J Thorac Cardiovasc Surg 1994;107:1364-1365
© 1994 Mosby, Inc.
Invited letter concerning: Acute interstitial nephritis in a cardiac transplant recipient receiving ciprofloxacin
Robert C. Bourge, MD
The University of Alabama at Birmingham
321-M Tinsley Harrison Tower
Birmingham, AL 35294
To the Editor:
The letter from Drs Rosado, Siskind, and Copeland from the University of Arizona illustrates one of the complications of quinolone and fluoroquinolone antibiotics—acute interstitial nephritis.
1, 2 Because of their wide spectrum of antimicrobial activity, these compounds are often used in both the general and cardiac transplant population for a variety of infections. Acute interstitial nephritis is the most common cause of nephrotoxicity resulting from ciprofloxacin. In this syndrome, there are most often signs and symptoms, which may include fever, rash, myalgias, eosinophilia, hematuria, proteinuria, a fractional excretion of sodium of greater than one, and possibly casts in the urine sediment. 3, 4 The condition may be oliguric, as inthe case report, or nonoliguric. 4 Treatment consists of withdrawing the suspected causative agent(s), hydration, and perhaps transient dialysis. The use of corticosteroids remains controversial because no controlled studies showing their usefulness have been conducted. 3 Fortunately, most cases resolve in time with normalization or near normalization of renal function.
Quinolone's use in the transplant population may be associated with asymptomatic acute renal failure not seemingly related to acute interstitial nephritis, as noted in the case report from our institution. 5 In this report, we suggested the possibilityof a "synergistic nephrotoxicity" between ciprofloxacin and cyclosporine. However, the cause of this possible interaction remains elusive. Studies have failed to show an effect of ciprofloxacin on cyclosporine pharmacokinetics. 6, 7 The effect of cyclosporine on ciprofloxacin levels has not been thoroughly evaluated. Although not the principal purpose of these studies, peak and trough ciprofloxacin levels were noted to be somewhat lower in human beings also receiving cyclosporine than in healthy volunteers not receiving cyclosporine. 7, 8 This makes unlikely the possibility that ciprofloxacin levels may be very high (and thus adversely affect renal function) when used in usual doses in patients also receiving cyclosporine. The possibility of "silent" acute renal failure, in addition to the often symptomatic acute interstitial nephritis noted by Rosado and associates, makes routine and close follow-up of renal function parameters and clinical course a prudent recommendation when quinolone antibiotics are used in the cardiac transplant recipient.
References
-
Patterson DR. Quinolone toxicity: methods of assessment. Am J Med 1991;91:35S-37S.
-
Christ W, Lehnert T, Ulbrich B. Specific toxicologic aspects of the quinolones. Rev Infect Dis 1988;10:S141-6.
-
Murray KM, Wilson MG. Suspected ciprofloxacin-induced interstitial nephritis. Ann Pharmacother 1990;24:379-80.[Abstract]
-
Bailey JR, Trott SA, Philbrick JT. Ciprofloxacin-induced acute interstitial nephritis. Am J Nephrol 1993;12:271-3.
-
Avent CK, Krinsky D, Kirklin JK, Bourge RC, Figg WD. Synergistic nephrotoxicity due to ciprofloxacin and cyclosporine. Am J Med 1988;85:452-3.[Medline]
-
Lang J, Finaz de Villaine J. Cyclosporine (cyclosporine A) pharmacokinetics in renal transplant patients receiving ciprofloxacin. Am J Med 1989;87:82S-5S.[Medline]
-
Tan KK, Trull AK, Shawket S. Co-administration of ciprofloxacin and cyclosporin: lack of evidence for a pharmacokinetic interaction. Br J Clin Pharmacol 1989;28:185-7.[Medline]
-
Kruger HU, Schuler U, Proksch B, Gober M, Ehninger G. Investigation of potential interaction of ciprofloxacin with cyclosporine in bone marrow transplant recipients. Antimicrob Agents Chemother 1990;34:1048-53.[Abstract/Free Full Text]
