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Acute Renal Failure Associated with Vancomycin- and Tobramycin-Laden Cement in Total Hip Arthroplasty

at time of writing, Pharmacy Practice Resident, The University of Montana and Community Medical Center, Missoula, MT; now, Clinical Staff Pharmacist, St. John's Medical Center, Jackson Hole, WY

Michael P Rivey, MS BCPS

Professor and Chair of Pharmacy Practice, Skaggs School of Pharmacy, The University of Montana; Clinical Pharmacy Consultant, Community Medical Center, Missoula

Douglas R Allington, PharmD BCPS

Associate Professor of Pharmacy Practice, The University of Montana

Reprints: Dr. Rivey, Skaggs School of Pharmacy, The University of Montana, 32 Campus Dr., #1522, Missoula, MT 59812-1522, fax 406/243-4353, michael.rivey{at}umontana.edu

OBJECTIVE: To describe 2 cases of acute renal failure (ARF) associated with the use of antibiotic-laden cement incorporated in total hip arthroplasties (THA).

CASE SUMMARIES: An 82-year-old female received a right THA with antibiotic-laden cement spacers. She developed ARF 5 months following implantation, concurrent with an elevated serum tobramycin concentration of 5.5 µg/mL. After explantation of the prosthesis and spacers, serum creatinine and antibiotic concentrations decreased to within normal limits. A 79-year-old male received antibiotic-laden cement spacers in a revision of his right THA due to infection. ARF developed 1 months after the revision; a serum tobramycin concentration was 2.9 µg/mL. Serum creatinine and antibiotic serum concentrations decreased to within normal limits with explantation.

DISCUSSION: More than 250 000 joint replacements are performed yearly in the US. A common complication is infection, which occurs in 1-2% of primary replacements and 3-4% of revisions of previously infected prostheses. Antibiotic-laden cement is used for prosthesis placement to prevent or treat infection, while minimizing systemic drug exposure. Both patients described here received antibiotic-laden spacers during THA and subsequently developed ARF in conjunction with elevated serum tobramycin concentrations. Use of the Naranjo probability scale and consideration of possible contributing factors suggest a probable association of the antibiotic-laden cement and the development of ARF in these patients.

CONCLUSIONS: Antibiotic-laden cement with aminoglycosides and/or vancomycin has the potential for systemic toxicity and should be used according to guidelines and with increased vigilance and prudent monitoring in patients at increased risk for nephrotoxicity.

Key Words: acute renal failure, antibiotic-laden cement, arthroplasty

Published Online, October 10, 2006. www.theannals.com, DOI 10.1345/aph.1H173