Abstract:images in clinical medicineT h e n e w e ng l a n d j o u r na l o f m e dic i n e n engl j med 358;13 www.nejm.org march 27, 2008 e14 A 60-year-old man infected with the human immunodeficiency virus (HIV) (CD4 count of 450 per cubic millimeter and HIV viral load of <50 copies per milliliter) who had HIV-associated dementia was admitted to our hospital because of an altered mental status, a temperature of 101°F (38.3°C), and seizure-like activity. His medications included efavirenz, emtricitabine, tenofovir, a… Show more
“…The proposed mechanism of acyclovir-associated renal injury is drug precipitation and crystallization in the renal tubules, which obstructs the tubules and possibly causes necrosis [14,15]. Typically, acyclovir is rapidly excreted in the urine.…”
Intravenous (IV) acyclovir is commonly administered medication for viral infection but is well known for its nephrotoxicity. However, there was no study for incidence, risk factors, and clinical outcomes of acute kidney injury (AKI) associated with IV acyclovir administration. We retrospectively reviewed the medical records of 287 patients who were medicated IV acyclovir from January 2008 to May 2013 in Gyeongsang National University Hospital. All had documented medical histories and underwent medical review. Demographic data, risk factors, concomitant drugs, laboratory findings and outcome were gathered from the medical records and analyzed. AKI occurred in 51 patients (17.8%). As per RIFLE classification, renal injury was graded as either at risk of renal dysfunction (62.7%), renal injury (15.6%), and renal failure (21.6%). There was no significant difference in age, sex, total dose, drug duration, and presence of hydration between AKI and non-AKI group. However, systolic pressure, underlying diabetes, concomitant vancomycin and non-steroidal anti-inflammatory drugs (NSAIDs) use was positively correlated with AKI occurrence (p = .04, p < .001, 0.01, and 0.04, respectively). Two patients underwent hemodialysis and these patients died. Higher mortality was observed in AKI patients (p < .001). Multivariate analysis also presented that presence of diabetes, concomitant NSAIDs, and vancomycin use was independent risk factor of acyclovir associated with AKI (p = .001, OR 3.611 (CI: 1.708–7.633), p = .050, OR 2.630 (CI: 1.000–6.917), and p = .009, OR 4.349 (CI: 1.452–13.022), respectively). AKI is relatively common in patients administrating acyclovir injection. Physicians should attempt to prevent, detect, and manage acyclovir associated AKI in patients prescribing acyclovir due to possible association of poor prognosis.
“…The proposed mechanism of acyclovir-associated renal injury is drug precipitation and crystallization in the renal tubules, which obstructs the tubules and possibly causes necrosis [14,15]. Typically, acyclovir is rapidly excreted in the urine.…”
Intravenous (IV) acyclovir is commonly administered medication for viral infection but is well known for its nephrotoxicity. However, there was no study for incidence, risk factors, and clinical outcomes of acute kidney injury (AKI) associated with IV acyclovir administration. We retrospectively reviewed the medical records of 287 patients who were medicated IV acyclovir from January 2008 to May 2013 in Gyeongsang National University Hospital. All had documented medical histories and underwent medical review. Demographic data, risk factors, concomitant drugs, laboratory findings and outcome were gathered from the medical records and analyzed. AKI occurred in 51 patients (17.8%). As per RIFLE classification, renal injury was graded as either at risk of renal dysfunction (62.7%), renal injury (15.6%), and renal failure (21.6%). There was no significant difference in age, sex, total dose, drug duration, and presence of hydration between AKI and non-AKI group. However, systolic pressure, underlying diabetes, concomitant vancomycin and non-steroidal anti-inflammatory drugs (NSAIDs) use was positively correlated with AKI occurrence (p = .04, p < .001, 0.01, and 0.04, respectively). Two patients underwent hemodialysis and these patients died. Higher mortality was observed in AKI patients (p < .001). Multivariate analysis also presented that presence of diabetes, concomitant NSAIDs, and vancomycin use was independent risk factor of acyclovir associated with AKI (p = .001, OR 3.611 (CI: 1.708–7.633), p = .050, OR 2.630 (CI: 1.000–6.917), and p = .009, OR 4.349 (CI: 1.452–13.022), respectively). AKI is relatively common in patients administrating acyclovir injection. Physicians should attempt to prevent, detect, and manage acyclovir associated AKI in patients prescribing acyclovir due to possible association of poor prognosis.
“…Severe intraparenchymal crystal precipitation can cause interstitial congestion and hemorrhage, leading to a decrease of renal blood flow (Fig. 2c ) [ 14 ]. Fig.…”
BackgroundAcyclovir is one of the most common prescribed antiviral drugs. Acyclovir nephrotoxicity occurs in approximately 12–48% of cases. It can present in clinical practice as acute kidney injury (AKI), crystal-induced nephropathy, acute tubulointerstitial nephritis, and rarely, as tubular dysfunction. Electrolytes abnormalities like hypokalemia, were previously described only when given intravenously.Case presentationA 54 year-old female presented with weakness and lower extremities paresis, nausea and vomiting after receiving oral acyclovir. Physical examination disclosed a decrease in the patellar osteotendinous reflexes (++ / ++++). Laboratory data showed a serum creatinine level of 2.1 mg/dL; serum potassium 2.1 mmol/L. Kidney biopsy was obtained; histological findings were consistent with acute tubular necrosis and acute tubulointerstitial nephritis. The patient was advised to stop the medications and to start with oral and intravenous potassium supplement, symptoms improved and continued until serum potassium levels were > 3.5 meq/L.ConclusionsThe case reported in this vignette is unique since it is the first one to describe hypokalemia associated to acute tubular necrosis induced by oral acyclovir.
“…It is difficult to find in the current literature a case of acyclovir crystalluria in a pediatric patient. We have to go back to 1986, when an article was published by Potter et al [11] in which there are two cases, a 7-year-old girl affected by lymphoblastic leukemia, and therefore in a state of immunosuppression; and another 12-year-old girl under treatment for herpetic encephalitis which eventually caused her death. This last case is the most similar to our patient, who was also healthy beforehand, and in which crystalluria did not affect the renal function.…”
Section: Discussionmentioning
confidence: 99%
“…However, it may also be associated with oral administration [9]. It is more common in immunosuppressed patients, probably due to the fact that acyclovir is more widely indicated in this patient group [10][11][12]. In the presence of acyclovir, kidney failure may be induced by the intratubular precipitation of crystals [13].…”
Section: Discussionmentioning
confidence: 99%
“…There are risk factors which promote the appearance of crystalluria, such as dehydration, an underlying renal condition and changes in the urine pH [6,11]. Therefore intravenous or oral rehydration is recommended, as well as withdrawal of the drug.…”
Acyclovir is a highly active antiviral drug that acts against the herpes simplex virus (HSV). Among its secondary effects, we can observe rare cases of crystalluria, which can be associated or not associated to renal failure. We present the case of a healthy lactating 13-month-old baby girl with gingivostomatitis, who 48 hours after the start of treatment with this drug showed a change in the color of her urine, which was associated with the appearance of crystals in the sediment. This finding was associated with the prescription of Acyclovir, because it has been described in the literature, and no other ascribable causes could be found. Crystalluria is a rare adverse effect that has been reported generally in adult immunosuppressed patients. We have only been able to find one case that could be compared to ours, in an immunocompetent pediatric patient in which a momentary treatment was implemented to treat a herpetic infection.
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