Enzymuria in gentamicin-induced kidney damage

Accelerated Glomerular Cell Senescence in Experimental Lupus Nephritis

BACKGROUND The aim of this study was to determine whether senescence in renal glomeruli is involved in lupus nephritis (LN); the expression of senescence-associated β-galactosidase (SA-β-Gal) and its association with glomerular lesions were investigated in a mouse model of LN. MATERIAL AND METHODS Eighteen MRL/lpr mice with severe proteinuria were randomly divided into 2 equal groups and intraperitoneally injected with dexamethasone (DEX) or saline; 4 age-matched mice with mild proteinuria served as controls. Serum creatinine and urinary protein levels were analyzed, and kidney histological changes were observed by periodic acid-Schiff and Sirius Red staining. SA-β-Gal was detected via histochemistry. Glomerular expression of collagen IV, α-SMA, and nephrin was analyzed by immunohistochemistry, and glomerular complement C3 deposition was tested by immunofluorescence. The relationships between SA-β-Gal expression and renal function or glomerular lesion markers were determined by Spearman's correlation analysis. RESULTS Mice with severe proteinuria exhibited glomerular segmental sclerosis and endothelial cell proliferation. DEX administration suppressed these lesions but had no significant effect on 24-hour urinary protein levels. The elevated glomerular expression of SA-β-Gal in proteinuric mice was attenuated by DEX treatment. In addition, DEX treatment markedly downregulated glomerular C3 deposition and collagen IV and α-SMA expression, while significantly increasing nephrin expression. Furthermore, SA-β-Gal expression was positively correlated with urinary protein levels and expression of α-SMA. CONCLUSIONS Accelerated senescence of glomerular cells may contribute to glomerular injury in LN.

Gentamicin Nephropathy and Contrast Media

Urine profiles were followed for 3 or 9 days after intravenous injection of diatrizoate, iohexol or saline in 30 rats, where a tubulointerstitial nephropathy was induced by gentamicin given over a 14-day period. Another 10 rats who had an injection of saline served as controls. Iohexol increased the excretion of lactate dehydrogenase significantly more than both saline and diatrizoate for the first 3 days, whereas diatrizoate had no effect. Both media caused significantly increased excretion of L-gamma-glutamyltransferase compared with saline, but iohexol significantly more than diatrizoate. Compared with saline S-creatinine was significantly increased following iohexol at 24 h, 3 and 9 days, and following diatrizoate only at 9 days. Among rats having gentamicin light microscopy revealed more severe changes in kidneys exposed to iohexol than to either diatrizoate or saline 3 days after their injection. Six days later no obvious differences were found between the 3 groups. In conclusion, iohexol induced more renal dysfunction than diatrizoate in this animal model of gentamicin induced nephropathy.

Impaired Renal Function Secondary to Gentamicin — Identifying the Special Risk Patient

Although gentamicin has been commercially available since 1969, reports concerning the incidence of nephrotoxicity from this drug and variables relating to this toxicity are still unclear and conflicting. In view of this, a prospective study of patients receiving gentamicin over a two month period was undertaken to determine the incidence of nephrotoxicity and to study the influence of several variables on the potential for developing gentamicin associated nephrotoxicity. The variables studied were patient's age; the total grams of gentamicin received; the total number of days the patient received gentamicin with a hemoglobin of less than 12 g%; sex; total days duration of therapy; hemoglobin prior to therapy; hematocrit prior to therapy; red blood cell count prior to therapy; albumin level prior to therapy; and if the patient received another potentially nephrotoxic drug concomitantly with gentamicin. Sixty patients in total were studied. However, in the “toxic” and “nontoxic” grouping process, seventeen patients were excluded from the study due to missing variables. Of the remaining sample, ten patients were classified as “toxic” and thirty-three were classified as “nontoxic.” Thus the incidence of nephrotoxicity was at least 10/60 or 16.7 percent. The data relating to the variables identified were analysed utilizing Chi-square, t-test, and multiple regression analyses. Two variables were found to be highly significant in relationship to the development of nephrotoxicity while receiving gentamicin therapy. These were (1) the albumin level prior to therapy (lower albumin level in the “toxic” group) and (2) the concomitant use of another potentially nephrotoxic drug. The mechanism behind the influence of albumin on gentamicin toxicity is unclear, but may be related to protein binding. The basis for nephrotoxicity relating to combined use of nephrotoxic drugs is probably additive or synergistic toxicity but this is also unclear.

Until larger prospective studies concerning gentamicin associated nephrotoxicity provide more meaningful information concerning the significance of the variables involved in this adverse reaction, caution is recommended when using this drug in the albumin deficient patient or in combination with nephrotoxic drugs. In addition, it is further recommended that in patients receiving gentamicin, renal function should be closely monitored and the dosage regimen determined accordingly.

Urinary lysosomal enzyme excretion in pregnant women with hypertensive disorders

BACKGROUND

The authors assessed proximal renal tubular dysfunction and/or damage in pregnant women with various types of hypertension by measuring the three urinary lysosomal enzyme levels: N-acetyl-β-d-glucosaminidase (NAG), arylsulfatase A and β-glucuronidase.

METHODS

The study consisted of 120 pregnant women divided into four groups: 41 women in 20th week of gestation or more, with pregnancy-induced hypertension (PIH group), 28 pregnant women after 20 weeks of pregnancy with pre-eclampsia (PE group), 21 pregnant women with chronic hypertension, identified before 20th week of pregnancy (CH group) and 30 healthy, pregnant women (healthy controls (HC) group).

RESULTS

Statistical analysis showed significantly higher levels of all the three of lysosomal enzymes in the urine of patients with PE compared with the healthy pregnant women, pregnant women with PIH and the ones with chronic hypertension. Additionally, significantly higher values of NAG were found in the group of pregnant women with PIH compared with healthy pregnancies. No correlation was found between the concentration of enzymes in urine and values of blood pressure in any of the analyzed groups of pregnant women.

CONCLUSIONS

The authors conclude that higher values of all the studied enzymes in PE group, in the comparison with the other groups, indicate proximal tubular damage at the cellular level. The lack of correlation between the concentration of lysosomal enzymes and blood pressure suggests that the damage to these parts of kidney is complex. In addition, mechanisms other than hypertension realizing intracellular enzymes may be involved in this process.

High compared with standard gentamicin dosing for chorioamnionitis: a comparison of maternal and fetal serum drug levels

OBJECTIVE

To compare umbilical cord and maternal serum peak gentamicin concentration, gentamicin elimination, and clinical outcomes between women who received once-daily compared with standard, thrice-daily dosing for clinical chorioamnionitis.

METHODS

We randomly assigned 38 laboring women, at least 34 weeks gestation, with clinical chorioamnionitis, into 1 of 2 gentamicin dosing groups: 5.1 mg/kg every 24 hours (once-daily; n = 18), or 120 mg followed by 80 mg every 8 hours (standard; n = 20). We measured maternal serum peak and delivery gentamicin concentrations and cord serum levels at delivery. Polynomial curve fitting was used to summarize gentamicin elimination. We also compared maternal and neonatal outcomes.

RESULTS

Demographic characteristics of the 2 groups were similar. Median maternal peak gentamicin levels were higher with once-daily (18.2 microg/mL) compared with standard dosing (7.1 microg/mL) (P < .001). Maternal serum levels decreased below 2 microg/mL by 10 hours in the once-daily group and by 5 hours in the standard dosing group. Extrapolated peak cord serum levels were 6.9 microg/mL in the once-daily and 2.9 microg/mL in the standard dosing arm. Cord levels decreased below 2 microg/mL by 10 hours in the once-daily and by 5 hours in the standard dosing group. We found no differences in maternal or neonatal outcomes.

CONCLUSION

Peak maternal serum gentamicin levels ranged from 13 to 25 microg/mL after a dose of 5.1 mg/kg. Single-dose gentamicin resulted in fetal serum peak levels that were closer to optimal neonatal values. Gentamicin clearance in the term fetus was similar to published values for the newborn infant. No adverse effects of high-dose therapy were noted.

Gentamicin-induced kidney damage and lipid peroxidation in rats

Although it has been reported that injections of gentamicin induces lipid peroxidation in rat renal cortex (Ramsammy et al. (1985) Biochem. Pharmacol. 34, 3895-3900), our results showed no modification of thiobarbituric-reagent substances (TBARS) or in analysis of the polyunsaturated fatty acid profile. Moreover, endogenous vitamin E and glutathione were not consumed. In in vitro systems, gentamicin incubated with microsomes, homogenates and kidney slices from the normal rat failed to induce lipid peroxidation. We show that the increase in TBARS in vivo detected by Ramsammy et al. was wrongly attributed to the oxidant power of gentamicin. As this antibiotic does react positively to thiobarbituric acid in the presence of a system generating free radicals, it is possible that these authors accidentally introduced such a system into their experiments.

Evaluation of enzymuria as an indicator of amikacin-induced renal damage in guinea pigs

Guinea pigs were injected subcutaneously for 10 days with amikacin (AK) at a dose of 0, 100, 200 or 400 mg/kg body wt. per day. The total daily dose was administered in either a single injection or divided equally and given as two daily injections. After the 10 days of AK treatment, uptake of the organic cation, tetraethylammonium (TEA) into renal cortical slices was inhibited in a dose-related manner. Changes in renal tubular morphology also increased with higher doses. The urinary excretion of the enzymes, N-acetyl-beta-D-glucosaminidase (NAG), and alkaline phosphatase (ALP) significantly increased during the course of AK treatment, however, due to the large intragroup variability, the daily fluctuations and the absence of any distinct trends in urinary enzyme excretion it was difficult to establish a dose-relationship between AK-induced renal damage and the resultant enzymuria. At doses of 100 and 200 mg/kg body wt., the two-injection regimen resulted in the greater renal accumulation of AK and damage as reflected by a greater inhibition of TEA uptake and greater changes in renal tubular morphology. In contrast, this difference in toxicity could not be detected with enzymuria again due to the large intragroup variability and the absence of discernable excretion patterns of NAG and ALP. Thus, neither NAG nor ALP appear to be suitable quantitative markers of AK-induced nephrotoxicity.

Does gentamicin induce acute renal failure by increasing renal TXA2 synthesis in rats?

Acute renal failure (ARF) induced with large doses of Gentamicin (GM) (an aminoglycoside) was associated with increased urinary TXB (TXA) excretion which provoked a decrease of the ratios of urinary PGE2/TXB2 and 6-keto-PGF1 alpha (PGI2)/TXB2 excretions. Furthermore, as indicated by light microscopy most of the epithelial cells lining the proximal tubules show obvious lesions varying from swelling of their cytoplasm to complete necrosis. Either the inhibitor, OKY-O46, of TXA-synthetase, or volume expansion (VE) with isotonic saline (IS) of the experimental animals diminished urinary TXB excretion which provoked 1) augmentation of the ratios of urinary PGE/TXB and 6-keto-PGF1 alpha/TXB excretions, 2) elevation of creatinine clearance (Ccr) and 3) diminution of proteinuria (PU). This protection against ARF-by OKY-O46 and VE can a can be seen in microscopic sections where necrosis of proximal tubules is almost absent. Only a few proximal tubules show swelling of their epithelial cells and some focal areas of tubule necrosis. We suggest that the metabolites of arachidonic acid (AA), TXA2 a (potent vasoconstrictor agent) and prostaglandins (PGE2 and PGI2), (potent vasodilator factors), play an important role in the development (TXA2) or in the prevention (PGs) of ARF induced by this antibiotic.

Seasonal effects on the daily variations of gentamicin-induced nephrotoxicity

The effect on kidney damage of the season of year at which gentamicin was administered to rats was studied. Rats received a single intramuscular dose of 200 mg/kg gentamicin at four different times of the day (08.00, 14.00, 20.00 or 02.00 hours. Studies were carried out in January-February, March-April, June-July and October-November. The nephrotoxicity was assessed by the increase of three urinary enzymes: two brush border enzymes, gamma-glutamyl transferase and alanine aminopeptidase, and a lysosomal enzyme: N-acetyl-beta-D-glucosaminidase. The results show that when the injection is administered at 20.00 hours in the January-February and the October-November studies and at 08.00 hours in the March-April study and at 14.00 hours in the June-July study there is a significant increase in the excretion of these enzymes. The renal toxicity of gentamicin therefore has circadian variations as well as seasonal variations. The peak enzyme level is displaced from the start to the end of the rest period of rats depending upon the time of year.

Aminoglycosides: another perspective

Despite the introduction of several new classes of antimicrobial agents, aminoglycosides are still recognized as first-line therapeutic agents in the management of severe gram-negative sepsis. The major obstacle limiting the use of aminoglycoside antibiotics has been, and continues to be, the possibility of drug-induced ototoxicity and nephrotoxicity. This review critically examines the definitions used to establish the diagnosis of aminoglycoside-induced nephrotoxicity and ototoxicity and the clinical significance of these adverse reactions. The review also focuses on the practical and economic issues surrounding therapeutic drug monitoring practices. We conclude that aminoglycoside antibiotics remain an effective and economical form of therapy for severe infections and that if careful criteria are used in the selection of these agents, the benefits of therapy outweigh the risk of toxicity.

Extracellular DNA in blood and urine as a potential marker for cytotoxicity and nephrotoxicity in the mouse

Cell death releases products of chromatin catabolism, particularly DNA, which can be measured by a DNA assay (using the nick translation reaction) as a marker of toxicity. Conditions for blood and urine collection have been established for quantitation of extracellular DNA in mice. Toxic doses of lipopolysaccharide (5 mg/kg) and HgCl2 (3.2 mg/kg) release DNA to plasma and urine. Increase in urinary DNA is observed 24 hours after a single injection (5 mg/kg) of gentamicin. Quantitation of extracellular DNA can be used to investigate the occurrence of cell death in vivo and applied to toxicological studies, in animals and man.

Obesity as a risk factor in drug-induced organ injury. III. Increased liver and kidney injury by furosemide in the obese overfed rat

Effects of the diuretic drug furosemide were examined in obese animals to evaluate the hypothesis that organ damage by reactive drug metabolites may be potentiated by this disease. Obese overfed Sprague-Dawley rats that were treated ip with 450 mg/kg furosemide on the basis of total body mass suffered a 58% mortality rate over 24 h. This contrasted with 0% mortality in animals of normal body mass. On the basis of median histopathology scores, organ necrosis was judged to be greater in the liver (2+) and kidneys (1+) of obese rats than in the liver (1+) and kidneys (less than 1+) of normal controls (p less than 0.05). Obese animals demonstrated a fourfold rise in fat mass over controls. The low solubility of furosemide in lipid makes it probable that aggravated drug toxicity in obese rats dosed to total body mass resulted in part from elevated furosemide concentrations in lean body mass. In a subsequent study designed to minimize this possibility, furosemide was administered on the basis of fat-free body mass to equalize initial drug exposure in obese and control rats. Even with this downward dosage adjustment, obese animals suffered increased hepatic necrosis (median score of 2+ versus 0 in treated controls), greater impairment of renal function (plasma creatinine concentration of 2.41 mg/dl versus 0.96 mg/dl in treated controls), and more extensive enzymuria (enzyme excretion 175-300% more elevated than in treated controls). In conclusion, obese rats appear to be at increased risk of furosemide-induced liver and kidney injury due to at least two factors: (1) increased exposure of target organs in lean body mass to furosemide when the dosing of this poorly lipophilic drug was based on total body mass, and (2) increased susceptibility of target organs in lean body mass to furosemide injury when dosing was adjusted downward to reflect fat-free body mass and to equalize initial drug exposure.

Enhanced urinary trypsin inhibitory activity in gentamicin-induced nephrotoxicity in rats

We delineated in rats, the relationship between trypsin inhibitory activity in the urine and the nephrotoxic effects of gentamicin, eg, proteinuria and deterioration of glomerular filtration rate (GFR), measured by creatinine clearance. Gentamicin, 70 mg/kg per day, was injected intraperitoneally for 6-10 successive days. Serum and urine gentamicin levels were determined by a microbiological test. Trypsin inhibitory activity was assayed by the casein digestion method. The results showed a steady increase in urinary trypsin inhibitory activity starting from the fourth injection day. The increased levels of urinary trypsin inhibitory activity were associated with increased levels of urinary gentamicin excretion (r = 0.36, p less than 0.02, n = 50 after the fourth injection day), and were significantly higher than in control groups (p less than 0.001). The urinary trypsin inhibitory activity was inversely correlated with the GFR (r = -0.45, p less than 0.01, after the second injection day). The serum trypsin inhibitory activity remained unchanged throughout the study period in all groups. These data suggest that increased urinary trypsin inhibitory activity may be involved in the pathogenesis of gentamicin-induced nephrotoxicity.

Relationship between the nephrotoxicity and ototoxicity induced by gentamicin in the guinea pig

Guinea pigs were treated with daily single subcutaneous injections of 60 mg gentamicin per kg for 3 weeks. Renal, cochlear and vestibular functions were monitored before, during and after treatment. The degree and onset of gentamicin oto- and nephrotoxocity differed during the treatment period. Alterations to the kidney functions were observed from the first week while the onset of ototoxicity occurred later, at the third and fourth week for the cochlear and vestibular functions respectively. Moreover, when treatment ended, renal function demonstrated signs of recovery, while auditory and vestibular function continued to worsen. Deficits in cochlear function and structural changes (missing outer hair cells) correlated with gentamicin serum concentrations, while vestibular alterations (loss in nystagmic reactions) did not. No distinct relationship could be established between auditory and vestibular loss and the renal parameters monitored. The results suggest that gentamicin-induced nephro- and oto-toxicity are dissociated phenomena and that cochleotoxicity was dependent on aminoglycoside serum level.

Aminoglycoside antibiotics in clinical use

Aminoglycosides are among the most used antibiotics despite competitive pressure from newer beta-lactam agents. The activity profile, pharmacology, toxicity potential, and methods of toxicity prevention of aminoglycosides are well appreciated after three decades. Nephrotoxicity, ototoxicity, and the added costs of drug level monitoring limit wider usage, but great activity against highly antibiotic resistant gram negative bacteria often outweigh these disadvantages and will likely keep aminoglycosides available for the foreseeable future.

A focus of tissue necrosis increases renal susceptibility to gentamicin administration

The purpose of this study was to determine whether a retained focus of necrotic tissue predisposes to aminoglycoside-induced acute renal failure (ARF). Rats were subjected to either (1) 25% liver ligation, creating a focus of ischemic tissue which was left in place; (2) 25% liver resection; or (3) sham liver ligation. Gentamicin, 80 mg/kg bid, was administered for two days after surgery to all three groups. A fourth group was subjected to 25% liver ligation but no gentamicin therapy. Only rats subjected to partial liver ligation plus gentamicin treatment developed ARF, manifested by azotemia (BUN 80 +/- 2; creatinine 1.63 +/- 0.21; mg/dl) and tubular necrosis. This occurred in the absence of any discernible reduction in arterial blood pressure, renal blood flow, excessive weight loss, or ascites formation. The partial liver ligation-gentamicin group had 70% higher renal gentamicin concentrations than the liver resection-gentamicin controls (P = 0.01). To assess whether factors released from necrotic liver might account for these findings, additional rats were infused with: (1) 1 ml of a soluble liver extract alone; (2) 1 ml of liver extract plus gentamicin; or (3) 1 ml of saline plus gentamicin. Only the liver extract/gentamicin group developed ARF (BUN 88 +/- 13; creatinine 1.46 +/- 0.25). This occurred in association with a 110% increase in renal gentamicin uptake (P less than 0.03). In separate experiments, 5 ml liver extract infusions caused ARF (BUN 118 +/- 7; creatinine 2.1 +/- 0.18) without gentamicin treatment. In conclusion, a focus of liver necrosis can predispose to experimental gentamicin nephrotoxicity.(ABSTRACT TRUNCATED AT 250 WORDS)

The dissociation between aminoglycoside serum concentrations and nephrotoxicity

Using newborn and adult rats we tested the correlation between aminoglycoside dose, resultant serum and renal cortical concentrations and nephrotoxicity evidenced by creatinine in serum and urine, N-acetylglucosaminidase and beta 2 microglobulins in urine and sphingomyelinase in renal cortical tissue. Our data reveal that aminoglycoside nephrotoxicity is clearly more evident in adult rats despite significantly lower drug serum concentrations and in the presence of substantially higher renal cortical concentrations. These data indicate that high aminoglycoside serum concentrations are not causing nephrotoxicity but rather reflect secondary body accumulation of the drug associated renal damage.

Age related changes of N-acetyl-beta-D-glucosaminidase and L-alanine aminopeptidase in mouse kidney, urine and plasma

Age and sex dependent differences of N-acetyl-beta-D-glucosaminidase (NAG) and L-alanine aminopeptidase (AAP) activities in kidney, urine and plasma of male and female mice were studied. The sex difference in NAG activity appeared between 27 and 38 days of age with the manifestation of significant differences in body weight and kidney growth. NAG activity in male kidneys was 3-fold that in females and its urinary level in mature males was over 10-fold higher. Androgenic regulation was found not only in the NAG contents in the kidneys and in the urinary excretion but also in the plasma NAG level, which showed higher in females. On the other hand, AAP activity in kidney, urine and plasma did not show much sex differences. Age related changes in AAP activity were not found except in the kidney and marked androgenic regulation was also not found in AAP. These results indicate that NAG and AAP, which are both urinary enzymes used as indicators of renal lesions, may be regulated differently.

Tobramycin and renal ischemia

Sprague-Dawley rats were injected with known nephrotoxic doses of tobramycin and then subjected to varying amounts of warm renal ischemia. Analysis of serum creatinine at the time of sacrifice revealed no statistically significant difference among controls and the two doses of tobramycin at any given duration of ischemia. Light microscopy revealed no worsening of tubular necrosis with increasing doses of tobramycin.

Benefit-risk assessment of investigational drugs: current methodology, limitations, and alternative approaches

Development of investigational drugs is a process integrated traditionally into four overlapping phases. The goal is to introduce new therapies to clinical medicine by assessing benefits and risks associated with administering the new drug. Benefit assessment is performed with respect to the disease for which the drug may comprise an effective treatment. In contrast, safety assessment is relatively standardized across many pharmacologic classes of agents. For purposes of benefit-risk assessment, investigational drugs are developed to provide benefit in three major disease categories: acute, episodic, and chronic. Benefit assessment is the major focus of conventional methodologies. Inherent limitations of risk assessment produced by conventional approaches are illustrated by the historical inability to detect toxicities of various drugs until large patient populations have been treated, typically after the drug is marketed. Alternative approaches to overcome these limitations include assessment of safety in studies specifically designed to optimize such evaluation and more extensive safety testing of investigational drugs in patient subgroups at higher risk. Such approaches serve the interest of patients, physicians, and developers by facilitating the development of new therapies by providing a more complete benefit-risk assessment prior to initial marketing of the drug.

Determination of rat beta 2-microglobulin in urine and in serum. II. Application of its urinary measurement to selected nephrotoxicity models

beta 2-microglobulin (beta 2-m) was measured in the urine of rats by a specific immunoassay based on latex particles agglutination. The excretion of this protein was compared to the excretion of the enzyme beta-N-acetyl-D-glucosaminidase (NAG), albumin and amino acids in rats treated with either a single dose of sodium chromate (5 and 10 mg kg-1), repeated doses of gentamicin (5 and 20 mg kg-1), or cadmium (1 mg kg-1), and in aging rats (from 2 to 20 months). All treatments resulted in an early increased excretion of beta 2-m indicative of functional alterations of the proximal tubular cells. An increased NAG excretion was observed only at the highest dose of chromate and in the cadmium model but the relative increases of beta 2-m were much larger (up to 200 times the control values against four times the control values for NAG). From 2 to 20 months of age, urinary beta 2-m increases by a factor of four. Aminoacids excretion showed little sensitivity in the various models. Albumin showed little variations in purely tubular or in the tubular phase of renal injury but the chronic progressive nephrosis of aging rats caused a 40-fold increase in its excretion between 2 and 20 months of age. Therefore urinary beta 2-m, albumin and albumin/beta 2-m ratio provide useful tools in the assessment of nephrotoxicity and of its mechanisms in various experimental models.

Urinary excretion of enzymes in cirrhotics with renal failure

We studied the significance of urinary enzyme measurements in diagnosing proximal tubular damage in cirrhosis of the liver. Urinary excretion (u-enzyme) and fractional urinary excretion (FEenzyme) of gamma-glutamyltranspeptidase (GGT), leucine aminopeptidase (LAP), alkaline phosphatase (AP) and beta-glucuronidase (B-GLU) were quantified in 14 control subjects (group I), 12 cirrhotics with functional renal failure (group II), 13 cirrhotics with renal tubular damage (group III) and 7 non-liver patients with renal tubular damage (group IV). Urinary enzyme excretion and fractional enzyme excretion were significantly higher in the cirrhotics of group III than in the controls or group II. In group III, these tests usually reached values within the range of group IV. The sensitivity of urinary enzyme excretion was 0.92 and specificity ranged from 0.75 (u-LAP) to 1 (u-GGT; u-B-GLU). The sensitivity of fractional enzyme excretion was between 0.61 (FEB-GLU) and 0.84 (FEGGT; FELAP), while specificity was from 0.91 (FELAP; FEAP) to 1 (FEGGT; FEB-GLU). The results indicate that measurement of urinary enzymes may be very useful in diagnosing renal tubular damage in cirrhotic patients with impaired renal function.

Increased nephrotoxicity of gentamicin in pyelonephritic rats

Multiple factors may increase the nephrotoxic potential of aminoglycosides. We studied gentamicin susceptibility of kidneys infected with E. coli. Several parameters of renal function, histological changes on light and electron microscopy, and drug levels in renal parenchyma were compared in pyelonephritic and normal rats treated with low doses (10 mg/kg/Q8 hr for 3 days), or high doses (60 mg/kg/day for 14 days), of gentamicin. A significant increase (P less than 0.01) in beta-galactosidase and protein excreted in urine over a period of 17 days associated with severe changes in diuresis and osmolality was noted in the infected treated rats (low doses) compared with normal, treated, infected or control animals. Histological modifications compatible with gentamicin nephrotoxicity were more persistent in the infected treated animals. A significant decrease in 14C inulin (P less than 0.01) and 3H-PAH clearance and secretion (P less than 0.02) was observed in the infected treated rats receiving high doses of antibiotics. Cellular necrosis and tubular desquamation also were more severe in this group. Gentamicin levels in the cortex and medulla of infected animals were significantly higher than in the normals (P less than 0.01) and might have been responsible for the increased toxicity noted in the pyelonephritic animals. Infected kidneys appeared to be more susceptible to the nephrotoxic potential of gentamicin.

Acute, subchronic, and chronic toxicity studies with 3-O-demethylfortimicin A disulfate, a new aminocyclitol antibiotic

The acute LD50 for 3-O-demethylfortimicin A disulfate (ODMF) in mice and rats were 419 and 778 mg activity/kg (dosages are expressed in terms of antibiotic activity (potency), rather than on a weight basis) for single-dose im administration and, 90 and 96 mg activity/kg for single-dose iv administration, respectively. No drug-related gross or microscopic lesions were found in rabbits given single iv infusions of ODMF at dosages of 10 to 400 mg activity/kg. Minimal to mild muscle irritation was seen in rabbits given im concentrations of 3.8 or 7.5% ODMF at dosages of 48 or 93 mg ODMF activity/kg. In 1-month iv studies in dogs treated with ODMF at dosages of 0.4, 1, 4, or 8 mg activity/kg/day, and in concurrent studies in rats treated with ODMF dosages of 1, 3, 6, or 12 mg activity/kg/day, treated animals remained essentially free of adverse effects. In 1-month im studies in dogs treated with ODMF at dosages of 1, 4, 8, or 16 mg activity/kg/day, no renal lesions occurred after an ODMF dosage of 1 mg activity/kg/day. Concurrent im studies in rats treated with ODMF at dosages of 6, 12, 24, or 48 mg activity/kg/day showed that ODMF dosages of 6 and 12 mg activity/kg/day did not produce renal lesions. In 6-month chronic im studies in dogs with ODMF dosages of 0.5, 1, or 4 mg activity/kg/day or gentamicin sulfate (GS) dosages of 2 mg activity/kg/day, and in concurrent studies in rats treated with ODMF dosages of 0.5, 2, or 6 mg activity/kg/day or GS dosages of 3 mg activity/kg/day, less severe local irritation and nephrotoxicity occurred after treatments with ODMF than with GS. In both rats and dogs treated by either the iv or the im route of administration, higher concentrations of ODMF and GS were found in the kidneys than in the sera. Mean serum and tissue concentrations of GS were higher than those of ODMF. Local tissue irritation and nephrotoxicity were lower with ODMF than with GS on a milligram activity per kilogram basis.

Significance of the measurement of urinary alanine aminopeptidase and N-acetyl-beta-D-glucosaminidase activity in evaluating patients with essential hypertension

To examine the relationship between the urinary levels of alanine aminopeptidase (AAP) or N-acetyl-beta-D-glucosaminidase (NAG) and the advance of essential hypertension, we measured the urinary levels of these enzymes in 20 normotensive controls, 8 subjects with borderline hypertension and 40 subjects with WHO stage I and stage II essential hypertension. The urinary level of NAG in stage II hypertensives was higher than that in the normotensives, and borderline or stage I hypertensives (p less than 0.01). Systolic blood pressure and the urinary level of NAG was positively correlated in hypertensives (rs = 0.43, p less than 0.01). The urinary level of NAG was correlated inversely with renal blood flow (rs = -0.61, p less than 0.01). The urinary level of AAP in stage II hypertensives was also higher than that in the normotensives (p less than 0.01) or stage I hypertension (p less than 0.01), but the urinary AAP level was not significantly correlated with systolic blood pressure or renal blood flow in hypertension.

[Value of the assay of 4 urinary enzyme activities in the diagnosis of the infectious or toxic (aminoglycosides) origin of a renal disease. Preliminary results]

Occurrence of a renal failure in an infected patient may be referred to various causes: infection, renal toxicity of drugs (for instance aminoglycosides), shock . . . Determination of some urinary enzymatic activities might be helpful in unravelling the mechanism involved in such cases. Therefore a prospective study of the specificity of some urinary enzymatic activities was performed. The whole LDH activity, the LDH isoenzyme 5 (LDH 5), and two lysosomal enzymes, N-acetyl-beta-D-glucosaminidase (NAG) and beta-glucuronidase (beta-GLU) were dosed systematically, in several groups of patients: I (n = 34): healthy control, with normal renal function; II (n = 24): renal impairment, without recent upper urinary-tract infection (UTI) or aminoglycoside treatment; III (n = 27): upper UTI without aminoglycoside treatment, IV (n = 22): patients treated with aminoglycosides (without upper UTI); V (n = 16): upper UTI treated with aminoglycosides. Results showed a rather good specificity of whole LDH and LDH 5 for infectious kidney damage, and of NAG for tubular injury due to aminoglycoside treatments. Values of urinary beta-glucuronidase varied over a wide range; they were little increased in group III, without a great discriminative value. No significant difference was noted between group I and group II, for any enzyme whatever.

Gentamicin-induced hypercalciuria in the rat

A study was made of the effects of gentamicin (40 mg/kg/day for 7 days) on the excretion of sodium, potassium, calcium and magnesium in the urine of rats. Volume of urine, protein excretion and the urinary activities of the enzymes alanine aminopeptidase, lactate dehydrogenase and N-acetyl-beta-glucosaminidase were also monitored. There were no significant changes in the excretion of sodium or potassium and the excretion of magnesium was too variable to permit a meaningful interpretation of changes in its excretion. Significant changes occurred in the excretion of calcium and protein and in the 24 hr urine osmolarity. The earliest of these changes, on day 4, was an increase in calcium excretion (P less than 0.01) which progressed until the drug was stopped and persisted throughout the 5 follow-up days. The increase in protein excretion was significant (P less than 0.01) by day 5 and the decrease in osmolarity (P less than 0.01) by day 6. These changes were preceded, on day 1, by a significant (P less than 0.001) rise in the activities in urine of all three enzymes. This early enzymuria suggests that considerable perturbation of cell integrity occurred before the increase in calcium excretion. Further studies are required to elucidate what role, if any, the loss of calcium plays in the genesis of tubular cell injury.

Further studies of the response of kidney lysosomes to aminoglycosides and other cations

Rat renal cortical lysosomes were isolated in 0.3 M sucrose containing 1 mM EDTA by differential centrifugation. Lysosomes were incubated in isotonic sucrose or isotonic glycine with various concentrations of endogenous and exogenous compounds at 37 degrees for 1 hr. Lysosomes were resedimented, and the N-acetyl-beta-glucosaminidase (NAG) activity was measured in the supernatant fraction and the disrupted pellet and the percentage of total NAG released was calculated. Gentamicin and its C1 and C2 components had similar potencies for inhibiting NAG release from lysosomes at low concentrations. The release of alpha-galactosidase and beta-galactosidase from lysosomes was also inhibited by streptomycin and gentamicin. Mepacrine at low concentrations stabilized lysosomes and at high concentrations disrupted lysosomes. This drug also enhanced the effect of low concentrations of gentamicin on lysosomes. Inositol hexaphosphoric acid was a potent antagonist of the effect of low concentrations of gentamicin and mepacrine on lysosomes. Rats were treated with gentamicin at doses of 40, 80 and 160 mg/kg for 1 and 3 days. NAG excretion in gentamicin-treated groups as compared to saline controls was unchanged at day 1. Only the 160 mg/kg treatment group showed a tendency toward elevated renal cortical NAG at day 1 (P less than 0.06). All treatment groups had elevated renal cortical NAG at day 3, while the 160 mg/kg group also had elevated NAG excretion. Lysine, arginine, L-canavanine and polymyxin B all affected NAG release from lysosomes in vitro. Lysine enhanced the disruptive effect of high gentamicin concentrations on lysosomes. Ferric and ferrous ions, tested over widely varied concentrations, inhibited NAG release at low concentrations while enhancing NAG release at high concentrations. We therefore conclude that the nephrotoxicity of aminoglycoside and other endogenous and exogenous renally excreted cationic compounds may be produced by their effects on lysosomes in the proximal renal tubule.

Reduction of renal blood flow and proximal bicarbonate reabsorption in rats by gentamicin

Although aminoglycoside-induced acute renal failure occurs commonly, little is known about the mechanisms which alter renal hemodynamics. In sodium-depleted Sprague-Dawley rats treated with gentamicin, we measured RBF and GFR at the onset of this model of nephrotoxic acute renal failure. After 10 days of sodium chloride depletion, one group of rats received a single injection of gentamicin, 100 mg/kg, while control animals received the gentamicin vehicle. Twenty-four hours later, PCr and UNa/UCr were similar in both groups. CIn was unchanged, but RBF was reduced significantly (12.40 +/- 1.33 vs. 16.89 +/- 1.24 ml/min). Micropuncture studies revealed that although SNGFR was unchanged, end-proximal and early distal flow rates were increased significantly. End-proximal TFCl was reduced significantly in gentamicin-treated animals when compared to controls (130.7 +/- 3.9 vs. 149.5 +/- 4.1 mEq/liter). Early distal TFCl was also reduced significantly (32.4 +/- 2.0 vs. 44.3 +/- 1.4 mEq/liter). In other rats, 24 hr after a second injection of gentamicin, PCr and UNa/UCr were increased significantly and both GFR and RBF were reduced significantly. We conclude that the earliest hemodynamic change in gentamicin-induced acute renal failure is a reduction in RBF which precedes any change in GFR. A single dose of gentamicin also impairs proximal bicarbonate and water reabsorption and reduces end-proximal and early distal chloride concentration.

Increased toxicity of oral antibiotics in sodium-deficient rats

The toxicity of an oral antibiotic mixture used to decontaminate the gastrointestinal tract of experimental animals was compared in rats with a normal sodium intake to rats on a sodium-deficient diet. Sodium-depleted rats are quite sensitive to the oral antibiotic mixture. The antibiotic mixture was nephrotoxic, resulting in necrosis of the proximal tubules. Therefore, since the parenteral administration of antibiotics also produced necrosis of the proximal tubules, the mechanism of antibiotic toxicity in sodium-deficient rats is not influenced by the route of antibiotic administration.

Gentamicin nephrotoxicity in cadmium, lead and mercury pretreated rats

The effect of a previous chronic exposure to cadmium, lead or inorganic mercury on the nephrotoxic potential of gentamicin was investigated in female Sprague-Dawley rats. A daily dose of 10 mg gentamicin/kg body weight/day was administered for 21 days to rats having a renal load of 168 micrograms Cd, 35 micrograms Pb or 129 micrograms Hg/g whole kidney. Urine analysis suggests an attenuation of the nephrotoxic potential of gentamicin while a microscopical examination of kidneys indicates a superimposition of the effects of the metals and the antibiotics. The only clear interaction observed consists in a reduction of gentamicin accumulation in the cortex of cadmium-treated animals. It is concluded that none of the metal pretreatments potentiates the nephrotoxic effects of gentamicin.

Use of renal enzymes to evaluate nephrotoxicity in lithium treated patients

N-acetyl-beta-glucosaminadase (NAG) is a renal enzyme which is an early, sensitive and reliable indicator of renal damage. NAG assays of midstream spot urines were not significantly different in a group of controls when compared to patients starting lithium for the first time, or to a group of patients who had been taking lithium for more than one year. However, a small number of lithium-treated patients may have evidence of renal damage, identifiable by NAG assay.

Clinical and pathophysiologic aspects of aminoglycoside nephrotoxicity

Aminoglycoside antibiotics continue to be a mainstay of therapy in the clinical management of gram negative infections, but a major factor in the clinical use of aminoglycosides is their nephrotoxicity. With gram negative organisms accounting for the majority of hospital acquired infections, the occurrence of aminoglycoside induced acute renal failure has become commonplace. Presently at least 10% of all cases of acute renal failure can be attributed to these antibiotics. This article will cover the renal handling of the aminoglycosides, the pathogenetic mechanisms of nephrotoxicity, and the clinical aspects of aminoglycoside induced acute renal failure with particular emphasis on recent data which have increased our understanding of the interaction of aminoglycosides with the renal tubular cell and the effects of this interaction on cellular function and integrity.

Effects of moxalactam and cefotaxime on rabbit renal tissue

To determine and compare the effects of moxalactam and cefotaxime on kidneys, we gave these drugs in doses of 750 and 1,500 mg/kg to rabbits for 7 days. Cephaloridine was included as a positive control. Neither moxalactam nor cefotaxime at either dose caused lysosomal enzymuria, changes visible by light microscopy or increased plasma creatine. Both drugs caused minor alterations in glomerular ultrastructure at the higher dose. Cephaloridine, on the other hand, caused widespread renal functional and morphological damage. We conclude that in rabbits, both moxalactam and cefotaxime are remarkably nonnephrotoxic.

The aminoglycosides

Aminoglycosides remain the cornerstone of prophylaxis and therapy against the majority of aerobic gram-negative organisms responsible for serious sepsis in the hospital. Gentamicin, tobramycin, amikacin are all equally efficacious against susceptible organisms and differ only in their patterns of resistance and pharmacokinetic profiles. The ototoxic and nephrotoxic potential of gentamicin, tobramycin, and amikacin is comparable. Amikacin appears to be preferred for general use at present because of its low resistance potential and superior pharmacokinetic profile (high and predictable serum peaks, wide toxic-therapeutic ratio, high "kill ratio," and q 12 h dosing). In spite of the introduction of the third generation cephalosporins, which are highly active against a variety of aerobic gram-negative organisms, the aminoglycosides will continue to play an important role in the treatment of gram-negative infections. Indeed, the expected usefulness of aminoglycosides may be prolonged by the introduction of the third generation cephalosporins since these drugs will probably be used in combination with aminoglycosides to extend spectrum and to take advantage of possible synergy.

Comparative nephrotoxicities of dibekacin, amikacin, and gentamicin in a rat model

The nephrotoxicity of dibekacin was compared with those of gentamicin and amikacin in a rat model. The doses used were 3, 10, and 30 times the suggested human therapeutic dose on a weight basis. Indices of glomerular and tubular function failed to clearly differentiate the drugs. Dibekacin and gentamicin produced equally severe injury to the renal tissue. Slightly less damage occurred with amikacin.

Toxic nephropathy from diagnostic and therapeutic agents. Review and commentary

Drugs commonly used for diagnostic and therapeutic purposes may cause toxic nephropathy. There are several factors that account for renal susceptibility. Precise mechanisms of toxicity are generally not known, and therapy depends upon recognizing and removing the offending agent. Drugs that affect identifiable segments of the nephron or that produce similar syndromes are grouped together. Measures that might prevent toxicity are presented.

Pathogenesis of renal failure due to aminoglycosides and contrast media used in roentgenography

The etiology of acute renal failure has changed in recent years due to the recognition of drug nephrotoxicity as a more common cause. In this communication we emphasize recent information concerning the pathophysiology of nephrotoxic acute renal failure produced by aminoglycoside antibiotics and the contrast media used in roentgenography. The aminoglycosides are excreted primarily by glomerular filtration; however, net tubular reabsorption and renal parenchymal accumulation do occur. The exact mechanism of uptake is not clear, but the luminal membrane seems primarily involved. The pathogenesis of nephrotoxicity, although probably linked to cortical accumulation, is complex since experimental animals recover from gentamicin-induced renal failure despite continued administration of the drug. Knowledge of the precise cellular mechanisms of injury awaits further studies. Histologic damage is usually limited to proximal tubular necrosis and, clinically, the renal failure is nonoliguric. Although reports of the contrast media used in roentgenography producing acute renal failure have increased, the pathogenesis is unclear. Evidence supporting various theories is reviewed.