Enzymuria determination in children treated with aminoglycosides drugs

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1 Human & Experimental Toxicology (2008) 27: treated with aminoglycosides drugs A Mohammadi-Karakani 1,2, S Asgharzadeh-Haghighi 1, M Ghazi-Khansari 2, A Seyed-Ebrahimi 1, A Ghasemi 1 and E Jabari 1 1 Alborz Hospital, Social Security Organization, Karaj, Iran; and 2 Department of Pharmacology, School of Medicine, Medical Sciences/ University of Tehran, Iran Although aminoglycosides antibiotics are used in children and adult commonly, they have serious side effects such as nephrotoxicity and ototoxicity. In clinical practice, for renal function, the levels of serum creatinine and blood urea nitrogen routinely are measured. Since these parameters have limitations such as unreliability, insensitivity, and nonspecificity, the rapid assessment of renal function based on these patients is very important. Increase in N-acetyl-β-D-glucosaminidase (NAG), a hydrolytic lysosomal enzyme, suggests proximal tubular cell damage. In this study, 32 children aged 2 months through 2 years, treated with gentamicin and amikacin for suspected infections at the pediatric ward of Alborz hospital from September 2006 to February 2007, were enrolled. Serum and fresh urine before and after drug infusion were obtained on the 1st, 3rd, and 5th days of antibiotic treatment. Serum urea and creatinine with urinary creatinine, albumin, NAG, lactate dehydrogenase (LDH) and alkaline phosphatase (AP) activity were then determined. A statistically significant increase in urinary NAG, LDH, and AP on 5th day was found compared with before gentamicin administration (P < 0.001, P < 0.01, P < 0.05, respectively). The urinary NAG activity may be a useful indicator of renal injury in children treated with aminoglycosides drugs compared with other routine clinical indicators. Key words: aminoglycosides antibiotics; children; serum creatinine; urinary enzymes Introduction In clinical practice, gentamicin and amikacin are the two most common antibiotics used in the therapy of infections caused by gram-negative bacilli in children, but their use is limited by their side effects like nephrotoxicity and ototoxicity. 1,2 Nephrotoxicity involves the partial reabsorption of these drugs by proximal tubular cells. Because of positively charged molecules, aminoglycosides can bind to acidic phospholipids of the brush border membrane and are rapidly transferred into endocytic vacuoles by megalin and are localized in endocytic vacuoles and lysosomes of proximal tubular cells. 3 5 The traditional clinical indicators such as serum creatinine and blood urea nitrogen are used for evaluation of drug-induced nephrotoxicity. Because of the insensitivity, unreliability, and nonspecificity of these parameters and time delay between renal injury Correspondence to: Mahmoud Ghazi-Khansari, Department of Pharmacology, School of Medicine, Medical Sciences/ University of Tehran, Iran. ghazikha@sina.tums.ac.ir and detection, various parameters have been examined in an attempt to detect early nephrotoxicity. 6,7 One of the most sensitive markers of early renal proximal tubule damage is activity of urinary N-acetyl-β-D-glucosaminidase (NAG; EC ). Due to its high molecular weight, NAG does not permit glomerular filtration; thus, increase in urinary NAG activity suggests a pathological state. 8,9 The NAG activity has been reviewed by Skalova. 10 Activity of urinary NAG was found to be associated with various kidney injuries due to exposure to various toxic substances, such as lead and cadmium; organic solvents; aminoglycosides antibiotics; and nephrotoxic drugs used for treating cancer, 10 diabetic nephropathy, 11 nephrotic syndrome, urinary tract infection, kidney transplants, and vesicoureteral reflux. 10 Also the measurement of urinary enzymes is considered a relatively simple, cheap, fast, and noninvasive method in the detection and follow-up of renal disorders. So we designed this study to determine the enzymes in urine in children treated with aminoglycosides (gentamicin and amikacin) for suspected infections before and after drug infusion on the 1st, 3 rd, and 5th days of treatment SAGE Publications /

2 880 Methods Subjects A total of 32 children (17 boys and 15 girls) aged 2 months through to 2 years treated with gentamicin and amikacin at pediatric ward, Alborz Hospital, Karaj, Iran, from September 2006 to February 2007 were enrolled. Children without a medical history or clinical examination suggesting history of kidney diseases were included. Urinary culture showed that none of the patients had urinary tract infection. The subjects rights were protected by an appropriate institutional reviewe board, and informed consent was obtained. Study design Urine and blood specimens were obtained from the subjects before and during days 1, 3, and 5 of the treatment. Urine and blood specimens were centrifuged (2000 g for 10 min) immediately after collection. Since lactate dehydrogenase (LDH) is not stable in refrigerator and alkaline phosphatase(ap) is stable only for 4 h after urine collection, all tests were conducted within 7 h of sample collection, expect NAG determination in which urine samples were frozen and stored at 37 C for 1 month. Biochemical analysis NAG activity in urine was measured at 37 C, according to described method, 12 with ρ-nitrophenyl-n-acetyl-β-d-glucosaminde as substrate. Serum and urinary creatinine and urea, AP, LDH, and microalbuminuria were measured by using a commercially available assay kit (Pars Azmun Co. Ltd, Iran) by Jaffe, Urease-GLDH, DGKG, DGKG, and immunoturbidometry method, respectively. All of these tests were measured with the Hitachi 902 autoanalyser (Hitachi Ltd., Japan). In order to correct variations in urine flow, the urinary enzyme activities (U/L) were normalized to urinary creatinine concentration (g/l) and given as U/g creatinine. Statistical calculations All data were presented as mean ± SEM. The differences between the two groups were calculated with Student s paired t-test. A P value of 0.05 denoted a statistically significant difference. Results Clinical characteristics of patients treated with gentamicin and amikacin are shown in Table 1. Biochemical parameters of patients treated with gentamicin Table 1 General characteristics of patients treated with gentamicin and amikacin (mean ± SEM) Patient data Age (months) 8.2 ± 1.8 Gender (M/F) 17/15 Weight (kg) 7.4 ± 0.55 Treatment data for gentamicin Daily dose (mg/kg/8 h) 1.5 Number of patients 14 (44 %) Reason of the therapy Pneumonia 12 (85 %) Gastroenteritis 2 (15 %) Treatment data for amikacin Daily dose (mg/kg/8 h) 5 Number of patients 18 (56 %) Reason of the therapy Pneumonia 11 (61 %) Gastroenteritis 7 (39 %) Characteristic or parameter and amikacin are given in Table 2. In the course of aminoglycosides treatment, no significant differences in serum creatinine, blood urea nitrogen, and urinary albumin were detected before and after aminoglycosides administration. In patients treated with gentamicin, a statistically significant increase in urinary Table 2 Biochemical parameters of patients treated with gentamicin and amikacin (mean ± SEM) Parameter Days Gentamicin (n = 14) Amikacin (n =18) Serum creatinine (mg/dl) ± ± ± ± ± ± ± ± 0.04 Serum urea (mg/dl) ± ± ± ± ± ± ± ± 0.7 Urinary creatinine (g/l) ± ± ± ± ± ± ± ± 0.03 Urinary NAG ( U/ g Cr) ± ± ± ± ± 1.7 *** 6.1 ± ± 2.9 *** 12.3 ± 3.1 *** Urinary LDH (U/g Cr) ± ± ±55 226± ±21 197± ±74** 199±37 Urinary AP (U/g Cr) ± ± ±72 248± ±41 351± ± 68 * 300 ± 49 Urinary albumin (mg/g Cr) 0 14 ± ± ± ± ± ± ± ± 2.6 *Significant difference between zero day and other days of gentamicin and amikacin administration. *P < **P < ***P <

3 NAG was noted on 3rd and 5th day compared with before drug administration (P < 0.001, P < 0.001, respectively), and also in urinary LDH and AP, a statistically significant increase was observed on 5th day compared with before drug administration (P < 0.01, P < 0.05, respectively). But in patients treated with amikacin, only in urinary NAG, a statistically significant increase on 5th day compared with before drug administration was noted (P < 0.001). Discussion One of the major reasons of acute kidney injury (AKI) is drug-induced nephrotoxicity, especially due to aminoglycosides. Incidence has been reported to be as high as 36% among patients diagnozed with AKI. 6 Main approaches toward reduction of aminoglycoside nephrotoxicity include once-daily dosing, 13 time of administration, 14 protective effect with antioxidants such as vitamin E, C, selenium, probucol, and deferoxamine, 3 polyaspartic acid, 15 antagonists of megalin, 5 and early diagnosis through biomarkers. 6 Conventional blood and urine parameters of kidney injury are insensitive, nonspecific, and do not indicate the region affected by the toxic insult. 6,7 Thus, there is a clear need for biomarkers of nephrotoxicity that could indicate when damage begins, assess the level of damage, and help to localize the lesion. The current status of sensitive and specific biomarkers for early diagnosis of AKI was reviewed by Vaidya. 6 In this study, we demonstrated that level of serum creatinine, blood urea nitrogen, and urinary albumin did not change after drug administration, but the level of urinary enzyme on 5th day after drug administration changed. These data agree with several studies in animals and humans Although some of studies reported that aminoglycoside-induced nephrotoxicity to be less frequent in children and newborn infants compared with adults, 21,22 we showed urinary NAG, LDH, and AP were increased on 5th day after gentamicin administration. Also, urinary NAG was increased on 5th day after amikacin administration. This finding confirms the previous research on aminoglycoside nephrotoxicity, which showed that gentamicin, due to enhanced generation of hydrogen peroxide and increase in renal cortical lipid peroxidation, 23 can be more potential nephrotoxic agent compared with other aminoglycosides. Disadvantages of other biomarkers used in this study are that LDH can be influenced by hepatic parenchymal injury and AP is not stable in urine for long time after urine collection, thus requiring gel filtration before analysis 24 ; therefore, urinary NAG can be an earliest biomarker for evaluation of drug-induced renal injury. We conclude that urinary NAG as an index of nephrotoxicity can be developed as a one useful test for early diagnosis and monitoring of druginduced nephrotoxicity. Acknowledgements The authors would be like to thank the Alborz hospital manager, Karaj, Iran, and Dr. M.H. Vahid for their support during this study. We thank Pars Azmun Co. Ltd (Tehran, Iran) for supplying the assay kits for this study and head nurse of pediatric ward, M. Dehghani, for the supplying clinical specimens. References 1 Hammett-Stabler, CA, Johns, T. Laboratory guidelines for monitoring of antimicrobial drugs. National Academy of Clinical Biochemistry. Clin Chem 1998; 44: Mendoza, SA. Nephrotoxic drugs. Pediatr Nephrol 1988; 2: Beauchamp, D, Labrecque, G. Aminoglycoside nephrotoxicity: do time and frequency of administration matter. Curr Opin Crit Care 2001; 7: Mingeot-Leclercq, MP, Tulkens, PM. Aminoglycosides: nephrotoxicity. Antimicrob Agents Chemother 1999; 43: Nagai, J, Takano, M. Molecular aspects of renal handling of aminoglycosides and strategies for preventing the nephrotoxicity. Drug Metab Pharmacokinet 2004; 19: Vaidya, VS, Bonventre, JV. Mechanistic biomarkers for cytotoxic acute kidney injury. Expert Opin Drug Metab Toxicol 2006; 2: Hewitt, SM, Dear, J, Star, RA. Discovery of protein biomarkers for renal diseases. J Am Soc Nephrol 2004; 15: Skalova, S, Chladek, J. Urinary N-acetyl-beta- D-glucosaminidase activity in healthy children. Nephrology (Carlton) 2004; 9: Tassi, C, Abbritti, G, Mancuso, F, Morucci, P, Feligioni, L, Muzi, G. Activity and isoenzyme profile of N-acetyl-beta-D-glucosaminidase in urine from workers exposed to cadmium. Clin Chim Acta 2000; 299: Skalova, S. The diagnostic role of urinary N-acetylbeta-D-glucosaminidase (NAG) activity in the detection of renal tubular impairment. Acta Medica (Hradec Kralove) 2005; 48: Mohammadi-Karakani, A, Asgharzadeh-Haghighi, S, Ghazi-Khansari, M, Hosseini, R. Determination of urinary enzymes as marker of early renal damage in diabetic patients. J Clin Lab Anal 2007; 21: Hosseini, R, Dehpour, AR, Rad, MH, Rankohi, KE. An improved method for evaluation of nephrotoxicity by 881

4 882 assay of urinary N-Acetyl-á-D-Glucosaminidase (NAG) activity. Toxicol Methods 1997; 7: Periti, P. Preclinical and clinical evaluation of oncedaily aminoglycoside chemotherapy. J Chemother 1995; 7: Prins, JM, Weverling, GJ, van Ketel, RJ, Speelman, P. Circadian variations in serum levels and the renal toxicity of aminoglycosides in patients. Clin Pharmacol Ther 1997; 62: Beauchamp, D, Laurent, G, Maldague, P, Abid, S, Kishore, BK, Tulkens, PM. Protection against gentamicin-induced early renal alterations (phospholipidosis and increased DNA synthesis) by coadministration of poly-l-aspartic acid. J Pharmacol Exp Ther 1990; 255: Gibey, R, Dupond, JL, Alber, D. Leconte des Floris, R, Henry, JC. Predictive value of urinary N-acetyl-beta- D-glucosaminidase (NAG), alanine-aminopeptidase (AAP) and beta-2-microglobulin (beta 2M) in evaluating nephrotoxicity of gentamicin. Clin Chim Acta 1981; 116: Whiting, PH, Brown, PA. The relationship between enzymuria and kidney enzyme activities in experimental gentamicin nephrotoxicity. Ren Fail 1996; 18: Assadamongkol, K, Tapaneya-Olarn, W, Chatasingh, S. Urinary N-acetyl-beta-D-glucosaminidase (NAG) in aminoglycoside nephrotoxicity. J Med Assoc Thai 1989; 1: Wiland, P, Szechcinski, J. Proximal tubule damage in patients treated with gentamicin or amikacin. Pol J Pharmacol 2003; 55: Marchewka, Z, Dlugosz, A. Enzymes in urine as markers of nephrotoxicity of cytostatic agents and aminoglycoside antibiotics. Int Urol Nephrol 1998; 30: McCracken Jr, GH. Aminoglycoside toxicity in infants and children. Am J Med 1986; 80: Heimann, G. Renal toxicity of aminoglycosides in the neonatal period. Pediatr Pharmacol (New York) 1983; 3: Baliga, R, Ueda, N, Walker, PD, Shah, SV. Oxidant mechanisms in toxic acute renal failure. Drug Metab Rev 1999; 31: Vaidya, VS, Ramirez, V, Ichimura, T, Bobadilla, NA, Bonventre, JV. Kidney injury molecule-1: a sensitive quantitative biomarker for early detection of kidney tubular injury. Am J Physiol Renal Physiol 2006; 290: F517 F529.

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