Acute renal failure secondary to ciprofloxacin use

Pattern, frequency and factors associated with inappropriate high dosing in chronic kidney disease patients at a tertiary care hospital in Pakistan

BACKGROUND

Patients with chronic kidney diseases (CKD) are susceptible to the toxic drug effects if given unadjusted doses. Although Pakistan harbors a high burden of CKD patients, there is limited information available on the frequency, pattern and factors associated with unadjusted drug doses among CKD patients.

METHODS

This cross-sectional study conducted at Sandeman Provincial Hospital, Quetta included 303 non-dialysis ambulatory CKD patients (glomerular filtration rate < 60 ml/min/1.73m²). The patients' data were collected through a purpose designed data collection form. The appropriateness of doses was checked against the renal drug handbook-2018, Kidney Disease Improving Global Outcomes guidelines, British National Formulary-2022, and manufacturer leaflets. Data were analysed by SPSS 23 and multiple binary logistic regression analysis was used to assess the factors associated with receiving inappropriate high doses. A p-value < 0.05 was considered statistically significant.

RESULTS

The patients received a total of 2265 prescription lines, with a median of eight different drugs per patient (interquartile range: 6-9 drugs). A total of 34.5% (783/2265) drugs required dose adjustment. Of these, doses were not adjusted for 56.1% (440) drugs in 162 (53.4%) patients. The most common pharmacological class of drugs requiring dose adjustment were antibiotics (79.1%), followed by antidiabetics (59.2%), diuretics (57.0%), angiotensin converting enzyme inhibitors (56.9%), beta blockers (56.9%), analgesics (56.0%), angiotensin receptor blockers (55.2%), domperidone (53.9%) and antihyperlipidmics (46.1%). Patient's age of 41-60 (OR = 5.76) and > 60 years (OR = 9.49), hypertension (OR = 2.68), diabetes mellitus (OR = 3.47) and cardiovascular diseases (OR = 2.82) had statistically significant association (p-value < 0.05) with inappropriate high doses.

CONCLUSION

The high frequency of inappropriate high doses suggests an important quality gap in medication dosing for patients with ND-CKD at the study site. Special attention should be paid to the drugs and patients with identified risk factors for receiving inappropriate high doses.

Nephrotoxicity of Ciprofloxacin: Five Cases and a Review of the Literature

Fluoroquinolones are usually well tolerated with a minimum of serious adverse effects; renal toxicity is uncommon. Apart from the renal side effects of ciprofloxacin, we aimed to highlight the renal impact of a ciprofloxacin overdose, and thus conducted a prospective study in the Department of Nephrology at La Rabta Hospital between 2010 and 2015. The cohort database was continually updated until the inclusion of five patients who were subjected to an overdose and who were initially admitted to the medical intensive care unit and then transferred to our department for acute renal failure (ARF) due to ciprofloxacin ingestion requiring urgent hemodialysis. All patients developed ARF after 12–36 h of ingestion. Renal ultrasound was normal in all cases. Twenty-four-hour proteinuria was present but not significant in one case, while microscopic hematuria was present in one case. Treatment consisted of supportive therapy and extrarenal purification by conventional intermittent hemodialysis. Four patients recovered normal renal function within 3 weeks and the remaining patient eventually had chronic kidney failure.

Assessment of the role of renal organic anion transporters in drug-induced nephrotoxicity

In the present review we have attempted to assess the involvement of the organic anion transporters OAT1, OAT2, OAT3, and OAT4, belonging to the SLC22 family of polyspecific carriers, in drug-induced renal damage in humans. We have focused on drugs with widely recognized nephrotoxic potential, which have previously been reported to interact with OAT family members, and whose underlying pathogenic mechanism suggests the participation of tubular transport. Thus, only compounds generally believed to cause kidney injury either by means of direct tubular toxicity or crystal nephropathy have been considered. For each drug, or class of agents, the evidence for actual transport mediated by individual OATs under in vivo conditions is discussed. We have then examined their role in the context of other carriers present in the renal proximal tubule sharing certain substrates with OATs, as these are critical determinants of the overall contribution of OAT-dependent transport to intracellular accumulation and transepithelial drug secretion, and thus the impact it may have in drug-induced nephrotoxicity.

Drug-induced crystal nephropathy: an update

BACKGROUND

Several medications that are insoluble in human urine are known to precipitate within the renal tubules. Intratubular precipitation of either exogenously administered medications or endogenous crystals (induced by certain drugs) can promote chronic and acute kidney injury, termed crystal nephropathy. Clinical settings that enhance the risk of drug or endogenous crystal precipitation within the kidney tubules include true or effective intravascular volume depletion, underlying kidney disease, and certain metabolic disturbances that promote changes in urinary pH favoring crystal precipitation.

OBJECTIVE

Identify and review previously described and recently recognized medications that cause crystal nephropathy.

METHOD

A literature review was performed, using PubMed, Ovid, and Google Scholar, focusing on drugs (sulfadiazine, acyclovir, indinavir, triamterene, methotrexate (MTX), orlistat, oral sodium phosphate preparation, ciprofloxacin) that cause crystal nephropathy.

RESULTS/CONCLUSION

Sulfadiazine, acyclovir, indinavir, triamterene, and MTX are known to cause crystal nephropathy. Recently, several medications, including orlistat, ciprofloxacin, and oral sodium phosphate solution, along with underlying risk factors have been described as causing crystal nephropathy.

Ciprofloxacin Crystal Nephropathy

Ciprofloxacin is a widely used fluoroquinolone for the treatment of patients with complicated and uncomplicated infections. With rare exceptions, only immune-mediated interstitial nephritis was described, with direct renal damage reported only in case of overdose. Experimental studies indicated that crystalluria may be associated with the administration of this drug, but the likelihood that ciprofloxacin crystal nephropathy would occur in humans was believed to be very low on the basis of previous data showing that ciprofloxacin crystalluria depended on a urine pH greater than 6.8. However, we report 2 cases of ciprofloxacin crystal-induced nephropathy with a clinical pattern of acute reversible tubular damage and intratubular crystals identical to that previously described in elderly patients treated with ciprofloxacin dosages within therapeutic schedules. Crystals in the tubules were negative for both the von Kossa stain for phosphates and alizarin red stain for calcium.

Medication dosing errors in hospitalized patients with renal impairment: a study in Palestine

BACKGROUND AND AIM

Reduced renal function requires dose adjustment for certain drugs to avoid toxicity. The aim of this study was to determine whether appropriate dosage adjustments were made for drugs that are nephrotoxic, excreted, or metabolized (TEM medications) by the kidney in patients with renal impairment.

METHODOLOGY

A cross-sectional study of a group of hospitalized patients was carried out at Al-Watni governmental hospital, Nablus, Palestine. All patients with creatinine clearance

RESULTS

A total of 78 patients had calculated creatinine clearance

CONCLUSION

In our study, a wide range of dosing errors was common among patients with renal impairment that was common during hospitalization. Continued medical education in the field of clinical pharmacokinetics is important for physicians.

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MESH Headings

• Adult
• Aged
• Aged, 80 and over
• Anti-Bacterial Agents/administration & dosage
• Anti-Bacterial Agents/adverse effects
• Anti-Bacterial Agents/pharmacokinetics
• Creatinine/blood
• Creatinine/urine
• Cross-Sectional Studies
• Digoxin/administration & dosage
• Digoxin/adverse effects
• Digoxin/pharmacokinetics
• Drug-Related Side Effects and Adverse Reactions
• Female
• Hospital Bed Capacity, 100 to 299
• Hospitals, Public
• Humans
• Israel
• Male
• Medication Errors
• Middle Aged
• Models, Statistical
• Pharmaceutical Preparations/administration & dosage
• Pharmacokinetics
• Ranitidine/administration & dosage
• Ranitidine/adverse effects
• Ranitidine/pharmacokinetics
• Renal Insufficiency/drug therapy
• Renal Insufficiency/physiopathology

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Affiliation(s)

Waleed M Sweileh College of Pharmacy, An-Najah National University, Nablus, Palestine.
Samah A Janem
Ansam F Sawalha
Adham S Abu-Taha
Sa'ed H Zyoud
Iyad A Sabri
Samah W Al-Jabi
Nidal A Jaradat
Abed Al-Naser M Zaid

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Les insuffisances rénales aiguës aux quinolones. Revue générale à propos d'une observation avec cristallisation liée à la ciprofloxacine

A 58 year-old woman developed an acute renal failure very quickly after ingestion of two 500 mg tablets of ciprofloxacin, without any other identifiable risk factor. Renal biopsy was performed. No sign of acute interstitial nephritis was observed but tubular lesions were found, accompanied by deposits of a brown-yellowish substance identified by infrared microscopy as a ciprofloxacin salt. The outcome was favourable. This observation gives the opportunity to remind the different forms of quinolone-induced renal injury and to discuss the possible ways for preventing renal side-effects related to the quinolone use.

Quinolone hypersensitivity

PURPOSE OF REVIEW

Quinolones are potent antibacterial agents that can cause drug hypersensitivity reactions affecting different organs. A better understanding of the underlying mechanism and the level of crossreactivity within different quinolones is needed to handle and prevent these diseases.

RECENT FINDINGS

The adverse side-effects caused by quinolones are the result of different immunological mechanisms and cause quite different diseases. The development of an assay detecting quinolone-specific IgE revealed specific antibodies in more than 50% of patients with immediate-type reactions, and the majority of sera also reacted with related compounds. In maculopapular drug exanthemas caused by ciprofloxacin, specific T cells could be detected and cloned. They reacted with ciprofloxacin directly, and crossreactivity to related compounds was detected in approximately 50% of the clones.

SUMMARY

Quinolones can cause drug hypersensitivity reactions by different immunological mechanisms. In-vitro analysis suggests that crossreactivity is common.

Nephrotoxicity and purpura associated with levofloxacin

OBJECTIVE

To report a patient with lung cancer and idiopathic myelofibrosis with myeloid metaplasia who developed purpura and acute renal failure while receiving levofloxacin, and review the existing literature on quinolone nephrotoxicity.

CASE SUMMARY

A 73-year-old white man, with a medical history of non-small-cell lung cancer and idiopathic myelofibrosis with myeloid metaplasia, was prescribed levofloxacin because of a lower urinary tract infection. Three days later, he presented with palpable purpura and erythematous skin lesions over the lower limbs and trunk, with a markedly reduced urinary output. Serum creatinine and urea nitrogen were 6.4 and 190 mg/dL, respectively. Levofloxacin was discontinued, and prednisone, furosemide, and intravenous fluids were given. The patient fully recovered over the ensuing 4 weeks.

CONCLUSIONS

Nephrotoxicity associated with levofloxacin is uncommon. Allergic interstitial nephritis or vasculitis is believed to be the underlying pathologic process. Definitive diagnosis requires performance of renal biopsy, although this is not always feasible. In this case, a return of renal function to normal, with the disappearance of purpura following the discontinuation of levofloxacin and corticosteroid treatment, supports the presumptive diagnosis of a hypersensitivity reaction to levofloxacin.