万古霉素致急性肾损伤临床报告并文献复习

Vancomycin Associated Acute Kidney Injury: A Case Report and Literature Review

目的探讨万古霉素致急性肾损伤的临床特点及预防、治疗方法,提高对万古霉素肾毒性的认识。方法对我科收治的1例万古霉素致急性肾损伤的临床资料进行回顾性分析,并复习相关文献。结果本例因先天性右髋关节脱位并右髋关节骨性关节炎入我院骨科,在硬膜外麻醉下行右侧全髋人工关节置换加右股骨近端截骨术,术前肝肾功能正常,手术过程顺利。术后给予预防性抗感染及抗凝治疗,万古霉素1 g每日2次、头孢曲松钠2 g每日1次静脉滴注,利伐沙班5 mg每日1次口服。术后第3天患者出现少尿、口渴、恶心、呕吐和烦躁不安等症状,查血肌酐及尿素升高明显,考虑药物性急性肾损伤,停用抗生素,查万古霉素血药浓度明显高于正常范围。因病情无好转,术后第4天转入重症医学科,予连续肾脏替代疗法(continuous renal replacement therapy,CRRT)等对症支持治疗,患者病情逐渐好转。结论临床上在应用万古霉素过程中应警惕其肾毒性,若患者出现不能用其他原因解释的急性肾损伤,应考虑到万古霉素的肾毒性。监测万古霉素血药浓度,及时停药,早期进行CRRT治疗可使此类患者肾功能得到恢复。

Objective To discuss the clinical characteristics, prophylaxis and therapy of Vancomycin associated acute kidney injury in order to improve the understanding about Vancomycin associated acute kidney injury. Methods Clinical data of a patient admitted to our department for Vancomycin associate acute kidney injury was retrospectively analyzed and related literature was reviewed. Results The patient was admitted to the department of orthopedics in our hospital for congenital hip dislocation on the right side and right hip osteoarthritis. He received a total hip artificial joint replacement underwent right proximal femoral osteotomy surgery, which was accomplished successfully under epidural anesthesia, and the preoperative liver and renal functions were at normal levels. Then Vancomycin 1 g bid combined with Ceftriaxone 2 g qd were given for anti-infection and Rivaroxaban tablets of 5 mg qd used as anticoagulant. On day 3, the patient developed clinical symptoms including oliguria, thirst, nausea, vomiting and irritability. Concentrations of serum creatinine and urea nitrogen were simultaneously increased significantly. Due to these complications ,the diagnosis was drug-induced acute kidney injury, antibiotics and anticoagulants were discontinued and Vancomycin level was much higher than normal. On postoperative day 4, the patient was transferred to department of critical care medicine because his condition became worse. With continous renal replacement therapy （CRRT） and other symptomatic treatment, the patient recovered gradually. Conclusion Clinicians should be vigilant about nephrotoxicity in the process of application of Vancomycin. If the symptoms of acute kidney injury occur without explainable reasons, its side effects of nephrotoxicity should be taken into consideration. Monitoring concentration of the drug, discontinuing infusion in time and initiating CRRT as early as possible are effective measures to recover renal function of the patients.