Ankur Gupta

Vancomycin is a key antibiotic in the management of severe Gram-positive infections. Recent emergence of methicillin-resistant staphylococcal strains with reduced susceptibility to vancomycin has prompted internists to administer high-dose treatment to achieve trough levels of 15 to 20 mg/l. Such high doses might be causative in nephrotoxicity. The risk further increases in patients who are critically ill and are on vasopressor support and/or concomitant nephrotoxic agents, with baseline deranged renal function, undergoing prolonged duration of therapy and are obese. However, data are insufficient to recommend the superiority of continuous infusion regimens as compared with intermittent dosing. This review discusses the literature pertaining to vancomycin nephrotoxicity.

Rhabdomyolysis (RML) is a pathological entity characterized by symptoms of myalgia, weakness and dark urine (which is often not present) resulting in respiratory failure and altered mental status. Laboratory testing for myoglobinuria is pathognomonic but so often not present during the time of testing that serum creatine kinase should always be sent when the diagnosis is suspected. Kidney injury from RML progresses through multiform pathways resulting in acute tubular necrosis. Early treatment (ideally<6 hoursfrom onset) is needed with volume expansion of all non-overloaded patients along with avoidance of nephrotoxins. There is insufficient data to recommend any specific fluid. The mortality rate ranges from 10% to up to 50% with severe AKI, so high index of suspicion and screening should be in care plan of seriously ill patients at risk for RML.

The term "prehypertension" defined as systolic blood pressure between 120 and 139 mmHg and/or diastolic pressures between 80 and 89 mmHg has now gained general acceptance. Prehypertension is associated with ~3-fold greater likelihood of developing hypertension, and roughly twice the number of cardiovascular events, than BP < 120/80 mmHg. When compared with normotensive individuals, prehypertensive individuals are more likely to be overweight and obese, to have other cardiovascular risk factors, to progress to established hypertension, and to experience premature clinical cardiovascular disease. The major unresolved issue is the appropriate management of such patients. Lifestyle modification is recommended for all patients with prehypertension as it effectively reduces rate of cardiovascular events. Presently pharmacological therapy is indicated for some patients with prehypertension who have specific comorbidities, including diabetes mellitus, chronic kidney disease, and coronary artery disease.