Prevention of cephalosporin nephrotoxicity by other cephalosporins and by penicillins without significant inhibition of renal cortical uptake

Adverse Drug Reactions in the Intensive Care Unit

Adverse drug reactions (ADRs) are undesirable effects of medications used in normal doses [1]. ADRs can occur during treatment in an intensive care unit (ICU) or result in ICU admissions. A meta-analysis of 4139 studies suggests the incidence of ADRs among hospitalized patients is 17% [2]. Because of underreporting and misdiagnosis, the incidence of ADRs may be much higher and has been reported to be as high as 36% [3]. Critically ill patients are at especially high risk because of medical complexity, numerous high-alert medications, complex and often challenging drug dosing and medication regimens, and opportunity for error related to the distractions of the ICU environment [4]. Table 1 summarizes the ADRs included in this chapter.

Aminoglycoside antibiotics reduce glucose reabsorption in kidney through down-regulation of SGLT1

Nephrotoxicity is known to be a major clinical side effect of aminoglycoside antibiotics. Aminoglycosides cause damage to proximal tubular cells in kidney, however the mechanism of toxicity is still unclear. In order to elucidate the mechanism of nephrotoxicity, we studied the effect of aminoglycoside antibiotics on glucose transport systems in vitro and in vivo. As a result, we found that the aminoglycosides significantly reduced Na(+)/glucose cotransporter (SGLT1)-dependent glucose transport and also down-regulated mRNA and protein levels of the SGLT1 in pig proximal tubular LLC-PK(1) cells. To obtain evidence about SGLT1 down-regulation in vivo, we studied the mRNA expression of SGLT1 using gentamicin C-treated murine kidney and found that gentamicin C down-regulated SGLT1 in vivo as well as in vitro. Furthermore, the gentamicin C-treated mice showed significant rise in urinary glucose excretion. These results indicate that one of the mechanisms of aminoglycoside nephrotoxicity is the down-regulation of SGLT1, which causes reduction in glucose reabsorption in kidney.

Effects of L-carnitine on the renal tubular transport of cephaloridine

It has been demonstrated recently that cephaloridine (Cld) inhibits the tubular reabsorption of filtered carnitine (Carn) in the rabbit kidney. This interaction has suggested that the limited net cell-to-luminal fluid movement of Cld following its secretory transport across the antiluminal membrane might result from a balance of active Cld reabsorption by a Carn carrier at the brush border approximately equal to its secretion into the tubular fluid, rather than the previously proposed luminal membrane block. Studies were done to determine the effects of L-Carn, 750 mg/kg, i.v. on the tubular secretion and cortical concentrations of Cld, infused i.v. at a dose of 28 mg/kg (Carn:Cld molar ratio = 70:1). The fractional excretions of Cld during three consecutive periods of 10 min each, one before and two following the bolus infusion of Carn, were (means +/- SEM): 1.18 +/- 0.14, 1.20 +/- 0.14, and 1.16 +/- 0.11, respectively (N = 6 each; differences NS). Cortex-to-serum concentration ratios of Cld in control and Carn-treated rabbits were 10.43 +/- 0.32 and 10.16 +/- 0.86, respectively (NS). The data provide evidence against the reabsorptive transport of Cld by a Carn carrier, and do not support a model of balanced secretion and reabsorption as the cause of limited clearance despite significant secretory transport of Cld into the tubular cell.

Toxicity of cephalosporins to fatty acid metabolism in rabbit renal cortical mitochondria

Cephaloglycin (Cgl) and cephaloridine (Cld) are acutely toxic to the proximal renal tubule, in part because of their cellular uptake by a contraluminal anionic secretory carrier and in part through their intracellular attack on the mitochondrial transport and oxidation of tricarboxylic acid (TCA) cycle anionic substrates. Preliminary studies with Cgl have provided evidence of a role of fatty acid (FA) metabolism in its nephrotoxicity, and work with Cld has shown it to be a potent inhibitor of renal tubular cell and mitochondrial carnitine (Carn) transport. Studies were therefore done to examine the effects of Cgl and Cld on the mitochondrial metabolism of butyrate, the anion of a short-chain FA that does not require the Carn shuttle to enter the inner matrix, and the effects of Cgl on the metabolism of palmitoylcarnitine (PCarn), the Carn conjugate of a long-chain FA that does enter the mitochondrion by the Carn shuttle. The following was found: (1) Cgl reduced the oxidation and uptake of butyrate after in vitro (2000 micrograms/mL, immediate effect) and after in vivo (300 mg/kg body weight, 1 hr before killing) exposure; (2) Cld caused milder in vitro toxicity, and no significant in vivo toxicity, to mitochondrial butyrate metabolism; (3) like Cld, Cgl reduced PCarn-mediated respiration after in vivo exposure, but, unlike Cld, it did not inhibit respiration with PCarn in vitro; (4) the Carn carrier was stimulated slightly by in vitro Cgl but was unaffected by in vivo Cgl; (5) in vivo Cgl had no effect on mitochondrial free Carn or long-chain acylCarn concentrations in the in situ kidney; (6) Cgl increased the excretion of Carn minimally compared with the effect of Cld; and (7) cephalexin, a nontoxic cephalosporin, caused mild reductions of respiration with butyrate and PCarn during in vitro exposure, but stimulated respiration with both substrates after in vivo exposure.

CONCLUSIONS

Cgl has essentially the same patterns of in vitro and in vivo toxicity against mitochondrial butyrate uptake and oxidation that both Cgl and Cld have against TCA-cycle substrates. Cld has little or no in vivo toxicity to mitochondrial butyrate metabolism, whereas in vivo Cgl is as toxic as Cld to respiration with PCarn. The greater overall in vivo toxicity of Cgl to mitochondrial FA metabolism, with lower cortical concentrations and AUCs than those of Cld, supports earlier evidence that Cld is less toxic than Cgl at the molecular level.

Nephrotoxic drugs

The nephrotoxic effects of cyclosporine, aminoglycoside antibiotics, cisplatin, amphotericin B, beta-lactam antibiotics and indomethacin are reviewed. These drugs were chosen because they are among the most frequent causes of renal injury in children. In addition, their nephrotoxicity is caused by different mechanisms. Several generalizations can be made, however. First, agents which cause tubular damage tend to be synergistic in their toxic effects. This synergism is seen when several nephrotoxic drugs are given simultaneously. In addition, the use of a nephrotoxic agent in a patient with pre-existing renal disease can result in severe tubular injury. Second, serum levels of the drug frequently fail to correlate with the degree of nephrotoxicity in individual patients. Third, early signs of renal injury can be subtle (e.g., minor changes in electrolyte excretion) or dramatic (e.g., acute renal failure). The subtle changes are particularly important, since they can be useful predictors of serious nephrotoxicity.

Nephrotoxic potential of first-, second-, and third-generation cephalosporins

First-, second-, and third-generation cephalosporins were investigated for their peroidative and nephrotoxic potential. Renal cortical slices from male Wistar rats were incubated at 37 C for 1 h in a phosphate-buffered medium containing the cephalosporin (1.25, 2.5, 5 or 10 mg/ml). In another series of experiments 5 mg/ml cephalosporin was incubated under the same conditions for 30, 60, 90 and 120 min. Subsequently, slices were incubated for 60 or 90 min in a bicarbonate- or phosphate-buffered medium containing pyruvate or tetraethylammonium (TEA) to determine gluconeogenesis and TEA accumulation, respectively. The peroxidative potential was determined at the end of the first incubation by measuring the increase in the malondialdehyde (MDA) content in renal cortical slices. The nephrotoxic potential was determined at the end of the second incubation by measuring the decrease in accumulation of the organic ion (TEA) and decrease of pyruvate-stimulated gluconeogenesis in renal cortical slices. First-generation cephalosporins, cephaloridine and cephalothin showed a time- and concentration-dependent increase in MDA content and a decrease in TEA accumulation and gluconeogenesis by renal cortical slices. Cefazolin, another first generation cephalosporin, showed a weak peroxidative and practically no nephrotoxic potential. In the group of second-generation cephalosporins, cefotiam showed a weak peroxidative potential comparable to that of cefoxitin but had a much greater nephrotoxic potential which was similar to that of cephaloridine. The third-generation cephalosporins, cefotaxime and cefoperazone showed a low peroxidative and no nephrotoxic potential.(ABSTRACT TRUNCATED AT 250 WORDS)