Acute kidney injury in patients using low dose (3 mg/kg/day) of gentamicin under therapeutic dose monitoring

Abstract

We read with interest the recent publication of Umbro et al. about sepsis-induced acute kidney injury. 1 Umbro I. Gentile G. Tinti F. Muiesan P. Mitterhofer A.P. Recent advances in pathophysiology and biomarkers of sepsis-induced acute kidney injury. J Infect. 2016; 72: 131-142 Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar In the intensive care unit, renal injury is multifactorial, including drug-induced acute renal failure. In the last decade, aminoglycosides have been important for the treatment of carbapenem-resistant Pseudomonas, Acinetobacter and Enterobacteriaceae infections. The antibiotic susceptibility profile of carbapenem-resistant Enterobacteriaceae (CRE) favors the use of aminoglycosides in some hospitals, however, nephrotoxicity is a concern about these drugs. 2 Oteo J. Ortega A. Bartolome R. Bou G. Conejo C. Fernández-Martínez M. et al. Prospective multicenter study of carbapenemase-producing Enterobacteriaceae from 83 hospitals in Spain reveals high in vitro susceptibility to colistin and meropenem. Antimicrob Agents Chemother. 2015; 59: 3406-3412 Crossref PubMed Scopus (116) Google Scholar The challenge is that some physicians are reluctant to prescribe high doses of gentamicin to patients at risk of renal failure. 3 Roger C. Nucci B. Molinari N. Bastide S. Saissi G. Pradel G. et al. Standard dosing of amikacin and gentamicin in critically ill patients results in variable and subtherapeutic concentrations. Int J Antimicrob Agents. 2015; 46: 21-27 Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar The once-daily aminoglycoside regimen and TDM (therapeutic drug monitoring) decreased the incidence of renal failure to less than 5%. 4 Nicolau D.P. Freeman C.D. Belliveau P.P. Nightingale C.H. Ross J.W. Quintiliani R. Experience with a once-daily aminoglycoside program administered to 2,184 adult patients. Antimicrob Agents Chemother. 1995; 39: 650-655 Crossref PubMed Scopus (579) Google Scholar However, the profile of patients in previous studies is different from those admitted at an ICU since most of them were young with normal renal function; whereas, patients in our ICUs can be old and with impaired basal renal function, including a non-optimal initial management of sepsis before ICU admission. Considering previous database from our hospitals, the ideal initial dose of gentamicin is 3 mg/kg/day, a dose enough to achieve an adequate peak and easier TDM.