Comportamiento de la vancomicina con las nuevas técnicas de diálisis / Behaviour of vancomycin with the new techniques in haemodialysis

Con el uso de técnicas de diálisis de alta convección surge la necesidad de plantearsela idoneidad de los protocolos habituales de administración de algunos fármacos,como la vancomicina.Objetivos: Confirmar si la pauta habitual de vancomicina es eficaz en pacientes atratamiento con biofiltración libre de acetato (AFB) y hemodiafiltración en línea(On-line). Proponer una pauta alternativa de administración.Materiales y métodos: Trece pacientes a tratamiento con AFB u On-line. Diez utilizabanfiltros de polisulfona y 3 de AN69. Primera parte: a 6 pacientes se les administró1 g iv de vancomicina en la última hora de diálisis. Segunda parte: a 7 pacientesse les administró una dosis de ataque de 30 mg/kg iv durante las dos últimas horas dediálisis, con un refuerzo de 500 mg post-diálisis. Se hizo un seguimiento de los nivelessanguíneos del antibiótico durante la semana siguiente a la administración.Resultados: En la primera fase se observó un descenso del 41% de los niveles séricosde vancomicina durante la diálisis, condicionando niveles subterapéuticos enel 83% de los pacientes hasta el final del estudio. Durante la segunda fase se consiguiómantener niveles terapéuticos y no tóxicos durante todo el estudio. Se confirmóla existencia de un rebote post-diálisis del 21%. Con la técnica de On-line se conseguíaun mayor aclaramiento de vancomicina que con AFB (176 vs 135 ml/min). Encontramosuna fuerte correlación entre el descenso del antibiótico y el volumen ultrafiltradocon la técnica de On-line.Conclusiones: La pauta habitual de vancomicina puede resultar insuficiente enpacientes a tratamiento con On-line y AFB. Podría ser adecuada una pauta basadaen una dosis de ataque de 30 mg/kg y un refuerzo de 500 mg al final de cada diálisis.Posiblemente el aclaramiento de este antibiótico con la técnica de On-line seproduzca por transporte convectivo

When using high convection dialysis techniques it arouses the necessity of consideringthe suitability of the regular protocols when administrating drugs, such as vancomycin. Objectives: To confirm if the usual guideline of vancomycin is efficient in patientsundergoing treatments with acetate free biofiltration (AFB) and haemodiafiltrationon-line (on-line). To propose an alternative guideline of administration.Material and methods: 13 patients treated with AFB or On-line. 10 of them usedfilters of polysulfone and 3 of them of AN69. First part: 6 patients were administered1 g iv during the last hour of dialysis. Second part: 7 patients were given a loadingdose of 30 mg/kg iv with a reinforcement of 500 mg post-dialysis. The blood levelsof the antibiotic were monitorized during the week following the administration.Outcomes: During the first phase it was noticed a decrease of 41% in the serumlevel of vancomycin during dialysis, conditioning subtherapeutic levels in the 83% ofthe patients until the end of the study. As for the second phase, therapeutic non-toxiclevels were maintained during the whole study. The existence of a post-dialysis reboundof the 21% was confirmed. A bigger clearance of vancomycin was obtainedwith the On-line technique rather than with AFB (176 vs 135 ml/min). We find astrong correlation between the decrease of the antibiotic and the volume ultrafiltratedwith the On-line technique.Conclusions: The usual guideline of vancomycin may not be enough with the newconvective dialysis techniques. A guideline based on a loading dose of 30 mg/kg anda reinforcement of 500 mg at the end of each dialysis could be adequate. The antibioticclearance with the On-line technique is probably made by convective transport

[Behaviour of vancomycin with the new techniques in haemodialysis]. / Comportamiento de la vancomicina con tas nuevas técnicas de diálisis.

UNLABELLED: When using high convection dialysis techniques it arouses the necessity of considering the suitability of the regular protocols when administrating drugs, such as vancomycin. OBJECTIVES: To confirm if the usual guideline of vancomycin is efficient in patients undergoing treatments with acetate free biofiltration (AFB) and haemodiafiltration on-line (on-line). To propose an alternative guideline of administration. MATERIAL AND METHODS: 13 patients treated with AFB or On-line. 10 of them used filters of polysulfone and 3 of them of AN69. First part: 6 patients were administered 1 g iv during the last hour of dialysis. Second part: 7 patients were given a loading dose of 30 mg/kg iv with a reinforcement of 500 mg post-dialysis. The blood levels of the antibiotic were monitorized during the week following the administration. OUTCOMES: During the first phase it was noticed a decrease of 41% in the serum level of vancomycin during dialysis, conditioning subtherapeutic levels in the 83% of the patients until the end of the study. As for the second phase, therapeutic non-toxic levels were maintained during the whole study. The existence of a post-dialysis rebound of the 21 % was confirmed. A bigger clearance of vancomycin was obtained with the On-line technique rather than with AFB (176 vs 135 ml/min). We find a strong correlation between the decrease of the antibiotic and the volume ultrafiltrated with the On-line technique. CONCLUSIONS: The usual guideline of vancomycin may not be enough with the new convective dialysis techniques. A guideline based on a loading dose of 30 mg/kg and a reinforcement of 500 mg at the end of each dialysis could be adequate. The antibiotic clearance with the On-line technique is probably made by convective transport.

Secondary hyperparathyroidism exacerbation: a rare side-effect of interferon-alpha?

Recombinant human interferon alpha (alpha IFN) is the only treatment with proven benefit for chronic hepatitis C virus (HCV) infection. Nevertheless its use in some susceptible individuals has led to the development or aggravation of different autoimmune conditions. We report the case of a 20 year old woman on peritoneal dialysis with chronic lobular hepatitis secondary to HCV infection who developed de novo psoriasis 9 months after starting treatment with alpha-IFN. In addition to psoriasis, alpha-IFN prescription was also concurrent with an unexpected and refractory secondary hyperparathyroidism exacerbation initially characterized by a marked reduction of serum calcium levels and a consequential increase of PTH. Both complications disappeared after drug withdrawal. The clinical sequence makes an alpha-IFN-induced autoimmune side effect the most plausible hypothesis. The case is discussed and some possible etiopathogenic factors are briefly reviewed.

Renal artery rupture secondary to pretransplantation Candida contamination of the graft in two different recipients.

Infected graft transplantation is an unwelcome complication that may lead to serious consequences in the immunosuppressed host. It can be caused by infection of the donor or by contamination of the organ during harvest, preservation and handling, or at transplantation. With current donor evaluation protocols, the risk of transmitting infections by exogenous contaminated grafts seems to be more frequent than true donor-transmitted infections. Nevertheless, although rare and usually free of clinically significant sequelae, if contamination is by some virulent organisms such as Staphylococcus aureus, gram-negative bacilli, or fungi, severe complications may occur. We report the clinical outcome of liver, heart, and kidney recipients from a single donor. Both renal allografts had to be removed because of renal artery rupture secondary to Candida albicans infection. Careful donor evaluation before transplantation, unusually early presentation of mycosis leading to anastomotic renal artery disruption, the histopathologic findings of the grafts, and the absence of Candida infection in the liver and heart recipients make us believe that exogenous contamination of the grafts occurred during donor procedure, kidney processing, or at transplantation. In summary, because infected grafts can lead to serious complications, besides careful donor screening, it is important to achieve early recognition of contaminated organs by culturing the perfusate to start specific antibiotic or antifungal therapy after transplantation if necessary and avoid the rare but, in this case, fatal consequences of these infections.

Voluntary ingestion of Cortinarius mushrooms leading to chronic interstitial nephritis.

'Magic mushrooms' ingestion among the drug-using population has become a popular cheap way to get hallucinogenic effects which is not free of complications. One of these is acute renal failure related to Cortinarius genus intake. This one greatly resembles 'magic mushrooms' and confusion is possible for inexperienced collectors. We report the case of a young male ex-drug addict who developed acute tubulointerstitial nephritis after voluntary ingestion of Cortinarius orellanus. The clinical picture was preceded by a long latency period, had an insidious course without any data of hepatoxicity and evolved to a chronic state. Renal biopsy showed nonspecific histopathological findings. In summary, it is important to bear this possibility in mind when facing an acute tubulointerstitial nephritis of unknown origin in a drug-taking patient.

Mesalazine-associated tubulo-interstitial nephritis in inflammatory bowel disease.

The 5-aminosalicylic acid (5-ASA) is currently the treatment of choice for patients with inflammatory bowel disease. It can be administered as sulfasalazine (5-ASA + sulfapyridine), mesalazine (5-ASA + resins or gels) and olsalazine (two molecules of 5-ASA). The recent trend has been to use formulations without sulfapyridine since they produce less side-effects although some cases of nephrotoxicity have been described. We report the case of a young female with Crohn's disease treated with mesalazine (400 mg every 8 hours) over a period of 12 months who developed acute interstitial nephritis. The characteristic features of renal function impairment were an insidious onset with non-specific laboratory data and progression towards a chronic state which partially improved with steroid treatment. In summary, it is important to bear this possibility in mind when confronted by any renal impairment which cannot be related to a relapse of inflammatory bowel disease. Renal function should be monitored routinely in patients receiving mesalazine at least during the first year of treatment and annually thereafter.