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Karimzadeh I, Strader M, Kane-Gill SL, Murray PT. Prevention and management of antibiotic associated acute kidney injury in critically ill patients: new insights. Curr Opin Crit Care 2023; 29:595-606. [PMID: 37861206 DOI: 10.1097/mcc.0000000000001099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Drug associated kidney injury (D-AKI) occurs in 19-26% of hospitalized patients and ranks as the third to fifth leading cause of acute kidney injury (AKI) in the intensive care unit (ICU). Given the high use of antimicrobials in the ICU and the emergence of new resistant organisms, the implementation of preventive measures to reduce the incidence of D-AKI has become increasingly important. RECENT FINDINGS Artificial intelligence is showcasing its capabilities in early recognition of at-risk patients for acquiring AKI. Furthermore, novel synthetic medications and formulations have demonstrated reduced nephrotoxicity compared to their traditional counterparts in animal models and/or limited clinical evaluations, offering promise in the prevention of D-AKI. Nephroprotective antioxidant agents have had limited translation from animal studies to clinical practice. The control of modifiable risk factors remains pivotal in avoiding D-AKI. SUMMARY The use of both old and new antimicrobials is increasingly important in combating the rise of resistant organisms. Advances in technology, such as artificial intelligence, and alternative formulations of traditional antimicrobials offer promise in reducing the incidence of D-AKI, while antioxidant medications may aid in minimizing nephrotoxicity. However, maintaining haemodynamic stability using isotonic fluids, drug monitoring, and reducing nephrotoxic burden combined with vigilant antimicrobial stewardship remain the core preventive measures for mitigating D-AKI while optimizing effective antimicrobial therapy.
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Affiliation(s)
- Iman Karimzadeh
- Department of Clinical Pharmacy, School of Pharmacy, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Michael Strader
- Department of Medicine, School of Medicine, University College Dublin, Dublin, Ireland
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh
- Department of Pharmacy, UPMC, Pittsburgh, Pennsylvania, USA
| | - Patrick T Murray
- Department of Medicine, School of Medicine, University College Dublin, Dublin, Ireland
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Al-Alawi AM, Al-Maqbali JS, Al-Adawi M, Al-Jabri A, Falhammar H. Incidence, patterns, risk factors and clinical outcomes of intravenous acyclovir induced nephrotoxicity. Saudi Pharm J 2022; 30:874-877. [PMID: 35812148 PMCID: PMC9257855 DOI: 10.1016/j.jsps.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 03/22/2022] [Indexed: 11/30/2022] Open
Abstract
Objectives Acyclovir is approved to treat herpes simplex virus (HSV) type 1, type 2 and varicella-zoster virus. It is mainly eliminated via the kidneys, for which drug crystals accumulation might lead to nephrotoxicity. This study aimed to determine the incidence, risk factors, preventive measures, and clinical outcomes of acyclovir induced-nephrotoxicity. Methods This is a retrospective cohort study of patients >12 years of age at Sultan Qaboos University Hospital (SQUH) receiving IV acyclovir therapy between January 2016 and December 2020. Results Out of 191 included patients, 40 (20.1%) developed acyclovir induced-nephrotoxicity. Age (per year older: OR 1.04, 95 %CI 1.01–1.07), total duration of treatment (per day OR1.19, 95 %CI 1.06–1.33), and concomitant use of vancomycin (OR 5.96, 95 %CI 1.87–19.01) were significant independent risk factors for acyclovir induced-nephrotoxicity development. Nine patients (4.5%) died during the same hospitalization, including those three patients who required renal replacement therapy (1.5%). Conclusion Frequent monitoring of kidney function for older patients with concurrent use of vancomycin and IV hydration is essential to prevent IV acyclovir induced-nephrotoxicity. Antimicrobial stewardship is a crucial method to reduce the duration of treatment with IV acyclovir as appropriate.
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Affiliation(s)
- Abdullah M. Al-Alawi
- Department of Medicine, Sultan Qaboos University Hospital, Muscat, Oman
- Internal Medicine Training Program, Oman Medical Speciality Board, Muscat, Oman
- Corresponding author at: Sultan Qaboos University, P.O. Box: 141, P.C. 123, Muscat, Oman.
| | | | - Maria Al-Adawi
- Internal Medicine Training Program, Oman Medical Speciality Board, Muscat, Oman
| | - Anan Al-Jabri
- Internal Medicine Training Program, Oman Medical Speciality Board, Muscat, Oman
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, NT, Australia
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Downes KJ, Boge CLK, Baro E, Wharton GT, Liston KM, Haltzman BL, Emerson HM, Doe E, Fulchiero R, Tran V, Yen L, Lieu P, Van Driest SL, Grisso AG, Aka IT, Hale J, Gillon J, Pingel JS, Coffin SE, McMahon AW. Acute Kidney Injury During Treatment with Intravenous Acyclovir for Suspected or Confirmed Neonatal Herpes Simplex Virus Infection. J Pediatr 2020; 219:126-132.e2. [PMID: 32037154 PMCID: PMC7096264 DOI: 10.1016/j.jpeds.2019.12.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/22/2019] [Accepted: 12/26/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To describe the epidemiology of and risk factors associated with acute kidney injury (AKI) during acyclovir treatment in neonates and infants. STUDY DESIGN We conducted a multicenter (n = 4), retrospective cohort study of all hospitalized infants age <60 days treated with intravenous acyclovir (≥1 dose) for suspected or confirmed neonatal herpes simplex virus disease from January 2011 to December 2015. Infants with serum creatinine measured both before acyclovir (baseline) and during treatment were included. We classified AKI based on changes in creatinine according to published neonatal AKI criteria and performed Cox regression analysis to evaluate risk factors for AKI during acyclovir treatment. RESULTS We included 1017 infants. The majority received short courses of acyclovir (median, 5 doses). Fifty-seven infants (5.6%) developed AKI during acyclovir treatment, with an incidence rate of AKI at 11.6 per 1000 acyclovir days. Cox regression analysis identified having confirmed herpes simplex virus disease (OR, 4.35; P = .002), receipt of ≥2 concomitant nephrotoxic medications (OR, 3.07; P = .004), receipt of mechanical ventilation (OR, 5.97; P = .001), and admission to an intensive care unit (OR, 6.02; P = .006) as risk factors for AKI during acyclovir treatment. CONCLUSIONS Among our cohort of infants exposed to acyclovir, the rate of AKI was low. Sicker infants and those exposed to additional nephrotoxic medications seem to be at greater risk for acyclovir-induced toxicity and warrant closer monitoring.
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Affiliation(s)
- Kevin J. Downes
- Division of Infectious Disease, Department of Pediatrics, Children’s Hospital of Philadelphia, Research Institute,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Craig L. K. Boge
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute
| | - Elande Baro
- Office of Biostatistics, Center for Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, MD
| | - Gerold T. Wharton
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, MD
| | - Kellie M. Liston
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute
| | - Brittany L. Haltzman
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute
| | - Hannah M. Emerson
- Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute
| | - Edwin Doe
- Neonatal Intensive Care, Inova Children’s Hospital, Falls Church, VA
| | - Rosanna Fulchiero
- Neonatal Intensive Care, Inova Children’s Hospital, Falls Church, VA
| | - Van Tran
- Neonatal Intensive Care, Inova Children’s Hospital, Falls Church, VA
| | - Lilly Yen
- Department of Pharmacy, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Phuong Lieu
- Department of Pharmacy, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Sara L. Van Driest
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Alison G. Grisso
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Ida T. Aka
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Jennifer Hale
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica Gillon
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Julie S. Pingel
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN
| | - Susan E. Coffin
- Division of Infectious Disease, Department of Pediatrics, Children’s Hospital of Philadelphia, Research Institute,Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Research Institute,Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA
| | - Ann W. McMahon
- Office of Pediatric Therapeutics, US Food and Drug Administration, Silver Spring, MD
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Aciclovir-induced acute kidney injury in patients with 'suspected viral encephalitis' encountered on a liaison neurology service. Ir J Med Sci 2018; 187:777-780. [PMID: 29307101 DOI: 10.1007/s11845-017-1728-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/04/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patients with 'suspected viral encephalitis' are frequently empirically treated with intravenous aciclovir. Increasing urea and creatinine are 'common', but rapidly progressive renal failure is reported to be 'very rare'. AIMS To describe the clinical course and outcome of cases of aciclovir-induced acute kidney injury (AKI) encountered by the Liaison Neurology Service at AMNCH and to highlight the importance of surveillance and urgent treatment of this iatrogenic complication. METHODS Retrospectively and prospectively collected data from the Liaison Neurology Service at AMNCH on patients who received IV aciclovir for suspected viral encephalitis and developed AKI were analysed. Aciclovir-induced AKI was defined by a consultant nephrologist in all cases as a rise in serum creatinine of > 26 μmol/L in 48 h or by ≥ 1.5 times the baseline value. Renal function, haematocrit, and fluid balance were monitored following AKI onset. RESULTS Data from 10 patients were analysed. Median time to AKI onset was 3.5 days (range: 1-6 days). Aciclovir was stopped or the dose adjusted. All patients recovered with IV normal saline, aiming for a urine output > 100-150 ml/h. The interval between first rise in creatinine and return to normal levels varied between 5 and 19 days. CONCLUSIONS Liaison neurologists and general physicians need to be aware that aciclovir may cause AKI attributed to distal intra-tubular crystal nephropathy. Daily fluid balance and renal function monitoring are essential because AKI may arise even with intensive pre-hydration. Prognosis is good if identified early and actively treated.
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