Acute Kidney Injury When Treating Periprosthetic Joint Infections After Total Knee Arthroplasties with Antibiotic-Loaded Spacers

Abstract

Background: 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. Methods: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/m 2 , 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).Results: 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 (b = 0.17; p = 0.002), perioperative hypovolemia (b = 0.28; p = 0.0001), and acute atrial fibrillation (b = 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.Conclusions: 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.Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. P eriprosthetic joint infection (PJI) continues to be one of the most common failure mechanisms after primary total knee arthroplasty (TKA), resulting in high mor-bidity 1-4 and mortality 5 . In North America, the management of chronic PJIs after TKA most commonly consists of a 2-stage exchange arthroplasty with a high-dose antibiotic-loaded bone Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked "yes" to ind...

Tobramycin Blood Levels after Local Antibiotic Treatment of Bone and Soft Tissue Infection

“…Hence, our study cannot determine directly what impact these local tobramycin dosing regimens may have on that population. Surgeons should proceed with caution when locally dosing antibiotics in these patients, as there have been reports of AKI in this population [21]. Additionally, biomarkers for declining kidney function were not used in our study.…”

“…The battle against infections in orthopedic surgery has always been challenging, and carriers used for the local delivery of antibiotics have become a formidable weapon in this fight [7]. Their chief drawback is renal problems; AKIs resulting from high-dose local antibiotic carriers have been reported as high as 14% in nonrenal patients and as high as 45% in patients with CKI [21]. Dagenaux et al recently documented AKI in 455 cases of periprosthetic joint infections with an overall rate of 19% [21].…”

“…Their chief drawback is renal problems; AKIs resulting from high-dose local antibiotic carriers have been reported as high as 14% in nonrenal patients and as high as 45% in patients with CKI [21]. Dagenaux et al recently documented AKI in 455 cases of periprosthetic joint infections with an overall rate of 19% [21]. They reported on a variety of dosing regimens using only Simplex PMMA (Stryker, Kalamazoo, MI, USA) as a carrier and concluded that an antibiotic dosing regimen of either vancomycin or an aminoglycoside over 3.6 g per bag of cement was a statistically significant risk factor for AKI, with a 2-fold increased risk of AKI.…”

“…There are few studies associating the local concentrations of antibiotics and their resulting systemic blood concentrations with a combination of carriers [18,21]. There is additionally a scarcity of large studies documenting local antibiotic dosing and resulting postoperative kidney injury [21].…”

“…There are few studies associating the local concentrations of antibiotics and their resulting systemic blood concentrations with a combination of carriers [18,21]. There is additionally a scarcity of large studies documenting local antibiotic dosing and resulting postoperative kidney injury [21]. In this present study, 52 patients who underwent 58 procedures were investigated for the systemic tobramycin concentrations occurring at 24, 48 and 72 h postoperatively following treatment of orthopedic infections with a combination of local vancomycin/tobramycin laden antibiotic PMMA spacers, CS spacers, and combinations thereof.…”