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Xu R, Gao Q, Zhang Y, Lin Y, Li Y, Su L, Zhou S, Cao Y, Gao P, Li P, Luo F, Chen R, Zhang X, Nie S, Xu X. Associations between Different Antivirals and Hospital-Acquired Acute Kidney Injury in Adults with Herpes Zoster. Clin J Am Soc Nephrol 2024; 19:694-703. [PMID: 38527975 PMCID: PMC11168829 DOI: 10.2215/cjn.0000000000000452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
Key Points Among intravenous antivirals, acyclovir was associated with the highest risk of hospital-acquired AKI, followed by penciclovir/ganciclovir and foscarnet. The risk of hospital-acquired AKI was dose dependent for intravenous nucleoside analogs. Background To examine the association of use of different antivirals with hospital-acquired AKI among Chinese adults with herpes zoster. Methods This study selected 3273 adult patients who received antiviral therapy for herpes zoster during hospitalization from the China Renal Data System. We identified and staged AKI using patient-level serum creatinine data according to the Kidney Disease Improving Global Outcomes criteria. We compared the relative risks of hospital-acquired AKI among patients treated with different antivirals using Cox proportional hazards models. Results Among 3273 patients, 1480 (45%), 681 (21%), 489 (15%), and 623 (19%) were treated with acyclovir/valacyclovir, ganciclovir, penciclovir/famciclovir, and foscarnet, respectively. During the follow-up period, a total of 111 cases of hospital-acquired AKI occurred, predominantly classified as AKI stage 1. The cumulative incidences of hospital-acquired AKI were 5%, 3%, 3%, and 1% in the patients receiving acyclovir/valacyclovir, ganciclovir, penciclovir/famciclovir, and foscarnet, respectively. Compared with acyclovir/valacyclovir, penciclovir/famciclovir/ganciclovir and foscarnet were associated with a lower risk of hospital-acquired AKI, with an adjusted hazard ratio of 0.59 (95% confidence interval [CI], 0.37 to 0.94) and 0.27 (95% CI, 0.11 to 0.63), respectively. Compared with intravenous acyclovir, intravenous penciclovir/ganciclovir and foscarnet were associated with a lower risk of hospital-acquired AKI with an adjusted hazard ratio of 0.53 (95% CI, 0.29 to 0.98) and 0.31 (95% CI, 0.12 to 0.76), respectively. The associations were consistent across various subgroups and sensitivity analyses. Conclusions Among antiviral therapies for herpes zoster, we found different risks of hospital-acquired AKI among the patients receiving different antivirals, in particular, those administered intravenously. Among intravenous antivirals, acyclovir was associated with the highest risk of hospital-acquired AKI, followed by penciclovir/ganciclovir and foscarnet. Confirmation studies with large samples from other populations are warranted.
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Affiliation(s)
- Ruqi Xu
- Division of Nephrology, State Key Laboratory of Organ Failure Research, Guangdong Provincial Key Laboratory of Renal Failure Research, National Clinical Research Center for Kidney Disease, Guangdong Provincial Institute of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Joerger T, Hayes M, Stinson C, Mikhail I, Downes KJ. Incidence of Antimicrobial-Associated Acute Kidney Injury in Children: A Structured Review. Paediatr Drugs 2024; 26:59-70. [PMID: 38093147 PMCID: PMC10983053 DOI: 10.1007/s40272-023-00607-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/08/2023] [Indexed: 01/06/2024]
Abstract
Acute kidney injury (AKI) is a commonly reported adverse effect of administration of antimicrobials. While AKI can be associated with poorer outcomes, there is little information available to understand rates of AKI in children exposed to various antimicrobials. We performed a structured review using the PubMed and Embase databases. Articles were included if they provided an AKI definition in patients who were < 19 years of age receiving an antimicrobial and reported the frequency of AKI. Author-defined AKI rates were calculated for each study and mean pooled estimates for each antimicrobial were derived from among all study participants. Pooled estimates were also derived for those studies that reported AKI according to pRIFLE (pediatric risk, injury, failure, loss, end stage criteria), AKIN (acute kidney injury network), or KDIGO (kidney disease improving global outcomes) creatinine criteria. A total of 122 studies evaluating 28 antimicrobials met the inclusion criteria. Vancomycin was the most commonly studied drug: 11,514 courses across 44 included studies. Among the 27,285 antimicrobial exposures, the overall AKI rate was 13.2% (range 0-42.1% by drug), but the rate of AKI varied widely across studies (range 0-68.8%). Cidofovir (42.1%) and conventional amphotericin B (37.0%) had the highest pooled rates of author-defined AKI. Eighty-one studies used pRIFLE, AKIN, or KDIGO AKI criteria and the pooled rates of AKI were similar to author-defined AKI rates. In conclusion, antimicrobial-associated AKI is reported to occur frequently in children, but the rates of AKI varies widely across studies and drugs. Most published studies examined hospitalized patients and heterogeneity in study populations and in author definitions of AKI are barriers to a comparison of nephrotoxicity risk among antimicrobials in children.
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Affiliation(s)
- Torsten Joerger
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Molly Hayes
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Connor Stinson
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Ibram Mikhail
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Kevin J Downes
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Infectious Diseases, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
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ElHassan NO, Crawford B, Alamarat Z, Painter JT. Clinical Review of Risk of Nephrotoxicity with Acyclovir Use for Treatment of Herpes Simplex Virus Infections in Neonates and Children. J Pediatr Pharmacol Ther 2023; 28:490-503. [PMID: 38130345 PMCID: PMC10731947 DOI: 10.5863/1551-6776-28.6.490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Indexed: 12/23/2023]
Abstract
OBJECTIVE This study aims to clarify the risk of nephrotoxicity with intravenous use of acyclovir (ACV) for the treatment of neonates (ages <3 months) and children (ages ≥3 months to <12 years) with herpes simplex virus (HSV) infections and to identify gaps in knowledge that could be further investigated. METHODS Multiple databases were searched to identify studies on risk of nephrotoxicity with ACV use for treatment of invasive HSV infections, defined as any neonatal infection or HSV encephalitis (HSE) in children. RESULTS There were 5 and 14 studies that evaluated the risk of ACV-associated nephrotoxicity in neonates and children, respectively. The US Food and Drug Administration (FDA) delayed the approval of high (HD; 60 mg/kg/day) ACV in neonates secondary to risk of toxicity. Based on our review, the risk of ACV-associated nephrotoxicity was lower in the neonatal compared with the pediatric population. Acyclovir dose >1500 mg/m2, older age, and concomitant use of nephrotoxic drugs were identified as variables that increased the risk of ACV nephrotoxicity in children. Although the FDA has approved the use of HD ACV for the treatment of HSE in children, the American Academy of Pediatrics recommends a lower dose to minimize the risk of toxicity. The efficacy and safety of high vs lower doses of ACV for the management of HSE in children has yet to be evaluated. CONCLUSIONS The risk of ACV-associated nephrotoxicity was lower among neonates compared with older children. Future studies are needed to identify the optimal dosage that minimizes toxicities and maximizes the efficacy of ACV in children with HSE.
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Affiliation(s)
- Nahed O. ElHassan
- Division of Neonatology (NOE), Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR
| | - Brendan Crawford
- Division of Nephrology (BC), Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR
| | - Zain Alamarat
- Division of Infectious Disease (ZA), Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children’s Hospital, Little Rock, AR
| | - Jacob T. Painter
- Division of Pharmaceutical Evaluation & Policy (JTP), College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR
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Adarsha N, Samprathi M, Sankhyan N, Singh MP, Bansal A, Jayashree M, Angurana SK, Nallasamy K. An Observational Study on Pattern of Empirical Acyclovir Therapy in Children With Acute Encephalitis From Northern India. Pediatr Crit Care Med 2023; 24:e322-e331. [PMID: 37097038 DOI: 10.1097/pcc.0000000000003237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
OBJECTIVES To identify the prevalence of herpes simplex encephalitis (HSE), factors influencing the duration of empirical acyclovir and frequency of acute kidney injury (AKI) in children with acute encephalitis syndrome (AES). DESIGN Prospective observational study. SETTING Pediatric Emergency Department and PICU of a tertiary hospital in Northern India. PATIENTS All consecutive, eligible children between 1 month and 12 years old presenting with AES, defined as altered consciousness for greater than 24 hours (including lethargy, irritability, or a change in personality) and two or more of the following signs: 1) fever (temperature ≥ 38°C) during the current illness, 2) seizures or focal neurological signs, 3) cerebrospinal fluid (CSF) pleocytosis, 4) electroencephalogram, and/or 5) neuroimaging suggesting encephalitis, who received at least one dose of acyclovir. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 101 children screened, 83 were enrolled. The median (interquartile range [IQR]) age was 3 years (1-6 yr). Thirty-one children (37.3%) were diagnosed with AES, of which four were labeled as probable HSE (three based on MRI brain, one based on serology). Scrub typhus, dengue, Japanese encephalitis, and mumps were the other infective causes. The median (IQR) duration of acyclovir therapy was 72 hours (24-264 hr); 21 children (25.3%) received acyclovir for less than 24 hours and 11 (13.3%) for greater than or equal to 14 days. New-onset AKI was seen in 18 children (21.7%) but was mostly transient. Death ( n = 8, 9.6%) and discontinuation of care due to futility or other reasons ( n = 15, 18%) were noted in 23 children (28%). Factors associated with duration of acyclovir greater than 7 days, on univariable analysis, were lower modified Glasgow Coma Score at admission, requirement of invasive ventilation, invasive intracranial pressure monitoring, and CSF pleocytosis (5-500 cells). On multivariable analysis, only CSF pleocytosis of 5-500 cells was associated with duration of acyclovir greater than 7 days. CONCLUSIONS Given the low prevalence of HSE, and the risk of AKI, this study sensitizes the need to review our practice on initiation and stopping of empirical acyclovir in children with acute encephalitis.
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Affiliation(s)
- Naik Adarsha
- Department of Pediatrics, Kasturba Medical College, Manipal, Karnataka, India
| | - Madhusudan Samprathi
- Department of Pediatrics, All India Institute of Medical Sciences Bibinagar, Hyderabad Metropolitan Region, Telangana, India
| | - Naveen Sankhyan
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Mini P Singh
- Department of Virology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Arun Bansal
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Muralidharan Jayashree
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Suresh Kumar Angurana
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Karthi Nallasamy
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Yalçınkaya R, Öz FN, Kaman A, Aydın Teke T, Yaşar Durmuş S, Çelikkaya E, Tanır G. Factors associated with acyclovir nephrotoxicity in children: data from 472 pediatric patients from the last 10 years. Eur J Pediatr 2021; 180:2521-2527. [PMID: 33956193 DOI: 10.1007/s00431-021-04093-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/24/2021] [Accepted: 04/28/2021] [Indexed: 12/29/2022]
Abstract
Acyclovir may cause acute kidney injury (AKI) due to the accumulation of relatively insoluble acyclovir crystals in renal tubules. The aim of this study was to evaluate risk factors associated with acyclovir-related AKI in children. Between January 2010 and December 2019, pediatric recipients of intravenous (IV) acyclovir were evaluated retrospectively. There were a total of 472 patients [249 (52.7%) boys] of which 32 (6.8%) had AKI [15 (46.8%) boys]. Patients with AKI had greater mean age, baseline creatinine level, and duration of treatment compared to patients without AKI (p<0.001). In the AKI group, concomitant nephrotoxic drug use was more frequent (p=0.032), and the percentage of patients treated with 1500 mg/m2/day dosage was higher (p<0.001). AKI was diagnosed at a mean of 4.3 ± 2.5 days after acyclovir initiation and creatinine levels returned to normal at a mean of 7.3 ± 3.6 days after AKI diagnosis. Only eight patients (25%) had vomiting which led to suspicion of AKI. Being older than 100.5 months (HR: 4.501, 95% CI: 1.802-11.241; p=0.001), use of 1500 mg/m2/day acyclovir (HR: 9.536, 95% CI: 2.157-42.158; p=0.003) and use of concomitant nephrotoxic drugs (HR: 5.043, 95% CI: 2.289-11.109; p<0.001) were the factors that independently increased the likelihood of nephrotoxicity.Conclusion: Most patients were asymptomatic when they were diagnosed with AKI. Clinicians should be aware of AKI risk in pediatric patients with risk factors (age >100.5 months, 1500 mg/m2/day dosage, concomitant use of nephrotoxic drugs). Acyclovir dosing should be evaluated in prospective, multicenter studies in order to identify the lowest possible therapeutic doses that do not increase AKI risk. What is Known: • Although acyclovir is mostly well tolerated, nephrotoxicity may be seen due to the accumulation of acyclovir crystals in renal tubules. • Older age, obesity, and concomitant use of other nephrotoxic drugs are reported to be risk factors for acyclovir-induced AKI in children. What is New: • In this study, pediatric patients with acyclovir-induced AKI were older, received treatment longer, received concomitant nephrotoxic drugs more commonly, and had higher acyclovir dosage and baseline creatinine levels compared to those without AKI. • Being older than 100.5 months of age, use of 1500 mg/m2/day dosage and use of nephrotoxic drugs concomitantly appear to be the prominent risk factors for AKI development in children treated with acyclovir.
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Affiliation(s)
- Rumeysa Yalçınkaya
- Department of Pediatric Infectious Diseases, Dr. Sami Ulus Children's Health and Diseases Research and Training Hospital, Ankara, Turkey.
| | - Fatma Nur Öz
- Department of Pediatric Infectious Diseases, Dr. Sami Ulus Children's Health and Diseases Research and Training Hospital, Ankara, Turkey
| | - Ayşe Kaman
- Department of Pediatric Infectious Diseases, Dr. Sami Ulus Children's Health and Diseases Research and Training Hospital, Ankara, Turkey
| | - Türkan Aydın Teke
- Department of Pediatric Infectious Diseases, Dr. Sami Ulus Children's Health and Diseases Research and Training Hospital, Ankara, Turkey
| | - Sevgi Yaşar Durmuş
- Department of Pediatric Infectious Diseases, Dr. Sami Ulus Children's Health and Diseases Research and Training Hospital, Ankara, Turkey
| | - Evra Çelikkaya
- Department of Pediatric Nephrology, Dr. Sami Ulus Children's Health and Diseases Research and Training Hospital, Ankara, Turkey
| | - Gönül Tanır
- Department of Pediatric Infectious Diseases, Dr. Sami Ulus Children's Health and Diseases Research and Training Hospital, Ankara, Turkey
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Du WW, Wang XX, Zhang D, Chen WQ, Zhang XL, Li PM. Retrospective analysis on incidence and risk factors of early onset acute kidney injury after lung transplantation and its association with mortality. Ren Fail 2021; 43:535-542. [PMID: 33736580 PMCID: PMC7993381 DOI: 10.1080/0886022x.2021.1883652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Acute kidney injury (AKI) is a common complication after lung transplantation (LTx) which is closely related to the poor prognosis of patients. We aimed to explore potential risk factors and outcomes associated with early post-operative AKI after LTx. METHODS A retrospective study was conducted in 136 patients who underwent LTx at our institution from 2017 to 2019. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) guideline. Univariate and multivariate analyses were conducted to identify risk factors related to AKI. The primary outcome was the incidence of AKI after LTx. Secondary outcomes were associations between AKI and short-term clinical outcomes and mortality. RESULTS Of the 136 patients analyzed, 110 developed AKI (80.9%). AKI was associated with higher baseline eGFR (odds ratio (OR) 1.01 (95% confidence interval (CI): 1.00-1.03)) and median tacrolimus (TAC) concentration (OR 1.15 (95% CI: 1.02-1.30)). Patients with AKI suffered longer mechanical ventilation days (p = .015) and ICU stay days (p = .011). AKI stage 2-3 patients had higher risk of 1-year mortality (HR 16.98 (95% CI: 2.25-128.45)) compared with no-AKI and stage 1 patients. CONCLUSIONS Our results suggested early post-operative AKI may be associated with higher baseline eGFR and TAC concentrations. AKI stage 1 may have no influence on survival rate, whereas AKI stage 2-3 may be associated with increased mortality at 1-year.
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Affiliation(s)
- Wen-Wen Du
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Xiao-Xing Wang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Dan Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Wen-Qian Chen
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Xiang-Lin Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
| | - Peng-Mei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, China
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Sarsam T, McWilliam SJ. Aciclovir and acute kidney injury: putting the research in context. Arch Dis Child 2020; 105:1206-1207. [PMID: 33032994 DOI: 10.1136/archdischild-2019-318764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/22/2020] [Accepted: 09/12/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Tania Sarsam
- Medical School, University of Liverpool, Liverpool, UK
| | - Stephen J McWilliam
- Department of Women's and Children's Health and MRC Centre for Drug Safety Science, University of Liverpool, Liverpool, UK
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