Renal dysfunction in orthopaedic surgery - with special reference to drug effects in the elderly

Abstract: Total hip replacement (THR) is a common procedure, generally performed in elderly persons. Previous studies indicated that the use of isoxazolyl penicillins could induce a transient post-operative renal dysfunction in these patients. By measuring urinary levels of markers for glomerular (albumin, IgG) and tubular (protein HC) function we studied the influence of systemic cloxacillin, the gentamicin in bone cement and the bone cement itself on renal function following THR or total knee replacement (TKR). We studied peroperative pharmacokinetics of cloxacillin in THR and TKR patients. In healthy elderly we studied the influence of diclofenac on cloxacillin pharmacokinetics, and also investigated exercise-induced proteinuria, and the possible effect of prostacyclin on it. Patients undergoing THR or TKR developed a transient increase in glomerular and tubular markers. This was not primarily caused by cloxacillin, gentamicin or bone cement. THR patients had lower creatinine clearance and lower clearance for cloxacillin than TKR patients, and lower than healthy elderly. Diclofenac did not alter the pharmacokinetics for cloxacillin in healthy, unstressed, elderly. Exercise induced a transient glomerular and proximal, but not distal, tubular impairment in the volunteers. The exercise-induced proteinuria was not altered by prostacyclin. Present surgical and anesthetic techniques have partly overcome the risk for developing postoperative renal failure, but THR patients probably still are at an increased risk. Proteinuria following surgery or exercise is suggested to share, in part, common pathways.