what type of kidney injury does vanc cause?

[Bluesaurus]

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Is it AIN?

 

[jdh71]

Is it AIN?

No.

This would probably be good to look up.

Though today's vanco formulations probably don't cause kidney injury.

 

[MedicineDoc]

I had one case last dec or jan. It's supposedly rare now that vancomycin is highly "purified" with other drugs more likely to be the culprit when getting multiple drugs. Normal kidney function by labs when I admitted him. This patient did not get any other drugs except maybe some inhaled anesthetics, to my knowledge, during an incision and drainage of an abscess in the OR. Young healthy guy that did manual labor. His trough level on vancomycin shot up from very low to over 90 and stayed there for a very long time. His bun/cr were in the normal range and then just kept climbing. He did continue to make urine. The nephrologist finally wound up putting him on temporary dialysis not to get rid of the vancomycin but just because of the severe decline in kidney function. I did not have a whole lot of confidence in that particular nephrologist. He stated that vancomycin couldn't be dialyzed but I believe I looked up somewhere at the time that it could be if you use a certain kind of dialysis membrane. ATN. He did have a history of using NSAIDs daily prior to admission but not recent or extremely high doses. After that I check kidney function at least every 24 hrs if on vanc for at least first 3 or 4 days even though guidelines don't call for it to be checked anywhere near that often.

 

[nephappl]

I have seen 3 cases this year with criteria for vanco induced AKI. All of them ATN but with no biopsy confirmation as they did recover after the medication was stopped. In the three cases the level was very high.
Doing this for a while, never seen AIN from Vanco

 

[Praziquantel86]

No.

This would probably be good to look up.

Though today's vanco formulations probably don't cause kidney injury.

I don't know if that's true - the literature supports a dose-dependent degree of nephrotoxicity with strong consistency across multiple studies. It's generally reversible and of uncertain long-term significance, but it is there.

The formulations themselves have improved, so the contribution of impurities is certainly not much of an issue any longer.

 

[jdh71]

Well. What can I say. Run the vanco high enough and it'll make the kidneys mad. I'll buy that.

Though the concern used to be that just running it therapeutic for too long could hurt the kidneys. I think all the kidney docs I've talked to about this, because I use a ****ton of vanco in a ****ton of patients whose kidneys go to crap and they are never too excited about vanco toxicity.

 

[Praziquantel86]

Well. What can I say. Run the vanco high enough and it'll make the kidneys mad. I'll buy that.

Though the concern used to be that just running it therapeutic for too long could hurt the kidneys. I think all the kidney docs I've talked to about this, because I use a ****ton of vanco in a ****ton of patients whose kidneys go to crap and they are never too excited about vanco toxicity.

I think what goes underappreciated is that it is not necessarily the high levels that cause nephrotoxicity. Depending on which analysis you're looking at, rates of nephrotoxicity increase by anywhere from 50 - 100% (or more) once the targeted trough switches from 10 - 15 versus 15 - 20. The point about running it for too long is well taken, though - clearance decreases after ~7 days of therapy, leading once "therapeutic" troughs to now become supratherapeutic. I've also had the same discussions with nephrologists and gotten the same response. To each their own, I suppose.

My main issue in this is that there really is marginal benefit demonstrated by aiming for higher troughs, with greater-than-proportional rises in toxicity.

 

[flipmd]

I had one case last dec or jan. It's supposedly rare now that vancomycin is highly "purified" with other drugs more likely to be the culprit when getting multiple drugs. Normal kidney function by labs when I admitted him. This patient did not get any other drugs except maybe some inhaled anesthetics, to my knowledge, during an incision and drainage of an abscess in the OR. Young healthy guy that did manual labor. His trough level on vancomycin shot up from very low to over 90 and stayed there for a very long time. His bun/cr were in the normal range and then just kept climbing. He did continue to make urine. The nephrologist finally wound up putting him on temporary dialysis not to get rid of the vancomycin but just because of the severe decline in kidney function. I did not have a whole lot of confidence in that particular nephrologist. He stated that vancomycin couldn't be dialyzed but I believe I looked up somewhere at the time that it could be if you use a certain kind of dialysis membrane. ATN. He did have a history of using NSAIDs daily prior to admission but not recent or extremely high doses. After that I check kidney function at least every 24 hrs if on vanc for at least first 3 or 4 days even though guidelines don't call for it to be checked anywhere near that often.

I think what's really hard to differentiate in your case is if the high Vanc levels caused renal failure, or if renal failure caused the high Vanc levels. Remember, increasing your Crea from 1 to 2 means you are NOT clearing anything (renal function would be a lot lower than the CrCl you end up with by using a Crea of 2 in the computation). This would cause the Vanc levels to skyrocket despite having "only" a Crea of 2. Now if your Creatinine stayed within normal for a few days with skyrocketing Vanc levels, then you could maybe make a case.

Infections by themselves can cause ATN. Anesthetics too.

 

[MedicineDoc]

I think what's really hard to differentiate in your case is if the high Vanc levels caused renal failure, or if renal failure caused the high Vanc levels. Remember, increasing your Crea from 1 to 2 means you are NOT clearing anything (renal function would be a lot lower than the CrCl you end up with by using a Crea of 2 in the computation). This would cause the Vanc levels to skyrocket despite having "only" a Crea of 2. Now if your Creatinine stayed within normal for a few days with skyrocketing Vanc levels, then you could maybe make a case.

Infections by themselves can cause ATN. Anesthetics too.

I have never heard of an abscess causing ATN. Septic shock yes. Abscess no. Pharmacy dosed the vancomycin. I never dose vancomycin or Coumadin as it's uneccessary to keep up with holding down a full panel of inpatients when pharmacy provides that service. The vancomycin level went from low to very high and yes the creatinine rose as if not being cleared at all. Inhalational anesthetics other than methoxyflurane are not thought to have much potential for nephrotoxicity from what I understand.

 

[surge55]

I have never heard of an abscess causing ATN. Septic shock yes. Abscess no. Pharmacy dosed the vancomycin. I never dose vancomycin or Coumadin as it's uneccessary to keep up with holding down a full panel of inpatients when pharmacy provides that service. The vancomycin level went from low to very high and yes the creatinine rose as if not being cleared at all. Inhalational anesthetics other than methoxyflurane are not thought to have much potential for nephrotoxicity from what I understand.

so you are certain the abscess was localized and he wasnt in sepsis?

 

[MedicineDoc]

Yes. He didn't meet any sepsis criteria and in fact kept asking when he could go home the whole time. I'm a hospitalist and have been out of residency for several yrs. Your not talking to the doctor "Nick" from the Simpsons. Although it can be "fun" being quizzed by residents/interns as if I was an intern.

 

[jdh71]

Yes. He didn't meet any sepsis criteria and in fact kept asking when he could go home the whole time. I'm a hospitalist and have been out of residency for several yrs. Your not talking to the doctor "Nick" from the Simpsons. Although it can be "fun" being quizzed by residents/interns as if I was an intern.

heh

I think some of the silliest consults I get are from hospitalists "years out"

I'm sure you're a fine doc, but don't get mad because people are asking questions. Medicine is a tricky bish.

 

[MedicineDoc]

That is generally my philosophy that I'm willing to listen to anyone but after being asked to supervise and teach some residents recently I have seen where one of the important things for them to pick up is to hold back on the idea that every case is an episode of CSI which mostly does nothing but drive the cost per case through the roof and create more work for everyone.i recently had a pretty solid intern (almost 2nd yr) from a medical knowledge perspective but he was always trying to dig deeper and deeper for questionable reasons with the bad habit of ordering a bunch of questionable stuff without discussing it with me first. I would not write this on his evaluation but told him so that he can work on reigning some of that in. I think it's a general tendency for some of the junior residents to lose track of the actual case at hand and go looking in a more "exciting" or different interpretation that somehow proves they are a "Marcus welby" right out of the box.

 

[surge55]

That is generally my philosophy that I'm willing to listen to anyone but after being asked to supervise and teach some residents recently I have seen where one of the important things for them to pick up is to hold back on the idea that every case is an episode of CSI which mostly does nothing but drive the cost per case through the roof and create more work for everyone.i recently had a pretty solid intern (almost 2nd yr) from a medical knowledge perspective but he was always trying to dig deeper and deeper for questionable reasons with the bad habit of ordering a bunch of questionable stuff without discussing it with me first. I would not write this on his evaluation but told him so that he can work on reigning some of that in. I think it's a general tendency for some of the junior residents to lose track of the actual case at hand and go looking in a more "exciting" or different interpretation that somehow proves they are a "Marcus welby" right out of the box.

😀ha ok then sorry. just a question is all.

I had a patient recently that I'm sure it contributed to her worsening kidney function. I'm sure it does still cause renal failure once in awhile; there's a reason pharmacokinetics still follows it and orders vanc levels periodically.

to your other point, I think digging deeper is part of medicine though. you can be satisfied with one answer but there is also erason to make sure your differential is broad. in fact, two patients I've had recently:

1) patient admitted for left knee pain; noted to have leg swelling, dopplers positive for DVT. however, patient had difficulty ambulating and noted the continued left knee pain. admitting team was ok with just the dvt diagnosis but my team took over and was not. got a knee MRI and sure enough she also had meniscal tear.

2) same admitting team admitted a guy for hyperkalemia with ekg changes; he had esrd and missed one session because he 'didn't feel well'. he also had ams; admitting team was ok to just dialyze; however, given his ams, general malaise and the fact his kidney function worsened so much with just one missed one session, we worked him up for infection and sure enough his crp is 20, his procalcitonin is 2.47 and he's got an effusion in his right lung with some loculation.

 

[MedicineDoc]

😀ha ok then sorry. just a question is all.

I had a patient recently that I'm sure it contributed to her worsening kidney function. I'm sure it does still cause renal failure once in awhile; there's a reason pharmacokinetics still follows it and orders vanc levels periodically.

to your other point, I think digging deeper is part of medicine though. you can be satisfied with one answer but there is also erason to make sure your differential is broad. in fact, two patients I've had recently:

1) patient admitted for left knee pain; noted to have leg swelling, dopplers positive for DVT. however, patient had difficulty ambulating and noted the continued left knee pain. admitting team was ok with just the dvt diagnosis but my team took over and was not. got a knee MRI and sure enough she also had meniscal tear.

2) same admitting team admitted a guy for hyperkalemia with ekg changes; he had esrd and missed one session because he 'didn't feel well'. he also had ams; admitting team was ok to just dialyze; however, given his ams, general malaise and the fact his kidney function worsened so much with just one missed one session, we worked him up for infection and sure enough his crp is 20, his procalcitonin is 2.47 and he's got an effusion in his right lung with some loculation.

It's true that dialysis patients can be tricky as far as diagnosing infections. From what I understand procalcitonin levels do correlate with possible infection even in dialysis patients with peritoneal dialysis patients potentially not so much as procalcitonin levels can be elevated anyway. I don't think the procalcitonin level use in dialysis patients is completely accepted as of yet but I may be wrong on that. I agree that there can be smoldering infections in dialysis patients without typical red flags. I don't know the case and findings well enough to comment. There can also be altered mental status in dialysis patients from "disequilibrium" syndrome thought to have to do with fluid shifts and cerebral edema. I have seen dialysis patients who are said to be always confused after dialysis with nephrologists unconcerned about it. I have also seen dialysis patients with increased confusion where the nephrologists suspects infection. Regardless if they are a dialysis patient they are going to have a nephrology consult and I normally discuss the case with the nephrologist especially if that is their outpatient nephrologist as they often know them extremely well. In the case of the knee I would not have gotten an MRI. The cost of that MRI comes out of the DRG of the admission and is not something that needs to be done in the hospital. I would have had them follow up with PCP as an outpatient. The hospital actually keeps statistics on each doctor with cost per case adjusted for acuity, in addition to other statistics like length of stay, readmission rates, mortality, patient satisfaction. If you were a hospitalist several MRIs that could have been done outpatient and someone would be asking you about it.

 

[Bostonredsox]

It's true that dialysis patients can be tricky as far as diagnosing infections. From what I understand procalcitonin levels do correlate with possible infection even in dialysis patients with peritoneal dialysis patients potentially not so much as procalcitonin levels can be elevated anyway. I don't think the procalcitonin level use in dialysis patients is completely accepted as of yet but I may be wrong on that. I agree that there can be smoldering infections in dialysis patients without typical red flags. I don't know the case and findings well enough to comment. There can also be altered mental status in dialysis patients from "disequilibrium" syndrome thought to have to do with fluid shifts and cerebral edema. I have seen dialysis patients who are said to be always confused after dialysis with nephrologists unconcerned about it. I have also seen dialysis patients with increased confusion where the nephrologists suspects infection. Regardless if they are a dialysis patient they are going to have a nephrology consult and I normally discuss the case with the nephrologist especially if that is their outpatient nephrologist as they often know them extremely well. In the case of the knee I would not have gotten an MRI. The cost of that MRI comes out of the DRG of the admission and is not something that needs to be done in the hospital. I would have had them follow up with PCP as an outpatient. The hospital actually keeps statistics on each doctor with cost per case adjusted for acuity, in addition to other statistics like length of stay, readmission rates, mortality, patient satisfaction. If you were a hospitalist several MRIs that could have been done outpatient and someone would be asking you about it.

I used to order procal's frequently early on in residency. Not so much anymore. I can't really think of a single case where its made any difference in my treatment plan. And as for the data on the procal's trend in terms of Improving septic shock, lactate clearance's data is stronger and its a cheaper test.

I do however agree with medicinedoc, dialysis patients are classically the severely septic patient who "does not look that sick". And a change on their baseline function in almost any category should raise a flag that their could be occult infection.

 

[jdh71]

I used to order procal's frequently early on in residency. Not so much anymore. I can't really think of a single case where its made any difference in my treatment plan. And as for the data on the procal's trend in terms of Improving septic shock, lactate clearance's data is stronger and its a cheaper test.

I do however agree with medicinedoc, dialysis patients are classically the severely septic patient who "does not look that sick". And a change on their baseline function in almost any category should raise a flag that their could be occult infection.

Use pro-calctonin when you're not sure about starting or stopping abx in a patient that maybe needs them

 

[surge55]

Use pro-calctonin when you're not sure about starting or stopping abx in a patient that maybe needs them

this.

 

[Bostonredsox]

Use pro-calctonin when you're not sure about starting or stopping abx in a patient that maybe needs them

Yes I'm aware the data points to using it as an adjunct test for possible infection. I still can't recall a time where it ever changed my management. I have always decided whether or not I was going to use antimicrobial therapy prior to seeing the result of this test. The few patients who did not truly meet criteria for sepsis, mainly with a few SIRS criteria and no source, I had already decided to give them abx before the positive procal came back. Maybe just coincidence though.

 

[jdh71]

Yes I'm aware the data points to using it as an adjunct test for possible infection. I still can't recall a time where it ever changed my management. I have always decided whether or not I was going to use antimicrobial therapy prior to seeing the result of this test. The few patients who did not truly meet criteria for sepsis, mainly with a few SIRS criteria and no source, I had already decided to give them abx before the positive procal came back. Maybe just coincidence though.

I've used it to either start or stop antibiotics a few times per month. You probably aren't considering it often enough.

 

[LoudBark]

I've used it to either start or stop antibiotics a few times per month. You probably aren't considering it often enough.

Do you usually use it for those radiology readings of "atelectasis vs infiltrate" and the patient is coughing but has a mildly high WBC of 11.5 and no fever?

 

[jdh71]

Do you usually use it for those radiology readings of "atelectasis vs infiltrate" and the patient is coughing but has a mildly high WBC of 11.5 and no fever?

kind of

since I use it in the unit, it's usually on tubed patients without a fever, new opacity(ies) on chest film and mild leukocytosis to decide if I'm going to start abx

and also if I'm wondering if I I should stop abx in a patient I wasn't crazy excited about starting them on in the first place

I feel pretty damn good about not starting or stoping abx in any patient with a pro-calcitonin in the low range as determined by lab assay