Department of Intensive Care, University Hospital, Vrije Universiteit, Brussels, Brussels, Belgium.
Ann Intensive Care. 2011 Jul 19;1(1):26. doi: 10.1186/2110-5820-1-26.
Continuous infusion of vancomycin is increasingly preferred as an alternative to intermittent administration in critically ill patients. Intermittent vancomycin treatment is associated with an increased occurrence of nephrotoxicity. This study was designed to determine the incidence and risk factors of acute kidney injury (AKI) during continuous infusion of vancomycin.
This was a retrospective, observational, two-center, cohort study in patients with microbiologically documented Gram-positive pneumonia and/or bacteremia and normal baseline renal function. Vancomycin dose was adjusted daily aiming at plateau concentrations of 15-25 μg/mL. AKI was defined as an increase in serum creatinine of 0.3 mg/dL or a 1.5 to 2 times increase from baseline on at least 2 consecutive days after the initiation of vancomycin. Primary data analysis compared patients with AKI with patients who did not develop AKI. A binary logistic regression analysis using the forward stepwise method was used to assess the risk factors associated with AKI.
A total of 129 patients were studied of whom 38 (29.5%) developed AKI. Patients with AKI had higher body weight (77.3 ± 15 vs. 70.5 ± 15.2 kg; p = 0.02), more diabetes (79% vs. 54%; p = 0.01), and a higher vasopressor need (87% vs. 59%; p = 0.002). Serum vancomycin levels, body weight, and SAPS 3 score were identified as variables contributing to AKI. The incidence of AKI increased substantially when treatment duration was prolonged (14.9 ± 9.8 vs. 9.2 ± 4.9 days; p = 0.05) and plasma levels exceeded 30 μg/mL.
AKI is frequently observed during continuous vancomycin infusion, particularly when conditions that cause acute (shock) or chronic (diabetes) renal dysfunction are present and vancomycin levels above target range are achieved. Although this study challenges the concept that continuous vancomycin infusion might alleviate the risk of nephrotoxicity in critically ill patients, a direct relationship between vancomycin and nephrotoxicity remains to be proven.
连续输注万古霉素在重症患者中越来越被视为替代间歇性给药的方法。间歇性万古霉素治疗与肾毒性发生率增加有关。本研究旨在确定连续输注万古霉素期间急性肾损伤（AKI）的发生率和危险因素。
这是一项回顾性、观察性、两中心队列研究，纳入了微生物学确诊的革兰氏阳性肺炎和/或菌血症且基线肾功能正常的患者。万古霉素剂量每天调整，目标是平台浓度为 15-25μg/mL。AKI 的定义为血清肌酐升高 0.3mg/dL 或万古霉素开始后至少连续 2 天从基线升高 1.5 至 2 倍。主要数据分析比较了 AKI 患者与未发生 AKI 的患者。采用向前逐步法的二项逻辑回归分析评估与 AKI 相关的危险因素。
共研究了 129 例患者，其中 38 例（29.5%）发生 AKI。AKI 患者的体重更高（77.3±15 与 70.5±15.2kg；p=0.02）、糖尿病更多（79%与 54%；p=0.01），且需要血管加压药的比例更高（87%与 59%；p=0.002）。万古霉素血清水平、体重和 SAPS 3 评分被确定为导致 AKI 的变量。当治疗持续时间延长（14.9±9.8 与 9.2±4.9 天；p=0.05）和血浆水平超过 30μg/mL 时，AKI 的发生率显著增加。
连续输注万古霉素时经常观察到 AKI，特别是在存在导致急性（休克）或慢性（糖尿病）肾功能障碍的情况下，并且达到目标范围以上的万古霉素水平时。尽管本研究对连续输注万古霉素可能减轻重症患者肾毒性风险的概念提出了挑战，但万古霉素与肾毒性之间的直接关系仍有待证实。
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