Antibiotic-Induced Nephrotoxicity. In: Robinson RR, Dennis VW, Ferris TF, Glassock RJ, Kokko JP, Tisher CC, editors. Nephrology. New York: Springer; 1984. pp. 844-68. [DOI: 10.1007/978-1-4612-5284-9_75]

Acute Renal Failure in Critically Ill Patients

Acute renal failure is an important cause of morbidity in critically ill patients. Acute renal failure results from pre renal and postrenal causes and, most importantly, acute tubular necrosis (ATN). Although it is known that renal toxins and renal ischemia are the most common causes of ATN in hospitalized patients, the exact pathogenesis of this entity is still not fully understood. Patients in the intensive care unit are at high risk for ATN because of hemodynamic instability, the administration of neph rotoxic antibiotics or chemotherapeutic agents, and ex posure to radiographic contrast agents. The acquired immunodeficiency syndrome is also associated with an increased risk of renal failure development, either from complications of the disease itself or from its treatment. Many consequences of acute renal failure such as vol ume overload, acidosis, hyperkalemia, and serositis can be managed adequately with peritoneal dialysis, hemo dialysis, or a newer technique, continuous arteriove nous hemofiltration. Despite improvements in treat ment, however, the mortality of ATN remains high. In this review, we recommend measures to prevent ATN in certain clinical situations that commonly occur among critically ill patients. We also review therapeutic options for treating patients in whom acute renal failure devel ops and discuss newer developments that may begin to reduce the excessive morbidity associated with ATN.

Drug-induced nephrotoxicity: the crucial role of risk factors

Although the exact incidence of drug-induced nephrotoxicity is not known, it is important for clinicians to be aware of the risks in certain patients and to know which drugs are the most commonly implicated. The latter include radiocontrast agents, aminoglycosides, nonsteroidal anti-inflammatory drugs, and angiotensin-converting enzyme inhibitors. Other medications also have nephrotoxic potential when they are prescribed in specific patient populations. Renal injury may be transient and mild in many cases, but recognition of the patient at high risk and application of preventive measures are essential to avoid a severe and protracted course.

Morphological alterations in distal and collecting tubules of the rat renal cortex after aminoglycoside administration at low doses

Ultrastructural alterations in the cortical, distal and collecting tubules have been examined in female Sprague-Dawley rats treated with various aminoglycosides in clinical use. Gentamicin, dibekacin (10 mg/kg X day), netilmicin, tobramycin (4 or 10 mg/kg X day) or amikacin (37.5 mg/kg X day) were administered intraperitoneally twice a day over different periods of time, extending from 4 to 14 days. The kidney cortex was examined after 4, 7, 10 or 14 days of aminoglycoside administration by light (semithin sections) and electron microscopy. After 7 or more days of treatment, lysosomes in collecting tubular cells (and to a lesser extent in distal tubular cells) contained concentric lamellar material (myeloid bodies), an ultrastructural alteration typical of drug-induced lysosomal phospholipidosis. Although this alteration appeared qualitatively similar to that observed in proximal tubular cells, it was less conspicuous and occurred later during treatment. In addition, distal tubular cells occasionally showed marked vacuolization and disruption of the basal cell architecture. The possible relationship between these alterations and the urine hypo-osmolality characteristic of aminoglycoside-induced renal dysfunction is discussed.