liquid, or IV solution. These medications are used by millions of people daily in America, so it is important to be aware of medication and health history among clients in your care. Everyone’s response to medication therapy can vary, so that is something to keep in mind as well, as there are millions of people who take medications that have the potential for nephrotoxicity and never experience nephrotoxicity (1,2,4,5,6,7).  

What Are the Clinical Criterium for Having Drug-Induced Nephrotoxicity? 

Clinical criterium for having drug-induced nephrotoxicity is the subject of much discussion in pharmacological, renal, and critical care spaces. The clinical criterium at baseline would examine renal health through bloodwork, such as GFR, creatinine, protein, BUN, cystatin C, and electrolytes. A urine sample is often recommended as well. Imaging, such as ultrasound, CT scan, or MRI, can be obtained as well. While creatinine levels can take time to note kidney dysfunction (it is estimated that half of all kidney function must be lost before an increase in creatinine is detected), they can still play a role in determining the progression of nephrotoxicity.  

That said, there is no set clinical criterium for drug-induced nephrotoxicity diagnosis. There are clinical criterium for AKIs, end-stage renal disease (ESRD), acute renal tubular necrosis, chronic kidney disease (CKD), all of which are possible outcomes of drug-induced nephrotoxicity. Because of the wide-range of clinical symptoms of drug-induced nephrotoxicity, such as fatigue, decreased urine output, lower back pain, and electrolyte imbalances, drug-induced nephrotoxicity is often diagnosed after a client has been diagnosed with another renal impairment cause.  

While much discussion exists about the exact clinical criterium for diagnosing drug-induced nephrotoxicity, given the wide range of drugs, renal health presentations, and polypharmacy among millions of people, there remains much inconclusive speculation about drug-induced nephrotoxicity clinical criterium. In general, general kidney health criterium and assessment are used to determine if a client is experiencing drug-induced nephrotoxicity (1,2,4,5,6,7,8,9,10,11,12,13).  

What Are Some Side Effects and Complications of Drug-induced Nephrotoxicity?  

For some people, there are no immediate side effects or complications of drug-induced nephrotoxicity. Presentation of drug-induced nephrotoxicity can vary, but some signs and drug-induced nephrotoxicity include decreased or no urine output, increased edema, fever, comatose state, headache, changes in blood pressure, changes in heart rate, changes in thirst, changes in skin texture, lower back pain, and pelvic pain. Complications of drug-induced nephrotoxicity can lead to kidney injury, kidney failure, or decreased kidney baseline health. Some instances of drug-induced nephrotoxicity can cause permanent organ damage to the kidneys, leaving the client with ESRD, the need for a kidney transplant, or chronic renal damage.  

While some people can recover from drug-induced nephrotoxicity with no lingering health outcomes, for many people, drug-induced nephrotoxicity can influence their renal health in some way for the rest of their lives. Given the wide range of possible and severe side effects and complications of drug-induced nephrotoxicity, careful monitoring of a client’s health and condition is essential. While some clients will have no symptoms initially, others can develop symptoms over time, especially if they have complex health histories or several medications being administered (1,2,4,5,6,7,10,11,14).  

What is the Average Cost for Drug-Induced Nephrotoxicity Treatment? 

Cost for drug-induced nephrotoxicity can significantly vary depending on the extent of nephrotoxicity, type of drug, drug concentration, dosage, frequency, client age, insurance, duration, and other factors. Very rarely can drug-induced nephrotoxicity be managed in an outpatient setting alone, as clients often need inpatient renal and other health monitoring to determine if they are progressing well after discontinuing the medication and in their overall renal health. Drug-induced nephrotoxicity is often an expensive medical complication leading to hospitalization and decreased quality of life for many.  

That said, inpatient care is often possibly the only way for some clients to improve their health and quality of life given their health situation. Cost is among a leading reason why many clients cannot maintain their medication and health care regime. If you suspect that cost is a concern for your client, consider reaching out to your local client care teams to find cost effective solutions for your clients (1,2,14,20).  

How Can Clients Self-Manage Drug-Induced Nephrotoxicity? 

Clients can rarely self-manage drug-induced nephrotoxicity on their own, as renal and kidney health needs to be monitored via bloodwork, imaging, and urine sample collection. Clients can stop taking a medication on their own in an outpatient setting, but rarely can clients mitigate the extent of drug-induced nephrotoxicity on their own without medical intervention (1,2,10,18).  

What Happens to Clients Who Do Not Have Access to Management for Drug-Induced Nephrotoxicity?   

Clients who do not have access to management for drug-induced nephrotoxicity can often have fatal health outcomes or severely decreased chronic renal function. Depending on the extent of drug-induced nephrotoxicity, clients can have chronic side effects, such as urine output changes and fatigue, for several days until they experience more severe side effects of drug-induced nephrotoxicity. As a result, it is important to educate clients on the importance of consistency in their treatment regime and the risks and benefits of taking possible nephrotoxic drugs (1,4,5,8).  

Special Considerations for Specific Client Populations or Conditions  

Given the wide range of uses for drugs with the possible side effect of nephrotoxicity, it is also important to consider their use in various client populations. Because several drugs have the possibility of nephrotoxicity, from OTC pain relivers to IV antibiotics, there are special considerations to be aware of for clients of certain age groups or with certain health conditions.  

Neonatal Populations 

Neonates can receive possible nephrotoxic medications for various reasons. Whether it is a possible nephrotoxic antibiotic, such as an aminoglycoside, or severe pre-term birth with very immature kidney development receiving supplemental fluids, neonates are at increased risk for drug-induced nephrotoxicity. Even if a neonate is full-term and healthy at delivery, because their renal systems are still underdeveloped, almost any medication can cause severe drug-induced nephrotoxicity. The most common cause of drug-induced nephrotoxicity in this population is an aminoglycoside, such as gentamycin, a common medication used for post-delivery Group B Strep exposure and other neonatal infections.  

Commonly, for many neonates, wet diapers are often used to measure urine and stool output. Unlike several adult clients, wet diapers, a straight catch urine sample, bloodwork, or imaging might be possible options to assess for drug-induced nephrotoxicity. Vital sign monitoring, skin turgor, responsiveness, and crying are also possible ways to assess for early signs of drug-induced nephrotoxicity. Even though drug-induced nephrotoxicity is a severe possible outcome for many neonates, there are no set guidelines or criteria for this population given the wide range of clinical presentations (1,2,15,21,22,23). 

When a neonate is suspected of drug-induced nephrotoxicity, the first line option is to stop the medication administration and let the provider know. Assessment of the neonate takes next priority, especially if the neonate is not having any wet diapers. In some instances, depending on the neonate’s health, an emergency code can be called, as neonatal health can decline extremely rapidly in the event of nephrotoxicity and kidney damage. Because neonatal health can also change so rapidly, close monitoring when a neonate is receiving a nephrotoxic medication is a must. Neonatal drug-induced nephrotoxicity is far different than those in pediatric, adult, or geriatric populations.  

Educating parents, caregivers, and family members about drug-induced nephrotoxicity is essential, especially since this can be a severe medical complication raising many questions for the caregivers. In fact, medication administration in neonates also needs to be monitored very carefully, as neonates use much smaller doses, concentrations, needle sizes, infusion pumps, and monitoring parameters. The exact prevalence of neonates who have experienced drug-induced nephrotoxicity is not known, but the risk is very present and remains a concern in pediatric outpatient settings and NICUs. Neonates must be assessed prior to administration of medications to determine the need, extent, duration, frequency, dosage, and strength. Neonatal condition and prognosis can also determine how a neonate can recover from drug-induced nephrotoxicity (1,2,10,11,15,21,22,23). 

Unlike adult populations, neonates are unable to verbalize their pain or comfort levels during medical interventions or if they are feeling ill. Neonates communicate mostly through crying, touching, and grimacing. Despite this, comfort measures and pain medication can be offered and administered to neonates who have experienced drug-induced nephrotoxicity. The use of  

blankets, skin-to-skin care, breastmilk or formula, dim lighting, and other interventions can be used when neonates are recovering from or are experiencing drug-induced nephrotoxicity. Taking the time to educate and inform parents about these interventions is essential. Assessing neonatal pain by examining for grimacing, excessive crying, skin changing, and other factors every hour is essential to determining if they have nephrotoxicity or if their nephrotoxic symptoms are being alleviated.  

For instance, the postpartum unit might have a healthy full-term infant at 40 weeks receiving penicillin as prophylaxis, and this infant might have fewer wet diapers over a 24-hour time frame. This might be an early indication of nephrotoxicity in what could be considered a healthy baby. Another infant could be a NICU client of 28-week pre-term infant receiving gentamycin as a result of the mother having sepsis from COVID-19 complications. While this infant might be in the NICU compared to the postpartum unit infant, both are at risk of drug-induced nephrotoxicity and need to regularly monitored and assessed. Because of the various differences in renal development, infant development, critical care, and acute monitoring needing for neonates, drug-induced nephrotoxicity is something that requires a good eye to detail, clear documentation, and excellent client care (1,2,10,11,15,21,22,23). 

Pediatric and Geriatric Populations 

Many pediatric clients take medications that can be nephrotoxic. From toddlers to adolescents and from OTC medications to IV medications in acute care settings, several pediatric clients are at risk of drug-induced nephrotoxicity. OTC and prescription medication use is increasingly more common in pediatric acute care settings, long-term care settings, and homes across America. Children can be on possible nephrotoxic medications for several reasons, such as pain relief, infection control, or immunosuppressive therapy. The long-term data in pediatric populations on drug-induced nephrotoxicity is varied, as there is much debate about whether underdeveloped renal systems influence drug metabolism or if the drug itself is nephrotoxic in this population. When a pediatric client is suspected of drug-induced nephrotoxicity, the first line option is to stop the medication administration and let the provider know.  

Assessment of the client takes next priority, especially if the client is unable to urinate. In some instances, depending on the client’s health, an emergency code can be called, as pediatric health can decline extremely rapidly in the event of nephrotoxicity and kidney damage. Because health can also change so rapidly, close monitoring when a pediatric client, especially a young child, is receiving a nephrotoxic medication is a must.  

Educating parents, caregivers, and family members about drug-induced nephrotoxicity is essential, especially since this can be a severe medical complication raising many questions for the caregivers. In fact, medication administration in pediatric clients also needs to be monitored very carefully, as young children in particular use much smaller doses, concentrations, needle sizes, infusion pumps, and monitoring parameters.  

The exact prevalence of pediatric clients who have experienced drug-induced nephrotoxicity is not known, but the risk is very present and remains a concern in pediatric outpatient and inpatient settings. Pediatric clients must be assessed prior to administration of medications to determine the need, extent, duration, frequency, dosage, and strength (1,2,10,11,12,13,14,15,23,24,25). 

Unlike adult populations, some pediatric clients might not be able to verbalize their pain or comfort levels during medical interventions or if they are feeling ill. Young children in particular communicate mostly through crying, touching, and grimacing. Adolescents and children who are able to speak can express their discomfort, but it is important to understand the role of non-verbal pain and signs of nephrotoxicity in clients as well. Taking the time to educate and inform parents about these interventions is essential. For instance, the emergency room might have a healthy 16-year-old teenager who is having trouble urinating and headaches after taking a whole bottle of ibuprofen over the past week to help with a sports injury. Another pediatric client might be a 3-year-old in the med-surg unit recovering from a surgery and receiving penicillin prophylaxis and has a decreased urine output and fatigue.  

While these two pediatric clients are different ages, have different health histories, and different experiences, both are at risk of drug-induced nephrotoxicity and need to regularly monitored and assessed. Because of the various differences in renal development, pediatric development, and acute monitoring needs for pediatric clients, drug-induced nephrotoxicity is something that requires a good eye to detail, clear documentation, and excellent client care (1,2,10,11,12,13,14,15,23,24,25). 

Like pediatric clients, geriatric clients also are a special population to consider for drug-induced nephrotoxicity. Geriatric clients are the most likely of all client populations to experience drug-induced nephrotoxicity because of their likelihood to have polypharmacy, chronic health conditions, decreased renal function, immunocompromised health, and increased medical encounters. As always, it is important to take a good, detailed health history and regularly monitor urine output, hydration, and vital signs (1,9,11,12,19,20,21,22,23). 

Pregnant Populations 

Several pregnant people take OTC and prescription medications with the possibility of nephrotoxicity. While there are guidelines for medication use during pregnancy or during the postpartum or breastfeeding time frame, much discussion remains about the role of drug-induced nephrotoxicity in pregnancy. Testing and assessment can remain the same, such as renal testing, imaging, and monitoring urine output. Stopping medication administration is the first step in suspected drug-induced nephrotoxicity. Fetal monitoring is also something needed and possible early induction or emergency delivery might have to be considered as well depending on maternal and fetal health.  

Since drug-induced nephrotoxicity can cause AKI or chronic kidney damage to the pregnant person, it is important to monitor pregnant clients closely, take a detailed health history, and perform detailed assessments. Further research is still needed to determine the long-term influence of drug-induced nephrotoxicity on pregnant people and infants and the role pregnancy plays in drug metabolism. The exact prevalence of pregnant clients who have experienced drug-induced nephrotoxicity is not known. Like all other clients, clients must be assessed prior to medication use to determine the need, extent, duration, frequency, dosage, and strength. Consultations with prenatal, maternal-fetal medicine, and genetic specialists are also recommended when administering possible nephrotoxic medications in pregnant populations (1,19,24,25,26,27).  

Oncology Populations 

Several clients who are undergoing cancer treatment or radiation or both are at increased risk of drug-induced nephrotoxicity because of the medications themselves, impaired renal health, dehydration, and fluid imbalances seen within clients with cancer. While there are several guidelines discussing the use of nephrotoxic medications among clients with cancer, the reality is that there are several types of medications that clients use OTC to help manage cancer-related pain, discomfort, and for quality-of-life measures. Even many medications and treatments used to manage cancer progression can be nephrotoxic, leading to increased risk of nephrotoxicity in this population.  

Testing and assessment can remain the same, such as renal testing, imaging, and monitoring urine output. Stopping medication administration is the first step in suspected drug-induced nephrotoxicity. Since drug-induced nephrotoxicity can cause AKI or chronic kidney damage to the client, it is important to monitor clients with cancer closely, take a detailed health history, and perform detailed assessments. Further research is still needed to determine the long-term influence of drug-induced nephrotoxicity on clients with cancer. The exact prevalence of clients with cancer who have experienced drug-induced nephrotoxicity is not known. Like all other clients, clients must be assessed prior to medication use to determine the need, extent, duration, frequency, dosage, and strength. Consultations with oncology specialists are also recommended when administering possible nephrotoxic medications in this population (1,2,4,5,6,28,29,30).  

Drug-Induced Nephrotoxicity Management and Complications 

Drug-induced nephrotoxicity is a serious adverse event that can change a client’s health and quality of life forever. If drug-induced nephrotoxicity is suspected, the first thing to do is stop administering the medication (if possible) and contact the provider. Next, assess the client to make sure they are stable, monitor urine output if possible, and report their status to a provider. Obtaining lab work, imaging results, and more is part of nephrotoxicity management, especially considering the client health and demographics as well. If not properly treated and managed, drug-induced nephrotoxicity is often fatal, leading to ESRD, AKI, or death in extreme cases. It is also important to be aware of any client allergies, other medication use, and pre-existing health conditions as well (1,2,4,5,6,7,14,15). 

Telemonitoring in Inpatient and Outpatient Settings 

With the rise of at home client care, telehealth, and remote client monitoring, several clients take one or more possible nephrotoxic medications at home, leading to drug-induced nephrotoxicity possibly starting in an outpatient setting. While telemonitoring has expanded significantly in the past decade as a result of the rise of telehealth nursing, technological advances, and more widespread insurance and Internet coverage, making sure clients are aware of the risks and benefits of their medications is essential to nursing care.  

While clients taking possible nephrotoxic medications outpatient should routinely seek advice and guidance from their medical care provider, many times, clients and caregivers can self-monitor their reactions from medications at home or in the event of lack of access to health care. Clients should be aware that if they suspect any complications with their medications, such as trouble urinating, increased pain or discomfort, or back pain, that they should tell the nurse immediately. Even though there are many possible complications from medications, many clients report high levels of satisfaction with remote monitoring, such as more independence in their daily activities and less time in transit to medical appointments (1,4,5,6,7,8,9,13,14,15). 

Nursing Considerations 

What Is the Nurses’ Role in Client Education and Management? 

Nurses remain the most trusted profession for a reason, and nurses are often pillars of client care in several health care settings. Clients turn to nurses for guidance, education, and support. While there is no specific guideline for the nurses’ role in managing drug-induced nephrotoxicity, here are some suggestions to provide quality care for clients taking possible nephrotoxic medications (1,4,5,6,7,8,9,13,14,15). 

1. Take a detailed health history of the client. Often times, vital signs and history taking can be complex, especially in acute settings. Many times, nephrotoxic medications are viewed as IV meds given in acute settings only. That is not true, as several OTC medications can be nephrotoxic. Several lifestyle factors can influence renal health and drug metabolism, such as smoking, drinking alcohol, and other medication use.  is started in acute settings and then transitioned to home use or less-acute settings if needed. As nurses, it is important to be involved in the vital signs and history taking process to learn about noticing any abnormalities or medical concerns that warrant medical attention. As nurses, we are aware that complications from nephrotoxicity, such as fatigue, changes in urine output, and changes in skin turgor. If a client is complaining of symptoms that could be related to drug-induced nephrotoxicity, such as urinating less, increasing back pain, or headaches, inquire more about that complaint.  
2. Clearly ask the client if they have any allergies.  
3. Educate the client and caregivers on medication administration. Educate the client to inform the nurse of any medication side effects. Take time to answer any questions about medication administration and to confirm the order as well. 
4. Regardless of how long a client has been on a medication, if the client complains of any new symptom, ask about how long the symptoms have lasted, what treatments have been tried, if these symptoms interfere with their quality of life, and if anything alleviates any of these symptoms. If you feel like a client’s complaint is not being taken seriously by other health care professionals, advocate for that client to the best of your abilities.  
5. Review medication history at every encounter. Often times, in busy clinical settings, reviewing health records can be overwhelming, especially for clients with a complex medical history. Millions of people take medications for various reasons, and people’s medication histories can look similar over time. Ask each client about how they are feeling on the medication, if their symptoms are improving, and if there are any changes to medication history.  
6. Communicate the care plan to other staff involved for continuity of care. For several clients, especially for clients with complex medical histories, care often involves a team of nurses, specialists, pharmacies, caregivers, and more. Ensure that clients’ records are up to date for ease in record sharing and continuity of care. 
7. Stay up to date on continuing education related to drug-induced nephrotoxicity, as evidence-based information is always evolving and changing. You can then present your new learnings and findings to other health care professionals and educate your clients with the latest information.    

How Can Nurses Identify if Someone Needs More Intervention for Drug-Induced Nephrotoxicity Administration and Care?  

Unfortunately, it is not possible to look at someone with the naked eye and determine if they are experiencing drug-induced nephrotoxicity. While some people might have notable complications, such as severe skin changes, comatose state, or no urination, the most common presentation for drug-induced nephrotoxicity. Even management of drug-induced nephrotoxicity can include administration of more fluids, other medications, monitoring, or a mix of both depending on the type of nephrotoxic drug. In addition, nurses can answer questions and concerns regarding medication for both clients and their caregivers. Nurses can provide quality care by completing health history, listening to client’s concerns, addressing caregiver’s concerns, and performing the medication rights prior to medication administration (1,4,5,6,7,8,9,13,14,15). 

• Tell the health care provider of any existing medical conditions and current medication use, including OTC medications (need to identify risk factors) 

• Tell the health care provider of any existing lifestyle concerns, such as alcohol use, tobacco use, other drug use, sleep habits, diet, surgical history, and allergies (need to identify lifestyle factors that can influence nephrotoxicity likelihood and need for other possible medical interventions and monitoring) 

• Tell the health care provider if you have any changes to your body, such as pain with urination, increased headaches, fatigue, or skin changes (potential early drug-induced nephrotoxicity symptoms) 

• Tell the nurse of health care provider if you experience any pain that increasingly becomes more severe or interferes with your quality of life 

• Keep track of your health, medication use, machine function, and health concerns via an app, diary, or journal (self-monitoring for any changes) 

• Take all prescribed medications as indicated and ask questions about medications and possible other treatment options, such as non-pharmacological options or surgeries 

• Tell the health care provider if you notice any changes while on medications (potential worsening or improving health situation)  

Research Findings 

There is extensive publicly available literature on IVIG therapy via the National Institutes of Health (NIH) and other evidence-based journals. If a client is interested in participating in clinical trial research, they can seek more information on clinical trials from local universities and health care organizations. 

Case Study 

Ana is a single mom to a 3-year-old living in a major USA city. Ana works as an accountant, and her child is in pre-school. When Ana picks Susan up from day care, she notices that Susan appears sick. After speaking with the day care staff, Ana learns that Susan has a low-grade fever. She decides to take Ana to the pediatrician, and the pediatrician writes a prescription for an antibiotic liquid. Ana gives Susan the medication and also gives OTC ibuprofen since Ana read online that ibuprofen is safe for kids. Susan is at home for a few days with a fever, and Ana continues to give Susan the antibiotic and ibuprofen a few times a day. After four days, Ana notices that Susan is having some trouble using the bathroom, even though Susan is potty trained. She is getting more concerned, the pediatrician is closed on the weekends, so she goes to the local pediatric ER. 

• What are some specific questions you’d want to ask Ana about Susan’s health? 

• What are some health history questions you’d want to highlight? 

• What antibiotics are appropriate for pediatric clients?  

• How would you perform an initial assessment on this client? 

• How does cost influence someone’s ability to access health care services? 

After speaking with Ana, the health care team determines that Susan has a pneumonia infection, but also possible early signs of drug-induced nephrotoxicity since the antibiotic dose was incorrect and the OTC ibuprofen that Ana was giving Susan was the adult dose. Ana is very concerned and starts crying in the emergency room. She wants to know if Susan will be OK. The health care team informs Ana that Susan will need to spend more time in the hospital for tests and bloodwork.   

• How would a nurse educate a parent/guardian in the hospital about doses for OTC medications for children compared to adults? 

• How can you assess for drug-induced nephrotoxicity in a 3-year-old? 

• How would a nurse educate a parent on drug-induced nephrotoxicity in a 3-year-old?  

• What are some contraindications for nephrotoxic medication use? 

• What are some ways to assess for drug-induced nephrotoxicity in children? 

Ana is a bit concerned since Susan has been a healthy child before this incident. She is still tearful in the ER and sees Susan undergo lab work and a urine collection. She is aware that IV fluids and not giving Susan an adult dose of ibuprofen can help with this situation. Labs show that Susan’s renal function is impaired, and the hospital wants to admit Susan for a few days. 

• What are some client education talking points you would discuss with Ana about a child receiving IV fluids to help with drug-induced nephrotoxicity? 

• How would you monitor vital signs in a 4-year-old receiving IV fluids for suspected drug-induced nephrotoxicity? 

• How would you monitor for complications in this client? 

After a two-day hospital stay, the hospital discharges Susan as she has recovered fairly well after monitoring and IV fluids. Ana is still concerned about Susan’s health and asks if there is anything else she can do to prevent future kidney damage or drug issues. The hospital health care team recommends her to follow up with the pediatrician and to also look for a pediatric nephrologist in the area to visit within a few weeks as well.   

• How can recovery for a client with drug-induced nephrotoxicity vary by age? 

• How would you further examine if a pediatric client has further possible renal complications? 

• How often can a child experience drug-induced nephrotoxicity? 

• What can happen if someone has repeated kidney complications? 

• What would be your next steps as a nurse with this client? 

• What would be your pharmacological and non-pharmacological recommendations presently? 

Conclusion

Millions of people use drugs that can induce nephrotoxicity for several reasons in outpatient and inpatient settings. While medications may be life-saving for many clients, because of the risks, a serious overview of risks and benefits must be considered to avoid and reduce the likelihood of drug-induced nephrotoxicity. Education and awareness of different medications can influence the lives of many people in a healthy way.  

➁ Complete Survey

Give us your thoughts and feedback

➂ Click Complete

To receive your certificate