Drug associated acute kidney injury (D-AKI) contributes to 20-30% of kidney related events in intensive care units (ICU). Drugs are a modifiable exposure providing an opportunity for interventions to prevent AKI occurrence or ameliorate AKI severity and promote kidney health. Consistent application of contemporary definitions for drug related kidney diseases should be adopted as it provides homogenous utility in pharmacovigilance and pharmacoepidemiology efforts.(PMID: 37946280) “Nephrotoxin stewardship is a set of coordinated patient care management strategies to improve the use of nephrotoxins, renally eliminated drugs and kidney disease treatments with the goal of enhancing patient outcomes through safe medication use, ensuring kidney health and avoiding unnecessary costs.” (PMID: 33752857) Identifying renally eliminated drugs and nephrotoxins to target for surveillance by standardizing focused lists is the first step in risk assessment and prevention. Nephrotoxin stewardship extends beyond single drugs for surveillance to consideration of drug burden and drug-drug interactions. The next step in nephrotoxin stewardship is hypervigilant inspection of risk and impending harm using traditional functional biomarkers and novel damage biomarkers. Approaches that have been used to identify risk for D-AKI are three drug nephrotoxin alerting (drug burden) and use of stress/damage biomarkers indicating risk before overt damage when serum creatinine rises. Strategies for nephrotoxin stewardship should be implemented in a cost-conscious manner. The key to preventing D-AKI is a coordinated nephrotoxin stewardship strategy.