Reduction of Vancomycin-Associated Acute Kidney Injury With Montelukast

Abstract Background Vancomycin ranks among the most utilized antimicrobial agents in the treatment of serious β-lactam–resistant gram-positive infections, but its use has been associated with nephrotoxicity. Reduction of acute kidney injury (AKI) has been reported in preclinical models with adjuvant montelukast. The purpose of the study was to ascertain if montelukast was associated with a reduction in the prevalence of vancomycin-associated AKI. Methods This retrospective cohort study examined adult patients who received intravenous vancomycin between January 2020 and January 2024. The RIFLE criteria (risk, injury, failure, loss, and end-stage kidney disease) were employed in identifying cases of AKI. Additionally, a preclinical vancomycin-associated nephrotoxicity model was established to provide insights into possible renal protective mechanisms. Results Patients receiving montelukast (n = 110) were compared with controls (n = 330), of which AKI was observed in 3 (2.7%) vs 35 (10.6%), respectively (P = .01). A multivariate logistic regression analysis revealed that weight (odds ratio [OR], 1.02; 95% CI, 1.006–1.03; P = .005) and intensive care unit admission (OR, 6.88; 95% CI, 2.96–18.8; P < .001) were independently associated with AKI, while montelukast (OR, 0.26; 95% CI, .06–.77; P = .03) and male gender were protective (OR, 0.41; 95% CI, .19–.85; P = .02). Our in vitro model also revealed that adjuvant montelukast can reduce injury to proximal tubule cells through activation of the p62/KEAP-1/HO-1 antioxidant pathway. Conclusions Our study suggests that montelukast during vancomycin therapy may be protective against AKI, which may reduce patient harm and hospitalization costs. Further studies are warranted to validate our findings prospectively.