HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jack G. Copeland Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Rosado, L. J. Articles by Copeland, J. G. Search for Related Content PubMed PubMed Citation Articles by Rosado, L. J. Articles by Copeland, J. G.

J Thorac Cardiovasc Surg 1994;107:1364
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Acute interstitial nephritis in a cardiac transplant recipient receiving ciprofloxacin

University of Arizona Heart Center
1501 N. Campbell Ave.
Tucson, AZ 85724

To the Editor:

A 47-year-old male patient underwent orthotopic heart transplantation for ischemic cardiomyopathy and was immunosuppressed with a regimen of prednisone, azathioprine, and cyclosporine. Thirty-two months later, the patient had an infection of the right great toe, and because he was allergic to penicillin, he was started on a regimen of ciprofloxacin 500 mg twice a day. Laboratory data from that day revealed the following: serum creatinine concentration 1.2 mg/dl, blood urea nitrogen level 26 mg/dl, and cyclosporine level in whole blood 103 ng/ml. The white blood count was 9.6 with 80% polymorphonuclear leukocytes, 10% lymphocytes, 7% monocytes, and 3% eosinophils.

The patient did not fill his prescription until 2 days later, at which time he took one tablet of ciprofloxacin. Within 2 hours he noted the onset of bilateral flank pain and fever. He also noted that his urine output markedly diminished. He took three tablets of ciprofloxacin before being evaluated in the emergency department. His examination at the time revealed a temperature of 38.3° C, blood pressure 110/85 mm Hg, and pulse rate 130 beats/min. Laboratory data on admission were as follows: creatinine concentration 2.4 mg/dl; blood urea nitrogen level 41 md/dl; white blood count 7.4 with 63% polymorphonuclear leukocytes, 24% lymphocytes, 1% basophils, and 12% eosinophils; and cyclosporine level 166 ng/ml. Urine analysis showed specific gravity of 1.008, pH 5.5, 1+ protein, no blood, and many white blood cells and white blood cell casts with some of these casts also containing a yellow-orange amorphous substance.

On the basis of the temporal relationship of the flank pain, decreased urine output, and eosinophilia with the initiation of ciprofloxacin, as well as the presence of crystals within urinary casts, we believed that his renal failure was due to ciprofloxacin-induced acute interstitial nephritis. The ciprofloxacin was discontinued, and over the next 3 days the creatinine concentration continued to rise, peaking at 3.9 mg/dl. From that point on, the creatinine level declined steadily and stabilized at 1.6 mg/dl 2 weeks after the ciprofloxacin was discontinued.

Although ciprofloxacin has been reported to cause acute interstitial nephritis in the general population, ^1-3 information regarding acute interstitial nephritis in the transplant population is lacking. A previous report has been published of acute renal failure occurring in a heart transplant patient receiving cyclosporine who was started on a regimen of ciprofloxacin, but the urinalysis in that case was benign and the cause was presumed to be due to a synergistic interaction of the two drugs, enhancing cyclosporine toxicity. ⁴

The role of crystalluria in the pathogenesis of ciprofloxacin-induced acute interstitial nephritis is uncertain. Free crystals in the urine have been observed in a variety of settings, including normal volunteers ingesting large doses of ciprofloxacin. ⁵ Our findings of yellow-orange crystals inside the casts has not been previously reported with ciprofloxacin-induced acute interstitial nephritis. However, the significance of this with regard to nephrotoxicity is unknown.

The possibility of acute renal failure, either by a synergistic toxic effect with cyclosporine or by drug-induced acute interstitial nephritis, should be kept in mind when transplant recipients are started on a program of ciprofloxacin for treatment of infectious complications. Close surveillance of renal function during the first few days of this antibiotic is recommended.

References

1. Ying LS, Johnson CA. Ciprofloxacin-induced interstitial nephritis. Clin Pharm 1989;8:518-20.[Medline]
   
2. Allon M, Lopez EJ, Min K. Acute renal failure due to ciprofloxacin. Arch Intern Med 1990;150:2187-9.[Abstract]
   
3. Rippelmeyer DJ, Synhavsky A. Ciprofloxacin and allergic interstitial nephritis. Ann Intern Med 1988;109:170.
   
4. Avent CK, Krinsky D, Kirklin JK, et al. Synergistic nephrotoxicity due to ciprofloxacin and cyclosporine. Am J Med 1988;85:452-3.[Medline]
   
5. Thorsteinsson SB, Bergan T, Oddsdottir S, et al. Crystalluria and ciprofloxacin, influence of urinary pH and hydratation. Chemotherapy 1986;32:408-17.[Medline]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Jack G. Copeland Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Rosado, L. J. Articles by Copeland, J. G. Search for Related Content PubMed PubMed Citation Articles by Rosado, L. J. Articles by Copeland, J. G.