Co-Trimoxazole Nephrotoxicity

Richmond, John; Whitworth, J. A.; Fairley, Kenneth F.; Kincaid‐Smith, Priscilla

doi:10.1016/s0140-6736(79)90846-8

Cited by 37 publications

(3 citation statements)

References 10 publications

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“…Tmp-Smx can, however, also cause global renal dysfunction secondary to an interstitial nephritis. [1][2][3] In conclusion, Tmp-Smx may lead to a potentially lethal hyperkalemia, even if used in the standard doses, particularly in the elderly patients who may have preexisting renal dysfunction or reduced glomerular function due to the process of aging 13 and who often develop dehydration when acutely ill. 14 The hyperkalemia usually appears during the first few days of treatment so serum potassium must be checked. If creatinine or potassium are increased significantly, then Tmp-Smx should be discontinued.…”

Section: Discussionmentioning

confidence: 94%

Hyperkalemia in an Elderly Patient Receiving Standard Doses of Trimethoprim-Sulfamethoxazol — Case Report and Brief Review of the Literature

Al-Murayeh¹,

Kjellstrand²

1995

Ann Saudi Med

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MA Al-Murayeh, CM Kjellstrand, Hyperkalemia in an Elderly Patient Receiving Standard Doses of TrimethoprimSulfamethoxazol -Case Report and Brief Review of the Literature. 1995; 15(4): 402-403 Trimethoprim sulfamethoxazole (Tmp-Smx) is a commonly used antimicrobial drug in the treatment of respiratory tract and urinary tract infections.Tmp-Smx has been in clinical use since 1968. 1 It may induce an isolated elevation of serum creatinine (pseudorenal failure), interstitial nephritis with acute renal failure 2-4 and mild hyperkalemia when used in patients with acquired immunodeficiency syndrome (AIDS).5 There have been rare case reports of dangerous hyperkalemia in patients receiving high doses of co-trimoxazole. 6 Recently, three elderly patients were reported to have developed hyperkalemia with standard doses of In this article we present the case history of a patient who developed moderate hyperkalemia while on regular dose Tmp-Smx and also a brief review of the literature on this topic to increase the awareness of this potentially lethal complication which may be under-recognized. Case ReportAn 89-year-old female fractured both her left hip and left humerus after a fall in her apartment. She underwent surgery and while an in-patient developed a symptomatic lower urinary tract infection caused by Escherichia coli, sensitive to both Tmp-Smx and ampicillin.Her serum chemistries on admission were Na 135 mmol/L, K 3.8 mmol/L, Cl 103 mmol/L, total C0 2 23.4 mmol/L, blood urea nitrogen (BUN) 5.1 mmol/L and creatinine 90 μmol/L Urinalysis on admission was normal. She was started on Tmp-Smx orally, one tablet twice a day. Each tablet consisted of trimethoprim 160 mg and sulfamethoxazole 800 mg.On the fourth day on Tmp-Smx her serum potassium increased to 5.8 mmol/L. This could not be explained on clinical grounds as she was not diabetic or hypertensive nor did she have renal failure. The patient was not on any known medication that might alter the potassium metabolism or homeostasis; there was no change in her diet and she was not dehydrated.Her serum chemistries were repeated on the sixth day and were as follows: Na 139 mmol/L, K 6.4 mmol/L, Cl 104 mmol/L, BUN 8.7 mmol/L, CO 2 22.5 mmol/L, creatinine 170 μmol/L. Urinalysis was unremarkable, there was no peripheral eosinophilia and clinically she continued to be afebrile and had no skin rashes. An electrocardiogram showed elevated and peaked T-waves.Tmp-Smx was discontinued and the patient was given kayexalate orally (30 g once) and 10 U of regular insulin in an intravenous drip of 500 mL dextrose 10%, infused over five hours. Serum potassium fell to 5.3 mmol/L and serum creatinine decreased to 120 μmol/L. During the week following discontinuation of Tmp-Smx, her serum potassium stabilized at 5.0 mmol/L and serum creatinine at 90 μmol/L. The clinical course of potassium and creatinine are demonstrated in Figure 1. DiscussionOur patient had mild acute renal failure and moderate hyperkalemia caused by Tmp-Smx. Hyperkalemia is not generally recognized as a complication...

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Section: Discussionmentioning

confidence: 94%

Hyperkalemia in an Elderly Patient Receiving Standard Doses of Trimethoprim-Sulfamethoxazol — Case Report and Brief Review of the Literature

Al-Murayeh¹,

Kjellstrand²

1995

Ann Saudi Med

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“…Although it is not usually nephrotoxic. the group at the Royal Melbourne Hospital has cau tioned against the use of co-trimoxazole in patients with underlying renal disease due to the development of AIN, renal failure, and even death [10,11]. Chronic intersti tial nephritis can also result from medications, and these patients may demonstrate granulomas on renal biopsy, but here, the differential diagnosis includes sarcoidosis, tuberculosis, Wegener's granulomatosis, fungal infec tions, idiopathic granulomatous disorders [1], and i.v.…”

Section: Discussionmentioning

confidence: 99%

Acute Granulomatous Interstitial Nephritis Due to Co-Trimoxazole

Cryst

Hammar²

1988

Am J Nephrol

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A 51-year-old man with diabetes mellitus and mild hypertension developed acute interstitial nephritis 4 days after starting a course of co-trimoxazole for bronchopneumonia. Following initial symptoms of overt hypersensitivity, he developed azotemia and renal tubular dysfunction with malaise and anorexia requiring hospitalization. Renal pathology demonstrated an acute granulomatous interstitial nephritis superimposed on chronic diabetic renal disease.

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“…Renal biopsies were performed in 2 patients and showed acute tubular necrosis [11]. Subsequently, others have reported cases of biopsy-proven tubulointerstitial nephrotoxicity, with high doses of co-trimoxazole occurring mainly, but not exclusively, in patients with CKD [12,13,14,15,16,17,18,19,20]. Since tubulointerstitial nephritis has also been described with other sulfonamides in monotherapy [11,21], Kalowski et al [11] hypothesized that co-trimoxazole nephrotoxicity was probably related to Sfx rather than to trimethoprim.…”

Section: Are Trimethoprim And/or Sfx Nephrotoxic? the First Casesmentioning

confidence: 99%

Trimethoprim, Creatinine and Creatinine-Based Equations

et al. 2011

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Co-trimoxazole is a frequently prescribed antibiotic worldwide. It is composed of both trimethoprim and sulfamethoxazol (Sfx) and is used in the treatment and prophylaxis of urinary tract and Pneumocystis jirovecii infections. The Sfx component appears to be nephrotoxic at high doses or doses inappropriately adjusted for glomerular filtration rate (GFR). The trimethoprim component, even at recommended doses, inhibits tubular creatinine secretion, leading to a rapid but ultimately reversible increase in serum creatinine independent of any changes in GFR. This translates into a falsely low estimated GFR when creatinine-based equations are used. This review focuses on evidence of the differential effects of trimethoprim and Sfx on serum creatinine concentrations and GFR and their relevance to clinical practice, with particular attention to kidney transplantation.

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Co-Trimoxazole Nephrotoxicity

Cited by 37 publications

References 10 publications

Hyperkalemia in an Elderly Patient Receiving Standard Doses of Trimethoprim-Sulfamethoxazol — Case Report and Brief Review of the Literature

Hyperkalemia in an Elderly Patient Receiving Standard Doses of Trimethoprim-Sulfamethoxazol — Case Report and Brief Review of the Literature

Acute Granulomatous Interstitial Nephritis Due to Co-Trimoxazole

Trimethoprim, Creatinine and Creatinine-Based Equations

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