Nephrotic syndrome and interstitial nephritis associated with celecoxib

Royal Jelly, A Super Food, Protects Against Celecoxib-Induced Renal Toxicity in Adult Male Albino Rats

Background

Celecoxib is a COX-2 nonsteroidal anti-inflammatory drug (NSAID). It is widely used for the treatment of osteoarthritis, rheumatoid arthritis, and ankylosing spondylitis.

Objective

This study aimed to explore the effect of long-term administration of celecoxib on kidney of male albino rats, and to study the potential effect of treatment discontinuation on such tissues. The study also examined the alleged ameliorative effect of royal jelly (RJ).

Methods

Fifty, male albino rats were divided into 5 equal groups; 10 each. Group 1: rats received no drug (control group). Group 2: rats received celecoxib (50 mg/kg/day, orally for 30 successive days). Group 3: rats received celecoxib (50 mg/kg/day, orally) and royal jelly (300 mg/kg/day, orally) for 30 successive days. Group 4: rats received celecoxib for 30 successive days, then rats were left untreated for another 30 days. Group 5: rats received celecoxib and RJ for 30 successive days, then rats were left untreated for another 30 days.

Results

Long-term celecoxib administration caused significant elevation in kidney function tests, with ameliorative effects of RJ against celecoxib-induced renal toxicity.

Conclusion

Long-term celecoxib administration caused renal toxicity in male albino rats, with ameliorative effects of RJ.

Spontaneous Remission of Minimal Change Disease in a Colon Cancer Patient: A Case Report

Introduction

Minimal change disease (MCD) is most often primary but may occur secondary to other systemic diseases such as malignancy. In secondary MCD, spontaneous remission of nephrotic syndrome after the treatment of related diseases without steroid therapy is rare.

Case Presentation

A 78-year-old man visited the outpatient clinic with foamy urine and generalized edema that had persisted for 2 months. The patient had nephrotic syndrome. Before a kidney biopsy, he underwent several tests to determine the secondary cause of the nephrotic syndrome. The serum CEA was slightly elevated, and colon cancer was detected in the sigmoid colon. MCD was diagnosed from a kidney biopsy. He immediately underwent surgery for colon cancer. Complete remission of the MCD was achieved within 2 weeks after surgery.

Conclusion

Here, we report a rare case of a patient with secondary MCD who successfully achieved spontaneous remission after colon cancer surgery.

Acute kidney injury associated with non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are ones of the commonly prescribed drugs worldwide. They primarily inhibit cyclooxygenase (COX) enzyme which is responsible for conversion of phospholipids to various prostaglandins (PGs). Disruption in PGs production affects the kidneys in several ways, including vasoconstriction that may result in ischemic acute kidney injury (AKI) in at-risk patients. They also impair salt and water excretion, leading to edema and hypertension. Other complications include hyperkalemia, hyponatremia, nephrotic syndrome, acute interstitial nephritis and chronic kidney disease progression. AKI from NSAIDs is usually reversible with favorable prognosis after discontinuation of NSAIDs. Avoidance of NSAIDs exposure is extremely important, especially among high-risk patients.

Acute nephrotic-range glomerular proteinuria following ibuprofen intoxication in two cats

Case series summary

In this report we describe the origin of protein loss and development of acute kidney injury after ibuprofen intoxication in two cats. Two 13-month-old neutered male domestic shorthair siblings were presented with acute kidney injury (AKI) and severe glomerular proteinuria following witnessed ibuprofen intoxication 3 days prior. Both cats presented with severe azotaemia (creatinine >900 µmol/l [>10 mg/dl]) and severe proteinuria (urine protein:creatinine [UPC] >20, normal <0.5). Urine protein electrophoresis upon presentation revealed mainly albumin and primary glomerular protein losses. The proteinuria and azotaemia resolved completely within 5 days of hospital treatment (8 days after ingestion). Urine protein electrophoresis, once the azotaemia and proteinuria resolved (UPC 0.11; normal <0.5), had a similar pattern to the one from admission. Both cats made a full recovery with supportive care.

Relevance and novel information

This is the first clinical report of AKI with nephrotic-range protein losses following ibuprofen intoxication in cats. We propose that this finding is due to idiosyncratic glomerular injury, as described in humans.

Ibuprofen-associated minimal change disease and acute interstitial nephritis with possibly linked membranous glomerulonephritis

Non-steroidal anti-inflammatory drugs are not only potent analgesics and antipyretics but also nephrotoxins, and may cause electrolyte disarray. In addition to the commonly expected effects, including hyperkalemia, hyponatremia, acute renal injury, renal cortical necrosis, and volume retention, glomerular disease with or without nephrotic syndrome or nephritis can occur as well including after years of seemingly safe administration. Minimal change disease, secondary membranous glomerulonephritis, and acute interstitial nephritis are all reported glomerular lesions seen with non-steroidal anti-inflammatory use. We report a patient who used non-steroidal anti-inflammatory drugs for years without diabetes, chronic kidney disease, or proteinuria; he then developed severe nephrotic range proteinuria with 7 g of daily urinary protein excretion. Renal biopsy showed minimal change nephropathy, a likely secondary membranous glomerulonephritis, and acute interstitial nephritis present simultaneously in one biopsy. Cessation of non-steroidal anti-inflammatory drug use along with steroid treatment resulted in a moderate improvement in renal function, though residual impairment remained. Urine heavy metal screen returned with elevated levels of urine copper, but with normal ceruloplasmin level. Workup suggested that the elevated copper levels were due to cirrhosis from non-alcoholic fatty liver disease. The membranous glomerulonephritis is possibly linked to non-steroidal anti-inflammatory drug exposure, and possibly to heavy metal exposure, and is clinically and pathologically much less likely to be a primary membranous glomerulonephritis with negative serological markers.

Minimal Change Disease After Elective Surgical Abortion: A Case Report

Patient: Female, 21-year-old

Final Diagnosis: Minimal change disease

Symptoms: Anasarca • proteinuria

Medication: —

Clinical Procedure: Abortion

Specialty: Nephrology

Risk of Nephrotic Syndrome for Non-Steroidal Anti-Inflammatory Drug Users

BACKGROUND AND OBJECTIVES

Nonsteroidal anti-inflammatory drugs (NSAIDs) have been associated with AKI. Their association with nephrotic syndrome has not been systematically studied. This study aimed to assess the risk of nephrotic syndrome associated with NSAID use.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A matched case-control study was performed in the UK primary care database. Cases were patients with a first diagnosis of nephrotic syndrome and controls were those without nephrotic syndrome. NSAID exposure (grouped either based on cyclooxygenase enzyme selectivity and chemical groups) was classified as either current (use at the nephrotic syndrome diagnosis date and corresponding date in the control group), recent, or past use. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated using unconditional logistic regression analysis.

RESULTS

We included 2620 cases and 10,454 controls. Compared with non-use, current use of 15-28 days and >28 days of conventional NSAIDs was associated with a higher relative risk of nephrotic syndrome: adjusted OR, 1.34; 95% CI, 1.06 to 1.70, and OR, 1.42; 95% CI, 0.79 to 2.55, respectively. Also, recent use (discontinuation 1-2 months before nephrotic syndrome diagnosis date; OR, 1.55; 95% CI, 1.11 to 2.15) and past use (discontinuation 2 months-2 years; OR, 1.24; 95% CI, 1.07 to 1.43), but not current use of <15 days (OR, 0.78; 95% CI, 0.46 to 1.31) nor past use (discontinuation >2 years; OR, 0.96; 95% CI, 0.85 to 1.09) were associated with a higher relative risk of nephrotic syndrome as well as past use of selective COX-2 inhibitors (discontinuation 2-24 months; OR, 1.24; 95% CI, 0.98 to 1.58). Categorization based on chemical groups showed that acetic acid and propionic acid derivatives were associated with a higher risk of nephrotic syndrome.

CONCLUSIONS

The use of conventional NSAIDs was associated with a higher risk of nephrotic syndrome starting from at least 2 weeks of exposure, as well as for recent and past exposure up to 2 years before the diagnosis of nephrotic syndrome. This higher risk appeared mainly attributable to acetic acid and propionic acid derivatives.

Drug-induced nephropathies

Drugs are associated frequently with the development of various types of acute and chronic kidney diseases. Nephrotoxicity is associated most commonly with injury in the tubulointerstitial compartment manifested as either acute tubular injury or acute interstitial nephritis. A growing number of reports has also highlighted the potential for drug-induced glomerular disease, including direct cellular injury and immune-mediated injury. Recognition of drug-induced nephropathies and rapid discontinuation of the offending agents are critical to maximizing the likelihood of renal function recovery. This review will focus on the pathology and pathogenesis of drug-induced acute interstitial nephritis and drug-induced glomerular diseases.

A clinical and safety review of paracetamol and ibuprofen in children

The antipyretic analgesics, paracetamol, and non-steroidal anti-inflammatory agents NSAIDs are one of the most widely used classes of medications in children. The aim of this review is to determine if there are any clinically relevant differences in safety between ibuprofen and paracetamol that may recommend one agent over the other in the management of fever and discomfort in children older than 3 months of age.

Chemical-Induced Nephropathy: A Review of the Renal Tubulointerstitial Lesions in Humans

It is almost ironic that one of the major organs that serves to maintain the “internal milieux” by secretion of various toxic agents, can itself become injured in the process. The pattern of morphologic renal injury is nonspecific and can involve any of the components of the kidney, although the injury and subsequent morphologic changes are most commonly noted in the tubules and/or interstitium. Of course, unless the drug/toxin is commonly or regularly noted to be associated with tubular and/or interstitial injury, the association of the drug with the renal changes may be missed and the correlation may not necessarily identify causation. For example, if a drug is associated with a renal injury in a given individual, it may be quite difficult to prove that the drug is the cause of the injury. This scenario is somewhat reminiscent of the test question—is it “true-true-related,” or “true-true-unrelated”? Sometimes it is only by the accrual of a great many examples or correlations, and or dissection of the pathophysiology, can it be shown that the drug is directly related to the observed morphologic (and subsequent clinical) injury. Renal changes induced by chemicals can affect the tubules, interstitium or both. This review of chemically induced nephropathy in humans considers acute tubular necrosis, interstitial nephritis , and tubulointerstitial nephritis or nephropathy. Because the tubules and the interstitium are so intimately related, injury to 1 of these 2 components may eventually lead to injury of the other, resulting in tubulointerstitial disease.

Drug-induced glomerular disease: direct cellular injury

The potential of medications to cause kidney injury is well known. Although nephrotoxicity is most commonly associated with injury in the tubulointerstitial compartment as either acute tubular necrosis or acute interstitial nephritis, a growing body of literature has also highlighted the potential for drug-induced glomerular lesions. This review surveys the three primary patterns of drug-induced glomerular diseases stratified by the cell type at which the glomerular lesion is focused: visceral epithelial cell (or podoctye) injury, endothelial cell injury, and mesangial cell injury. A number of commonly prescribed medications, including IFNs, bisphosphonates, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and antiangiogenesis drugs, that are both prescribed and available over the counter, have been implicated in these iatrogenic forms of glomerular disease. Recognition of these drug-induced etiologies of glomerular disease and rapid discontinuation of the offending agent are critical to maximizing the likelihood of renal function recovery.

Drug-induced acute kidney injury in children

Acute kidney injury (AKI) is a serious problem occurring in anywhere between 8 and 30% of children in the intensive care unit. Up to 25% of these cases are believed to be the result of pharmacotherapy. In this review we have focused on several relevant drugs and/or drug classes, which are known to cause AKI in children, including cancer chemotherapeutics, non-steroidal anti-inflammatory drugs and antimicrobials. AKI demonstrates a steady association with increased long term risk of poor outcomes including chronic kidney disease and death as determined by the extent of injury. For this reason it is important to understand the causality and implications of these drugs and drug classes. Children occupy a unique patient population, advocating the importance of understanding how they are affected dissimilarly compared with adults. While the kidney itself is likely more susceptible to injury than other organs, the inherent toxicity of these drugs also plays a major role in the resulting AKI. Mechanisms involved in the toxicity of these drugs include oxidative damage, hypersensitivity reactions, altered haemodynamics and tubule obstruction and may affect the glomerulus and/or the tubules. Understanding these mechanisms is critical in determining the most effective strategies for treatment and/or prevention, whether these strategies are less toxic versions of the same drugs or add-on agents to mitigate the toxic effect of the existing therapy.

Nonsteroidal antiinflammatory drugs, cyclooxygenase-2, and the kidneys

Nonsteroidal antiinflammatory drugs (NSAIDs) are one of the most commonly used classes of medications in the world, which function by inhibiting the cyclooxygenase (COX) enzymes and downregulating the inflammatory pathway. COX enzymes are constitutively expressed in the kidneys and function to maintain a homeostatic environment in terms of maintaining the glomerular filtration rate, blood pressure, sodium, water, and osmotic regulation. When the COX enzymes are inhibited by NSAIDs, a multitude of renal and vascular complications occur. This article aims to enlighten primary care physicians of the complications that arise with NSAIDs from a renal perspective and to present some management strategies.

A patient with minimal change disease and acute focal tubulointerstitial nephritis due to traditional medicine: a case report and small literature review

Gongjin-dan (GJD) is a traditional formula that is widely used in Korea and China, and it has been used from 1345 AD in China to improve the circulation between the kidneys and the heart and to prevent all diseases. However, its adverse effects have not yet been reported. We present a patient with minimal change disease and focal tubulointerstitial nephritis associated with GJD. A 72-year-old man visited the clinic for generalized edema 20 days after starting GJD. His serum albumin level was low and nephrotic-range proteinuria was detected. A kidney biopsy showed minimal change disease and acute tubulointerstitial nephritis. After stopping GJD, a spontaneous complete remission was achieved. We discuss the possible pathogenesis of GJD-induced minimal change disease and review the adverse effects of GJD's ingredients and traditional Chinese medicines that can induce proteinuria. We report a new adverse effect of GJD, which might induce increased IL-13 production and an allergic response, leading to minimal change disease and focal tubulointerstitial nephritis.

Albumin-induced podocyte injury and protection are associated with regulation of COX-2

Albuminuria is both a hallmark and a risk factor for progressive glomerular disease, and results in increased exposure of podocytes to serum albumin with its associated factors. Here in vivo and in vitro models of serum albumin overload were used to test the hypothesis that albumin-induced proteinuria and podocyte injury directly correlate with COX-2 induction. Albumin induced COX-2, MCP-1, CXCL1 and the stress protein HSP25 in both rat glomeruli and cultured podocytes, while B7-1 and HSP70i were also induced in podocytes. Podocyte exposure to albumin induced both mRNA and protein and enhanced the mRNA stability of COX-2, a key regulator of renal hemodynamics and inflammation, which renders podocytes susceptible to injury. Podocyte exposure to albumin also stimulated several kinases (p38 MAPK, MK2, JNK/SAPK and ERK1/2), inhibitors of which (except JNK/SAPK) down-regulated albumin-induced COX-2. Inhibition of AMPK, PKC and NFκB also down-regulated albumin-induced COX-2. Critically, albumin-induced COX-2 was also inhibited by glucocorticoids and thiazolidinediones, both of which directly protect podocytes against injury. Furthermore, specific albumin-associated fatty acids were identified as important contributors to COX-2 induction, podocyte injury and proteinuria. Thus, COX-2 is associated with podocyte injury during albuminuria, as well as with the known podocyte protection imparted by glucocorticoids and thiazolidinediones. Moreover, COX-2 induction, podocyte damage and albuminuria appear mediated largely by serum albumin-associated fatty acids.

Nephrotic-range proteinuria and interstitial nephritis associated with the use of a topical loxoprofen patch

A 76-year-old woman with a history of lumbar fracture and marked proteinuria, bilateral pitting edema, malaise and pruritus was referred for an evaluation of an impaired renal function. A renal biopsy led to a tentative diagnosis of acute interstitial nephritis (AIN) with minimal change disease caused by nonsteroidal anti-inflammatory drugs (NSAIDs). Following the discontinuation of oral NSAIDs, the patient's symptoms disappeared spontaneously. However, nephrotic-range proteinuria relapsed one month after discharge, following loxoprofen patch use. The withdrawal of the topical loxoprofen patches once again resulted in the disappearance of all symptoms. This is the first case report of nephrotic-range proteinuria and AIN secondary to topical NSAID patch use.

Safe administration of celecoxib to a patient with repeated episodes of nephrotic syndrome induced by NSAIDs

Nephrotic syndrome, with or without concomitant tubulointerstitial nephritis, is a rare renal adverse effect of NSAIDs. In the present report we describe a case of a 60-year-old Caucasian man who was admitted because of nephrotic syndrome following several days of use of meloxicam for hip osteoarthritis. Renal histopathology revealed minimal change disease, one of the commonest causes of nephrotic syndrome. The patient's condition resolved rapidly upon discontinuation of meloxicam. Because he had already experienced two episodes of nephrotic syndrome after administration of diclofenac several years previously, it was concluded that the patient had renal hypersensitivity to both diclofenac and meloxicam. While waiting for the hip arthroplasty, he was prescribed celecoxib for pain control. After 1 month of regular celecoxib use the patient remained in remission with respect to nephrotic syndrome and had normal renal function. We conclude that challenge with a structurally distinct NSAID (such as celecoxib in this case) may be an option, under close surveillance, in a patient with a history of nephrotic syndrome associated with use of an NSAID when continued treatment with an NSAID is indicated.

Drug-induced acute interstitial nephritis

Acute interstitial nephritis (AIN) is a common cause of acute kidney injury. Many etiologies of AIN have been recognized--including allergic/drug-induced, infectious, autoimmune/systemic, and idiopathic forms of disease. The most common etiology of AIN is drug-induced disease, which is thought to underlie 60-70% of cases. Multiple agents from many different classes of drugs can cause AIN, and the clinical presentation and laboratory findings vary according to the class of drug involved. AIN is characterized by interstitial inflammation, tubulitis, edema, and in some cases, eventual interstitial fibrosis. A definitive diagnosis of AIN can be established only by kidney biopsy. Noninvasive tests such as (67)gallium scintigraphy and testing for eosinophiluria have limited diagnostic utility. The mainstay of therapy for drug-induced AIN is timely discontinuation of the causative agent. Although the benefits of corticosteroid therapy remain unproven, they do appear to have a positive effect in some patients with drug-induced AIN, especially when treatment is initiated early in the course of the disease. In general, the prognosis for drug-induced AIN is good, and at least partial recovery of kidney function is normally observed. Early recognition is crucial because patients can ultimately develop chronic kidney disease.

Drug-induced Kidney Disease – Pathology and Current Concepts

The kidneys can be damaged by a large number of therapeutic agents. The aim of this article is to discuss the pathological features of drug-induced renal disease as diagnosed by kidney biopsy. The literature is reviewed and cases seen by the authors that have a known drug association are analysed. Mechanisms of injury are varied and all renal structures may be affected. The tubulointerstitial compartment is most frequently involved, but glomerular and vascular lesions are seen in a significant proportion of cases. Key words: Drug, Kidney, Nephrotoxicity, Pathology

The potential of liposomal drug delivery for the treatment of inflammatory arthritis

OBJECTIVE

To review the use of liposomes as a delivery agent in inflammatory arthritis.

METHODS

The literature on liposomes and liposomal drug delivery for the treatment of inflammatory arthritis was reviewed. A PubMed search of articles in the English-language journals from 1965 to 2007 was performed. The index words used were as follows: "rheumatoid arthritis," "liposomes," and "targeted delivery." Papers identified were reviewed, abstracted, and summarized.

RESULTS

Liposomes have the capacity to be used as delivery and targeting agents for the administration of antirheumatic drugs at lower doses with reduced toxicity. In other areas of medicine, the pace of progress has been rapid. In the case of infectious diseases and cancer, liposomal drug delivery has progressed and developed into commercially viable therapeutic options for the treatment of fungal infections (amphotericin B), or metastatic breast cancer and Kaposi sarcoma (doxorubicin, daunorubicin), respectively. In arthritis, the efficacy of prednisolone-loaded long-circulating liposomes is currently being evaluated in a phase II clinical trial. Liposome's application to arthritis is still in its infancy but appears promising as new patents are filed. With improvements in liposomal formulation and targeted synovial delivery, liposomes offer increased therapeutic activity and improvement in the risk-benefit ratio.

CONCLUSION

Recent research into synovial targets and improved liposomal formulations continues to improve our capacity to use liposomes for targeted delivery. With time, this approach has the potential to improve drug delivery and reduce systemic complications.

Metformin-induced lactic acidosis and acute pancreatitis precipitated by diuretic, celecoxib, and candesartan-associated acute kidney dysfunction

Polypharmacy may lead to synergistic complications from the different medications. We report the case of a 50-year-old woman who was prescribed 11 drugs, including a diuretic, celecoxib, metformin, and candesartan, and who developed acute kidney dysfunction while on these drugs, manifesting as severe proteinuria, acute azotemia, hyperkalemia. The kidney injury caused the accumulation of metformin, leading to lactic acidosis and acute pancreatitis. Sodium bicarbonate hemodialysis not only improved the metabolic abnormalities but also hastened the removal of metformin.

Membranous nephropathy associated with the relatively selective cyclooxygenase-2 inhibitor, etodolac, in a patient with early rheumatoid arthritis

Renal dysfunction and urinary abnormalities, which are usually related to drug toxicity, secondary amyloidosis, or those which overlap with other autoimmune conditions, are frequently observed in patients with rheumatoid arthritis. This is the first case report of membranous nephropathy in a patient with early-stage rheumatoid arthritis treated with the relatively selective cyclooxygenase-2 inhibitor, etodolac. The present case suggests that any kind of non-steroidal anti-inflammatory drug can cause membranous nephropathy; thus, physicians should be aware of this renal toxicity when prescribing these drugs.

Drug-induced glomerulopathies

Normal renal function depends upon an intact glomerular apparatus. Many drugs and chemicals are capable of damaging the glomerulus, causing its increased permeability to large molecules. Glomerular lesions are usually responsible for proteinuria and the nephrotic syndrome. This also holds true for the drug-induced glomerulopathies, of which membranous glomerulo-nephritis is the most frequent type of lesion encountered. Apart from this, several cases of different glomerular changes such as focal segmental glomerulosclerosis and crescentic glomerulonephritis have also been reported. The drug-induced glomerulopathies are probably immune mediated. This is, for instance, reflected in the fact that patients with drug-induced nephritic syndrome frequently have the HLA-B8 and DR3 antigens. In depth information is provided for the previously mentioned disorders.

Drug-induced nephropathy: an update

Medications cause renal disease by promoting various types of injury in the kidney. Several drugs reduce renal perfusion and cause prerenal azotemia. Vascular disease can develop following exposure to various medications through direct and indirect effects. A number of glomerular lesions have been described with therapeutic agents and illicit drugs. Acute interstitial nephritis occurs from a drug-induced allergic reaction, which promotes interstitial inflammation and tubular damage. Acute tubular necrosis is a dose-dependent process that occurs from direct drug toxicity on tubular epithelia. Other less common patterns of drug-induced tubular injury include osmotic nephropathy, crystal nephropathy and acute nephrocalcinosis. Finally, postrenal azotemia from structural or functional obstruction of the urinary tract also complicates therapy with a number of medications.

Glomerular tip lesion associated with nonsteroidal anti-inflammatory drug-induced nephrotic syndrome

Glomerular tip lesion and its relation to different glomerular diseases is a subject of controversy. The therapeutic and prognostic clinical implications of glomerular tip lesions are ambiguous. We present a case of glomerular tip lesion associated with nonsteroidal anti-inflammatory drug-induced nephrotic syndrome that further complicates this issue. To our knowledge, this is the first case report of glomerular tip lesion associated with nonsteroidal anti-inflammatory drug-induced nephrotic syndrome.

Albumin microspheres as carriers for the antiarthritic drug celecoxib

The present study investigates the preparation of celecoxib-loaded albumin microspheres and the biodistribution of technetium-99m ((99m)Tc)-labeled celecoxib as well as its microspheres after intravenous administration. Microspheres were prepared using a natural polymer BSA using emulsification chemical cross-linking method. The prepared microspheres were characterized for entrapment efficiency, particle size, and in vitro drug release. Surface morphology was studied by scanning electron microscopy. Biodistribution studies were performed by radiolabeling celecoxib (CS) and its microspheres (CMS) using (99m)Tc and injecting arthritic rats intravenously. The geometric mean diameter of the microspheres was found to be 5.46 microm. In vitro release studies indicated that the microspheres sustained the release of the drug for 6 days. Radioactivity measured in different organs after intravenous administration of celecoxib solution showed a significant amount of radioactivity in the liver and spleen. In case of celecoxib-loaded microspheres, a significant amount of radioactivity accumulated in the lungs. No significant difference (P > .1) in the radioactivity was observed between the inflamed joint and the noninflamed joint following intravenous injection of (99m)Tc-CS. However, in case of the microspheres (CMS), the radioactivity present in the inflamed joint was 2.5-fold higher than in the noninflamed joint. The blood kinetic studies revealed that celecoxib-loaded albumin microspheres exhibited prolonged circulation than the celecoxib solution.

Acute interstitial nephritis predisposed a six-year-old girl to minimal change nephrotic syndrome

A six-year-old girl was admitted to our hospital with acute renal failure. We made a clinical diagnosis of acute interstitial nephritis and oral corticosteroid therapy was started. Her renal failure soon recovered, and renal biopsy showed acute interstitial nephritis by light microscopy with glomerular foot process effacement by electron microscopy. Although her proteinuria was not heavy at the time of biopsy, her proteinuria subsequently increased to show nephrotic syndrome. We continued to give corticosteroids and her nephrotic syndrome went into remission 13 days after biopsy. Serological and bacteriological examination showed no evidence of known pathogen or drug hypersensitivity. The time changes in proteinuria were monitored by fractional total protein excretion (FETP) and fractional beta2 microglobulin excretion (FEbeta2MG) in order to evaluate the severity of proteinuria under different glomerular filtration rates and different proximal tubular functions. The results revealed that nephrotic syndrome had occurred during recovery from acute interstitial nephritis. This is the first case report to show the sequential occurrence of acute interstitial nephritis and nephrotic syndrome based on evidence from fractional protein excretion.

Celecoxib-Induced Nephrotoxicity in a Renal Transplant Recipient

A 47-year-old renal transplant recipient came to the transplant clinic with a serum creatinine level that was elevated above her baseline value. She had been taking celecoxib for arthritic pain. She was told to discontinue the drug, and shortly after, her serum creatinine level returned to baseline. Several case reports describe nephrotoxicity with cyclooxygenase (COX)-2 inhibitors. However, only two of these reports involved renal transplant recipients, and in both, rofecoxib was the COX-2 inhibitor of concern. To our knowledge, this is the first case report of a renal transplant recipient who developed nephrotoxicity while taking celecoxib. The potential renal effects of COX-2 inhibitors have received little attention, even though nonsteroidal anti-inflammatory drugs are considered to carry the risk of nephrotoxicity in patients with comorbidities such as diabetes mellitus and hypertension. Further studies are necessary to determine the safety of COX-2 inhibitors in transplant recipients and other patient groups that may be at heightened risk of nephrotoxicity.

Drug-induced renal failure: a focus on tubulointerstitial disease

Therapeutic agents induce acute renal failure (ARF) by promoting various types of injury to the kidney. Acute interstitial nephritis (AIN) develops from medications that incite an allergic reaction, leading to interstitial inflammation and tubular damage. Acute tubular necrosis (ATN) is a dose-dependent process that develops from direct toxicity on tubular epithelia, typically in the absence of inflammation. Additional, less common patterns of drug-induced renal injury include osmotic nephropathy, crystal nephropathy, and acute nephrocalcinosis. This review focuses on the multitude of patterns of drug-induced renal failure due to tubulointerstitial disease.

Making Progress in the Management of Postoperative Pain: A Review of the Cyclooxygenase 2–Specific Inhibitors

Postoperative pain is one of the most common forms of acute pain. Optimal pain management decreases the stress response to surgery, reduces complications, improves recovery time, and results in improved economic and quality-of-life outcomes. A preoperative, multimodal approach to postoperative analgesia can be achieved through a combination of therapies that continue beyond the immediate perioperative time frame. This multimodal approach provides superior analgesia with opioid-sparing effects and reduced opioid-related adverse events. Although the use of nonspecific nonsteroidal antiinflammatory drugs in a surgical setting has been limited owing to concerns of renal and gastrointestinal complications as well as platelet dysfunction, cyclooxygenase (COX)-2-specific inhibitors appear to be safe and effective alone and in combination with opioids for a variety of surgical procedures. The COX-2-specific inhibitors may have an important role in extending the use of balanced, multimodal analgesia to a broad surgical population, thus ultimately improving patient outcomes after surgery.

Arterial Thrombosis due to Minimal Change Glomerulopathy Secondary to Nonsteroidal Anti-Inflammatory Drugs

The authors report a 49-year-old woman who had been treated with diclofenac for her back pain. Nephrotic syndrome followed by occlusion of the right profound femoral and popliteal arteries occurred. Successful thrombectomy was performed. Another nonsteroidal anti-inflammatory drug (NSAID) was administered by injection during hospitalization. Renal biopsy showed minimal change glomerulopathy (MCG). Remission was delayed despite large-dose steroid administration. The delayed remission in this patient may be caused by impaired renal function and the possible effect of a second period of NSAID administration. The authors present the first case of femoral arterial thrombosis associated with nephrotic syndrome secondary to NSAID-associated MCG. Careful history-taking and physical examination may detect early causes and complications of nephrotic syndrome. Any rechallenge of NSAID should be avoided.

Acute renal failure and hyperkalaemia associated with cyclooxygenase-2 inhibitors

BACKGROUND

The renal effects of cyclooxygenase-2 (COX-2) inhibitors have been incompletely elucidated, and acute renal failure (ARF) due to COX-2 inhibitors has been reported.

METHODS

In order to determine the causes of ARF and hyperkalaemia in five patients during COX-2 inhibitor therapy, we carefully analysed case studies of consecutive in-patients or out-patients referred to our Renal Division over a 6-month period for ARF and hyperkalaemia who had recently received COX-2 inhibitors.

RESULTS

ARF developed 2-3 weeks after COX-2 inhibitor therapy in five patients. The ARF was consistent with pre-renal azotaemia from renal hypoperfusion. Four patients were receiving the loop diuretic, furosemide. Four patients developed hyperkalaemia and decreased serum bicarbonate despite diuretic therapy, and one patient had changes in plasma renin activity and aldosterone levels consistent with reversible hyporeninaemic hypoaldosteronism. Renal failure was reversible after discontinuation of diuretics and COX-2 inhibitors.

CONCLUSIONS

COX-2 inhibitors may cause reversible ARF and hyperkalaemia in patients with oedematous conditions treated with low sodium diets and loop diuretics.

Cyclooxygenases, the kidney, and hypertension

Selective cyclooxygenase (COX)-2 inhibitors that are in widespread clinical use were developed to avoid side effects of conventional NSAIDs, including gastrointestinal and renal toxicity. However, COX-2 is constitutively expressed in the kidney and is highly regulated in response to alterations in intravascular volume. COX-2 metabolites have been implicated in maintenance of renal blood flow, mediation of renin release, and regulation of sodium excretion. COX-2 inhibition may transiently decrease urine sodium excretion in some subjects and induce mild to moderate elevation of blood pressure. Furthermore, in conditions of relative intravascular volume depletion and/or renal hypoperfusion, interference with COX-2 activity can have deleterious effects on maintenance of renal blood flow and glomerular filtration rate. In addition to physiological regulation of COX-2 expression in the kidney, increased renal cortical COX-2 expression is seen in experimental models associated with altered renal hemodynamics and progressive renal injury (decreased renal mass, poorly controlled diabetes), and long-term treatment with selective COX-2 inhibitors ameliorates functional and structural renal damage in these conditions.

COX-2 inhibition and prostaglandin receptors in experimental nephritis

BACKGROUND

Renal cyclooxygenases (COX) produce the prostaglandins (PG) E2, I2 and thromboxane (TxA2), which interact with distinct G protein-coupled receptors. We investigated the expression of the three EP receptors EP2, EP3 and EP4 and the receptors for PGI2 (IP) and TxA2 (TP) in rats with passive Heymann nephritis (PHN). We studied their regulation by COX-2 inhibition with celecoxib.

MATERIALS AND METHODS

Four groups of Wistar rats were studied: healthy rats (group A), healthy rats treated with celecoxib (group B), rats with PHN (group C), and rats with PHN receiving celecoxib (group D). Expression of the mRNA for all receptors in the renal cortex and for the EP3 receptor in cultured mesangial cells (MCs) was determined by semiquantitative reverse transcriptase polymerase chain reaction. Stable prostaglandin metabolites were measured in the urine by radioimmunoassay.

RESULTS

Rats with PHN (group C) showed an 1.8-fold increase of cortical EP3 receptor mRNA expression as compared with controls (group A). In celecoxib-treated PHN rats (group D) the mRNA expression of the EP3 and EP4 receptors was significantly reduced to 1.0-fold and 0.7-fold induction, respectively. Furthermore, the excretion of bicyclo-prostaglandin E2 (PGE2) was inhibited by celecoxib. No changes were observed in the expression of the other PG-receptors. In cultured MC, PGE2 enhanced the EP3 mRNA expression.

CONCLUSIONS

These data suggest a predominant role of the EP3 receptor in the transduction of PGE2-actions in PHN. It was concluded that COX-2-dependent PGE2 is able to potentiate its effects in the kidney by up-regulating its own receptors.

Adverse Drug Events Involving COX-2 Inhibitors

OBJECTIVE

To describe the types and severity of adverse drug-related events (ADEs) observed in patients receiving cyclooxygenase-2 (COX-2) inhibitors and to increase the awareness of risk factors that predispose patients to ADEs associated with COX-2 inhibitors.

METHODS

A review of ADEs reported at the University of Pittsburgh Medical Center Presbyterian Hospital (UPMC-P) revealed significant events related to use of celecoxib or rofecoxib. A query of the internal ADE database was performed to identify ADEs involving COX-2 inhibitors from January 1999 to June 2002. A similar query was performed to identify ADEs involving nonselective nonsteroidal antiinflammatory drugs (NSAIDs) reported during this same time period. Utilization data were also collected.

RESULTS

Forty-eight ADEs involving 24 patients receiving COX-2 inhibitors were reported and validated via the UPMC-P ADE review process compared with 38 events in 33 patients receiving nonselective NSAIDs. The types of ADEs reported as related to COX-2 inhibitors were similar to those reported in association with nonselective NSAIDs. Forty-two percent of ADEs (n = 20) involving COX-2 inhibitors and 45% of events (n = 17) involving nonselective NSAIDs were classified as severe. All patients receiving COX-2 inhibitors and 91% of patients receiving nonselective NSAIDs exhibited risk factors that increased their risk to experience an ADE; all but 1 of these patients were receiving outpatient COX-2 inhibitor therapy.

CONCLUSIONS

The observed ADEs involving COX-2 inhibitors were similar to those associated with nonselective NSAIDs. Most events may have been preventable, highlighting the need for education regarding the appropriate use of COX-2 inhibitors.