NDT Advance Access originally published online on July 12, 2006
Nephrology Dialysis Transplantation 2006 21(10):2982-2983; doi:10.1093/ndt/gfl320
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© The Author [2006]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
(Section Editor: G. H. Neild)
Ciprofloxacin crystalluria
1Research laboratory on urine of Unità Operativa di Nefrologia, Fondazione IRCCS, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, 2Unità Operativa di Nefrologia Ospedale S. Paolo, Milano, Italy and 3Service de Biochimie A, Hôpital Necker, Paris, France
Correspondence and offprint requests to: Giovanni B. Fogazzi, U.O. di Nefrologia, Fondazione IRCCS, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Via Commenda, 15 20122 Milano, Italy. Email: fogazzi{at}policlinico.mi.it
Keywords: ciprofloxacin crystalluria; crystalluria; crystalluria due to drugs; urinary sediment
Ciprofloxacin can cause crystalluria in alkaline urine (especially at pH > 7.3), both in experimental animals and in healthy human volunteers after oral or intravenous administration [1–3].
In clinical practice, a crystalluria due to ciprofloxacin was recorded in two out of 63 000 patients [4], as well as in a patient who developed obstructive uropathy due to massive ciprofloxacin crystal precipitation in the distal ureters and bladder, after a 24-day treatment at a dose of 500 mg twice daily [5]. In addition, a new case with acute renal failure and ciprofloxacin crystalluria has recently been published [6].
To our knowledge, very few images of ciprofloxacin crystals are available in the literature [2,6].
Herein, we wish to fill this void by showing several images of ciprofloxacin crystals obtained in the alkaline urine (pH = 8.5) of a healthy volunteer (one of the authors, G.B.F.), in whom a marked, transient and isolated crystalluria was obtained after the oral administration of 250 mg of ciprofloxacin and sodium bicarbonate 500 mg four times in 24 h with a normal liquid intake.
The crystals, which infrared spectroscopy performed in blind conditions by one of us (M.D.) identified as the magnesium salt of ciprofloxacin, showed a wide array of appearances.
These included: ‘needles’, ‘sheaves’, ‘stars’, ‘fans’, ‘butterflies’ and other unusual shapes, all with a lamellar structure, whose sizes ranged from 30 x 5 µm to 360 x 237 µm. Some crystals were colourless while others, especially the largest ones, showed a brownish hue. Under polarizing light, all the crystals were strongly birefringent (Figure 1).
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The crystals observed differed greatly from the crystals commonly found in the urine such as uric acid, mono- or bi-hydrated calcium oxalate, calcium phosphate or triple phosphate. They also differed from pathological crystals such as cholesterol, cystine, tyrosine, leucine or 2,8 di-hydroxyadenine.
This fact confirms the view that a drug must be considered whenever an unusual and pleomorphic crystalluria is found [7].
To prevent crystalluria, patients receiving high-dose ciprofloxacin should be well hydrated and alkalinity of the urine should be avoided [8].
Conflict of interest statement. None declared.
References
- Schlüter G. (1987) Ciprofloxacin: review of potential toxicologic effects. Am J Med 82 [Suppl 4A]:91–93.
- Thorsteinsson SB, Bergan T, Oddsdottir S, et al. (1986) Crystalluria and ciprofloxacin, influence of urinary pH and hydration. Chemotherapy 32:408–417.[Web of Science][Medline]
- Nix DE, Spivey JM, Normal A, et al. (1992) Dose-ranging pharmacokinetic study of ciprofloxacin after 200-, 300-, and 400 mg intravenous doses. Ann Pharmacother 26:8–10.[Abstract]
- Boll P and Tillotson G. (1995) Tolerability of fluoroquinolone antibiotics. Drug Safety 13:344–358.
- Chopra N, Fine PL, Price B, et al. (2000) Bilateral hydronephrosis from ciprofloxacin induced crystalluria and stone formation. J Urol 164:438.[CrossRef][Web of Science][Medline]
- Sedlacek M, Suriawinata AA, Schoolwert A, et al. (2006) Ciprofloxacin crystal nephropathy – a ‘new’ cause of acute renal failure [letter]. Nephrol Dial Transplant doi:10.1093/ndt/gfl160.
- Fogazzi GB, Cantù M, Saglimbeni L, et al. (2003) Amoxycillin, a rare but possible cause of crystalluria. Nephrol Dial Transplant 18:212–214.
[Free Full Text] - Christ W, Lehnert T, Ulbrich B. (1988) Specific toxicologic aspects of the quinolones. Rev Infect Dis 10:Suppl 1, S141–S146.
Accepted in revised form: 8. 5.06
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