TABLE 3.

Nephrotoxic medications frequently used in neonates.

Medication	Mechanism of action	Site of kidney damage	Nephrotoxicity	Notes
Acyclovir	Inhibits DNA synthesis and viral replication via inhibition of viral DNA polymerase	Tubule	Crystallization and obstruction occur causing tubular damage, particularly when in low urinary flow state	Can be used for prophylaxis (CMV, HSV, varicella, herpes zoster), suppression (HSV), and treatment (varicella zoster, herpes zoster, HSV, varicella). Dosage adjustment for renal impairment available (93).
Amikacin	Inhibits protein synthesis via binding to 30S ribosomal subunits	Proximal tubule, S1 and S2 segments, late changes in S3	Proximal tubular damage after accumulation of aminoglycoside	Dosage adjustment for renal impairment as well as augmented renal clearance available (93).
Amphotericin B	Disrupts fungal cell wall synthesis and cell membrane permeability via binding to ergosterol which causes leakage of cellular components and subsequent cell death	Distal tubule	Vasoconstriction and direct distal tubular toxicity	Hydration and sodium repletion prior to administration of amphotericin B may reduce risk of renal toxicity. Dosage adjustment for renal impairment available (93).
Gentamicin	Disrupts bacterial protein synthesis and cell membrane integrity via biding to 30S ribosomal subunit	Proximal tubule, S1 and S2 segments, late changes in S3	Proximal tubular damage after accumulation of aminoglycoside	Dosage adjustment for renal impairment available (93).
Indomethacin	Non-selective cyclooxygenase inhibitor decreasing prostaglandin synthesis	Afferent arteriole	Hemodynamically mediated: causes afferent arteriole vasoconstriction and reduced GFR	Dosage adjustment for renal impairment available (93).
Piperacillin/Tazobactam	Inhibits bacterial cell wall synthesis leading to bacteria lysis	Tubule, particularly proximal tubule	Inhibits tubular secretion and clearance, direct toxicity	Dosage adjustment for renal impairment available (93).
Vancomycin	Inhibits cell wall synthesis of gram-positive bacteria via blocking glycol-peptide polymerization	Proximal tubule	Direct toxicity, otherwise unclear	Dosage adjustment for renal impairment available (93).

DNA, deoxyribonucleic acid; CMV, cytomegalovirus; HSV, herpes simplex virus; GFR, glomerular filtration rate.