HEMATURIA AND PROTEINURIA ASSOCIATED WITH METHICILLIN ADMINISTRATION

Interstitial nephritis with acute renal failure following cardiac surgery and treatment with methicillin

Six patients developed acute renal failure 13-19 days after cardiac surgery with extracorporeal circulation. None of the patients had suffered from postoperative hypotension; slight hemolysis was present for only 1-2 days post-operatively. Acute renal failure lasted for 11-80 days in four patients. In two patients creatinine clearance stabilized at reduced values. Seven renal biopsies from the six patients showed severe acute interstitial nephritis with mononuclear cellular infiltration and distal tubular damage. No immune deposits were detected in glomeruli or tubular basement membrane. All six patients had been treated prophylactically with methicillin and the acute renal disease was probably elicited by this drug.

Tubulointerstitial nephritis

Tubulointerstitial nephritis (TIN) describes a range of pathological processes that are at least partly responsible for the progression of renal disease of nearly all aetiologies. TIN is frequently the most important pathological manifestation of progressive glomerulonephritis, obstructive uropathy, reflux nephropathy and cystic diseases, although it may also present as a primary disease process associated with infection, drug use or other immunologically mediated disease. Recent clinical and laboratory research has increased our knowledge of tubulointerstitial structure, physiological function and tubulointerstitial response to injury. This review presents a classification of TIN in which acute and chronic tubulointerstitial diseases are recognized as forming a continuum. Primary TIN and TIN associated with glomerulonephritis, obstructive nephropathy and chronic progressive renal disease are discussed from both clinical and pathogenic aspects. It is argued that chronic TIN is a disease process in which inflammation is accompanied by a destructive tubulopathy and fibrogenesis. In acute TIN there is a cessation and reversal of this process. It is suggested that most forms of TIN have an immunological basis because of the presence of immune cell infiltrates, the occurrence of TIN in several immune diseases and immunological animal models of TIN. However, to date TIN has not been convincingly modified in patients by immune manipulation. Experimental evidence suggesting an important pathogenic role for proteinuria and antigenuria, and the renal tubule cell acting as an antigen-presenting cell is discussed.

Acute tubulointerstitial nephritis

Acute tubulointerstitial nephritis (ATIN) is a common disorder characterized by a spectrum of clinical manifestations ranging from asymptomatic urinary abnormalities to acute oliguric renal failure. Tubular dysfunction out of proportion to the degree of renal failure is an important clue to the diagnosis. This review describes its pathogenesis, pathophysiology, diagnosis, differential diagnosis and therapy, emphasizing the drug-induced form of ATIN.

Nephrotoxic tubular and interstitial lesions: morphology and classification

Nephrotoxic renal injury, and especially drug nephrotoxicity is now a common cause of acute renal failure. The most common patterns of renal injury produced by nephrotoxins, tubular damage, and interstitial nephritis, are discussed here. Toxic agents which are primarily tubular toxins include certain antibiotics, cisplatinum, anesthetics, and radiocontrast agents. In tubules injured by toxins, alterations range from subtle ultrastructural abnormalities to extensive tubular necrosis. Mechanisms of tubular injury include direct tubular cell toxicity, and alterations in intrarenal blood flow producing secondary tubular damage. Other commonly used therapeutic agents, including the penicillins, other antibiotics, and non-steroidal anti-inflammatory agents, produce renal dysfunction by inducing interstitial nephritis. Long-term analgesic abuse is associated with a particularly striking interstitial damage with frank papillary necrosis. Criteria for differentiating primary tubular injury with inflammation and primary interstitial nephritis with tubular injury are discussed. Individual commonly-used therapeutic agents are considered in some detail, with discussion of both clinical and morphological aspects of drug nephrotoxicity.

Treatment of bacterial infections of the central nervous system

Antimicrobial agents for the treatment of bacterial meningitis and other pyogenic intracranial infections have now been in use for approximately 45 years. The last decade, however, has been a period of tremendous advances in knowledge of the pharmacokinetics and other characteristics of the available drugs. The identification of factors that affect their in vivo metabolism and excretion, the importance of drug interactions, and the development of methods for estimation of serum and cerebrospinal fluid levels have added both complexity and sophistication to the clinical utilization of the antimicrobial agents. The number of available antimicrobials has expanded greatly during recent years, although the penicillins, chloramphenicol, and the aminoglycosides remain the mainstay of antibiotic treatment in the majority of cases of bacterial infection of the central nervous system.

Toxic nephropathy from diagnostic and therapeutic agents. Review and commentary

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

Nafcillin therapy for Staphylococcus aureus endocarditis

Semisynthetic penicillinase-resistant penicillins are recommended for therapy of Staphylococcus aureus endocarditis, but evaluation of the efficacy and safety of individual agents has received little attention. At The New York Hospital, 11 heroin addicts and 5 nonaddicts were treated with nafcillin. The 11 addicts did well clinically, but four of the five nonaddicts had severe complications, and three of them died. Important adverse reactions to nafcillin occurred in two patients: one developed leukopenia, and one developed an extensive rash. Methicillin was employed to treat two heroin addicts and four nonaddicts. Five of the six patients were cured bacteriologically, but three patients developed nephritis and one patient developed an extensive rash. Nafcillin appears to be highly efficacious for the treatment of S. aureus endocarditis, yielding results at least equal to those obtained with other drugs. Because adverse reactions appear to occur more frequently with methicillin than with nafcillin, we regard nafcillin as the preferable penicillinase-resistant penicillin for the treatment of S. aureus endocarditis.

Clinical pharmacology of mezlocillin

Mezlocillin is a new broad-spectrum semisynthetic penicillin that has shown encouraging in vitro activity against the infecting organisms most likely to cause mortality and morbidity in cancer patients receiving chemotherapy. The serum clearances and urine recoveries of mezlocillin, ampicillin, and carbenicillin were compared after the intravenous administration of single 3-g doses. The peak mean serum concentrations of mezlocillin and carbenicillin were 269 and 278 mug/ml, respectively, whereas the peak ampicillin level was lower at 167 mug/ml. The terminal half-life of mezlocillin, 66 min, was not significantly different from those of ampicillin and carbencillin (63 and 77 min, respectively). Recoveries of mezlocillin, ampicillin, and carbenicillin from urine over 6-h periods after drug dosage were 45, 61, and 80%, respectively. A further study in 11 cancer patients examined serum maintenance levels of mezlocillin when 3-g doses were given intravenously every 4 h for at least 7 consecutive days. After 3 days of therapy, the mean serum concentrations were maintained above 50 mug/ml. Although therapeutic efficacy was not an objective of this study, all of three documented bacterial infections were cured, and no serious toxicity was encountered.

Methicillin hemorrhagic cystitis

Interstitial nephritis is a recognized complication of methicillin therapy. Hemorrhagic cystitis due to methicillin has not been emphasized. Evidence of hemorrhagic cystitis developed in six patients receiving methicillin therapy and was confirmed by cystoscopy in three of them.

Hyaline cast formation in patients treated with cephaloridine

The administration of 6 g. cephaloridine daily produced large numbers of hyaline casts during treatment, occasionally accompanied by red and white cells and albumin. These cleared when treatment ended and are of uncertain and doubtful significance.