Fewer than ten biopsy-proven case reports exist on vancomycin-associated interstitial nephritis (VAIN) and vancomycin-associated acute tubular necrosis (VAATN). Among these, several are confounded by the use of other potentially offending drugs. We report a case of isolated VAIN/VAATN in a patient on no other potentially nephrotoxic agents other than vancomycin. The patient received intravenous vancomycin for coagulase-negative staphylococcus bacteremia. Her baseline serum creatinine of 0.9 mg/dL increased to 9.6 mg/dL after 1 week of therapy during which vancomycin levels peaked at 141 μg/mL. Renal biopsy revealed acute interstitial nephritis with lymphocytic and eosinophilic infiltrate and acute tubular necrosis. Upon discontinuation of vancomycin and administration of prednisone complete renal recovery ensued over a period of 4 weeks.

Creatinine is a product of muscle protein breakdown cleared by the kidneys at a constant rate. The glomerular filtration rate is estimated based on serum creatinine. There is no definitive level of serum creatinine which is itself incompatible with human survival. We present the highest serum creatinine associated with survival based on a thorough review of the literature. A 34-year-old male patient with baseline serum creatinine of 1.2 mg/dl presented our emergency department with a six week history of new onset of uremic symptoms. His past medical history was unremarkable. On exam, he was in no distress. His BMI was 28. His exam was significant only for elevated blood pressure and asterixis. His peak serum creatinine was 53.9 mg/dl. The patient subsequently required maintenance hemodialysis and later changed to long-term peritoneal dialysis. To our knowledge, based on a thorough review of the literature using PubMed, Cochrane Database and the United States Renal Data System (USRDS), this is the highest level of serum creatinine ever reported. We conclude that serum creatinine itself is non-lethal. It is more likely that other electrolyte and retained metabolic abnormalities of renal failure frequently cause symptoms or death before creatinine toxicity, if such a level exists, creatinine has reached.

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