Recent
literature has linked AKI with vancomycin and zosyn and it was thought that the
higher vancomycin levels might have been the culprit.
It was
also assumed that the injury was either AIN or ATN. Few biopsies done in these
cases were suggestive of ATN in the past( vancomycin mainly). Personal
experience, I have seen ATN from vancomycin as well that is biopsy proven.
In JASN,
Luque et al might have discovered what is the mechanism behind
vancomycin toxicity. The biopsy of a single case presented showed tubular casts
entangled with uromodulin. EM showed
vancomycin particles in the tubular cast when immunogold labeling was
used. Staining with anti-vancomycin
antibody revealed the specific accumulation of vancomycin in the tubular lumen
mainly. Similar to myeloma casts, this leads to an intratubular obstructive
ATN. A CD68+ macrophagic infiltrate was also observed
surrounding the casts and within the kidney’s interstitium, suggesting that
pathologic casts might induce an inflammatory process. To further confirm the pathogenicity of
vancomycin-associated casts, they retrospectively
examined eight additional renal biopsies with ATN that had been performed in
the clinical context of high-vancomycin trough levels preceding AKI. Similar
findings were noted in the biopsies. Vancomycin
trough levels ranged from 35-106mg/dl in the 8 patients. 50% of the patients required dialysis. To confirm, they did in studies in mice and injected
vancomycin and observed effects in the kidney.Kidney injuries have been visible
as early as two days after vancomycin injection.
In summary, this article is the first to describe the
novel form of injury an antibiotic can give.This can explain the sometimes noticed rapid rises we
noted in some cases of acute ATN with vancomycin and perhaps even other antibiotics.
Should we be giving pre and post hydration like we do for
acyclovir when giving vancomycin to prevent AKI?
Check out this amazing paper! Kudos on thinking out of the box and finally giving us a potential mechanism!
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