背景:尽管通常认为肝毒性与万古霉素之间的相关性很低,据观察,使用万古霉素可导致肝功能指标异常,如天冬氨酸转氨酶升高,丙氨酸氨基转移酶,甲胎蛋白,和黄疸。进一步了解万古霉素肝毒性的临床特点,为临床提供指导。我们对万古霉素致肝损伤的特点和临床表现进行了分析。
方法:选取2016-2021年在中南大学湘雅三医院和湖南省妇幼保健院接受万古霉素治疗的肝功能损害患者,对其一般特征进行回顾性分析。万古霉素疗程,剂量,肝功能指标,肝损伤的严重程度,和伴随的药物。
结果:在4562名接受万古霉素治疗的患者中,最终纳入了17名患者,发病率为0.37%。在这些病人中,男性12人(70.6%),女性5人(29.4%),年龄从17岁到84岁,平均年龄为45.41±20.405岁。所有患者均使用Naranjo评分进行评估,评分≥3分。剂量,时间,分析万古霉素的血浆浓度,发现9例患者(52.94%)最初每12小时服用1g时肝功能异常。总的来说,14例(82.35%)肝损伤患者服用万古霉素联合2~4种药物,万古霉素与两种药物联合使用的患者发生严重的肝损伤。肝损伤的发生时间为万古霉素开始后2-12天,平均4.53±2.401天。在这些病人中,16例(94.1%)患者在服药后7天内出现肝功能异常,2例3-4级肝损伤患者均在服用药物后3天内出现肝功能异常。17例患者中只有4例(23.53%)万古霉素血药浓度在正常范围内,血药浓度与肝损伤严重程度无相关性。肝损伤严重程度与万古霉素的相关性分析显示,无1例患者出现皮疹等过敏,两名患者(11.76%)有黄疸,5例(29.41%)患者出现疲劳。其余10例(58.82%)患者均无肝损伤相关症状。所有17例患者的天冬氨酸转氨酶/丙氨酸转氨酶水平均异常,9例患者的胆红素水平也异常。15例患者(88.24%),肝损伤的严重程度为1级,表明轻度肝损伤,肝损伤严重程度与肌酐无相关性。在17名患者中,1例患者未接受干预,4例患者发生肝损伤后停止服用万古霉素,1名患者减少了剂量,11例患者(64.7%)接受了肝脏保护剂治疗。
结论:尽管该研究得出结论,肝损伤的发生率不高,临床使用万古霉素时仍应考虑万古霉素的肝毒性,监测肝功能指标。
BACKGROUND: Although the correlation between liver toxicity and
vancomycin is generally considered low, it has been observed that the use of
vancomycin can lead to abnormal liver function indicators, such as elevated aspartate aminotransferase, alanine aminotransferase, alpha fetoprotein, and jaundice. To further understand the clinical features associated with
vancomycin-induced liver toxicity and to provide clinical guidance, we conducted an analysis of the characteristics and clinical manifestations of vancomycin-induced liver injury.
METHODS: Patients with liver function injury who received
vancomycin treatment at the Third Xiangya Hospital of Central South University and Hunan Maternal and Child Health Hospital between 2016 and 2021 were selected for retrospective analysis of their general characteristics, vancomycin course, dose, liver function index, severity of liver injury, and concomitant medications.
RESULTS: Of the 4562 patients who received
vancomycin, 17 patients were finally included, with an incidence rate of 0.37%. Of these patients, 12 were male (70.6%) and 5 were female (29.4%), ranging in age from 17 to 84 years with a mean average age of 45.41 ± 20.405 years. All patients were evaluated using Naranjo\'s score, with score ≥ 3. The dosage, time, and plasma concentration of vancomycin were analyzed and it was found that nine patients (52.94%) had abnormal liver function when initially given a dose of 1 g every 12 hours. In total, 14 patients (82.35%) with liver injury were taking vancomycin in combination with two to four drugs, and severe liver injury occurred in patients taking vancomycin in combination with two drugs. The occurrence time of liver injury was 2-12 days after starting vancomycin, with a mean of 4.53 ± 2.401 days. Of these patients, 16 patients (94.1%) showed liver function abnormalities within 7 days of taking the drug, and 2 patients with grade 3-4 liver injury both showed liver function abnormalities within 3 days of taking the drug. Only 4 of the 17 patients (23.53%) had vancomycin blood concentrations within the normal range, and there was no correlation found between blood concentration and severity of liver injury. Analysis of the correlation between the severity of liver injury and vancomycin showed that none of the patients had allergies such as rash, two patients (11.76%) had jaundice, and fatigue occurred in five patients (29.41%). The remaining ten patients (58.82%) had no symptoms related to liver injury. All 17 patients had abnormal aspartate aminotransferase/alanine aminotransferase levels and 9 patients also had abnormal bilirubin levels. In 15 patients (88.24%), the severity of liver injury was grade 1, indicating mild liver injury, and no correlation was observed between the severity of liver injury and creatinine. Of the 17 patients, 1 patient received no intervention, 4 patients stopped taking vancomycin after developing liver injury, 1 patient reduced the dose, and 11 patients (64.7%) were treated with hepatic protectant.
CONCLUSIONS: Although the study concluded that the incidence of liver injury was not high, the liver toxicity of vancomycin should still be considered and liver function indicators should be monitored during the clinical use of vancomycin.