Analgesic Nephropathy


Article Author:
Mansoor Keen


Article Editor:
Narothama Aeddula


Editors In Chief:
Myron Bodman
Donald Kushner


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
6/14/2019 9:25:49 PM

Introduction

As early as 1950, they recognised analgesics as a significant cause of chronic kidney disease, particularly for individuals requiring them long term rather than brief periods. They withdrew phenacetin from the US market in the early seventies. The drugs reported in this pathology include the usually used over-the-counter analgesics like aspirin, paracetamol/acetaminophen, and ibuprofen [1] Even though newer classes of analgesics/anti-inflammatory medications such as COX-2 inhibitors were hoped to be theoretically less likely a cause, there is now significant evidence pointing out they are equally culpable causing chronic kidney disease in the long run. Overall, there has been no consensus on the long-term safety of these drugs in the general population, principally in the elderly, where ageing kidneys are already compromised. The evidence implicates chronic overuse of these medications over the years rather than a few days or weeks as likely cause.

Although chronic NSAID use is considered generally safe, regular use for years can correspond with a risk of renal function deterioration and if unrecognised can advance to chronic kidney and end-stage renal disease.[2] The suggested action after diagnosis is to stop the causative analgesia/NSAID (aspirin, paracetamol, ibuprofen, COX-2 inhibitors).[3][4][5] Unfortunately, this may not reverse already established changes but will be the most plausible choice.[6]

Etiology

The likely cause of analgesia/NSAID induced nephropathy has not been clearly established. but, the evidence so far from different case studies and controlled randomised trials appears to associate it to the hypotensive effects induced by inhibition of the vasodilatory effects of prostaglandin synthesis, and high metabolite concentrations in the medullary region leading to papillary necrosis, chronic interstitial nephritis, and chronic tubular interstitial nephritis.[7][8]

Histological evidence of papillary necrosis is a feature in practically all cases of analgesic-induced nephropathy.[7][8]

Epidemiology

The incidence is significantly greater in women compared to males, with around 50 to 80% in females. The most commonly affected age group is 30 to 70 years, with a peak frequency around the early fifties.

In some studies, there were reportedly fewer than 200 cases per year for the period 2002-2015 in the US. There is almost a similar prevalence in Europe and Australia. However, increased risk has been observed in aged people with already impaired kidney function and eGFR.[9][10]

Pathophysiology

 The likely cause for impaired kidney function from long-term analgesia overuse is a hypotensive insult from inhibition of the prostaglandin pathway. Inhibition of the vasodilatory effect from prostaglandins pathway is the most recognised and accepted mechanism of hypoperfusion-related medullary ischemia,[11] which is generally accompanied by papillary damage in the form of necrosis in the vast majority of cases. The other pathological manifestations include interstitial tubular necrosis and interstitial nephritis.[12][13]    

Histopathology

From mononuclear infiltration to eosinophilic deposits, the different histopathological features in confirmed cases of nephropathy include features of interstitial fibrosis and occasionally papillary calcifications and metabolite deposits in the medullary zone.[11] A considerable amount of inflammatory changes also present with evidence of necrosis (papillary) in most cases. There can further be features of sloughed papillary changes detectable on CT scan.[14][15]

Toxicokinetics

History and Physical

Patients with a history of chronic NSAID/analgesic use can be asymptomatic usually and are generally picked up on routine investigations. This situation can pose a challenge, as there are seldom any gross abnormal manifestations and symptoms of this during the subtle presentation. From sterile pyuria, micro or gross haematuria to mild proteinuria, the first abnormalities include deranged urine concentrating capacity, irregularities in acidifying urine and abnormal sodium conservation.[3]

Some cases can have progression to chronic kidney disease/end-stage renal disease, acknowledging no gross symptomatic aberration. Most patients are diagnosed when presented with unusual blood parameters on a routine check or when being investigated for some other associated co-morbidity. Patients with established changes of the chronic kidney disease can have clinical symptoms of anaemia, fatigue, hypertension, headaches or GI manifestations of chronic NSAIDs or analgesic use.[16][17][18]

An insignificant proportion can present with renal colic and associated haematuria and will be evaluated for urinary bladder malignancies, which the patients of analgesia nephropathy are at increased risk (i.e., transitional cell carcinoma of uroepithelium). Women present with an increased prevalence of urinary tract infections, which if left untreated can increase the possibility of deteriorating kidney function and end-stage renal disease.[19][20]

Evaluation

As the presentation can be variable from asymptomatic haematuria, sterile pyuria, or proteinuria, to symptomatic anaemia with features of chronic kidney disease or acute presentations of urinary tract infection, specifically in women, further evaluation might get delayed. A routine urinary examination might not be essentially helpful, except for the features mentioned above. However, urinary PCR (protein creatinine ratio) as a next diagnostic step might turn out useful sometimes, when the presentation will be nephrotic.[21] 

Basic investigations include routine blood investigations, even considering extended anaemia profile. An ultrasound of abdomen especially kidney, the urinary bladder can be useful in looking for obstructive, infective or secondary causes. CT scan imaging is the most valuable diagnostic tool for uncovering specific features of NSAID/analgesia induced nephropathy.[22]

Renal Biopsy is a gold standard but is not considered always appropriate.

A non-enhanced computed tomography abdomen is preferred and can show features suggestive of analgesic nephropathy, which include decreased in renal mass, renal scarring, reduction in renal volume with irregular renal surfaces or/and papillary calcifications. It can also show features of parenchymal thinning.

Pyelograms are not useful in the diagnosis and can even be harmful, provided that contrast can exacerbate the clinical picture and renal insult.

As the most frequent abnormality detected is papillary necrosis, one needs to rule out alternative causes of the same presentation, covered in differentials area of this topic.[23]

Treatment / Management

 The first line of treatment is discontinuation of the offending drug to prevent any further damage until further investigations are completed to rule out other likely secondary causes. Adequate hydration is essential in the early stages of the disease to achieve restoration of blood perfusion even in normotensive patients. Treatment of infections is necessary to prevent any further deterioration, especially pyelonephritis.

Urinary catheterisation has been discouraged in such patients to make infection riskless.

Overall, the clinical course of this is variable and depends mainly on the extent of renal damage, scarring, fibrosis and the reversibility of keeping kidney parenchyma.[12]

Unfortunately, even after stopping the offending drug the changes of recovery may not occur quickly, and sometimes might progress further.

Differential Diagnosis

Several differentials require exclusion while considering this diagnosis because of less prevalence. As the common pathology in almost all patients with analgesic nephropathy is papillary necrosis, other common conditions can mimic this. These include diabetes mellitus type 2, sickle cell disease with a renal crisis, obstructive uropathy, pyelonephritis, tuberculosis of the renal tract, alcohol abuse, systemic vasculitis, and renal vein thrombosis.[24][25]

Some infections other than tuberculosis have also been implicated, especially leptospirosis.[26][27]

Prognosis

As mentioned in earlier sections, the presentation and prognosis of analgesia induced nephropathy are variable and unpredictable. One may expect to regain complete normal kidney function in most patients who present in the early course of renal involvement, as compared to a few individuals who will progress to end-stage renal disease and dialysis even after stopping drugs if there is established damage and scarring to the renal tissue.

Complications

End-stage renal disease and related complications can be sequelae, but it primarily depends on the extent of damage and duration of the disease.    

Deterrence and Patient Education

Many studies have revealed that the most critical point of patient education is avoiding long-term analgesic use in preventing nephropathy.

In some western countries, not promoting commercials for over-the-counter analgesia use has also shown effectiveness as a prevention strategy. Lastly, a collective effort is necessary for educating the general masses and patients for this preventable cause of renal disease. 

       

Enhancing Healthcare Team Outcomes

Overall, the likely possibility of eventually improving the outcome of condition analgesia induced nephropathy will require the effort of a multidisciplinary, interprofessional team involved in the care including physicians, nephrologists, nurses, and pharmacists, who each lend their unique perspective in preventing and managing this. Studies have shown a significant decrease in the incidence and prevalence of this as compared to the seventies because of better patient education and other preventive measures. The physician, pharmacist, nurses and all health care professionals should emphasize to the patient the detrimental effects of long-term usage of analgesia. We should offer blood monitoring in the community for early recognition of this complication.


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Analgesic Nephropathy - Questions

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A 63-year-old with a 30-years history of ankylosing spondylitis managed on NSAIDs (piroxicam, etoricoxib) was admitted with confusion and fever attributed to a urinary tract infection. He recovered after initial treatment with rehydration and antibiotics. However, his kidney function continued to decline with an increased urinary protein/creatinine ratio. Biopsy reveals papillary necrosis of renal tubules. What do you think is the safest choice of pain management for this patient if needed?



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A 70-year-old male was admitted in a hospital with lower limb swelling and shortness of breath. Flu-like symptoms preceded these symptoms with severe myalgia and cough productive of greenish sputum. He was febrile on presentation, and his preliminary examination revealed BP of 130/90 mmHg, HR (heart rate)of 101 bpm, SaO2 of 92% on room air which improved to 96% on 5 liters of oxygen by nasal cannula. He had a history of osteoarthritis for which he had been using over-the-counter medications for a long time. His investigations revealed raised WBC and left shift with a C-reactive protein of 67 mg/L. Chest x-ray suggested a right lower zone shadow suggestive of community-acquired pneumonia. It had concerned the team looking after him with his abnormal kidney function with a creatinine of 3.6 mg/dl and eGFR (glomerular filtration rate)of 45. Which of the following best explains kidney dysfunction seen in this patient considering the long history of analgesics?



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Analgesic Nephropathy - References

References

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