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Goodlet KJ, McCreary EK, Nailor MD, Barnes D, Brokhof MM, Bova S, Clemens E, Kelly B, Lichvar A, Pluckrose DM, Summers BB, Szempruch KR, Tchen S. Therapeutic Myths in Solid Organ Transplantation Infectious Diseases. Open Forum Infect Dis 2024; 11:ofae342. [PMID: 38983710 PMCID: PMC11232700 DOI: 10.1093/ofid/ofae342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 06/12/2024] [Indexed: 07/11/2024] Open
Abstract
Infection management in solid organ transplantation poses unique challenges, with a diverse array of potential pathogens and associated antimicrobial therapies. With limited high-quality randomized clinical trials to direct optimal care, therapeutic "myths" may propagate and contribute to suboptimal or excessive antimicrobial use. We discuss 6 therapeutic myths with particular relevance to solid organ transplantation and provide recommendations for infectious diseases clinicians involved in the care of this high-risk population.
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Affiliation(s)
- Kellie J Goodlet
- Department of Pharmacy Practice, Midwestern University, Glendale, Arizona, USA
| | - Erin K McCreary
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael D Nailor
- Department of Pharmacy Services, St Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Darina Barnes
- Department of Pharmacy, Comprehensive Transplant Center, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Marissa M Brokhof
- Department of Pharmacy, Rush University Medical Center, Chicago, Illinois, USA
| | - Sarah Bova
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Evan Clemens
- Department of Pharmacy, University of Washington Medical Center, Seattle, Washington, USA
| | - Beth Kelly
- Department of Pharmacy, Indiana University Health, Indianapolis, Indiana, USA
| | - Alicia Lichvar
- Center for Transplantation, UC San Diego Health, San Diego, California, USA
| | - Dawn M Pluckrose
- Department of Pharmacy, Tufts Medical Center, Boston, Massachusetts, USA
| | - Bryant B Summers
- Comprehensive Transplant Center, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Kristen R Szempruch
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, North Carolina, USA
| | - Stephanie Tchen
- Department of Pharmacy, Froedtert Hospital, Milwaukee, Wisconsin, USA
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Azencot R, Saint-Jacques C, Haymann JP, Frochot V, Daudon M, Letavernier E. Sulfamethoxazole-induced crystal nephropathy: characterization and prognosis in a case series. Sci Rep 2024; 14:6078. [PMID: 38480876 PMCID: PMC10937937 DOI: 10.1038/s41598-024-56322-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/05/2024] [Indexed: 03/17/2024] Open
Abstract
Cotrimoxazole (Trimethoprim/Sulfamethoxazole-SMX) is frequently used in critically ill and immunocompromised patients. SMX is converted to N-acetyl-sulfamethoxazole (NASM) and excreted by the kidneys. NASM may form crystals in urine, especially in acid urine, that may induce a crystalline nephropathy. However, the imputability of crystals in acute kidney injury (AKI) has not been proven. We aimed to assess whether NASM crystals may promote AKI and to investigate risk factors associated with NASM crystalline nephropathy. Patients from Ile-de-France, France who developed AKI under SMX treatment introduced during hospitalization and had a crystalluria positive for NASM crystals were selected. Patients with excessive preanalytical delay for crystalluria or missing data regarding SMX treatment were excluded. We used the Naranjo score to assess the causal relationship between SMX and the development of AKI in patients with positive NASM crystalluria. Fourteen patients were included. SMX was the probable cause of AKI for 11 patients and a possible cause for 3 patients according to Naranjo score. Patients were exposed to high doses of SMX (but within recommended ranges), and most of them had a preexisting chronic kidney disease and were hypoalbuminemic. Urine pH was mildly acid (median 5.9). AKI occured more rapidly than expected after introduction of SMX (median 4 days) and recovered rapidly after drug discontinuation in most, but not all, cases. SMX is a probable cause of crystalline nephropathy. Monitoring of crystalluria in patients exposed to SMX may be of interest to prevent the development of crystalline nephropathy. Approval number of the study: BPD-2018-DIAG-008.
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Affiliation(s)
- Ruben Azencot
- Physiology Unit, Service des Explorations Fonctionnelles Multidisciplinaires, AP-HP, Hôpital Tenon, 4 Rue de la Chine, 75020, Paris, France
| | - Camille Saint-Jacques
- Physiology Unit, Service des Explorations Fonctionnelles Multidisciplinaires, AP-HP, Hôpital Tenon, 4 Rue de la Chine, 75020, Paris, France
| | - Jean-Philippe Haymann
- Physiology Unit, Service des Explorations Fonctionnelles Multidisciplinaires, AP-HP, Hôpital Tenon, 4 Rue de la Chine, 75020, Paris, France
- UMR S 1155, Sorbonne Université, 75020, Paris, France
- UMR S 1155, INSERM, 75020, Paris, France
| | - Vincent Frochot
- Physiology Unit, Service des Explorations Fonctionnelles Multidisciplinaires, AP-HP, Hôpital Tenon, 4 Rue de la Chine, 75020, Paris, France
- UMR S 1155, Sorbonne Université, 75020, Paris, France
- UMR S 1155, INSERM, 75020, Paris, France
| | - Michel Daudon
- Physiology Unit, Service des Explorations Fonctionnelles Multidisciplinaires, AP-HP, Hôpital Tenon, 4 Rue de la Chine, 75020, Paris, France
- UMR S 1155, Sorbonne Université, 75020, Paris, France
- UMR S 1155, INSERM, 75020, Paris, France
| | - Emmanuel Letavernier
- Physiology Unit, Service des Explorations Fonctionnelles Multidisciplinaires, AP-HP, Hôpital Tenon, 4 Rue de la Chine, 75020, Paris, France.
- UMR S 1155, Sorbonne Université, 75020, Paris, France.
- UMR S 1155, INSERM, 75020, Paris, France.
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Reversal of Trimethoprim-Induced Antikaliuresis in an HIV Patient With Pneumocystis Pneumonia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2022. [DOI: 10.1097/ipc.0000000000001114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hirai T, Yamaga R, Ishikawa Y, Hanada K, Iwamoto T, Itoh T. Effect of high-dose sulfamethoxazole/trimethoprim and glucocorticoid use on hyperkalemic event: A retrospective observational study. J Infect Chemother 2021; 27:1607-1613. [PMID: 34301486 DOI: 10.1016/j.jiac.2021.07.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/27/2021] [Accepted: 07/12/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Sulfamethoxazole/trimethoprim causes hyperkalemia; however, the effect of sulfamethoxazole/trimethoprim dose and co-administered glucocorticoids on hyperkalemia has not been clarified. METHODS This single-center, retrospective, observational cohort, chart review study involving patients (>20 years) who were treated with sulfamethoxazole/trimethoprim was conducted at Tokyo Women's Medical University, Medical Center East from June 2015 to May 2019. Multivariate Cox proportional hazard model was used to identify risk factors for hyperkalemia (serum potassium level > 5.5 mEq/L). Additionally, Kaplan-Meier curve analyzed the cumulative incidence of hyperkalemia focusing on sulfamethoxazole/trimethoprim dose and concomitant use of glucocorticoids with mineralocorticoid activity. RESULTS Among 333 patients, 44 (13%) patients developed hyperkalemia associated with sulfamethoxazole/trimethoprim use for over 49 (interquartile range; 17-233) days. We found associations between the time to hyperkalemia development and sulfamethoxazole/trimethoprim dose (hazard ratio 1.238, 95% confidence interval 1.147-1.338, p < 0.001) and glucocorticoid use (hazard ratio 0.678, 95% confidence interval 0.524-0.877, p = 0.003). Interestingly, the Kaplan-Meier curves revealed that the concomitant use of glucocorticoids did not attenuate the risk of hyperkalemia in patients receiving high-dose sulfamethoxazole/trimethoprim (p = 0.747), whereas concomitant use of glucocorticoids significantly reduced the risk of hyperkalemia in patients receiving non-high dose sulfamethoxazole/trimethoprim (p < 0.001). CONCLUSIONS High-dose sulfamethoxazole/trimethoprim is a significant predictor of hyperkalemia. The effect of glucocorticoids on hyperkalemia varies depending on the sulfamethoxazole/trimethoprim dose.
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Affiliation(s)
- Toshinori Hirai
- Department of Pharmacy, Mie University Hospital, Faculty of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Ryosuke Yamaga
- Department of Pharmacy, Tokyo Women's Medical University, Medical Centre East: 2-1-10, Nishiogu, Arakawa-ku, Tokyo, 116-0011, Japan
| | - Yutori Ishikawa
- Department of Pharmacy, Tokyo Women's Medical University, Medical Centre East: 2-1-10, Nishiogu, Arakawa-ku, Tokyo, 116-0011, Japan
| | - Kazuhiko Hanada
- Department of Pharmacometrics and Pharmacokinetics, Meiji Pharmaceutical University, 2-522-1 Noshio, Kiyose, Tokyo, 204-8588, Japan
| | - Takuya Iwamoto
- Department of Pharmacy, Mie University Hospital, Faculty of Medicine, Mie University, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Toshimasa Itoh
- Department of Pharmacy, Tokyo Women's Medical University, Medical Centre East: 2-1-10, Nishiogu, Arakawa-ku, Tokyo, 116-0011, Japan
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Montebello A, Gruppetta M. Cotrimoxazole-induced hyperkalaemia in a patient with known hypoaldosteronism. BMJ Case Rep 2021; 14:14/3/e239543. [PMID: 33664032 PMCID: PMC7934741 DOI: 10.1136/bcr-2020-239543] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A70-year-old man, with established hypoadrenalism due to a previous bilateral adrenalectomy, was admitted with recurrent episodes of postural dizziness and presyncope. He had been discharged from hospital 3 weeks earlier on a 1-month course of cotrimoxazole following a diagnosis of prostatitis. His electrolytes on admission showed new onset hyponatraemia and hyperkalaemia.His usual glucocorticoid replacement dose was doubled in view of a presumed diagnosis of hypocortisolaemia. However, the hyperkalaemia persisted. On rereviewing his treatment, we suspected a possible diagnosis of cotrimoxazole-induced hyperkalaemia. Cotrimoxazole was stopped and ciprofloxacin started instead. His fludrocortisone replacement was doubled for 3 days after stopping treatment to decrease his postural symptoms. His postural symptoms improved, his serum potassium decreased to normal levels and he was safely discharged.It is essential to remember that cotrimoxazole, a commonly used antibiotic, can induce a potentially fatal hyperkalaemia especially in patients with known hypoadrenalism.
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Affiliation(s)
| | - Mark Gruppetta
- Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta
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Al AdAwi RM, Albu-Mahmood Z, Abdelgelil M, Abdelaziz H, Stewart D, Awaisu A. Incidence of Co-Trimoxazole-Induced Hyperkalemia in a Tertiary Care Hospital. Risk Manag Healthc Policy 2021; 14:519-525. [PMID: 33603518 PMCID: PMC7887151 DOI: 10.2147/rmhp.s283471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 12/17/2020] [Indexed: 11/23/2022] Open
Abstract
Background Co-trimoxazole is a broad-spectrum antibiotic associated with hyperkalemia. Objective To determine the incidence of hyperkalemia and its risk factors in patients receiving co-trimoxazole. Materials and Methods A retrospective observational study involving all patients who received co-trimoxazole between 1 January 2012 and 1 January 2013 was conducted. Subjects were identified through a list generated from a computerized pharmacy system. The patients' demographic and clinical characteristics were retrieved from electronic medical records. Data were analyzed using univariate and multivariate logistic regression. Results One hundred sixty-one patients fulfilled the eligibility criteria. Of these, 46 (28.6%) experienced hyperkalemia. Around 35 (76%) of the patients who experienced hyperkalemia received co-administered medications that might induce hyperkalemia. The co-administration of co-trimoxazole with other medications that may induce hyperkalemia was found to be associated with higher incidence of hyperkalemia when compared to co-trimoxazole administration alone [adjusted OR 3.2, 95% CI (1.4-7.3), p=0.005]. Additionally, age > 60 years was associated with an increased risk of hyperkalemia when compared to younger age group 18-39 years [adjusted OR 6.5, 95% CI (2.1-19.7); p=0.001]. Conclusion Co-trimoxazole use is associated with high incidence of hyperkalemia, especially among older patients and those receiving it in combination with other medications that might contribute to hyperkalemia development such as calcineurin inhibitors and β-blockers.
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Affiliation(s)
- Rana M Al AdAwi
- Clinical Pharmacist, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Zainab Albu-Mahmood
- Clinical Pharmacist, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Mohamed Abdelgelil
- Clinical Pharmacist, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Hani Abdelaziz
- Clinical Pharmacist Supervisor, Al Wakra Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Derek Stewart
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Doha, Qatar
| | - Ahmed Awaisu
- Department of Clinical Pharmacy and Practice, College of Pharmacy, QU Health, Doha, Qatar
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Type IV RTA in Chronic Adrenal Insufficiency and Concomitant Lisinopril Treatment. Case Rep Endocrinol 2020; 2020:8897112. [PMID: 33133704 PMCID: PMC7591977 DOI: 10.1155/2020/8897112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/30/2020] [Accepted: 10/09/2020] [Indexed: 11/18/2022] Open
Abstract
Type IV renal tubular acidosis (RTA) is the only RTA characterized by hyperkalemia, and it is caused by a true aldosterone deficiency or renal tubular aldosterone hyporesponsiveness. It is frequent among hospitalized patients as it is related to type 2 diabetes mellitus (T2DM) and common medications such as ACE-inhibitors (ACE-is) and trimethoprim-sulfamethoxazole (TMP-SMX). Drug-induced RTA commonly manifests in patients with predisposing conditions such as mild renal insufficiency and certain pharmacological therapies. ACE-i use and chronic adrenal insufficiency (cAI) are other significant risk factors. Chronic ACTH suppression is thought to induce global adrenal atrophy, including the zona glomerulosa, thus affecting aldosterone secretion as well. Furthermore, in the setting of cAI, treatment with ACE-is further suppresses aldosterone production. This case report describes a patient with cAI secondary to corticosteroid use for years who developed type IV RTA in the setting of lisinopril use. Potassium (K) elevation persisted despite removing underlying conditions and metabolic acidosis correction. The patient required long-term treatment with mineralocorticoids in addition to sodium bicarbonate to maintain normal K levels and acid-base status. Mineralocorticoid administration is a second-line treatment for type IV RTA, but it might be necessary for a subgroup of high-risk patients. In fact, it is important to consider patients with chronic adrenal insufficiency and on ACE-is treatment at increased risk for refractory hyperkalemia in the setting of type IV RTA. Indeed, this subgroup of patients can have severe hypoaldosteronism.
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8
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Co-trimoxazole induced hyperkalemia and potassium monitoring in hospitalized patients. Int J Clin Pharm 2020; 42:1405-1411. [PMID: 33025449 DOI: 10.1007/s11096-020-01039-8] [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: 11/25/2019] [Accepted: 04/15/2020] [Indexed: 10/23/2022]
Abstract
Background Co-trimoxazole is an antibiotic combination used for the treatment of Pneumocystis jirovecii pneumonia, amongst others. Co-trimoxazole is known to increase serum potassium. For this reason, Dutch guidelines advise serum potassium monitoring in high-risk patients. Objective This study aimed to determine average serum potassium rise after administration of intravenous co-trimoxazole in hospitalized patients, compared to intravenous ceftriaxone. This study also aimed to determine adherence to Dutch guidelines by measuring the incidence of serum potassium monitoring in these patients. Setting Data was collected retrospectively from patients in five departments of the Canisius Wilhelmina Hospital, a teaching hospital in Nijmegen, the Netherlands. Method Data was collected and compared from patients that received intravenous co-trimoxazole (n = 66) and intravenous ceftriaxone (n = 132) in the period of November 2008-November 2017. For each patient using co-trimoxazole, two patients using ceftriaxone were included in a paired fashion. Baseline and follow-up potassium were collected, if available. Additionally, it was tested if serum potassium was measured around the initiation of antibiotic therapy. Main outcome measure Changes in serum potassium where obtainable in 30 patients using cotrimoxazole and 40 patients using ceftriaxone. When compared to ceftriaxone, administration of intravenous co-trimoxazole was associated with a significant mean increase in serum potassium (+0.55 mmol/l, 95% CI 0.29-0.80, p < 0.001). After correction for confounders (baseline potassium, estimated glomerular filtration rate 30 ≤ 60, the presence of haematological malignancies and the usage of corticosteroids), this effect shrunk noticeably, but remained significant (+0.28 mmol/l, 95% CI 0.03-0.53, p = 0.031). Results The incidence of hyperkalemia at follow-up was 20% in the cotrimoxazole group, compared to 5% in the ceftriaxone group. Despite this, serum potassium was often not measured in patients using intravenous cotrimoxazole, being 76% at baseline and 55% in the period of 48-120 h after antibiotic therapy initiation, compared to 87% and 34% in the ceftriaxone group respectively. Conclusion Adherence to Dutch guidelines was poor as serum potassium monitoring was often not performed. As intravenous co-trimoxazole usage is associated with a significant increase in mean serum potassium, monitoring is strongly recommended.
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Barreto JN, Thompson CA, Wieruszewski PM, Pawlenty AG, Mara KC, Potter AL, Tosh PK, Limper AH. Incidence, clinical presentation, and outcomes of Pneumocystis pneumonia when utilizing Polymerase Chain Reaction-based diagnosis in patients with Hodgkin lymphoma. Leuk Lymphoma 2020; 61:2622-2629. [PMID: 32623928 DOI: 10.1080/10428194.2020.1786561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A Polymerase Chain Reaction-based diagnosis of Pneumocystis Pneumonia (PCP) and the need for anti-Pneumocystis prophylaxis in Hodgkin lymphoma patients receiving chemotherapy requires further investigation. This retrospective, single-center, study evaluated 506 consecutive adult patients diagnosed with Hodgkin lymphoma receiving chemotherapy between January 2006 and August 2018. The cumulative incidence of PCP 1 year after start of chemotherapy was 6.2% (95% CI 3.8-8.5%). Mortality 30 days from PCP diagnosis was 8% (n = 2) with one death attributable to PCP. Bleomycin-containing combination chemotherapy regimen was not significantly associated with a higher risk for PCP when compared to other regimens (HR = 1.59, 95% CI 0.55-4.62 p = 0.40). Anti-Pneumocystis prophylaxis was not significantly associated with a decreased incidence of PCP (HR = 0.51, 95% CI 0.15-1.71, p = 0.28). As the overall incidence is above the commonly accepted 3.5% threshold, clinicians should consider the potential value of prophylaxis. The utility of universal vs. targeted anti-Pneumocystis prophylaxis requires prospective, randomized investigation.
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Affiliation(s)
| | - Carrie A Thompson
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | | | - Kristin C Mara
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | | | - Pritish K Tosh
- Division of Infectious Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, MN USA
| | - Andrew H Limper
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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10
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Plantaz MMEA, Veldman BAJ, Esselink AC, Fleuren HWHA, Kramers C. Co-trimoxazole induced hyperkalemia and potassium monitoring in hospitalized patients. Int J Clin Pharm 2020; 42:965-971. [PMID: 32390087 PMCID: PMC7275024 DOI: 10.1007/s11096-020-01052-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Co-trimoxazole is an antibiotic combination used for the treatment of Pneumocystis jirovecii pneumonia, amongst others. Co-trimoxazole is known to increase serum potassium. For this reason, Dutch guidelines advise serum potassium monitoring in high-risk patients. Objective This study aimed to determine average serum potassium rise after administration of intravenous co-trimoxazole in hospitalized patients, compared to intravenous ceftriaxone. This study also aimed to determine adherence to Dutch guidelines by measuring the incidence of serum potassium monitoring in these patients. Setting Five departments of the Canisius Wilhelmina Hospital, a teaching hospital in Nijmegen, the Netherlands. Method Data was collected and compared from patients that received intravenous co-trimoxazole (n = 66) and intravenous ceftriaxone (n = 132) in the period of November 2008–November 2017. For each patient using co-trimoxazole, two patients using ceftriaxone were included in a paired fashion. Baseline and follow-up potassium were collected, if available. Additionally, it was tested if serum potassium was measured around the initiation of antibiotic therapy. Main outcome measure Changes in serum potassium where obtainable in 30 patients using cotrimoxazole and 40 patients using ceftriaxone. When compared to ceftriaxone, administration of intravenous co-trimoxazole was associated with a significant mean increase in serum potassium (+ 0.55 mmol/l, 95% CI 0.29–0.80, p < 0.001). After correction for confounders (baseline potassium, estimated glomerular filtration rate 30 to < 60, the presence of haematological malignancies and the usage of corticosteroids), this effect shrunk noticeably, but remained significant (+ 0.28 mmol/l, 95% CI 0.03–0.53, p = 0.031). Results The incidence of hyperkalemia at follow-up was 20% in the cotrimoxazole group, compared to 5% in the ceftriaxone group. Despite this, serum potassium was often not measured in patients using intravenous cotrimoxazole, being 76% at baseline and 55% in the period of 48–120 h after antibiotic therapy initiation, compared to 87% and 34% in the ceftriaxone group respectively. Conclusion Adherence to Dutch guidelines was poor as serum potassium monitoring was often not performed. As intravenous co-trimoxazole usage is associated with a significant increase in mean serum potassium, monitoring is strongly recommended.
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Affiliation(s)
- Milan M E A Plantaz
- Department of Clinical Pharmacy A16, Canisius Wilhelmina Hospital, PO Box 9015, 6532 SZ, Nijmegen, The Netherlands
| | - Bart A J Veldman
- Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Anne C Esselink
- Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Hanneke W H A Fleuren
- Department of Clinical Pharmacy A16, Canisius Wilhelmina Hospital, PO Box 9015, 6532 SZ, Nijmegen, The Netherlands
| | - Cornelis Kramers
- Department of Clinical Pharmacy A16, Canisius Wilhelmina Hospital, PO Box 9015, 6532 SZ, Nijmegen, The Netherlands.
- Department of Internal Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.
- Department of Pharmacology-Toxicology, Radboud University Medical Centre, Nijmegen, The Netherlands.
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Hyponatremia Associated with Prophylactic Low-Dose Trimethoprim during Systemic Corticosteroid Therapy for AQP4-Positive Optic Neuritis in a Diabetic Patient. Antibiotics (Basel) 2020; 9:antibiotics9040201. [PMID: 32340132 PMCID: PMC7235834 DOI: 10.3390/antibiotics9040201] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 12/16/2022] Open
Abstract
Hyponatremia associated with low-dose trimethoprim in patients on concomitant systemic corticosteroid therapy has rarely been reported. Here, we describe a 57-year-old woman with a history of diabetes mellitus and hypertension treated with telmisartan, who presented with progressive visual impairment of the left eye due to anti-aquaporin-4 antibody-positive optic neuritis. The patient received pulsed intravenous methylprednisolone followed by oral prednisolone at 30 mg/day and trimethoprim-sulfamethoxazole prophylaxis (160 mg and 800 mg daily). Her serum sodium level steadily decreased, and the potassium level was slightly elevated despite well-preserved renal function. This state persisted even after telmisartan discontinuation. In addition to hypotonic hyponatremia (125 mEq/L) with natriuresis, hyperkalemic renal tubular acidosis was diagnosed based on normal anion gap metabolic acidosis and hyperkalemia with low urinary potassium excretion. After trimethoprim-sulfamethoxazole cessation, electrolytes and acid-base imbalances swiftly recovered. We can conclude that caution must be exercised when treating such patients, because even low-dose trimethoprim may cause hyponatremia concomitant with hyperkalemic renal tubular acidosis, despite the mineralocorticoid effects of systemic corticosteroids.
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12
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Rajput J, Moore LSP, Mughal N, Hughes S. Evaluating the risk of hyperkalaemia and acute kidney injury with cotrimoxazole: a retrospective observational study. Clin Microbiol Infect 2020; 26:1651-1657. [PMID: 32220637 DOI: 10.1016/j.cmi.2020.02.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 01/12/2020] [Accepted: 02/17/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Increasing antimicrobial resistance has renewed interest in older, less used antimicrobials. Cotrimoxazole shows promise; however, hyperkalaemia and acute kidney injury (AKI) are potential complications. Identifying risk factors for and quantification of these events is required for safe use. This study aimed to evaluate predictors of cotrimoxazole-associated AKI and hyperkalaemia in a clinical setting. METHODS Patients prescribed cotrimoxazole were identified using electronic healthcare records over 3 years (1 April 2016 to 31 March 2019). Individual risk factors were recognized. Serum creatinine and potassium trends were analysed over the subsequent 21 days. AKI and patients with hyperkalaemia were classified using Kidney Disease Improving Global Outcomes (KDIGO) and laboratory criteria. Univariate and multiple logistic regression analyses were performed. RESULTS Among 214 patients prescribed cotrimoxazole, 42 (19.6%, 95% confidence interval (CI) 14.6-25.7) met AKI criteria and 33 (15.4%, 95% CI 11.0-21.1) developed hyperkalaemia. Low baseline estimated glomerular filtration rate (<60 mL/min/1.73 m2, odds ratio (OR) 7.78, 95% CI 3.57-16.13, p < 0.0001) and cardiac disorders (OR 2.40, 95% CI 1.17-4.82, p 0.011) predicted AKI, while low baseline estimated glomerular filtration rate (<60 mL/min/1.73 m2, OR 6.80, 95% CI 3.09-15.06, p < 0.0001) and higher baseline serum potassium (p 0.001) predicted hyperkalaemia. Low-dose cotrimoxazole (<1920 mg/d) was associated with lower AKI and hyperkalaemia risk (p 0.007 and 0.019 respectively). Early (within the first 2-4 days of therapy) serum creatinine changes predicted AKI (OR 3.65, 95% CI 1.73-7.41, p 0.001), and early serum potassium changes predicted hyperkalaemia (>0.6 mmol/L, OR 2.47, 95% CI 1.14-5.27, p 0.0236). CONCLUSIONS Cotrimoxazole-associated AKI and hyperkalaemia is frequent and dose dependent. Renal function, serum potassium and preexisting cardiac disorders should be evaluated before prescribing cotrimoxazole. Serum creatinine and potassium monitoring within first 2 to 4 days of treatment to identify susceptible patients is recommended, and the lowest effective dose ought to be prescribed.
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Affiliation(s)
- J Rajput
- Imperial College London, South Kensington Campus, London, England, UK
| | - L S P Moore
- Imperial College London, South Kensington Campus, London, England, UK; Chelsea and Westminster NHS Foundation Trust, London, England, UK; North West London Pathology, Imperial College Healthcare NHS Trust, London, England, UK
| | - N Mughal
- Imperial College London, South Kensington Campus, London, England, UK; Chelsea and Westminster NHS Foundation Trust, London, England, UK; North West London Pathology, Imperial College Healthcare NHS Trust, London, England, UK
| | - S Hughes
- Chelsea and Westminster NHS Foundation Trust, London, England, UK.
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Design and rationale of a multi-center, pragmatic, open-label randomized trial of antimicrobial therapy - the study of clinical efficacy of antimicrobial therapy strategy using pragmatic design in Idiopathic Pulmonary Fibrosis (CleanUP-IPF) clinical trial. Respir Res 2020; 21:68. [PMID: 32164673 PMCID: PMC7069004 DOI: 10.1186/s12931-020-1326-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 02/19/2020] [Indexed: 01/20/2023] Open
Abstract
Abstract Compelling data have linked disease progression in patients with idiopathic pulmonary fibrosis (IPF) with lung dysbiosis and the resulting dysregulated local and systemic immune response. Moreover, prior therapeutic trials have suggested improved outcomes in these patients treated with either sulfamethoxazole/ trimethoprim or doxycycline. These trials have been limited by methodological concerns. This trial addresses the primary hypothesis that long-term treatment with antimicrobial therapy increases the time-to-event endpoint of respiratory hospitalization or all-cause mortality compared to usual care treatment in patients with IPF. We invoke numerous innovative features to achieve this goal, including: 1) utilizing a pragmatic randomized trial design; 2) collecting targeted biological samples to allow future exploration of ‘personalized’ therapy; and 3) developing a strong partnership between the NHLBI, a broad range of investigators, industry, and philanthropic organizations. The trial will randomize approximately 500 individuals in a 1:1 ratio to either antimicrobial therapy or usual care. The site principal investigator will declare their preferred initial antimicrobial treatment strategy (trimethoprim 160 mg/ sulfamethoxazole 800 mg twice a day plus folic acid 5 mg daily or doxycycline 100 mg once daily if body weight is < 50 kg or 100 mg twice daily if ≥50 kg) for the participant prior to randomization. Participants randomized to antimicrobial therapy will receive a voucher to help cover the additional prescription drug costs. Additionally, those participants will have 4–5 scheduled blood draws over the initial 24 months of therapy for safety monitoring. Blood sampling for DNA sequencing and genome wide transcriptomics will be collected before therapy. Blood sampling for transcriptomics and oral and fecal swabs for determination of the microbiome communities will be collected before and after study completion. As a pragmatic study, participants in both treatment arms will have limited in-person visits with the enrolling clinical center. Visits are limited to assessments of lung function and other clinical parameters at time points prior to randomization and at months 12, 24, and 36. All participants will be followed until the study completion for the assessment of clinical endpoints related to hospitalization and mortality events. Trial Registration ClinicalTrials.gov identifier NCT02759120.
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Gbinigie O. Trimethoprim is associated with a greater risk of acute kidney injury and hyperkalaemia in older adults compared with other antibiotics used to treat UTIs. BMJ Evid Based Med 2018; 23:233-234. [PMID: 29959157 PMCID: PMC6287555 DOI: 10.1136/bmjebm-2018-110991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/15/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Oghenekome Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliff Primary Care Building, Woodstock Road, Oxford, England
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15
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Menegussi J, Tatagiba LS, Vianna JGP, Seguro AC, Luchi WM. A physiology-based approach to a patient with hyperkalemic renal tubular acidosis. ACTA ACUST UNITED AC 2018; 40:410-417. [PMID: 30048563 PMCID: PMC6534002 DOI: 10.1590/2175-8239-jbn-3821] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 09/04/2017] [Indexed: 11/21/2022]
Abstract
Hyperkalemic renal tubular acidosis is a non-anion gap metabolic acidosis that
invariably indicates an abnormality in potassium, ammonium, and hydrogen ion
secretion. In clinical practice, it is usually attributed to real or apparent
hypoaldosteronism caused by diseases or drug toxicity. We describe a 54-year-old
liver transplant patient that was admitted with flaccid muscle weakness
associated with plasma potassium level of 9.25 mEq/L. Additional investigation
revealed type 4 renal tubular acidosis and marked hypomagnesemia with high
fractional excretion of magnesium. Relevant past medical history included a
recent diagnosis of Paracoccidioidomycosis, a systemic fungal infection that is
endemic in some parts of South America, and his outpatient medications contained
trimethoprim-sulfamethoxazole, tacrolimus, and propranolol. In the present
acid-base and electrolyte case study, we discuss a clinical approach for the
diagnosis of hyperkalemic renal tubular acidosis and review the pathophysiology
of this disorder.
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Affiliation(s)
| | | | | | - Antonio Carlos Seguro
- Universidade de São Paulo, Faculdade de Medicina, Departamento de Nefrologia, Laboratório de Pesquisa Médica - LIM12, São Paulo, SP, Brasil
| | - Weverton Machado Luchi
- Universidade Federal do Espírito Santo, Departamento de Clínica Médica, Divisão de Nefrologia, Vitória, ES, Brasil
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16
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Abstract
PURPOSE OF REVIEW Hyperkalemia develops in a patient with systemic arterial hypertension (HTN) if one or more risk factors are present, namely chronic kidney disease (CKD) (especially severe stage 4-5 CKD), diabetes mellitus (DM), heart failure (HF), or pharmacological therapies that interfere with potassium homeostasis, mainly through renin-angiotensin-aldosterone inhibition (RAASi). Hyperkalemia is a considerable reason of morbidity (emergency department (ED) visits and hospitalizations) and portends a higher mortality risk in patients at risk; for instance, hyperkalemia increases the risk of mortality within 1 day of a hyperkalemic event. This review aims to identify the risk factors for high-serum potassium, highlight the risk versus benefit of RAASi in certain patient populations, and outline preventive as well as therapeutic strategies for hyperkalemia. RECENT FINDINGS A growing body of evidence supports the safety and efficacy of cation-exchange resins, patiromer, or sodium zirconium cyclosilicate, in patients with a compelling indication for RAASi, yet in whom such therapy was complicated by hyperkalemia, allowing these patients to benefit from continued RAASi therapy. In summary, novel cation exchange polymers present the clinician with a new and safe strategy to address hyperkalemia in patients with a compelling indication for ongoing RAASi therapy instead of withdrawal of such therapy.
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Affiliation(s)
- Jay Ian Lakkis
- University of Hawaii John A. Burns School of Medicine, 95 Maui Lani Pkwy, Wailuku, HI, 96793-2416, USA
| | - Matthew R Weir
- Division of Nephrology, University of Maryland School of Medicine, 22 S. Greene St., Room N3W143, Baltimore, MD, 21201, USA.
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17
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Crellin E, Mansfield KE, Leyrat C, Nitsch D, Douglas IJ, Root A, Williamson E, Smeeth L, Tomlinson LA. Trimethoprim use for urinary tract infection and risk of adverse outcomes in older patients: cohort study. BMJ 2018; 360:k341. [PMID: 29438980 PMCID: PMC5806507 DOI: 10.1136/bmj.k341] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine if trimethoprim use for urinary tract infection (UTI) is associated with an increased risk of acute kidney injury, hyperkalaemia, or sudden death in the general population. DESIGN Cohort study. SETTING UK electronic primary care records from practices contributing to the Clinical Practice Research Datalink linked to the Hospital Episode Statistics database. PARTICIPANTS Adults aged 65 and over with a prescription for trimethoprim, amoxicillin, cefalexin, ciprofloxacin, or nitrofurantoin prescribed up to three days after a primary care diagnosis of UTI between April 1997 and September 2015. MAIN OUTCOME MEASURES The outcomes were acute kidney injury, hyperkalaemia, and death within 14 days of a UTI treated with antibiotics. RESULTS Among a cohort of 1 191 905 patients aged 65 and over, 178 238 individuals were identified with at least one UTI treated with antibiotics, comprising a total of 422 514 episodes of UTIs treated with antibiotics. The odds of acute kidney injury in the 14 days following antibiotic initiation were higher following trimethoprim (adjusted odds ratio 1.72, 95% confidence interval 1.31 to 2.24) and ciprofloxacin (1.48, 1.03 to 2.13) compared with amoxicillin. The odds of hyperkalaemia in the 14 days following antibiotic initiation were only higher following trimethoprim (2.27, 1.49 to 3.45) compared with amoxicillin. However, the odds of death within the 14 days following antibiotic initiation were not higher with trimethoprim than with amoxicillin: in the whole population the adjusted odds ratio was 0.90 (95% confidence interval 0.76 to 1.07) while among users of renin-angiotensin system blockers the odds of death within 14 days of antibiotic initiation was 1.12 (0.80 to 1.57). The results suggest that, for 1000 UTIs treated with antibiotics among people 65 and over, treatment with trimethoprim instead of amoxicillin would result in one to two additional cases of hyperkalaemia and two admissions with acute kidney injury, regardless of renin-angiotensin system blockade. However, for people taking renin-angiotensin system blockers and spironolactone treatment with trimethoprim instead of amoxicillin there were 18 additional cases of hyperkalaemia and 11 admissions with acute kidney injury. CONCLUSION Trimethoprim is associated with a greater risk of acute kidney injury and hyperkalaemia compared with other antibiotics used to treat UTIs, but not a greater risk of death. The relative risk increase is similar across population groups, but the higher baseline risk among those taking renin-angiotensin system blockers and potassium-sparing diuretics translates into higher absolute risks of acute kidney injury and hyperkalaemia in these groups.
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Affiliation(s)
- Elizabeth Crellin
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Kathryn E Mansfield
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Clémence Leyrat
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Dorothea Nitsch
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Ian J Douglas
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Adrian Root
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Elizabeth Williamson
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Liam Smeeth
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Laurie A Tomlinson
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
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18
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Abstract
PURPOSE OF REVIEW The aim of this paper is to discuss strategies for prevention and management of hyperkalemia in patients with heart failure, including the role of novel therapies. RECENT FINDINGS Renin-angiotensin-aldosterone system (RAAS) antagonists, including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), and mineralocorticoid receptor antagonists (MRA) decrease mortality and morbidity in heart failure but increase the risk of hyperkalemia, especially when used in combination. Prevention of hyperkalemia and its associated complications requires careful patient selection, counseling regarding dietary potassium intake, awareness of drug interactions, and regular laboratory surveillance. Recent data suggests that the risk of hyperkalemia may be further moderated through the use of combined angiotensin-neprilysin inhibitors, novel MRAs, and novel potassium binding agents. Clinicians should be mindful of the risk of hyperkalemia when prescribing RAAS inhibitors to patients with heart failure. In patients at highest risk, such as those with diabetes, the elderly, and advanced chronic kidney disease, more intensive laboratory surveillance of potassium and creatinine may be required. Novel therapies hold promise for reducing the risk of hyperkalemia and enhancing the tolerability of RAAS antagonists.
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Affiliation(s)
- Ersilia M DeFilippis
- Cardiovascular Division (ASD) and Department of Medicine (EMD, ASD), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division (ASD) and Department of Medicine (EMD, ASD), Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. .,Advanced Heart Disease Section, Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
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Potassium regulation in the neonate. Pediatr Nephrol 2017; 32:2037-2049. [PMID: 28378030 DOI: 10.1007/s00467-017-3635-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2016] [Revised: 02/13/2017] [Accepted: 02/21/2017] [Indexed: 10/19/2022]
Abstract
Potassium, the major cation in intracelluar fluids, is essential for vital biological functions. Neonates maintain a net positive potassium balance, which is fundamental to ensure somatic growth but places these infants, especially those born prematurely, at risk for life-threatening disturbances in potassium concentration [K+] in the extracellular fluid compartment. Potassium conservation is achieved by maximizing gastrointestinal absorption and minimizing renal losses. A markedly low glomerular filtration rate, plus adaptations in tubular transport along the nephron, result in low potassium excretion in the urine of neonates. Careful evaluation of clinical data using reference values that are normal for the neonate's postmenstrual age is critical to avoid over-treating infants with laboratory results that represent physiologic values for their developmental stage. The treatment should be aimed at correcting the primary cause when possible. Alterations in the levels or sensitivity to aldosterone are common in neonates. In symptomatic patients, the disturbances in [K+] should be corrected promptly, with close electrocardiographic monitoring. Plasma [K+] should be monitored during the first 72 h of life in all premature infants born before 30 weeks of postmenstrual age as these infants are prone to develop non-oliguric hyperkalemia with potential serious complications.
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20
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Caron F, Wehrle V, Etienne M. The comeback of trimethoprim in France. Med Mal Infect 2017; 47:253-260. [DOI: 10.1016/j.medmal.2016.12.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/03/2016] [Accepted: 12/01/2016] [Indexed: 11/16/2022]
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21
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Advances in the management of hyperkalemia in chronic kidney disease. Curr Opin Nephrol Hypertens 2017; 26:235-239. [DOI: 10.1097/mnh.0000000000000320] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Life-threatening Interaction Between Renin-angiotensin-aldosterone System Inhibitors and Trimethoprim-sulfamethoxazole in Older Adults. J Nurse Pract 2016. [DOI: 10.1016/j.nurpra.2015.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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23
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Pascoe VL, Fenves AZ, Wofford J, Jackson JM, Menter A, Kimball AB. The spectrum of nephrocutaneous diseases and associations. J Am Acad Dermatol 2016; 74:247-70; quiz 271-2. [DOI: 10.1016/j.jaad.2015.05.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 05/26/2015] [Accepted: 05/26/2015] [Indexed: 12/31/2022]
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24
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Higashioka K, Niiro H, Yoshida K, Oryoji K, Kamada K, Mizuki S, Yokota E. Renal Insufficiency in Concert with Renin-angiotensin-aldosterone Inhibition Is a Major Risk Factor for Hyperkalemia Associated with Low-dose Trimethoprim-sulfamethoxazole in Adults. Intern Med 2016; 55:467-71. [PMID: 26935365 DOI: 10.2169/internalmedicine.55.5697] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Low-dose trimethoprim-sulfamethoxazole (TMP-SMX) is commonly used to prevent pneumocystis pneumonia in daily practice. Previous reports have shown a relationship between high- or standard-dose of TMP-SMX and hyperkalemia, however it remains unclear whether this is true for low-dose TMP-SMX. In this study we sought to determine the risk factors for hyperkalemia associated with low-dose TMP-SMX. METHODS In this retrospective cohort study, 186 consecutive adult patients who received TMP-SMX as prophylaxis for pneumocystis pneumonia from January 2014 to January 2015 were evaluated. Data on the patients' age, gender, baseline estimated glomerular filtration rate (eGFR), baseline serum potassium, maximum serum potassium, duration reaching the maximal serum potassium level, dosage, and concomitant use of angiotensin-converting enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB), β-blockers, non-steroidal anti-inflammatory drugs and potassium-sparing diuretics were retrospectively collected. Hyperkalemia was defined as a serum potassium level ≥5 mEq/L. Univariate and multivariate analyses were performed. RESULTS The median age of the patients was 66 years and 51.1% were men. Hyperkalemia associated with low-dose TMP-SMX was observed in 32 patients (17.2%). The median duration to reach the maximal serum potassium level was 12 days. The multivariate logistic regression analysis identified renal insufficiency to be a major risk factor for hyperkalemia associated with low-dose TMP-SMX (eGFR <60 mL/min/1.73 m(2), adjusted OR 4.62). Moreover, in the subpopulation of patients with renal insufficiency, ACEi/ARB use was considered to be a major risk factor for hyperkalemia (adjusted OR 3.96). CONCLUSION Renal insufficiency in concert with ACEi/ARB use is a major risk factor for hyperkalemia induced by low-dose TMP-SMX.
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Ayach T, Nappo RW, Paugh-Miller JL, Ross EA. Postoperative hyperkalemia. Eur J Intern Med 2015; 26:106-11. [PMID: 25698564 DOI: 10.1016/j.ejim.2015.01.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Revised: 01/08/2015] [Accepted: 01/23/2015] [Indexed: 01/30/2023]
Abstract
Hyperkalemia occurs frequently in hospitalized patients and is of particular concern for those who have undergone surgery, with postoperative care provided by clinicians of many disciplines. This review describes the normal physiology and how multiple perioperative factors can disrupt potassium homeostasis and lead to severe elevations in plasma potassium concentration. The pathophysiologic basis of diverse causes of hyperkalemia was used to broadly classify etiologies into those with altered potassium distribution (e.g. increased potassium release from cells or other transcellular shifts), reduced urinary excretion (e.g. reduced sodium delivery, volume depletion, and hypoaldosteronism), or an exogenous potassium load (e.g. blood transfusions). Surgical conditions of particular concern involve: rhabdomyolysis from malpositioning, trauma or medications; bariatric surgery; vascular procedures with tissue ischemia; acidosis; hypovolemia; and volume or blood product resuscitation. Certain acute conditions and chronic co-morbidities present particular risk. These include chronic kidney disease, diabetes mellitus, many outpatient preoperative medications (e.g. beta blockers, salt substitutes), and inpatient agents (e.g. succinylcholine, hyperosmolar volume expanders). Clinicians need to be aware of these pathophysiologic mechanisms for developing perioperative hyperkalemia as many of the risks can be minimized or avoided.
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Affiliation(s)
- Taha Ayach
- Division of Nephrology, Hypertension and Renal Transplantation, University of Florida, USA
| | - Robert W Nappo
- University of Florida Shands Hospital, Gainesville, FL, USA
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26
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Minimize drug-induced hyperkalaemia by increasing awareness and using preventative strategies. DRUGS & THERAPY PERSPECTIVES 2015. [DOI: 10.1007/s40267-014-0171-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Brown GR. Cotrimoxazole - optimal dosing in the critically ill. Ann Intensive Care 2014; 4:13. [PMID: 24910807 PMCID: PMC4031607 DOI: 10.1186/2110-5820-4-13] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2013] [Accepted: 03/24/2014] [Indexed: 12/24/2022] Open
Abstract
The optimum dosage regimen for cotrimoxazole in the treatment of life threatening infections due to susceptible organisms encountered in critically ill patients is unclear despite decades of the drug's use. Therapeutic drug monitoring to determine the appropriate dosing for successful infection eradication is not widely available. The clinician must utilize published pharmacokinetic, pharmacodynamic, and effective inhibitory concentration information to determine potential dosing regimens for individual patients when treating specific pathogens. Using minimum inhibitory concentrations known to successfully block growth for target pathogens, the pharmacokinetics of both trimethoprim and sulfamethoxazole can be utilized to establish empiric dosing regimens for critically ill patients while considering organ of clearance impairment. The author's recommendations for appropriate dosing regimens are forwarded based on these parameters.
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Affiliation(s)
- Glen R Brown
- Pharmacy Department, St. Paul’s Hospital, 1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada
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29
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Johnstone J, Macduff A. Successful Conservative Management of Trimethoprim Induced Life-Threatening Hyperkalaemia in a Patient with <i>Pneumocystis jirovecii</i> Pneumonia. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/crcm.2014.38103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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30
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Stangoe D, Jenkins N, Coakes J. A Case of Refractory Hyperkalaemia in an HIV-Positive Patient with Pneumocystis Jirovecii Pneumonia. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 58-year-old gentleman admitted to the intensive care unit (ICU) with Pneumocystis jirovecii pneumonia and advanced HIV developed a potentially lethal hyperkalaemia secondary to his antibiotic treatment. The mechanism and treatment are described.
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Affiliation(s)
| | | | - James Coakes
- Anaesthetic Consultant, Basingstoke and North Hampshire Hospital
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31
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Trimethoprim-induced hyperkalemia in burn patients treated with intravenous or oral trimethoprim sulfamethoxazole for methicillin-resistant Staphylococcus aureus and other infections: nature or nurture? J Burn Care Res 2013; 34:127-32. [PMID: 23292580 DOI: 10.1097/bcr.0b013e3182700b18] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Trimethoprim is well known to cause rashes; however, what is not commonly known is that it causes sudden and profound hyperkalemia in 10 to 20% of treated patients. The uniqueness of burn patients begs the question whether changes known to occur in these patients might also increase this trimethoprim effect. After institutional review board approval, a retrospective study evaluated 224 patients with thermal injury who had been treated with trimethoprim sulfamethoxazole (TMP-SMX), 24 of whom had underlying renal impairment (creatinine clearances <50 ml/min) and were excluded, leaving 200 patients for analysis. Three definitions of drug-induced hyperkalemia were used: 1) a ≥ 1 mEq/L rise, 2) a >0.8 mEq rise in potassium in <24 hours warranting early discontinuation of TMP-SMX, and 3) "marked" hyperkalemia defined as serum potassium of ≥ 5.5 mEq/L within 48 hours. A potassium level before trimethoprim exposure (TxK) and after TxK were collected retrospectively. Demographic data were analyzed with Student's t-test and trimethoprim dose alone, demonstrating a significant difference. Analysis of 200 patients exposed to trimethoprim demonstrated an elevation of potassium (first definition) in 31 patients (15.5%), a rapid change in serum potassium in two patients (second definition), and marked hyperkalemia (>5.5 mEq/L) in 13 patients (6.5%). Hyperkalemia never occurred in 166 of 200 patients (82%; before TxK, 3.9 ± 0.4; after TxK, 4.3 ± 0.5 mEq/L). Change in serum potassium among patients with hyperkalemia was 4.0 ± 0.5 mEq/L before TxK and 5.3 ± 0.7 mEq/L after TxK. Twelve published hyperkalemia risk factors were reviewed in these 200 patients and only history of hypertension and need for intubation was more common in those with hyperkalemia. A nearly 20% incidence of hyperkalemia and 6% serious hyperkalemia in burn patients is consistent with reports in patients without burn injury. These data also suggest that the metabolic and hormonal changes associated with burn injury do not increase further the genetically predisposed hyperkalemia resulting from exposure to trimethoprim. These data suggest patients treated with TMP-SMX should have routine serum potassium monitoring before discharge.
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Schürmann R, Blode H, Benda N, Cronin M, Küfner A. Effect of Drospirenone on Serum Potassium and Drospirenone Pharmacokinetics in Women With Normal or Impaired Renal Function. J Clin Pharmacol 2013; 46:867-75. [PMID: 16855071 DOI: 10.1177/0091270006289973] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This open-label study investigated whether drospirenone, a novel progestin with antimineralocorticoid properties, increases the risk for hyperkalemia in subjects with renal impairment. Women with normal renal function and mild or moderate renal impairment were given drospirenone 3 mg/d for 14 days. Mean serum potassium concentrations did not significantly change during steady-state drospirenone treatment. No difference in drospirenone effects on serum potassium concentrations in subjects with renal insufficiency versus subjects with normal renal function was found. Steady-state pharmacokinetics was similar in subjects with normal renal function and mild renal impairment, whereas, due to results from 1 subject, drospirenone exposure was slightly higher in the moderate renal impairment group. Given the reported tolerability of drospirenone, this small increase in serum drospirenone is not expected to be clinically significant. In conclusion, this study demonstrated that drospirenone has no significant effect on serum potassium levels in patients with mild to moderate renal insufficiency.
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Trimethoprim-sulfamethoxazole-induced hyperkalemia in a patient with normal renal function. Case Rep Emerg Med 2012; 2012:815907. [PMID: 23326725 PMCID: PMC3542892 DOI: 10.1155/2012/815907] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2012] [Accepted: 11/16/2012] [Indexed: 11/18/2022] Open
Abstract
The authors present a case of Trimethoprim-sulfamethoxazole-induced hyperkalemia in a patient with normal renal function. While toxicity of this drug has been reported in patients with renal insufficiency, this case highlights the toxicity associated with normal kidney function. Due to its popularity in the medical field and to the largely unrecognized effect of hyperkalemia, it is important to consider such adverse effects when prescribing TMX-SMX. One must be reminded of the possibility of the development of life-threatening hyperkalemia in relatively healthy patients.
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Bonatti HJ, Colon N, Ott M, Morris JA, Miller RS, Riordan WP, May AK. Trimethoprim-Associated Hyperkalemia in a Young Trauma Victim. Surg Infect (Larchmt) 2011; 12:419-20. [DOI: 10.1089/sur.2011.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Hugo J.R. Bonatti
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nadja Colon
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mickey Ott
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John A. Morris
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard S. Miller
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William P. Riordan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Addison K. May
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Antoniou T, Gomes T, Mamdani MM, Yao Z, Hellings C, Garg AX, Weir MA, Juurlink DN. Trimethoprim-sulfamethoxazole induced hyperkalaemia in elderly patients receiving spironolactone: nested case-control study. BMJ 2011; 343:d5228. [PMID: 21911446 PMCID: PMC3171211 DOI: 10.1136/bmj.d5228] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To characterise the risk of admission to hospital for hyperkalaemia in elderly patients treated with trimethoprim-sulfamethoxazole in combination with spironolactone. DESIGN Population based nested case-control study. SETTING Ontario, Canada, from 1 April 1992 to 1 March 2010. PARTICIPANTS Cases were residents of Ontario aged 66 years or above receiving chronic treatment with spironolactone and admitted to hospital with hyperkalaemia within 14 days of receiving a prescription for either trimethoprim-sulfamethoxazole, amoxicillin, norfloxacin, or nitrofurantoin. Up to four controls for each case were identified from the same cohort, matched on age, sex, and presence or absence of chronic kidney disease and diabetes, and required to have received one of the study antibiotics within 14 days before the case's index date. MAIN OUTCOME MEASURES Odds ratio for association between admission to hospital with hyperkalaemia and receipt of a study antibiotic in the preceding 14 days, adjusted for conditions and drugs that may influence risk of hyperkalaemia. RESULTS During the 18 year study period, 6903 admissions for hyperkalaemia were identified, 306 of which occurred within 14 days of antibiotic use. Of these, 248 (81%) cases were matched to 783 controls. 10.8% (17,859/165,754) of spironolactone users received at least one prescription for trimethoprim-sulfamethoxazole. Compared with amoxicillin, prescription of trimethoprim-sulfamethoxazole was associated with a marked increase in the risk of admission to hospital for hyperkalaemia (adjusted odds ratio 12.4, 95% confidence interval 7.1 to 21.6). The population attributable fraction was 59.7%, suggesting that approximately 60% of all cases of hyperkalaemia in older patients taking spironolactone and treated with an antibiotic for a urinary tract infection could be avoided if trimethoprim-sulfamethoxazole was not prescribed. Treatment with nitrofurantoin was also associated with an increase in the risk of hyperkalaemia (adjusted odds ratio 2.4, 1.3 to 4.6), but no such risk was found with norfloxacin (adjusted odds ratio 1.6, 0.8 to 3.4) CONCLUSIONS Among older patients receiving spironolactone, treatment with trimethoprim-sulfamethoxazole was associated with a major increase in the risk of admission to hospital for hyperkalaemia. This drug combination should be avoided when possible.
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Publow SW, Branam DL. Hypotension and bradycardia associated with concomitant tizanidine and lisinopril therapy. Am J Health Syst Pharm 2011; 67:1606-10. [PMID: 20852161 DOI: 10.2146/ajhp090657] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE A case of severe bradycardia and hypotension associated with concomitant tizanidine and lisinopril therapy is reported. SUMMARY An 85-year-old man with a chief complaint of profound weakness was admitted to the hospital with a blood pressure reading of 60/32 mm Hg and a heart rate of 37 beats/min. His medical history included type 2 diabetes mellitus, congestive heart failure, gastroesophageal reflux disease, chronic obstructive pulmonary disease, osteoarthritis, restless leg syndrome, benign prostatic hyperplasia, generalized anxiety disorder with depression, and severe chronic back pain for which he was receiving treatment at a pain clinic. Two days before hospital admission, he had been seen at the pain clinic and started on ti-zanidine. Additional medications included acetaminophen, chlorpromazine, citalopram, finasteride, lidocaine patch, lisinopril, metformin, pramipexole, omeprazole, simvastatin, theophylline, diclofenac topical gel, hydrocodone-acetaminophen, and ondansetron. After taking three doses of the newly prescribed tizanidine, he developed severe hypotension and bradycardia. Notable laboratory test values included a serum creatinine concentration of 1.90 mg/dL, a blood urea nitrogen concentration of 21 mg/dL, a serum potassium concentration of 5.5 meq/L, and a serum sodium concentration of 128 meq/L. Upon admission, tizanidine, lisinopril, theophylline, omeprazole, and simvastatin were withheld, and i.v. fluids were administered. The patient's vital signs began to gradually improve. Within 24 hours, the patient's blood pressure and heart rate had improved, as had the previously abnormal laboratory test values. Tizanidine was discontinued, and all of his other preadmission medications were restarted at discharge. CONCLUSION The addition of tizanidine in a patient receiving long-term treatment with lisinopril was associated with severe hypotension and bradycardia.
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Affiliation(s)
- Susan W Publow
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Weir MA, Juurlink DN, Gomes T, Mamdani M, Hackam DG, Jain AK, Garg AX. Beta-blockers, trimethoprim-sulfamethoxazole, and the risk of hyperkalemia requiring hospitalization in the elderly: a nested case-control study. Clin J Am Soc Nephrol 2010; 5:1544-51. [PMID: 20595693 DOI: 10.2215/cjn.01970310] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES The simultaneous use of beta adrenergic receptor blockers (beta-blockers) and trimethoprim-sulfamethoxazole (TMP-SMX) may confer a high risk of hyperkalemia. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Two nested case-control studies were conducted to examine the association between hospitalization for hyperkalemia and the use of TMP-SMX in older patients receiving beta-blockers. Linked health administrative records from Ontario, Canada, were used to assemble a cohort of 299,749 beta-blockers users, aged 66 years or older and capture data regarding medication use and hospital admissions for hyperkalemia. RESULTS Over the study period from 1994 to 2008, 189 patients in this cohort were hospitalized for hyperkalemia within 14 days of receiving a study antibiotic. Compared with amoxicillin, the use of TMP-SMX was associated with a substantially greater risk of hyperkalemia requiring hospital admission (adjusted odds ratio, 5.1; 95% confidence interval [CI], 2.8 to 9.4). No such risk was identified with ciprofloxacin, norfloxacin, or nitrofurantoin. When dosing was considered, the association was greater at higher doses of TMP-SMX. When the primary analysis was repeated in a cohort of non-beta-blocker users, the risk of hyperkalemia comparing TMP-SMX to amoxicillin was not significantly different from that found among beta-blocker users. CONCLUSIONS Although TMP-SMX is associated with an increased risk of hyperkalemia in older adults, these findings show no added risk when used in combination with beta-blockers.
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Jao J, Wyatt CM. Antiretroviral medications: adverse effects on the kidney. Adv Chronic Kidney Dis 2010; 17:72-82. [PMID: 20005491 DOI: 10.1053/j.ackd.2009.07.009] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Revised: 07/17/2009] [Accepted: 07/21/2009] [Indexed: 11/11/2022]
Abstract
The widespread introduction of highly active antiretroviral therapy (HAART) in the mid-1990s dramatically altered the course of human immunodeficiency virus (HIV) infection, with improvements in survival and reductions in the incidence of AIDS-defining illnesses. Although antiretroviral therapy has been shown to reduce the incidence of both AIDS-defining and non-AIDS conditions, long-term exposure to HAART may also be associated with significant toxicity. This article reviews the potential nephrotoxicity of specific antiretroviral agents and the impact of antiretroviral therapy on related metabolic disorders. The antiretroviral agents most strongly associated with direct nephrotoxicity include the nucleotide reverse transcriptase inhibitor, tenofovir, and the protease inhibitor indinavir, although other agents have been implicated less frequently. Tenofovir and related nucleotide analogs have primarily been associated with proximal tubular dysfunction and acute kidney injury, whereas indinavir is known to cause nephrolithiasis, obstructive nephropathy, and interstitial nephritis. Kidney damage related to antiretroviral therapy is typically reversible with early recognition and timely discontinuation of the offending agent, and nephrologists should be familiar with the potential toxicity of these agents to avoid delays in diagnosis.
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Zietse R, Zoutendijk R, Hoorn EJ. Fluid, electrolyte and acid–base disorders associated with antibiotic therapy. Nat Rev Nephrol 2009; 5:193-202. [DOI: 10.1038/nrneph.2009.17] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
The form of renal tubular acidosis associated with hyperkalemia is usually attributable to real or apparent hypoaldosteronism. It is therefore a common feature in diabetes and a number of other conditions associated with underproduction of renin or aldosterone. In addition, the close relationship between potassium levels and ammonia production dictates that hyperkalemia per se can lead to acidosis. Here I describe the modern relationship between molecular function of the distal portion of the nephron, pathways of ammoniagenesis, and hyperkalemia.
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Affiliation(s)
- Fiona E Karet
- Cambridge Institute for Medical Research (Room 4.3), Addenbrooke's Hospital Box 139, Hills Road, Cambridge, CB2 0XY, UK.
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Fine DM, Perazella MA, Lucas GM, Atta MG. Renal disease in patients with HIV infection: epidemiology, pathogenesis and management. Drugs 2008; 68:963-80. [PMID: 18457462 DOI: 10.2165/00003495-200868070-00006] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
With the introduction of highly active antiretroviral therapy, we have witnessed prolonged survival with the potential for normal life expectancy in HIV-infected individuals. With improved survival and increasing age, HIV-infected patients are increasingly likely to experience co-morbidities that affect the general population, including kidney disease. Although HIV-associated nephropathy, the most ominous kidney disease related to the direct effects of HIV, may be prevented and treated with antiretrovirals, kidney disease remains an important issue in this population. In addition to the common risk factors for kidney disease of diabetes mellitus and hypertension, HIV-infected individuals have a high prevalence of other risk factors, including hepatitis C, cigarette smoking and injection drug use. Furthermore, they have exposures unique to this population, including antiretrovirals and other medications. Therefore, the differential diagnosis is vast. Early identification (through efficient screening) and definitive diagnosis (by kidney biopsy when indicated) of kidney disease in HIV-infected individuals are critical to optimal management. Earlier interventions with disease-specific therapy, often with the help of a nephrologist, are likely to lead to better outcomes. In those with chronic kidney disease, interventions, such as aggressive blood pressure control with the use of ACE inhibitors or angiotensin receptor antagonists where tolerated, tight blood glucose control in those with diabetes, and avoidance of potentially nephrotoxic medications, can slow progression and prevent end-stage renal disease. Only with greater awareness of kidney-disease manifestations and their implications in this particularly vulnerable population will we be able to achieve success in confronting this growing problem.
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Affiliation(s)
- Derek M Fine
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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Faridi AB, Weisberg LS. Acid-Base, Electrolyte, and Metabolic Abnormalities. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50060-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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de Silva TI, Post FA, Griffin MD, Dockrell DH. HIV-1 infection and the kidney: an evolving challenge in HIV medicine. Mayo Clin Proc 2007; 82:1103-16. [PMID: 17803878 DOI: 10.4065/82.9.1103] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
With the advent of highly active antiretroviral therapy (HAART), the incidence of opportunistic infections has declined substantially, and cardiovascular, liver, and renal diseases have emerged as major causes of morbidity and mortality in individuals with human immunodeficiency virus (HIV). Acute renal failure is common in HIV-infected patients and is associated with acute infection and medication-related nephrotoxicity. HIV-associated nephropathy is the most common cause of chronic kidney disease in HIV-positive African American populations and may respond to HAART. Other important HIV-associated renal diseases include HIV immune complex kidney diseases and thrombotic microangiopathy. The increasing importance of non-HIV-associated diseases, such as diabetes mellitus, hypertension, and vascular disease, to the burden of chronic kidney disease has been recognized, focusing attention on prevention and control of these diseases in HIV-positive individuals. HIV-positive individuals who experience progression to end-stage renal disease and who have undetectable HIV-1 viral loads while receiving HAART should be evaluated for renal transplant. Emerging evidence suggests that HIV-positive individuals may have graft and patient survival comparable to HIV-negative individuals. Several studies suggest that HIV-1 can potentially infect renal cells, and HIV transgenic mice have clarified the roles of a number of HIV proteins in the pathogenesis of HIV-associated renal disease. Host factors may modify disease expression at the level of cytokine networks and the renal microvasculature and contribute to the pathogenic effects of HIV-1 infection on the kidney.
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Affiliation(s)
- Thushan I de Silva
- Section of Infection, Inflammation and Immunity, University of Sheffield School of Medicine and Biomedical Sciences, L Floor, Royal Hallamshire Hospital, Glossop Road, Sheffield, UK
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Sica DA, Hess M. Pharmacotherapy in congestive heart failure: aldosterone receptor antagonism: interface with hyperkalemia in heart failure. ACTA ACUST UNITED AC 2005; 10:259-64. [PMID: 15470306 DOI: 10.1111/j.1527-5299.2004.02814.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Aldosterone receptor antagonism (ARA) is an increasingly well-accepted element of heart failure therapy. The experimental underpinnings for the use of ARA in heart failure are strong being linked to a variety of tissue-based cardiac effects characteristic of drugs in this class. However, the benefits of ARA therapy do not come without some risk since drugs in this class are potent inhibitors of renal potassium (K+) elimination. Thus, some increment in serum K+, up to and including the development of overt hyperkalemia (typically defined as a serum K+ value in excess of 6.0 mEq/L), is to be expected whenever they are used. Hyperkalemia attributable to ARA relates to several factors including ARA dose, patient predisposition to hyperkalemia, as in the case of renal failure, and dietary intake of K+. The risk of some change in serum K+ with ARA should not be a deterrent to use of drugs in this class but, rather should prompt careful surveillance for the onset of this potentially life-threatening electrolyte disturbance. The frequency of such scrutiny should be patient-specific and based on the constellation of risk factors for hyperkalemia.
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Affiliation(s)
- Domenic A Sica
- Department of Medicine, Medical College of Virginia of Virginia Commonwealth University, Richmond, VA 23298-0160, USA.
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Current Awareness. Pharmacoepidemiol Drug Saf 2000. [DOI: 10.1002/1099-1557(200009/10)9:5<441::aid-pds491>3.0.co;2-b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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