amphotericin-b and Renal-Insufficiency--Chronic

Two-stage exchange arthroplasty with a high-dose antibiotic-loaded bone cement (ALBC) spacer and intravenous or oral antibiotics is the most common method of managing a periprosthetic joint infection (PJI) after a total knee arthroplasty (TKA). However, little is known about the contemporary incidence, the risk factors, and the outcomes of acute kidney injuries (AKIs) in this cohort.. We identified 424 patients who had been treated with 455 ALBC spacers after resection of a PJI following a primary TKA from 2000 to 2017. The mean age at resection was 67 years, the mean body mass index (BMI) was 33 kg/m2, 47% of the patients were women, and 15% had preexisting chronic kidney disease (CKD). The spacers (87% nonarticulating) contained a mean of 8 g of vancomycin and 9 g of an aminoglycoside per construct (in situ for a mean of 11 weeks). Eighty-six spacers also had amphotericin B (mean, 412 mg). All of the patients were concomitantly treated with systemic antibiotics for a mean of 6 weeks. An AKI was defined as a creatinine level of ≥1.5 times the baseline or an increase of ≥0.3 mg/dL within any 48-hour period. The mean follow-up was 6 years (range, 2 to 17 years).. Fifty-four AKIs occurred in 52 (14%) of the 359 patients without preexisting CKD versus 32 AKIs in 29 (45%) of the 65 patients with CKD (odds ratio [OR], 5; p = 0.0001); none required acute dialysis. Overall, when the vancomycin concentration or aminoglycoside concentration was >3.6 g/batch of cement, the risk of AKI increased (OR, 1.9 and 1.8, respectively; p = 0.02 for both). Hypertension (β = 0.17; p = 0.002), perioperative hypovolemia (β = 0.28; p = 0.0001), and acute atrial fibrillation (β = 0.13; p = 0.009) were independent predictors for AKI in patients without preexisting CKD. At the last follow-up, 8 patients who had sustained an AKI had progressed to CKD, 4 of whom received dialysis.. In our study, the largest series to date that we are aware of regarding this issue, AKI occurred in 14% of patients with normal renal function at baseline, and 2% developed CKD after undergoing a 2-stage exchange arthroplasty for a PJI after TKA. However, the risk of AKI was fivefold greater in those with preexisting CKD. The causes of acute renal blood flow impairment were independent predictors for AKI.. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Topics: Acute Kidney Injury; Administration, Oral; Adult; Aged; Aged, 80 and over; Amphotericin B; Anti-Bacterial Agents; Arthroplasty, Replacement, Knee; Bone Cements; Creatinine; Disease Progression; Drug Implants; Female; Follow-Up Studies; Gentamicins; Humans; Incidence; Injections, Intravenous; Male; Middle Aged; Odds Ratio; Prosthesis-Related Infections; Renal Insufficiency, Chronic; Retrospective Studies; Risk; Risk Factors; Tobramycin; Treatment Outcome; Vancomycin

Pentavalent antimonials are the first-line drug treatment for American tegumentary leishmaniasis. We report on a patient with chronic renal failure on hemodialysis who presented with cutaneous lesions of leishmaniasis for four months. The patient was treated with intravenous meglumine under strict nephrological surveillance, but cardiotoxicity, acute pancreatitis, pancytopenia, and cardiogenic shock developed rapidly. Deficient renal clearance of meglumine antimoniate can result in severe toxicity, as observed in this case. These side effects are related to cumulative plasma levels of the drug. Therefore, second-line drugs like amphotericin B are a better choice for patients on dialysis.

Topics: Adult; Amphotericin B; Antiprotozoal Agents; Brazil; Drug-Related Side Effects and Adverse Reactions; Humans; Leishmaniasis, Cutaneous; Male; Meglumine Antimoniate; Renal Dialysis; Renal Insufficiency, Chronic

The case of a patient who experienced probable infusion-related reactions to amphotericin B lipid complex (ABLC) but tolerated continued amphotericin B therapy after a switch to an alternative lipid-based formulation is reported.. A 28-year-old immunocompromised man with pneumonia, respiratory failure, and neutropenic fever was initiated on ABLC and other antibiotics for suspected invasive aspergillosis. Due to the patient's deteriorating renal function, the use of amphotericin B was deemed preferable to the standard therapy for invasive aspergillosis (voriconazole) even though he had experienced likely infusion-related reactions to ABLC on two prior occasions. During the infusion of ABLC, significant increases in the man's temperature, respiratory rate, systolic blood pressure, and heart rate were observed. Although those symptoms were suspected to be infusion related, it was decided that continuing amphotericin B therapy with an alternative lipid-based form of the drug was the best course of action. After the patient was switched to liposomal amphotericin B one day later, no further infusion-related adverse reactions were noted for the duration of therapy. While this case suggests that adverse reactions to one type of amphotericin B might not occur with the use of an alternative formulation, further research is needed to better define the potential for cross-reactivity among various forms of amphotericin B and related safe-infusion practices.. A patient with invasive aspergillosis who experienced likely infusion- related reactions to ABLC was able to tolerate continued amphotericin B therapy after a switch to the liposomal formulation.

Topics: Adult; Amphotericin B; Antifungal Agents; Aspergillosis; Comorbidity; Cross Reactions; Dosage Forms; Drug Administration Routes; Humans; Immunocompromised Host; Infusions, Intravenous; Male; Neutropenia; Pneumonia; Precursor Cell Lymphoblastic Leukemia-Lymphoma; Renal Insufficiency, Chronic; Respiratory Insufficiency

We report a case of a 62-year-old female patient who developed peritonitis after receiving a renal transplant. Candida glabrata was detected and treated with voriconazole. As the patient did not improve under therapy, laparotomy was performed. Mould-like plaques were found on the peritoneum. Using culture as well as pan-fungal polymerase chain reaction (PCR) followed by DNA microarray hybridisation of the amplicon, the causative agent was identified as Rhizopus microsporus. Despite aggressive surgical treatment, intravenous therapy with amphotericin B and topical administration of Lavasept (polyhexamethylenbiguanide), the patient died.

Topics: Amphotericin B; Biguanides; Candida glabrata; DNA, Fungal; Fatal Outcome; Female; Humans; Kidney Transplantation; Laparoscopy; Middle Aged; Mucormycosis; Nucleic Acid Hybridization; Oligonucleotide Array Sequence Analysis; Peritonitis; Polymerase Chain Reaction; Renal Insufficiency, Chronic; Rhizopus