A Case of Severe Acute Kidney Injury Due to an Antibiotic-Loaded Cement Spacer for Infected Knee Arthroplasty

Abstract

The treatment for periprosthetic joint infection frequently involves the placement of a high-dose antibiotic-loaded bone cement spacer (ALCS) into the debrided joint. Typical antibiotics in the spacer include aminoglycosides and vancomycin. It has been believed that systemic absorption of intraarticular antibiotics would be low, and early experience suggested that the risk of acute kidney injury (AKI) from ALCS was minimal. However, recent case reports and case series have suggested a risk of AKI owing to antibiotic absorption, though confounding factors are common. We report a case of severe AKI requiring hemodialysis with extremely high systemic tobramycin levels after the placement of an ALCS with increased dosing of antibiotics after previous failure to resolve a periprosthetic joint infection with a prior ALCS. There was no concomitant use of intravenous nephrotoxic antibiotics, nor were there other confounding factors. Despite dialysis, the patient needed urgent removal of the ALCS to control tobramycin levels, with subsequent resolution of the AKI. This case highlights the potentially serious nephrotoxicity of ALCSs, the importance of antibiotic type and dosing, and the value of close monitoring after ALCS placement, especially in a patient with chronic kidney disease.

Keywords: Acute kidney injury (AKI); Antibiotic-loaded bone cement spacer (ALCS); Chronic kidney disease (CKD); Joint spacer; Periprosthetic joint infection (PJI); Tobramycin.