Pathophysiology, risk factors and clinical management for polymyxin-associated acute kidney injury

Polymyxins serve as a 'last-line' defence against Gram-negative bacterial infections and are frequently used in critically ill patients with multidrug-resistant pathogens. However, polymyxin-associated acute kidney injury (PA-AKI) remains a major factor limiting their clinical application. This review examines the pathophysiology, risk factors and clinical management of PA-AKI, providing updated perspectives on its prevention and treatment. Reducing exposure to concomitant nephrotoxic agents, together with timely and standardized monitoring of serum creatinine, urine volume and polymyxin concentrations, plays a key role in mitigating the risk and progression of PA-AKI. Although several biomarkers show promise for the early prediction of PA-AKI and may enable earlier intervention, many have not yet undergone extensive clinical validation. There is a clear need to incorporate real-world evidence into clinical practice guidelines for polymyxin use. Further research should focus on identifying genetic risk factors for PA-AKI and developing novel polymyxin analogues with reduced nephrotoxicity.