AMINOGLYCOSIDES

Absorption
Aminoglycosides are highly polar cations and therefore are very poorly absorbed from
the GI tract. The drugs are not inactivated in the intestine and are eliminated quantitatively in the
feces. Long-term oral or rectal administration of aminoglycosides may result in accumulation to
toxic concentrations in patients with renal impairment. Absorption of gentamicin from the GI
tract may be increased by GI disease (e.g., ulcers or inflammatory bowel disease). Instillation of
these drugs into body cavities with serosal surfaces also may result in rapid absorption and
unexpected toxicity (i.e., neuromuscular blockade). Similarly, intoxication may occur when
aminoglycosides are applied topically for long periods to large wounds, burns, or cutaneous
ulcers, particularly if there is renal insufficiency. All the aminoglycosides are absorbed rapidly
from intramuscular sites of injection. Peak concentrations in plasma occur after 30-90 minutes
and are similar to those observed 30 minutes after completion of an intravenous infusion of an
equal dose over a 30-minute period. These concentrations typically range from 4-12 μg/mL
following a 1.5-2 mg/kg dose of gentamicin, tobramycin, or netilmicin and from 20 to 35 μg/mL
following a 7.5 mg/kg dose of amikacin or kanamycin. In critically ill patients, especially those
in shock absorption of drug may be reduced from intramuscular sites because of poor perfusion.

Distribution
Because of their polar nature, the aminoglycosides do not penetrate into most cells, the
CNS, or the eye. Except for streptomycin, there is negligible binding of aminoglycosides to
plasma albumin. The aminoglycosides distribute poorly into adipose tissue. Concentrations of
aminoglycosides in secretions and tissues are low. High concentrations are found only in the
renal cortex and the endolymph and perilymph of the inner ear; the high concentration in these
sites likely contribute to the nephrotoxicity and ototoxicity caused by these drugs. As a result of
active hepatic secretion, concentrations in bile approach 30% of those found in plasma, but this
represents a very minor excretory route for the aminoglycosides. Inflammation increases the
penetration of aminoglycosides into peritoneal and pericardial cavities. Concentrations in CSF in
the absence of inflammation are <10% of those in plasma; this value may approach 25% when
there is meningitis (Kearney and Aweeka, 1999).

Elimination
The aminoglycosides are excreted almost entirely by glomerular filtration, and urine
concentrations of 50-200 μg/mL are achieved. A large fraction of a parenterally administered
dose is excreted unchanged during the first 24 hours, with most of this appearing in the first 12
hours. The half-lives of the aminoglycosides in plasma are similar, 2-3 hours in patients with
normal renal function. Renal clearance of aminoglycosides is approximately twothirds of the
simultaneous creatinine clearance; this observation suggests some tubular reabsorption of these
drugs. After a single dose of an aminoglycoside, disappearance from the plasma exceeds renal
excretion by 10-20%; however, after 1-2 days of therapy, nearly 100% of subsequent doses
eventually is recovered in the urine. This lag period probably represents saturation of binding
sites in tissues. The rate of elimination of drug from these sites is considerably longer than from
plasma; the t1/2 for tissue-bound aminoglycoside has been estimated to range from 30 to 700
hours. For this reason, small amounts of aminoglycosides can be detected in the urine for 10-20
days after drug administration is discontinued. Aminoglycoside bound to renal tissue exhibits
antibacterial activity and protects experimental animals against bacterial infections of the kidney
even when the drug no longer can be detected in serum (Bergeron et al., 1982).

Adverse Effect
Approximately 8-26% of patients who receive an aminoglycoside for several days
develop mild renal impairment that is almost always reversible. The toxicity results from
accumulation and retention of aminoglycoside in the proximal tubular cells (Lietman and Smith,
1983). The initial manifestation of damage at this site is excretion of enzymes of the renal
tubular brush border (Banday et al., 2008). The non-oliguric phase of renal insufficiency is
thought to be due to the effects of aminoglycosides on the distal portion of the nephron with a
reduced sensitivity of the collecting-duct epithelium to endogenous antidiuretic hormone (Appel,
1982). Although severe acute tubular necrosis may occur rarely, the most common significant
finding is a mild rise in plasma creatinine (5-20 μg/mL; 40-175 μM). Hypokalemia,
hypocalcemia, and hypophosphatemia are seen very infrequently. The impairment in renal
function is almost always reversible because the proximal tubular cells have the capacity to
regenerate.
The biochemical events leading to tubular cell damage and glomerular dysfunction are
poorly understood but may involve perturbations of the structure of cellular membranes.
Aminoglycosides inhibit various phospholipases, sphingomyelinases, and ATPases, and they
alter the function of mitochondria and ribosomes (Humes et al., 1984; Queener et al., 1983).
Because of the ability of cationic aminoglycosides to interact with anionic phospholipids, these
drugs may impair the synthesis of membrane-derived autacoids and intracellular second
messengers such as prostaglandins, inositol phosphates, and diacylglycerol. The nephrotoxic
potential varies among individual aminoglycosides. The relative toxicity correlates with the
concentration of drug found in the renal cortex in experimental animals. Neomycin, which
concentrates to the greatest degree, is highly nephrotoxic in human beings and should not be
administered systemically. Streptomycin does not concentrate in the renal cortex and is the least
nephrotoxic.

Aminoglycoside Nephrotoxicity
- Most experimental evidence indicates that net reabsorption of aminoglycosides occurs in the
proximal tubule by means of a high-capacity transport system.
- Net drug secretion might occur in the early proximal tubule at high doses, whereas net
secretion in the late proximal tubule ol' juxtamedullary nephrons might occur at lower doses.
- Renal handling of aminoglycoside:
 Aminoglycoside binding to brushborder membrane sites  Luminal drug uptake 
Absorptive pinocytosis  Lysosomal processing  Uptake by renal tubular cell 
Aminoglycosides reside  Prolonged tissue halflives of aminoglycosides
- The tubular toxicity of gentamicin presents two aspects:
o The death of tubular epithelial cells, mainly within the proximal segment, with a very
important inflammatory component associated.
o The nonlethal, functional alteration of key cellular components involved in water and
solute transport.

1. Death of Tubular Epithelial Cells

- Culture and treatment of experimental animals with gentamicin causes both apoptosis and
necrosis of tubular epithelial cells.
- However, the most commonly observed phenotype in vitro is apoptosis, probably because it
is necessary to expose cultured cells to high concentrations of the drug (>1 to 2 mg/ml) to
observe a modest cytotoxic effect.
- Apoptosis & necrosis:
o Apoptosis is an ATP-requiring process.
 o When the cell’s ATP reserve drops, the death mode loses the typical characteristics of
apoptosis and acquires those of necrosis.
- Gentamicin cytotoxicity occurs in those cell types in which the drug accumulates.
- In the kidneys, these cells constitute the epithelial cells in the cortex, mainly in the
proximal tubule of experimental animals and humans, and also in the distal and collecting
ducts.
- A higher accumulation of gentamicin in these cells is consistent with the expression of a
transporter of proteins and cations, namely, the giant endocytic complex formed by megalin
and cubilin, which is restricted to the proximal tubule.
- This complex is known to transport gentamicin and, in general, aminoglycosides, by
endocytosis.
- These drugs then traffic through the endosomal compartment and accumulate mostly in
lysosomes, the Golgi, and endoplasmic reticulum.
- Gentamicin binds to membrane phospholipids, alters their turnover and metabolism,
and, as a consequence, causes a condition known as phospholipidosis that has been observed
in humans and experimental animals treated with the drug.
- Lysosomal phospholipidosis results from:
o The reduction in the available negative charge necessary for the correct
function of phospholipases.
o Inhibition of A1, A2, and C1 phospholipases.
- Phospholipidosis correlates tightly with the level of toxicity of aminoglycosides.
- When the concentration of aminoglycoside in endosomal structures exceeds an undetermined
threshold, their membrane is disrupted and their content, along with the drug, is poured into
the cytosol.
- Cytosolic gentamicin then acts on mitochondria directly and indirectly, and thus activates
the intrinsic pathway of apoptosis, interrupts the respiratory chain, impairs ATP
production, and produces oxidative stress by increasing superoxide anions and hydroxyl
radicals, which further contributes to cell death.
- Indirect mitochondrial effect:
o Increasing Bax levels through the inhibition of its proteosomal degradation.
o The lysosomal content bears highly active proteases named cathepsins.
o Cathepsin-mediated cell death occurs through apoptosis by directly cleaving active
executioner caspases and indirectly unleashing the intrinsic pathway through the
proteolytic activation of Bid that, especially under low ATP conditions, leads to a rapid,
necrotic-like mode of cell death.
- In the endoplasmic reticulum:
o Gentamicin inhibits protein synthesis, impairs translational accuracy, and might
interfere with the correct posttranslational protein folding.
 o This generates endoplasmic reticulum stress and activates the unfolded protein
response that, on continuous stimulation, activates apoptosis through calpains and
caspase.
- Other mechanism:
o Activation of the extracellular calcium-sensing receptor (CaSR) with gentamicin and
other aminoglycosides has also been shown to induce a mild degree of apoptosis in
CaSR-expressing tubule cells and not in those lacking it.
o However, CaSR is also expressed in gentamicin-resistant cells including bone, brain,
colon, parathyroid gland, smooth muscle, endothelial cells, and so on.
o Therefore, more information is necessary to clarify the exact role and the relative weight
of CaSR stimulation in tubule cell death induced by aminoglycosides.

2. Sub-lethal Alterations in Tubular Reabsorption

- Gentamicin, independently of cell injury, inhibits a variety of cell membrane transporters of
both the brush-border and the basolateral membrane.
- The membrane transporters are:
o Na-Pi cotransporter and Na-H exchange
o Carrier-mediated dipeptide transport
o Electrogenic Na transport
o Na-K adenosine triphosphatase
- Transport inhibition affects tubular reabsorption, but it may also compromise cell viability.
- Gentamicin is transported by and also competes with proteins, organic cations, and other
molecules for the megalin–cubilin endocytic complex in the proximal tubule, and thus
impairs their reabsorption.

Clinical Manifestation
- Reduced glomerular filtration rate:
o The spilling of tissue and cellular residues to the tubular lumen partially or totally
obstructs the tubules.
o Tubular obstruction reduces, or even voids, the excretory function of the affected
nephrons.
o In addition, it increases the hydrostatic pressure inside the tubule and in the Bowmans’
capsule, which reduces filtration pressure gradient and, therefore, the glomerular
filtration rate (GFR).
- Reduced filtration:
o The increase of intratubular pressure increases the leak of the ultrafiltrate toward the
interstitial space (backleak) and peritubular capillaries, and, thus, decreases excretion of
the filtrate products.
- Tubuloglomerular Feedback:
o Tubular damage leads to a dysfunctional reabsorption process that produces an excessive
delivery of water and electrolytes to the distal part of the nephron, which in turn triggers
the tubuloglomerular feedback (TGF) mechanism.