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Tetracycline Pleurodesis-Associated Acute Renal Failure

1993; Elsevier BV; Volume: 104; Issue: 4 Linguagem: Inglês

10.1378/chest.104.4.1274

1931-3543

W. Roy Smythe, Joseph E. Bavaria,

Pericarditis and Cardiac Tamponade

Chemical pleurodesis is a frequently performed procedure for pneumothorax and effusion and significant adverse effects are unusual. We present a previously unreported case of acute renal failure associated with tetracycline pleurodesis. Recent studies have shown that intrapleural drug administration may lead to therapeutic serum levels. Systemic toxic drug effects may therefore be noted with chemical pleurodesants such as tetracycline. Alternative methods of pleurodesis should always be considered if a sensitivity or metabolic abnormality is suspected. Chemical pleurodesis is a frequently performed procedure for pneumothorax and effusion and significant adverse effects are unusual. We present a previously unreported case of acute renal failure associated with tetracycline pleurodesis. Recent studies have shown that intrapleural drug administration may lead to therapeutic serum levels. Systemic toxic drug effects may therefore be noted with chemical pleurodesants such as tetracycline. Alternative methods of pleurodesis should always be considered if a sensitivity or metabolic abnormality is suspected. Experimental and clinical data have proven concentrated tetracycline solution pleurodesis to be an effective method for management of refractory or recurrent pneumothorax.1Macoviak JA Stephenson LW Ochs R Edmunds LH Jr Tetracycline pleurodesis during active pulmonary-pleural air leak for prevention of recurrent pneumothorax.Chest. 1982; 81: 87-91Crossref Scopus (39) Google Scholar, 2Krasnik M Christensen B Halbier E Hoier-Madsen K Jelnes R Wied V Pleurodesis in spontaneous pneumothorax by means of tetracycline: followup evaluation of a method.Scand J Thorac Cardiovase Surg. 1987; 21: 181-182Crossref PubMed Scopus (19) Google Scholar, 3Light RW O'Hara VS Moritz TE McElhinny AJ Butz R Haahenson CM et al.Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax: results of a Department of Veterans Affairs cooperative study.JAMA. 1990; 264: 2224-2230Crossref PubMed Scopus (191) Google ScholarReported adverse effects related to tetracycline pleurodesis have been few and relatively minor.4Gravelyn TR Michelson MK Gross BH Sitrin RG Tetracycline pleurodesis for malignant pleural effusion: a 10-year retrospective study.Cancer. 1987; 59: 1973-1977Crossref PubMed Scopus (58) Google Scholar We report a case of acute nonoliguric renal failure associated with tetracycline pleurodesis for spontaneous pneumothorax.Case ReportA 56-year-old black man was admitted to the hospital with a 12-h history of pleuritic right lateral chest pain that began acutely following a bout of vigorous coughing.The medical history was significant for stable cardiac angina, hypertension, and a myocardial infarction eight years prior to hospital admission. The patient admitted to consumption of more than 8 ounces of alcohol per day and an 80 pack-sear smoking history. Medications included alpha-methyldopa and rare sublingual nitroglycerin, both taken for several years prior to hospital admission. He denied allergies or drug sensitivities. No prior pulmonary or renal disease was noted.Evaluation revealed a thin tachspneic black man. Respirations were 28/min, pulse was 120 beats/min, and blood pressure was 120/80 mm Hg. Physical examination was significant for absent breath sounds at the right hemithorax with tympanitic percussion. The hospital admission laboratory studies included a hemoglobin of 14.7 g/dl, mean corpuscular volume of 103 Fl, white blood cells count of 8.3 tho/μL, potassium of 3.4 mmol/L, sodium of 142 mmol/L, BUN of 8 mg/dl, and creatinine of 1.9 mg/dl. The creatinine kinase was normal as were results of all liver function examinations, excluding an elevated gamma-glutamyl transpeptidase of 68 U/L. A chest radiograph revealed a complete right-sided pneumothorax.A thoracostomy tube was inserted and placed on 20 cm ILO suction with immediate 90 percent reexpansion of the lung noted on follow-up chest radiograph. Following two days of intravenous hydration, the patient's creatinine fell to 0.9 mg/dl. A persistent 10 to 15 percent apical pneumothorax was noted on serial radiographs that worsened with each attempt to discontinue suction.On the ninth hospital day, the BUN and creatinine were 14 and 1.1 mg/dl, respectively (Fig 1). Pleurodesis was performed on days 9 to 11 with 1 g of tetracycline solution and 100 to 120 mg of 1 percent lidocaine instillation anesthesia. The patient's BUN and creatinine rose to 27 and 2.4 mg/dl on day 2 of pleurodesis and peaked three days later at 68 and 4.3 mg/dl, respectively, with a potassium level of 5.6 mmol/L.Random urine chemistry studies obtained on day 3 of pleurodesis were as follows: sodium, 93 mmol/L; potassium, 21.6 mmol/L; and creatinine, 42.2 mg/dl. Urine specific gravity was 1.007 and microscopy revealed no leukocytes, erythrocytes, or casts. A urine output of 1,500 to 3,500 ml/d was maintained and no complaints referable to the upper or lower urinary tract were noted. Renal ultrasound demonstrated normal-sized kidneys without hydronephrosis, as well as generalized increased echogenicity and a 1-cm-diameter simple right renal cyst.The thoracostomy tube was removed on hospital day 17, with no residual pneumothorax noted on radiograph. The BUN and creatinine had decreased to 32 and 2.2 mg/dl prior to discharge on hospital day 21.DiscussionA large number of chemical and mechanical agents have been utilized as pleural sclerosants, and many of these such as talc insufflation, silver nitrate, quinacrine, and kaolin have been virtually abandoned secondary to undesirable adverse effects.Tetracycline pleurodesis is widely used in the treatment of a number of pleural and pulmonary parenchymal conditions leading to pneumothorax or effusion. Comparison with other chemical sclerosants such as silver nitrate have shown tetracycline to be associated with fewer adverse effects.5Wied V Halbier E Hoier-Madsen K Tetracycline versus silver nitrate pleurodesis in spontaneous pneumothorax.J Thorac Cardiovasc Surg. 1983; 86: 591-593PubMed Google Scholar Relatively minor effects such as fever, small pleural effusion, and pleuritic pain are most often reported. Fever and effusion are usually self-limited, and pain may be adequately controlled in most patients with lidocaine instillation anesthesia with or without systemic analgesia.Little attention has been given to the systemic sequelae of intrapleural drug administration; however, one recent study evaluated systemic absorption of tetracycline (1 g) and lidocaine (150 mg) following administration of pleurodesis. Tetracycline and lidocaine serum levels were found to be in the therapeutic range after 1 treatment in 4 of 5 and 4 of 7 patients, respectively.6Wooten SA Barbarash RA Strange C Sahn SA Systemic absorption of tetracycline and lidocaine following intrapleural instillation.Chest. 1988; 94: 960-963Abstract Full Text Full Text PDF PubMed Scopus (31) Google ScholarThis patient's clinical course and laboratory profile suggest acute renal failure, possibly acute tubular necrosis, related to pleurodesis (Fig 1). Lidocaine has no reported renal toxicity; however, tetracycline has been implicated in a number of toxic nephropathies. Acute tubular necrosis is relatively rare among these, although acute reversible renal failure has been noted in patients with hepatic dysfunction treated with a tetracycline derivative.7Miller PD Linas SL Schrier RH Plasma demeclocycline levels and nephrotoxicity.JAMA. 1984; 243: 2513Crossref Scopus (86) Google Scholar Abnormally high drug levels may accumulate at normal doses secondary to hepatic metabolic dysfunction. Although this patient did not exhibit enzymatic hepatic dysfunction, a degree of occult synthetic or metabolic dysfunction could have been present with the history obtained of heavy alcohol use.In summary, a case of nonoliguric acute renal failure secondary to tetracycline pleurodesis is presented. Tetracycline is now used less frequently due to availability; however, other similar drugs such as doxycycline are being utilized. Practitioners should be cognizant of systemic absorption of drugs administered at pleurodesis and the potential for resultant adverse effects. Alternatives to standard methods of pleurodesis could be considered in an effort to reduce systemic absorption, including more frequent administration of smaller doses of the active substance, use of inert slurries (such as talc),8Daniel TM Tribble CG Rodgers BM Thoracoscopy and talc poudrage for pneumothoraces and effusions.Ann Thorac Surg. 1990; 50: 186-189Abstract Full Text PDF PubMed Scopus (79) Google Scholar and thoracoscopic-directed infusion of chemical pleurodesants or thoracoscopic mechanical pleurodesis. Experimental and clinical data have proven concentrated tetracycline solution pleurodesis to be an effective method for management of refractory or recurrent pneumothorax.1Macoviak JA Stephenson LW Ochs R Edmunds LH Jr Tetracycline pleurodesis during active pulmonary-pleural air leak for prevention of recurrent pneumothorax.Chest. 1982; 81: 87-91Crossref Scopus (39) Google Scholar, 2Krasnik M Christensen B Halbier E Hoier-Madsen K Jelnes R Wied V Pleurodesis in spontaneous pneumothorax by means of tetracycline: followup evaluation of a method.Scand J Thorac Cardiovase Surg. 1987; 21: 181-182Crossref PubMed Scopus (19) Google Scholar, 3Light RW O'Hara VS Moritz TE McElhinny AJ Butz R Haahenson CM et al.Intrapleural tetracycline for the prevention of recurrent spontaneous pneumothorax: results of a Department of Veterans Affairs cooperative study.JAMA. 1990; 264: 2224-2230Crossref PubMed Scopus (191) Google Scholar Reported adverse effects related to tetracycline pleurodesis have been few and relatively minor.4Gravelyn TR Michelson MK Gross BH Sitrin RG Tetracycline pleurodesis for malignant pleural effusion: a 10-year retrospective study.Cancer. 1987; 59: 1973-1977Crossref PubMed Scopus (58) Google Scholar We report a case of acute nonoliguric renal failure associated with tetracycline pleurodesis for spontaneous pneumothorax. Case ReportA 56-year-old black man was admitted to the hospital with a 12-h history of pleuritic right lateral chest pain that began acutely following a bout of vigorous coughing.The medical history was significant for stable cardiac angina, hypertension, and a myocardial infarction eight years prior to hospital admission. The patient admitted to consumption of more than 8 ounces of alcohol per day and an 80 pack-sear smoking history. Medications included alpha-methyldopa and rare sublingual nitroglycerin, both taken for several years prior to hospital admission. He denied allergies or drug sensitivities. No prior pulmonary or renal disease was noted.Evaluation revealed a thin tachspneic black man. Respirations were 28/min, pulse was 120 beats/min, and blood pressure was 120/80 mm Hg. Physical examination was significant for absent breath sounds at the right hemithorax with tympanitic percussion. The hospital admission laboratory studies included a hemoglobin of 14.7 g/dl, mean corpuscular volume of 103 Fl, white blood cells count of 8.3 tho/μL, potassium of 3.4 mmol/L, sodium of 142 mmol/L, BUN of 8 mg/dl, and creatinine of 1.9 mg/dl. The creatinine kinase was normal as were results of all liver function examinations, excluding an elevated gamma-glutamyl transpeptidase of 68 U/L. A chest radiograph revealed a complete right-sided pneumothorax.A thoracostomy tube was inserted and placed on 20 cm ILO suction with immediate 90 percent reexpansion of the lung noted on follow-up chest radiograph. Following two days of intravenous hydration, the patient's creatinine fell to 0.9 mg/dl. A persistent 10 to 15 percent apical pneumothorax was noted on serial radiographs that worsened with each attempt to discontinue suction.On the ninth hospital day, the BUN and creatinine were 14 and 1.1 mg/dl, respectively (Fig 1). Pleurodesis was performed on days 9 to 11 with 1 g of tetracycline solution and 100 to 120 mg of 1 percent lidocaine instillation anesthesia. The patient's BUN and creatinine rose to 27 and 2.4 mg/dl on day 2 of pleurodesis and peaked three days later at 68 and 4.3 mg/dl, respectively, with a potassium level of 5.6 mmol/L.Random urine chemistry studies obtained on day 3 of pleurodesis were as follows: sodium, 93 mmol/L; potassium, 21.6 mmol/L; and creatinine, 42.2 mg/dl. Urine specific gravity was 1.007 and microscopy revealed no leukocytes, erythrocytes, or casts. A urine output of 1,500 to 3,500 ml/d was maintained and no complaints referable to the upper or lower urinary tract were noted. Renal ultrasound demonstrated normal-sized kidneys without hydronephrosis, as well as generalized increased echogenicity and a 1-cm-diameter simple right renal cyst.The thoracostomy tube was removed on hospital day 17, with no residual pneumothorax noted on radiograph. The BUN and creatinine had decreased to 32 and 2.2 mg/dl prior to discharge on hospital day 21. A 56-year-old black man was admitted to the hospital with a 12-h history of pleuritic right lateral chest pain that began acutely following a bout of vigorous coughing. The medical history was significant for stable cardiac angina, hypertension, and a myocardial infarction eight years prior to hospital admission. The patient admitted to consumption of more than 8 ounces of alcohol per day and an 80 pack-sear smoking history. Medications included alpha-methyldopa and rare sublingual nitroglycerin, both taken for several years prior to hospital admission. He denied allergies or drug sensitivities. No prior pulmonary or renal disease was noted. Evaluation revealed a thin tachspneic black man. Respirations were 28/min, pulse was 120 beats/min, and blood pressure was 120/80 mm Hg. Physical examination was significant for absent breath sounds at the right hemithorax with tympanitic percussion. The hospital admission laboratory studies included a hemoglobin of 14.7 g/dl, mean corpuscular volume of 103 Fl, white blood cells count of 8.3 tho/μL, potassium of 3.4 mmol/L, sodium of 142 mmol/L, BUN of 8 mg/dl, and creatinine of 1.9 mg/dl. The creatinine kinase was normal as were results of all liver function examinations, excluding an elevated gamma-glutamyl transpeptidase of 68 U/L. A chest radiograph revealed a complete right-sided pneumothorax. A thoracostomy tube was inserted and placed on 20 cm ILO suction with immediate 90 percent reexpansion of the lung noted on follow-up chest radiograph. Following two days of intravenous hydration, the patient's creatinine fell to 0.9 mg/dl. A persistent 10 to 15 percent apical pneumothorax was noted on serial radiographs that worsened with each attempt to discontinue suction. On the ninth hospital day, the BUN and creatinine were 14 and 1.1 mg/dl, respectively (Fig 1). Pleurodesis was performed on days 9 to 11 with 1 g of tetracycline solution and 100 to 120 mg of 1 percent lidocaine instillation anesthesia. The patient's BUN and creatinine rose to 27 and 2.4 mg/dl on day 2 of pleurodesis and peaked three days later at 68 and 4.3 mg/dl, respectively, with a potassium level of 5.6 mmol/L. Random urine chemistry studies obtained on day 3 of pleurodesis were as follows: sodium, 93 mmol/L; potassium, 21.6 mmol/L; and creatinine, 42.2 mg/dl. Urine specific gravity was 1.007 and microscopy revealed no leukocytes, erythrocytes, or casts. A urine output of 1,500 to 3,500 ml/d was maintained and no complaints referable to the upper or lower urinary tract were noted. Renal ultrasound demonstrated normal-sized kidneys without hydronephrosis, as well as generalized increased echogenicity and a 1-cm-diameter simple right renal cyst. The thoracostomy tube was removed on hospital day 17, with no residual pneumothorax noted on radiograph. The BUN and creatinine had decreased to 32 and 2.2 mg/dl prior to discharge on hospital day 21. DiscussionA large number of chemical and mechanical agents have been utilized as pleural sclerosants, and many of these such as talc insufflation, silver nitrate, quinacrine, and kaolin have been virtually abandoned secondary to undesirable adverse effects.Tetracycline pleurodesis is widely used in the treatment of a number of pleural and pulmonary parenchymal conditions leading to pneumothorax or effusion. Comparison with other chemical sclerosants such as silver nitrate have shown tetracycline to be associated with fewer adverse effects.5Wied V Halbier E Hoier-Madsen K Tetracycline versus silver nitrate pleurodesis in spontaneous pneumothorax.J Thorac Cardiovasc Surg. 1983; 86: 591-593PubMed Google Scholar Relatively minor effects such as fever, small pleural effusion, and pleuritic pain are most often reported. Fever and effusion are usually self-limited, and pain may be adequately controlled in most patients with lidocaine instillation anesthesia with or without systemic analgesia.Little attention has been given to the systemic sequelae of intrapleural drug administration; however, one recent study evaluated systemic absorption of tetracycline (1 g) and lidocaine (150 mg) following administration of pleurodesis. Tetracycline and lidocaine serum levels were found to be in the therapeutic range after 1 treatment in 4 of 5 and 4 of 7 patients, respectively.6Wooten SA Barbarash RA Strange C Sahn SA Systemic absorption of tetracycline and lidocaine following intrapleural instillation.Chest. 1988; 94: 960-963Abstract Full Text Full Text PDF PubMed Scopus (31) Google ScholarThis patient's clinical course and laboratory profile suggest acute renal failure, possibly acute tubular necrosis, related to pleurodesis (Fig 1). Lidocaine has no reported renal toxicity; however, tetracycline has been implicated in a number of toxic nephropathies. Acute tubular necrosis is relatively rare among these, although acute reversible renal failure has been noted in patients with hepatic dysfunction treated with a tetracycline derivative.7Miller PD Linas SL Schrier RH Plasma demeclocycline levels and nephrotoxicity.JAMA. 1984; 243: 2513Crossref Scopus (86) Google Scholar Abnormally high drug levels may accumulate at normal doses secondary to hepatic metabolic dysfunction. Although this patient did not exhibit enzymatic hepatic dysfunction, a degree of occult synthetic or metabolic dysfunction could have been present with the history obtained of heavy alcohol use.In summary, a case of nonoliguric acute renal failure secondary to tetracycline pleurodesis is presented. Tetracycline is now used less frequently due to availability; however, other similar drugs such as doxycycline are being utilized. Practitioners should be cognizant of systemic absorption of drugs administered at pleurodesis and the potential for resultant adverse effects. Alternatives to standard methods of pleurodesis could be considered in an effort to reduce systemic absorption, including more frequent administration of smaller doses of the active substance, use of inert slurries (such as talc),8Daniel TM Tribble CG Rodgers BM Thoracoscopy and talc poudrage for pneumothoraces and effusions.Ann Thorac Surg. 1990; 50: 186-189Abstract Full Text PDF PubMed Scopus (79) Google Scholar and thoracoscopic-directed infusion of chemical pleurodesants or thoracoscopic mechanical pleurodesis. A large number of chemical and mechanical agents have been utilized as pleural sclerosants, and many of these such as talc insufflation, silver nitrate, quinacrine, and kaolin have been virtually abandoned secondary to undesirable adverse effects. Tetracycline pleurodesis is widely used in the treatment of a number of pleural and pulmonary parenchymal conditions leading to pneumothorax or effusion. Comparison with other chemical sclerosants such as silver nitrate have shown tetracycline to be associated with fewer adverse effects.5Wied V Halbier E Hoier-Madsen K Tetracycline versus silver nitrate pleurodesis in spontaneous pneumothorax.J Thorac Cardiovasc Surg. 1983; 86: 591-593PubMed Google Scholar Relatively minor effects such as fever, small pleural effusion, and pleuritic pain are most often reported. Fever and effusion are usually self-limited, and pain may be adequately controlled in most patients with lidocaine instillation anesthesia with or without systemic analgesia. Little attention has been given to the systemic sequelae of intrapleural drug administration; however, one recent study evaluated systemic absorption of tetracycline (1 g) and lidocaine (150 mg) following administration of pleurodesis. Tetracycline and lidocaine serum levels were found to be in the therapeutic range after 1 treatment in 4 of 5 and 4 of 7 patients, respectively.6Wooten SA Barbarash RA Strange C Sahn SA Systemic absorption of tetracycline and lidocaine following intrapleural instillation.Chest. 1988; 94: 960-963Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar This patient's clinical course and laboratory profile suggest acute renal failure, possibly acute tubular necrosis, related to pleurodesis (Fig 1). Lidocaine has no reported renal toxicity; however, tetracycline has been implicated in a number of toxic nephropathies. Acute tubular necrosis is relatively rare among these, although acute reversible renal failure has been noted in patients with hepatic dysfunction treated with a tetracycline derivative.7Miller PD Linas SL Schrier RH Plasma demeclocycline levels and nephrotoxicity.JAMA. 1984; 243: 2513Crossref Scopus (86) Google Scholar Abnormally high drug levels may accumulate at normal doses secondary to hepatic metabolic dysfunction. Although this patient did not exhibit enzymatic hepatic dysfunction, a degree of occult synthetic or metabolic dysfunction could have been present with the history obtained of heavy alcohol use. In summary, a case of nonoliguric acute renal failure secondary to tetracycline pleurodesis is presented. Tetracycline is now used less frequently due to availability; however, other similar drugs such as doxycycline are being utilized. Practitioners should be cognizant of systemic absorption of drugs administered at pleurodesis and the potential for resultant adverse effects. Alternatives to standard methods of pleurodesis could be considered in an effort to reduce systemic absorption, including more frequent administration of smaller doses of the active substance, use of inert slurries (such as talc),8Daniel TM Tribble CG Rodgers BM Thoracoscopy and talc poudrage for pneumothoraces and effusions.Ann Thorac Surg. 1990; 50: 186-189Abstract Full Text PDF PubMed Scopus (79) Google Scholar and thoracoscopic-directed infusion of chemical pleurodesants or thoracoscopic mechanical pleurodesis.