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Bergelson I, Walker C, Frank EL, Steinberg R. Felbamate urolithiasis. BMJ Case Rep 2023; 16:e253883. [PMID: 38129082 DOI: 10.1136/bcr-2022-253883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Drug-induced nephrolithiasis is an important consideration in recurrent stone formers with polypharmacy. While felbamate nephrolithiasis has previously been published in the paediatric population, we present the oldest published case of a felbamate stone in an adult, a man in his 30s with Lennox-Gastaut syndrome. Even with moderate dosing, high drug serum levels can occur. Performing at least one stone analysis remains a critical component to care in these patients. Urologists should have a high index of suspicion for drug stone when stone analysis returns indeterminate characterisation in the absence of infection. Close communication with neurology is key to preventing recurrent stone disease.
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Affiliation(s)
- Ilana Bergelson
- Department of Urology, The University of Iowa Hospitals and Clinics, Iowa City, lowa, USA
| | - Chance Walker
- Department of Pathology, University of Utah Health, Salt Lake City, Utah, USA
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, Utah, USA
| | - Elizabeth L Frank
- ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, Utah, USA
- University of Utah Health, Salt Lake City, Utah, USA
| | - Ryan Steinberg
- Department of Urology, The University of Iowa Hospitals and Clinics, Iowa City, lowa, USA
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Walsh SJ, Chen RJ, Ershad M, Krueger JA. The Toxicity of Newer and Lesser-Known Anticonvulsant Drugs. Curr Emerg Hosp Med Rep 2020. [DOI: 10.1007/s40138-020-00220-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Sighinolfi MC, Eissa A, Bevilacqua L, Zoeir A, Ciarlariello S, Morini E, Puliatti S, Durante V, Ceccarelli PL, Micali S, Bianchi G, Rocco B. Drug-Induced Urolithiasis in Pediatric Patients. Paediatr Drugs 2019; 21:323-344. [PMID: 31541411 DOI: 10.1007/s40272-019-00355-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Drug-induced nephrolithiasis is a rare condition in children. The involved drugs may be divided into two different categories according to the mechanism involved in calculi formation. The first one includes poorly soluble drugs that favor the crystallization and calculi formation. The second category includes drugs that enhance calculi formation through their metabolic effects. The diagnosis of these specific calculi depends on a detailed medical history, associated comorbidities and the patient's history of drug consumption. There are several risk factors associated with drug-induced stones, such as high dose of consumed drugs and long duration of treatment. Moreover, there are some specific risk factors, including urinary pH and the amount of fluid consumed by children. There are limited data regarding pediatric lithogenic drugs, and hence, our aim was to perform a comprehensive review of the literature to summarize these drugs and identify the possible mechanisms involved in calculi formation and discuss the management and preventive measures for these calculi.
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Affiliation(s)
- Maria Chiara Sighinolfi
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy.
| | - Ahmed Eissa
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
- Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Luigi Bevilacqua
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Ahmed Zoeir
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
- Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Silvia Ciarlariello
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Elena Morini
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Stefano Puliatti
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Viviana Durante
- Pediatric Surgery Department, University of Modena & Reggio Emilia, Modena, Italy
| | - Pier Luca Ceccarelli
- Pediatric Surgery Department, University of Modena & Reggio Emilia, Modena, Italy
| | - Salvatore Micali
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Giampaolo Bianchi
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
| | - Bernardo Rocco
- Department of Urology, University of Modena & Reggio Emilia, Via del Pozzo 71, 41100, Modena, Italy
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Títoff V, Moury HN, Títoff IB, Kelly KM. Seizures, Antiepileptic Drugs, and CKD. Am J Kidney Dis 2019; 73:90-101. [DOI: 10.1053/j.ajkd.2018.03.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 03/06/2018] [Indexed: 01/19/2023]
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Abstract
Drug-induced calculi represent 1-2% of all renal calculi. The drugs reported to produce calculi may be divided into two groups. The first one includes poorly soluble drugs with high urine excretion that favour crystallisation in the urine. Among them, drugs used for the treatment of patients with human immunodeficiency, namely atazanavir and other protease inhibitors, and sulphadiazine used for the treatment of cerebral toxoplasmosis, are the most frequent causes. Besides these drugs, about 20 other molecules may induce nephrolithiasis, such as ceftriaxone or ephedrine-containing preparations in subjects receiving high doses or long-term treatment. Calculi analysis by physical methods including infrared spectroscopy or X-ray diffraction is needed to demonstrate the presence of the drug or its metabolites within the calculi. Some drugs may also provoke heavy intra-tubular crystal precipitation causing acute renal failure. Here, the identification of crystalluria or crystals within the kidney tissue in the case of renal biopsy is of major diagnostic value. The second group includes drugs that provoke the formation of urinary calculi as a consequence of their metabolic effects on urinary pH and/or the excretion of calcium, phosphate, oxalate, citrate, uric acid or other purines. Among such metabolically induced calculi are those formed in patients taking uncontrolled calcium/vitamin D supplements, or being treated with carbonic anhydrase inhibitors such as acetazolamide or topiramate. Here, diagnosis relies on a careful clinical inquiry to differentiate between common calculi and metabolically induced calculi, of which the incidence is probably underestimated. Specific patient-dependent risk factors also exist in relation to urine pH, volume of diuresis and other factors, thus providing a basis for preventive or curative measures against stone formation.
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Affiliation(s)
- Michel Daudon
- CRISTAL Laboratory, Tenon Hospital, Paris, France.
- Laboratoire des Lithiases, Service des Explorations Fonctionnelles Multidisciplinaires, AP-HP, Hôpital Tenon, 4, rue de la Chine, 75020, Paris, France.
- INSERM, UMRS 1155 UPMC, Tenon Hospital, Paris, France.
| | - Vincent Frochot
- Laboratoire des Lithiases, Service des Explorations Fonctionnelles Multidisciplinaires, AP-HP, Hôpital Tenon, 4, rue de la Chine, 75020, Paris, France
- INSERM, UMRS 1155 UPMC, Tenon Hospital, Paris, France
| | - Dominique Bazin
- CNRS, UPMC, Paris, France
- Laboratoire de Chimie de la Matière Condensée de Paris, UPMC, Paris, France
| | - Paul Jungers
- Department of Nephrology, Necker Hospital, AP-HP, Paris, France
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Khaleghi-Rad A, Beyramabadi SA, Morsali A, Ebrahimi M, Khorzandi-Chenarboo M. Tautomerism of the antiepileptic drug Felbamate: A DFT study. J STRUCT CHEM+ 2017. [DOI: 10.1134/s0022476617020044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Ghousheh AI, Groth TW, Fryjoff KM, Wille DF, Mandel NS, Roddy JT, Durkee CT. Urolithiasis in patients on high dose felbamate. J Urol 2012; 189:1865-9. [PMID: 23262038 DOI: 10.1016/j.juro.2012.12.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE We report 4 cases of felbamate urolithiasis. We identified only 1 prior case report of a felbamate stone. Felbamate is an antiepileptic drug used to treat refractory seizures and has minor side effects when given in recommended doses. We analyzed the characteristics, evaluation, treatment and outcomes in this challenging group of patients. MATERIALS AND METHODS Following institutional review board approval, we conducted a retrospective chart review of all patients who presented with a diagnosis of urolithiasis, were on felbamate and had stone analysis consistent with a felbamate origin. RESULTS All 4 patients had refractory seizures and 3 had severe developmental delay. Presentation ranged from an incidental finding to gross hematuria to agitation and pain. Stones were not visible on plain x-ray except in 1 case involving mixed stone composition. Decrease or cessation of the drug has not been feasible in 2 patients, and 3 patients have had recurrent stones. Initial stone analysis did not correctly identify the stone composition as felbamate in 2 cases, suggesting that the origin of these stones may not always be recognized. CONCLUSIONS We report the occurrence of felbamate stones in a series of patients on high dose felbamate therapy. Accurate diagnosis is made more difficult by the clinical complexity of the patient population (including severe developmental delay), the radiolucent nature of the stones and the possibility of inaccurate analysis of stone composition.
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Affiliation(s)
- Anas I Ghousheh
- Department of Urology, Children's Hospital of Wisconsin, Milwaukee, Wisconsin 53226, USA
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Abstract
The newer antiepileptic drugs (AEDs) provide more therapeutic options and overall improved safety and tolerability for patients. To provide the best care, physicians must be familiar with the latest tolerability and safety data. This is particularly true in children, given there are relatively fewer studies examining the effects of AEDs in children compared with adults. Since we now have significant paediatric literature on each of these agents, we provide a comprehensive and current literature review of the newer AEDs, focusing on safety and tolerability data in children and adolescents. Because the safety profiles in children differ from those in adults, familiarity with this literature is important for child neurologists and other paediatric caregivers. We have organized the data by organ system for each AED for easier reference.
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Affiliation(s)
- Dean P Sarco
- Department of Neurology, Division of Epilepsy and Clinical Neurophysiology, Children's Hospital Boston, Boston, Massachusetts, USA.
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Abstract
OBJECTS The relationship between antiepileptic drugs (AEDs) polytherapy and urinary pH was studied to demonstrate the effect and difference of AED polytherapy compared to monotherapy. MATERIALS AND METHODS A total of 271 urine samples from patients receiving AED polytherapy aged from 7 months to 35 years were enrolled. Two AEDs were co-administered to 215 patients, three AEDs to 45 patients, four AEDs to ten patients, and five AEDs to one patient. RESULTS The distribution of urinary pH shifted to the alkaline range with increasing numbers of co-administered AEDs (p < 0.0001). The distribution of urinary pH shifted to the alkaline side with AED polytherapy that included valproate (p < 0.05) or acetazolamide (p < 0.03). The distribution of urinary pH did not change with or without zonisamide, carbamazepine, phenobarbital, phenytoin, or clonazepam. CONCLUSIONS Urinary pH should be monitored in patients receiving AED polytherapy, particularly those receiving valproate, acetazolamide, or various AEDs in combination.
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Affiliation(s)
- Tohshin Go
- Department of Infants' Brain and Cognitive Development, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
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Abstract
INTRODUCTION Drugs and their metabolites are known factors in 1% to 2% of all kidney stones. Certain antiepileptic drugs are known to cause stone formation. Phenytoin is used as a first line antiepileptic therapy for many seizure disorders. We present what we believe to be the first report of a phenytoin metabolite urinary stone. METHODS A 79-year-old woman with a fever and seizure disorder was found to have a right pelvic kidney with hydronephrosis and multiple large calcifications. She had been taking the antiepileptic medication phenytoin for the past 10 years. Average total serum phenytoin level from the year prior was in the normal range. Free phenytoin levels were not routinely monitored, but the one value available was elevated at 5.1 ng/dL. The patient underwent a percutaneous nephrolitomy, ultimately expiring from medical complications after the procedure. Final stone analysis revealed a composition of 35% phenytoin metabolite (5-(para-hydroxyphenyl)-5-phenylhydantoin) and 65% proteinaceous material. An extensive review of literature including PubMed, MedLine, and various internet search engines was performed, searching for any prior reports of urinary calculi formed from phenytoin or its metabolite. RESULTS No previous reports of phenytoin or phenytoin metabolite urinary stones were found in the medical literature. Phenytoin has many known ill effects on the genitourinary system including acute interstitial nephritis, nephrotic syndrome, acute renal failure, and priapism. Now we can add urinary lithiasis to the list of its potential adverse effects. This article represents the first report of a phenytoin metabolite urinary stone. CONCLUSION A metabolite of the commonly used antiepileptic medication phenytoin can cause clinically relevant urolithiasis leading to significant morbidity and even mortality. Clinicians should have an increased level of suspicion for metabolite stone formation in symptomatic patients taking antiepileptic medications. Further studies on phenytoin metabolism and its potential for inducing urinary lithiasis should be performed.
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Abstract
The number of medications used to treat different types of seizures has increased over the last 10-15 years. Most of the newer antiepileptic drugs (AEDs) are likely to be unfamiliar to many nephrologists. For both the older and newer AEDs, basic pharmacokinetic information, recommendations for drug dosing in patients with reduced kidney function or who are on dialysis, and adverse renal and fluid-electrolyte effects are reviewed. Newer AEDs are less likely to have significant drug-drug interactions than older agents, but are more likely to need dosage adjustment in patients with reduced kidney function. The most common renal toxicities of these drugs include metabolic acidosis, hyponatremia, and nephrolithiasis; interstitial nephritis and other adverse effects are less common. Little is known about the clearance of most of the newer AEDs with high-efficiency hemodialyzers or with peritoneal dialysis. Monitoring of drug levels when available, careful clinical assessment of patients taking AEDs, and close collaboration with neurologists is essential to the management of patients taking AEDs.
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Affiliation(s)
- Rubeen K Israni
- Renal-Electrolyte and Hypertension Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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Abstract
OBJECTS Since alkaline urine is a risk factor for urolithiasis, the relationship between antiepileptic drugs and urinary pH was retrospectively studied in epilepsy patients treated with antiepileptic drug monotherapy for more than 1 month. METHODS A total of 913 urinary samples from antiepileptic drug-treated patients were compared with 780 age-matched control samples, and with 112 samples from epilepsy patients who had not been treated with antiepileptic drugs. The antiepileptic drugs administered were carbamazepine, valproate, phenobarbital, zonisamide, sulthiame, and phenytoin. CONCLUSIONS The proportion of the acid urine in the valproate-treated patients was lower than that in controls. The proportion of the alkaline urine in the valproate-treated patients was higher than that in controls. This effect was independent of age, sex, and the serum valproate concentration. There was no significant difference in urinary pH among the epilepsy patients treated with other antiepileptic drugs, the epilepsy patients who had not been treated with antiepileptic drugs, and the controls.
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Affiliation(s)
- Tohshin Go
- Department of Infants' Brain and Cognitive Development, Tokyo Women's Medical University, Tokyo, 162-8666, Japan.
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Abstract
Urolithiasis is a rare side effect of antiepileptic drugs. To clarify the risk factors for urolithiasis induced by antiepileptic drugs, the effect of antiepileptic drug monotherapy on crystalluria was studied, and zonisamide or sulthiame therapy and alkaline urine were demonstrated to be risk factors. In the next investigation, the effect of antiepileptic drug polytherapy on crystalluria was retrospectively studied in epilepsy patients treated for more than 1 month during the last 7 years. A total of 278 urine specimens from epilepsy patients aged between 7 months and 36 years were enrolled in this study. The mean age was 12.3 years. There were 109 samples from females and 169 from males. Antiepileptic drugs administered in this study were valproate (174 urinary samples), zonisamide (139), carbamazepine (138), phenobarbital (65), phenytoin (52), acetazolamide (17), clonazepam (15), sulthiame (6), ethosuximide (6), nitrazepam (4), and clobazam (4). Epilepsy patients treated with antiepileptic drug polytherapy were frequently found to have crystalluria in patients demonstrating alkaline urine and taking acetazolamide, zonisamide (particularly with high serum levels), or many antiepileptic drugs in combination. Regular urinalysis seems to be necessary in these patients, and the evaluation for urolithiasis should be performed if persistent crystalluria is demonstrated.
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Affiliation(s)
- Tohshin Go
- Department of Infants' Brain and Cognitive Development, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
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