Is Clindamycin Nephrotoxic?
Yes, clindamycin is potentially nephrotoxic and can cause acute kidney injury, though this adverse effect is uncommon. 1
FDA-Recognized Nephrotoxicity
The FDA drug label explicitly states that clindamycin is potentially nephrotoxic and cases with acute kidney injury have been reported. 1 The label recommends:
- Consider monitoring renal function, particularly in patients with pre-existing renal dysfunction or those taking concomitant nephrotoxic drugs 1
- Discontinue clindamycin when acute kidney injury occurs and no other etiology is identified 1
Clinical Characteristics of Clindamycin-Induced AKI
When nephrotoxicity occurs, it presents with distinctive features:
- Onset is rapid, typically within 48 hours of starting clindamycin at doses of 1.0-2.0 g/day 2, 3
- Gross hematuria is common (66-68% of cases), which is an important clinical clue 2, 3
- Fever, skin rash, and eosinophilia are rare, unlike typical drug-induced acute interstitial nephritis 2, 3
- Urine analysis shows mild proteinuria with severe tubular dysfunction 2, 3
- Most cases (87.5%) progress to AKI stage 3, requiring renal replacement therapy 2, 3
Mechanisms of Kidney Injury
Renal biopsy studies demonstrate two primary pathologic patterns:
- Acute interstitial nephritis (AIN) 3
- Acute tubular necrosis (ATN) from direct tubular toxicity and drug crystal deposition 3
- The lymphocyte transformation assay is positive in 63.2% of cases, suggesting immune-mediated injury 3
Prognosis and Recovery
Despite the severity of presentation:
- Clindamycin-induced AKI is largely reversible 2, 3
- All patients in case series showed significant recovery of renal function within 2 months after drug discontinuation 2, 3
Dosing in Renal Impairment
Importantly, clindamycin pharmacokinetics are minimally affected by renal dysfunction:
- No dose adjustment is necessary in mild to moderate renal impairment 4, 5
- In severe renal failure, less than 1% of the drug is excreted in urine (compared to 11.9% in normal subjects) 4
- Clindamycin is not removed by hemodialysis 4, 5
- Normal adult doses (150-300 mg four times daily) can be given safely in chronic renal failure 5
- Standard prophylactic doses (600 mg) require no adjustment for renal status 6
Clinical Pitfalls to Avoid
- Do not dismiss gross hematuria in patients on clindamycin as a urinary tract infection—consider drug-induced AKI 2, 3
- The absence of fever, rash, or eosinophilia does not exclude clindamycin nephrotoxicity 2, 3
- Avoid combining clindamycin with other nephrotoxic agents when possible, as multiple nephrotoxins increase AKI risk by 53% per additional agent 7
- Monitor for rapid deterioration—most cases progress to severe AKI requiring dialysis within 48 hours 2, 3