What agents are suggested to act by a direct toxic effect to cause tubular necrosis, ultimately leading to renal failure?

This is a rare effect of some common drugs which normally occurs when excessive doses have been used or the drug has accumulated in a patient with pre-existing renal disease. Commonly implicated important drugs are:

		acyclovir;
		aminoglycosides;
		cyclosporin;
		paracetamol (in overdose); and
		tacrolimus.

Other toxins which can cause tubular necrosis are:

		DDT;
		ethylene glycol;
		heavy metals;
		ethanol; and
		paraquat.

For a fuller discussion and list of agents which can cause drug-induced renal disease:

Magee P and Beeley L. (14 April 1990) Pharmaceutical Journal p452-453 and Ashley C and Holt S. (5 May 2001) Pharmaceutical Journal 266: no7146 p625-628.