Acetaminophen, aspirin, and chronic renal failure

NSAIDs, analgesics, antiplatelet drugs, and decline in renal function: a retrospective case-control study with SIDIAP database

INTRODUCTION

We aim to explore the association between NSAIDs consumption, Symptomatic Slow Action Drugs for Osteoarthritis (SYSADOA), analgesics, and antiplatelet drugs, and decline in renal function by estimated Glomerular Filtration Rate (eGFR).

METHODS

We performed a case-control study using the SIDIAP database in Catalonia. We considered defined cases, patients with an eGFR value ≤ 45 ml/min/1.73 m2 in the period 2010-2015 with a previous eGFR value ≥ 60, and no eGFR ≥ 60 after this period. Controls had an eGFR ≥ 60 with no previous eGFR < 60. Five controls were selected for each case, matched by sex, age, index date, Diabetes Mellitus and Hypertension. We estimated Odds Ratios (OR, 95% Confidence Intervals) of decline in renal function for drugs group adjusting with logistic regression models, by consumption measured in DDD. There were n = 18,905 cases and n = 94,456 controls. The mean age was 77 years, 59% were women. The multivariate adjusted model showed a low risk for eGFR decline for NSAIDs (0.92;0.88-0.97), SYSADOA (0.87;0.83-0.91) and acetaminophen (0.84;0.79-0.89), and an high risk for metamizole (1.07;1.03-1.12), and antiplatelet drugs (1.07;1.03-1.11). The low risk in NSAIDs was limited to propionic acid derivatives (0.92;0.88-0.96), whereas an high risk was observed for high doses in both acetic acid derivatives (1.09;1.03-1.15) and Coxibs (1.19;1.08-1.30). Medium and high use of major opioids shows a high risk (1.15;1.03-1.29). Triflusal showed high risk at medium (1.23;1.02-1.48) and high use (1.68;1.40-2.01).

CONCLUSION

We observed a decline in renal function associated with metamizole and antiplatelet agent, especially triflusal, and with high use of acetic acid derivates, Coxibs, and major opioids. Further studies are necessary to confirm these results.

Kidney Disease Modeling with Organoids and Organs-on-Chips

Kidney disease is a global health crisis affecting more than 850 million people worldwide. In the United States, annual Medicare expenditures for kidney disease and organ failure exceed $81 billion. Efforts to develop targeted therapeutics are limited by a poor understanding of the molecular mechanisms underlying human kidney disease onset and progression. Additionally, 90% of drug candidates fail in human clinical trials, often due to toxicity and efficacy not accurately predicted in animal models. The advent of ex vivo kidney models, such as those engineered from induced pluripotent stem (iPS) cells and organ-on-a-chip (organ-chip) systems, has garnered considerable interest owing to their ability to more accurately model tissue development and patient-specific responses and drug toxicity. This review describes recent advances in developing kidney organoids and organ-chips by harnessing iPS cell biology to model human-specific kidney functions and disease states. We also discuss challenges that must be overcome to realize the potential of organoids and organ-chips as dynamic and functional conduits of the human kidney. Achieving these technological advances could revolutionize personalized medicine applications and therapeutic discovery for kidney disease.

Prevalence and assessment of risk factors of chronic kidney disease in the ASIR region of Saudi Arabia

Introduction

Chronic kidney disease (CKD) is a major health concern in Saudi Arabia. The prevalence of CKD and associated risk factors in Saudi Arabia's general population are not efficiently studied. The goal of this research is to determine the prevalence rate of CKD in the ASIR region and its associated epidemiological risk factors.

Methodology

This is a cross-sectional study that used a comprehensive direct questionnaire to collect data on CKD prevalence and risk factors in the ASIR region of Saudi Arabia. The study was carried out in different age groups. Demographic characteristics, presence of CKD, and associated factors such as a history of acute kidney disease, obstructive sleep apnoea, family history, history of non-steroid anti-inflammatory drugs (NSAID), smoking status, comorbidities, and history of periodontal diseases were asked. The survey tool was validated through a pilot study, and a statistical p value of 0.05 was considered significant.

Results

A total of 967 participants were included in the study, with a CKD prevalence rate of 1.9%. Sex, history of acute kidney disease, obstructive sleep apnoea, family history of kidney disease, smoking, diabetes, peptic ulcer disease, hypertension and hyperlipidemia were commonly found to be associated with CKD. A binary logistic regression model was carried out to assess the risk factors for CKD. Sex, history of acute kidney disease, family history of kidney disease, obstructive sleep apnoea, smoking status, peptic ulcer, diabetes, hypertension, hyperlipidemia, hypertension and diabetes, two or more comorbidities and NSAID use had an increased risk of CKD.

Conclusion

Sex, history of acute kidney disease, obstructive sleep apnoea, family history, smoking, diabetes, hypertension, peptic ulcer, hyperlipidemia, multi-comorbidity, and use of NSAIDs are all associated with an increased risk of CKD. The prevalence of CKD in this study is comparatively lower when compared to other regions in Saudi Arabia.

Fatality owing to pulmonary hemorrhage following pamidronate disodium administration in a neonate with osteogenesis imperfecta type 2: A case report

We report the case of a patient with osteogenesis imperfecta (OI) who developed pulmonary hemorrhage 4 d after pamidronate disodium (PA) administration, despite a relatively stable respiratory status. Bisphosphonates are introduced to reduce osteoclast activity and are now widely used in patients with OI. Bisphosphonates are typically well-tolerated in children, and the standard of care involves cyclic intravenous administration of PA. However, in practice, there is limited experience with the use of PA for severe OI during the neonatal period, and its safety remains uncertain. This report aimed to describe the respiratory events potentially associated with PA in a neonatal patient with OI type 2, suggesting that serious life-threatening complications of pulmonary hemorrhage may occur after PA administration. Further studies are required to assess the relationship between pulmonary hemorrhage and PA administration, aiming to enhance prophylaxis measures.

Cardiovascular Protection of Aspirin in Chronic Kidney Disease Patients: An Updated Systematic Review and Meta-Analysis

PURPOSE

To evaluate aspirin's cardiovascular (CV) protective effect in chronic kidney disease (CKD) patients.

METHODS

We searched PubMed, Embase, Cochrane Library, and Web of Science (up to December 2022) for randomized controlled trials (RCTs) and observational studies comparing aspirin with placebo in CKD patients for the prevention of CV disease (CVD). Efficacy outcomes included CVD, heart failure, myocardial infarction, stroke, CV and all-cause mortality; safety outcomes included major bleeding, minor bleeding, and renal events.

RESULTS

Six RCTs and 6 observational studies, including 35,640 participants, met the inclusion criteria and reported relevant CV outcomes, with a mean follow-up of 46.83 months. The pooled data showed aspirin had no significant preventive effect on CVD events (RR=1.03; 95% CI, 0.84-1.27). However, CV mortality was significantly reduced in the aspirin group (RR=0.74; 95% CI, 0.58-0.95). Furthermore, aspirin use did not increase the risk of major bleeding and renal events but significantly increased minor bleeding events (RR=2.11; 95% CI, 1.30-3.44). Renal events were significantly increased after sensitivity analysis (RR=1.10; 95% CI, 1.04-1.16).

CONCLUSION

Aspirin did not prevent CV events, with a significantly increased risk of minor bleeding and renal events. Besides, aspirin use had no statistically significant reduction in the risk of all-cause mortality but had a statistically significant reduction in the risk of CV mortality.

In-hospital adverse events and recurrence in hospitalized patients with acute pericarditis

BACKGROUND

Acute pericarditis occasionally requires invasive treatment, and may recur after discharge. However, there are no studies on acute pericarditis in Japan, and its clinical characteristics and prognosis are unknown.

METHODS

This was a single-center, retrospective cohort study of clinical characteristics, invasive procedures, mortality, and recurrence in patients with acute pericarditis hospitalized from 2010 to 2022. The primary in-hospital outcome was adverse events (AEs), a composite of all-cause mortality and cardiac tamponade. The primary outcome in the long-term analysis was hospitalization for recurrent pericarditis.

RESULTS

The median age of all 65 patients was 65.0 years [interquartile range (IQR), 48.0-76.0 years], and 49 (75.3 %) were male. The etiology of acute pericarditis was idiopathic in 55 patients (84.6 %), collagenous in 5 (7.6 %), bacterial in 1 (1.5 %), malignant in 3 (4.6 %), and related to previous open-heart surgery in 1 (1.5 %). Of the 8 patients (12.3 %) with in-hospital AE, 1 (1.5 %) died during hospitalization and 7 (10.8 %) developed cardiac tamponade. Patients with AE were less likely to have chest pain (p = 0.011) but were more likely to have symptoms lasting 72 h after treatment (p = 0.006), heart failure (p < 0.001), and higher levels of C-reactive protein (p = 0.040) and B-type natriuretic peptide (p = 0.032). All patients complicated with cardiac tamponade were treated with pericardial drainage or pericardiotomy. We analyzed 57 patients for recurrent pericarditis after excluding 8 patients: 1 with in-hospital death, 3 with malignant pericarditis, 1 with bacterial pericarditis, and 3 lost to follow-up. During a median follow-up of 2.5 years (IQR 1.3-3.0 years), 6 patients (10.5 %) had recurrences requiring hospitalization. The recurrence rate of pericarditis was not associated with colchicine treatment or aspirin dose or titration.

CONCLUSIONS

In acute pericarditis requiring hospitalization, in-hospital AE and recurrence were each observed in >10 % of patients. Further large studies on treatment are warranted.

Drug induced nephrotoxicity- A mechanistic approach

The main goal of the treatment of patients is its effectiveness and safety. However, all currently prescribed drugs being used also have certain adverse effects, which might be seen as an unavoidable but necessary cost of pharmacotherapy. The kidney is the primary organ for xenobiotics elimination, making it particularly susceptible to the harmful effects of drugs and their metabolites during their excretion from the body. Moreover, certain medications have a preferential nephrotoxicity potential, which means that using them increases the risk of kidney injury. Drug nephrotoxicity is, therefore, both a significant problem and a complication of pharmacotherapy. It should be noted that, there is presently no accepted definition of drug-induced nephrotoxicity and no established diagnostic criteria. The current review briefly describes the pathogenic mechanism of drug-induced nephrotoxicity, the various basic drugs with nephrotoxicity potential and the renal biomarkers for the treatment of the drug-related kidney damage.

Twenty-Three-Year Trends in the Use of Potentially Nephrotoxic Drugs in Denmark

Background

The occurrence of acute and chronic kidney diseases has been rising in the last decades. Although drug use is a common risk factor for impaired kidney function, changes in utilization of potential nephrotoxic drugs have received little attention.

Purpose

To describe temporal trends in the utilization of potentially nephrotoxic drugs in Denmark between 1999 and 2021.

Methods

Specific drugs known or suspected to be nephrotoxic were identified in the literature. Data on the sold defined daily doses (DDDs) of potentially nephrotoxic drugs between 1999 and 2021 were retrieved using the Danish Register of Medical Product Statistics. Trends in sales of DDDs per 1000 inhabitants per day were tabulated and illustrated graphically.

Results

From 1999 to 2021, the total sale of all selected drugs increased from 286 to 457 DDDs per 1000 inhabitants per day. The overall sale reached a preliminary peak in 2012 with 449 DDDs per 1000 inhabitants per day and remained relatively stable thereafter until reaching an all-time high in 2021 with 457 DDDs per 1000 inhabitants per day. Contributing with the majority in volume, sales of drugs inhibiting the renin-angiotensin-aldosterone system (RAAS) increased dramatically throughout the period. The same was observed for acetaminophen, methotrexate, tacrolimus, and iodinated contrast dye. In contrast, the sales of diuretics, acetylsalicylic acid, and ciclosporin decreased during the last decade of the study period.

Conclusion

From 1999-2021 considerable changes in sales of potentially nephrotoxic drugs were observed. In general, the sales increased, in volume predominated by RAAS inhibiting drugs. This increase in sales of potential nephrotoxins could contribute to an increasing occurrence of kidney diseases.

Aspirin for Primary and Secondary Prevention of Mortality, Cardiovascular Disease, and Kidney Failure in the Chronic Renal Insufficiency Cohort (CRIC) Study

Rationale and Objective

Chronic kidney disease is a risk enhancing factor for cardiovascular disease (CVD) and mortality, and the role of aspirin use is unclear in this population. We investigated the risk and benefits of aspirin use in primary and secondary prevention of CVD in the Chronic Renal Insufficiency Cohort Study.

Study Design

Prospective observational cohort.

Setting & Participants

3,664 Chronic Renal Insufficiency Cohort participants.

Exposure

Aspirin use in patients with and without preexisting CVD.

Outcomes

Mortality, composite and individual CVD events (myocardial infarction, stroke, and peripheral arterial disease), kidney failure (dialysis and transplant), and major bleeding.

Analytical Approach

Intention-to-treat analysis and multivariable Cox proportional hazards model to examine associations of time varying aspirin use.

Results

The primary prevention group was composed of 2,578 (70.3%) individuals. Mean age was 57 ± 11 years, 46% women, 42% Black, and 47% had diabetes. The mean estimated glomerular filtration rate was 45 mL/min/1.73 m2. Median follow-up was 11.5 (IQR, 7.4-13) years. Aspirin was not associated with all-cause mortality in those without preexisting cardiovascular disease (CVD) (HR, 0.84; 95% CI, 0.7-1.01; P = 0.06) or those with CVD (HR, 0.88; 95% CI, 0.77-1.02, P = 0.08). Aspirin was not associated with a reduction of the CVD composite in primary prevention (HR, 0.97; 95% CI, 0.77-1.23; P = 0.79) and in secondary prevention because the original study design was not meant to study the effects of aspirin.

Limitations

This is not a randomized controlled trial, and therefore, causality cannot be determined.

Conclusions

Aspirin use in chronic kidney disease patients was not associated with reduction in primary or secondary CVD events, progression to kidney failure, or major bleeding.

CD8+ T Cells in OA Knee Joints Are Differentiated into Subsets Depending on OA Stage and Compartment

Osteoarthritis (OA) is no longer considered a purely degenerative disease. OA is defined as a disease of the entire joint, in which inflammation occurs in various joint tissues. The overall aim of this study was to analyze the presence and polarization of CD8⁺ T cell subsets in OA knee joints, in relation to the OA stage and compartment (synovial fluid (SF), synovial membrane (SM,) peripheral blood (PB)). A quantitative flow analysis of CD8⁺ T cell subsets to compare the SF, SM, PB, was performed in patients with different stages of OA (early, unicondylar and bicondylar OA). Samples of the SF, SM and PB were harvested from a total of 55 patients at the time of surgery. Early OA was confirmed by independent surgeons intraoperatively. Uni- and bicondylar OA was confirmed and graded by two plane radiographs. Samples were analyzed by flow cytometry for surface markers, and cytokines by intracellular staining (ICS). CD8⁺ T cells were shown to be differentiated into pro-inflammatory IFN-γ producing Tc1 and IL-17A producing Tc17, as well as anti-inflammatory IL-4 producing Tc2. All CD8⁺ T cell subsets (Tc1, Tc17, and Tc2) were detected in both the SM and SF. The percentage of CD8⁺ T cell subsets of the total CD8⁺ T cell population was dependent on the OA stage and compartment. Compared with the peripheral blood (PB), the proportion of CD8⁺IFN-γ⁺ Tc1 and CD8⁺IL-17A⁺ Tc17 was significantly increased in OA SF. This was confirmed in our data for both early OA and end-stage OA. In the SM samples of end-stage OA patients, the proportion of CD8⁺IL-17A⁺ Tc17 was significantly increased compared to the PB. Comparing SF and SM samples of end-stage OA patients, the proportion of CD8⁺IFN-γ⁺ Tc1 was significantly increased in SF, whereas there were no differences concerning CD8⁺IL-4⁺ Tc2 and CD8⁺IL-17A⁺ Tc17. End-stage OA samples showed a significant increase of CD8⁺IL-4⁺ Tc2 in the SM for both unicondylar and bicondylar OA compared to early OA. CD8⁺ T cells infiltrating the SM and SF in OA knees are differentiated into IFN-γ-, IL-17A-, and IL-4-producing CD8⁺ T cell subsets (Tc1, Tc17, Tc2). This differentiation depends on the OA stage and OA compartment. Further investigation of CD8⁺ T cell subsets and their interaction with other inflammatory cells such as CD4⁺ T cells and macrophages may help to identify novel therapeutic anti-inflammatory strategies for containing OA progression.

Predictors and Outcomes of Postoperative Hemoglobin of <8 g/dL in Total Joint Arthroplasty

BACKGROUND

Restrictive transfusion practices have decreased transfusions in total joint arthroplasty (TJA). A hemoglobin threshold of <8 g/dL is commonly used. Predictors of this degree of postoperative anemia in TJA and its association with postoperative outcomes, independent of transfusions, remain unclear. We identified predictors of postoperative hemoglobin of <8 g/dL and outcomes with and without transfusion in TJA.

METHODS

Primary elective TJA cases performed with a multimodal blood management protocol from 2017 to 2018 were reviewed, identifying 1,583 cases. Preoperative and postoperative variables were compared between patients with postoperative hemoglobin of <8 and ≥8 g/dL. Logistic regression and receiver operating characteristic curves were used to assess predictors of postoperative hemoglobin of <8 g/dL.

RESULTS

Positive predictors of postoperative hemoglobin of <8 g/dL were preoperative hemoglobin level (odds ratio [OR] per 1.0-g/dL decrease, 3.0 [95% confidence interval (CI), 2.4 to 3.7]), total hip arthroplasty (OR compared with total knee arthroplasty, 2.1 [95% CI, 1.3 to 3.4]), and operative time (OR per 30-minute increase, 2.0 [95% CI, 1.6 to 2.6]). Negative predictors of postoperative hemoglobin of <8 g/dL were tranexamic acid use (OR, 0.42 [95% CI, 0.20 to 0.85]) and body mass index (OR per 1 kg/m2 above normal, 0.90 [95% CI, 0.86 to 0.94]). Preoperative hemoglobin levels of <12.4 g/dL in women and <13.4 g/dL in men best predicted postoperative hemoglobin of <8 g/dL. Overall, 5.2% of patients with postoperative hemoglobin of 7 to 8 g/dL and 95% of patients with postoperative hemoglobin of <7 g/dL received transfusions. Patients with postoperative hemoglobin of <8 g/dL had longer hospital stays (p < 0.001) and greater rates of emergency department visits or readmissions (p = 0.001) and acute kidney injury (p < 0.001). Among patients with postoperative hemoglobin of <8 g/dL, patients who received transfusions had a lower postoperative hemoglobin nadir (p < 0.001) and a longer hospital stay (p = 0.035) than patients who did not receive transfusions.

CONCLUSIONS

Postoperative hemoglobin of <8 g/dL after TJA was associated with worse outcomes, even for patients who do not receive transfusions. Optimizing preoperative hemoglobin levels may mitigate postoperative anemia and adverse outcomes.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Metformin and the Risk of Anemia of Advanced Chronic Kidney Disease in Patients With Type 2 Diabetes Mellitus

This retrospective cohort study determines whether metformin monotherapy or combination therapies can decrease anemia risk in the progress of advanced chronic kidney disease for patients with type 2 diabetes mellitus. The data set was obtained from the National Health Insurance Research Database, containing 1 million randomly selected beneficiaries. After matching, 9303 pairs (1:1) of metformin users and nonusers were acquired. Every patient was individually recorded from 1997 to 2012 to identify anemia incidence (hemoglobin <9 gm/dL). Cox regression models were used to compute hazard ratios and 95% confidence intervals (CIs). There were 305 (0.7%) and 76 (0.8%) erythropoietin-stimulating agent cases in the metformin and non-metformin cohorts over a mean follow-up period of 6.8 and 5.6 years. After matching, the use of metformin decreased the risk of usage of erythropoietin-stimulating agents with an adjusted hazard ratio of 0.76 (95%CI, 0.45-1.29) for dosage of <357 g to 0.30 (95%CI, 0.17-0.56) for >1368 g. The combination of metformin and dipeptidyl peptidase-4 inhibitors decreased with a hazard ratio of 0.42 (95%CI, 0.18-0.99), compared to metformin alone. Metformin combined with dipeptidyl peptidase-4 inhibitors is superior to metformin monotherapy or non-metformin antidiabetic therapies for reducing the risk of anemia in the progress of advanced chronic kidney disease among patients with type 2 diabetes.

Exposure of human fetal kidneys to mild analgesics interferes with early nephrogenesis

Acetaminophen, aspirin, and ibuprofen are mild analgesics commonly used by pregnant women, the sole current recommendation being to avoid ibuprofen from the fifth month of gestation. The nephrotoxicity of these three analgesics is well documented in adults, as is their interference with prostaglandins biosynthesis. Here we investigated the effect of these analgesics on human first trimester kidneys ex vivo. We first evaluated prostaglandins biosynthesis functionality by performing a wide screening of prostaglandin expression patterns in first trimester human kidneys. We demonstrated that prostaglandins biosynthesis machinery is functional during early nephrogenesis. Human fetal kidney explants aged 7-12 developmental weeks were exposed ex vivo to ibuprofen, aspirin or acetaminophen for 7 days, and analyzed by histology, immunohistochemistry, and flow cytometry. This study has revealed that these analgesics induced a spectrum of abnormalities within early developing structures, ranging from cell death to a decline in differentiating glomeruli density. These results warrant caution for the use of these medicines during the first trimester of pregnancy.

Gender Differences in the Association Between Obesity Indices and Chronic Kidney Disease Among Middle-Aged and Elderly Taiwanese Population: A Community-Based Cross-Sectional Study

BACKGROUND

Traditional risk factors for chronic kidney disease (CKD) include diabetes mellitus (DM), hypertension (HTN), and metabolic syndrome, which are health conditions related to obesity. We aimed to investigate which of the three obesity indices has the strongest association with CKD and to explore whether there are gender differences in these relationships in the middle-aged and elderly Taiwanese population.

METHODS

This was a cross-sectional, community-based study. It included 400 residents (141 males and 259 females, age 50-90 years) residing in a community in northern Taiwan. Each participant was asked to fill a questionnaire that collected personal information, medical history, medication use, and anthropometric measurements. The laboratory data were obtained by testing the blood and urine samples. The baseline characteristics were compared, and the obesity indices included body mass index (BMI), waist circumference (WC), and visceral adiposity index (VAI). CKD was defined as the presence of renal dysfunction (urine albumin-creatinine ratio ≥ 30 mg/g) or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73m². We used a multiple logistic regression model to evaluate the association between each obesity index and CKD for both genders. Further, we used the area under the receiver operating characteristic (ROC) curve (AUC) to examine the best obesity indices to predict CKD in different genders.

RESULTS

The average age of the subjects was 64.47 ± 8.45 years, and men were significantly older. CKD was found in 31 (22.0%) males and 50 (19.3%) females. In men, there was no significant difference between the CKD and non-CKD groups among the three obesity indices. However, in women, only VAI was significantly higher in subjects with CKD (1.9 [1.1, 3.4]) than in subjects without CKD (1.5 [1.0, 2.2]) (p-value = 0.03). The multivariate logistic regression revealed that even after adjusting for possible confounding factors, VAI was found to be an independent risk factor for CKD in women (OR: 1.32, 95% CI: 1.04-1.69, p = 0.02), but not in men (OR: 1.20, 95% CI: 0.85-1.69, p = 0.30). The AUC of VAI had a significant ability to predict CKD in women but not in men.

CONCLUSION

Our results showed that among the three obesity indices, VAI had the strongest association with CKD compared to BMI and WC in women. In addition, VAI in women should be given more importance in the screening for CKD among the middle-aged and elderly Taiwanese population.

[Is Concomitant Therapy with Acetaminophen and Low-dose Aspirin a Risk Factor for CKD Progression? A 6-Year Cohort Study]

Concomitant therapy with acetaminophen (APAP) and low-dose aspirin is often used in clinical settings; however, it is unclear whether this combination is involved in the progression of chronic kidney disease (CKD). We hypothesized that concomitant therapy with APAP and low-dose aspirin may cause CKD progression. We carried out a retrospective 6-year cohort study that included all patients who received low-dose aspirin from January 2011 to December 2016 at Kaetsu Hospital. Primary outcome was defined as CKD progression at the end of the study compared with baseline. Among the 441 patients treated during the study period, we identified 89 cases of CKD progression. Multivariate regression analysis showed that exposure to APAP>50 g [odds ratio (OR), 2.68, 95% confidence interval (CI), 1.08-6.70], age increase by 1 year (OR, 1.05, 95% CI, 1.02-1.08), and diabetes mellitus (OR, 2.40, 95% CI, 1.41-4.08) had positive associations with CKD progression. Our findings suggested that concomitant therapy with APAP and low-dose aspirin increased the risk of CKD progression. Therefore, we recommend more thorough monitoring of serum creatinine when patients are on such concomitant therapy. Moreover, it is important to advise users of low-dose aspirin to avoid unnecessary use of APAP, in order to reduce the risk of CKD progression.

Cross-shift change of acute kidney injury biomarkers in sugarcane farmers and cutters

Sugarcane farmers and cutters have been reported to be at high risk of acute kidney injury. This cross-sectional study aimed to assess acute kidney injury biomarkers, and cross-shift change among 150 sugarcane cutters and 98 sugarcane farmers in Thailand. Physical health examination, environmental measurements, and measured urinary neutrophil gelatinase-associated lipocalin (NGAL) were assessed. Cross-shift change of urine creatinine (uCr), albumin creatinine ratio (ACR), and NGAL between sugarcane farmers and cutters was compared. Factors influencing abnormal post-shift ACR and NGAL were analyzed by binary logistic regression adjusted with covariates. Sugarcane cutters were significantly more likely to take nonsteroidal anti-inflammatory drugs (NSAID) and herbs to relieve pain than sugarcane farmers. Males were more likely to be current smokers and drinkers although 62% of cutters and 56% of farmers were female. Sugarcane farmers and cutters had similar post-shift estimated glomerular filtration rate (eGFR) and ACR levels. Cross-shift measurements showed that both sugarcane cutters and sugarcane farmers had significantly higher post-shift geometric mean (GM) urinary NGAL, but that the cross-shift changes of NGAL were significantly higher for sugarcane cutters (182%) vs. sugarcane farmers (112%). Water intake less than recommendation of subjects was a significant predictor of a higher risk for an abnormal post-shift ACR after controlling for covariates, while being a sugarcane cutter was a predictor of a lower risk of an abnormal risk of a post-shift NGAL after controlling for covariates. Measurements of heat stress (WBGT plus workload) found that sugarcane cutters exceeded recommended exposures while sugarcane farmers were compliance to the TLV. These findings suggest that to protect sugarcane farmers and cutters, preventative measures are needed.

Channeling Bias in the Analysis of Risk of Myocardial Infarction, Stroke, Gastrointestinal Bleeding, and Acute Renal Failure with the Use of Paracetamol Compared with Ibuprofen

INTRODUCTION

Observational studies estimating severe outcomes for paracetamol versus ibuprofen use have acknowledged the specific challenge of channeling bias. A previous study relying on negative controls suggested that using large-scale propensity score (LSPS) matching may mitigate bias better than models using limited lists of covariates.

OBJECTIVE

The aim was to assess whether using LSPS matching would enable the evaluation of paracetamol, compared to ibuprofen, and increased risk of myocardial infarction, stroke, gastrointestinal (GI) bleeding, or acute renal failure.

STUDY DESIGN AND SETTING

In a new-user cohort study, we used two propensity score model strategies for confounder controls. One replicated the approach of controlling for a hand-picked list. The second used LSPSs based on all available covariates for matching. Positive and negative controls assessed residual confounding and calibrated confidence intervals. The data source was the Clinical Practices Research Datalink (CPRD).

RESULTS

A substantial proportion of negative controls were statistically significant after propensity score matching on the publication covariates, indicating considerable systematic error. LSPS adjustment was less biased, but residual error remained. The calibrated estimates resulted in very wide confidence intervals, indicating large uncertainty in effect estimates once residual error was incorporated.

CONCLUSIONS

For paracetamol versus ibuprofen, when using LSPS methods in the CPRD, it is only possible to distinguish true effects if those effects are large (hazard ratio > 2). Due to their smaller hazard ratios, the outcomes under study cannot be differentiated from null effects (represented by negative controls) even if there were a true effect. Based on these data, we conclude that we are unable to determine whether paracetamol is associated with an increased risk of myocardial infarction, stroke, GI bleeding, and acute renal failure compared to ibuprofen, due to residual confounding.

Assessment of Prescription Analgesic Use in Older Adults With and Without Chronic Kidney Disease and Outcomes

IMPORTANCE

Pain is a common symptom among patients with kidney disease. However, little is known about use of analgesics among patients aged 65 years or older with chronic kidney disease (CKD) who do not receive dialysis treatment.

OBJECTIVE

To assess national trends and geographic variations in use of opioids and prescription nonsteroidal anti-inflammatory drugs (NSAIDs) in older adults with and without CKD in the US (2006-2015) and examine associations between use of opioids and patient outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used the 5% Medicare claims data (2005-2015) to select 10 retrospective annual cohorts of Medicare Part D beneficiaries aged 65 years and older from 2006 to 2015 and a retrospective longitudinal cohort. Data were analyzed in August 2019.

EXPOSURES

CKD status and other comorbidities identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes.

MAIN OUTCOMES AND MEASURES

Analgesic use was measured by overall use (proportion of ever used opioids/NSAIDs), long-term use (prescribed >90 days), and cumulative use (total annual days' supply). Patient outcomes included progression to end-stage kidney disease (ESKD) and all-cause mortality.

RESULTS

A total of 6 260 454 beneficiaries (9.6% identified with CKD by claims) were selected in the annual cohorts and 649 339 beneficiaries (8.3% identified with CKD) were selected in the longitudinal cohort. There was significant growth in opioid use (31.2%-42.4%) and NSAID use (10.7%-16.6%) among patients aged 65 years and older with CKD from 2006 to 2015. Long-term use of opioids increased during 2006 to 2014 (25.8%-36.7%) but decreased through 2015 at 35.6%, while long-term use of NSAIDs remained stable. Opioid use was higher in patients with CKD, particularly CKD stages 4 to 5 (odds ratio [OR], 1.35; 95% CI, 1.33-1.37; P < .001) compared with non-CKD. NSAID use was lower in patients with CKD stages 4 to 5 (OR, 0.55; 95% CI, 0.54-0.56; P < .001). Substantial geographic variations in analgesic use were observed across states (opioid use in CKD: 24.7%-54.3%; NSAID use in CKD: 11.2%-20.8%, 2012-2015). Opioid use was associated with progression to ESKD (hazard ratio [HR], 1.10; 95% CI, 1.04-1.16; P = .001) and death (HR, 1.19; 95% CI, 1.18-1.20; P < .001) independent of CKD status and other covariates. There was an inverse association between NSAID use and death (HR, 0.84; 95% CI, 0.83-0.85; P < .001).

CONCLUSIONS AND RELEVANCE

Among Medicare patients with CKD, use of prescription analgesics, both opioid and NSAID, increased from 2006 to 2015. Optimizing pain management in a complex condition such as kidney disease should remain a priority for clinicians and researchers alike.

Influence of acetaminophen on renal function: a longitudinal descriptive study using a real-world database

PURPOSE

Long-term acetaminophen (APAP) use has poorly defined effects on renal function. We investigated these effects using a real-world database.

METHODS

We used a database of health data routinely collected from 185 hospitals serving 20 million patients in Japan. Individuals with chronic pain were selected for the study. The primary outcome was the change in renal function, as measured by 1/serum creatinine (SCr) during the postindex period.

RESULTS

After excluding individuals who did not meet the inclusion criteria, 241,167 patients were included in the analysis (median age 79.0, range 65-101 years; 111,252 were men). APAP was prescribed significantly more frequently to patients with a low renal function (P < 0.001). The annual changes in 1/SCr median and interquartile range (IQR) were - 0.038 (- 0.182 to 0.101) in patients receiving APAP, - 0.040 (- 0.187 to 0.082) in patients receiving non-steroidal anti-inflammatory drugs (NSAIDs), and - 0.025 (- 0.142 to 0.079) in nonmedicated control patients (P < 0.001). These changes were not significantly different among patients with a low renal function, with 0.003 (- 0.066 to 0.113) in the APAP group, 0.000 (- 0.089 to 0.090) in the NSAID group, and - 0.009 (- 0.086 to 0.089) in the control group (P = 0.327).

CONCLUSION

Physicians tended to select APAP for individuals with a low renal function. The annual changes in 1/SCr were significantly different based on APAP and NSAID use or no analgesia, but the differences were not significant among patients with a low renal function. Overall, long-term use of APAP does not appear to exacerbate the renal function in a clinical setting.

Association of Opioids and Nonsteroidal Anti-inflammatory Drugs With Outcomes in CKD: Findings From the CRIC (Chronic Renal Insufficiency Cohort) Study

RATIONALE & OBJECTIVE

Safe analgesic choices are limited in chronic kidney disease (CKD). We conducted a comparative analysis of harm from opioids versus nonsteroidal anti-inflammatory drugs (NSAIDs) in CKD.

STUDY DESIGN

Prospective cohort study.

SETTING & PARTICIPANTS

3,939 patients with CKD in the Chronic Renal Insufficiency Cohort (CRIC) Study.

EXPOSURES

30-day analgesic use reported at annual visits.

OUTCOMES

A composite outcome of 50% glomerular filtration rate reduction and kidney failure requiring kidney replacement therapy (KRT), as well as the outcomes of kidney failure requiring KRT, hospitalization, and pre-kidney failure death.

ANALYTICAL APPROACH

Marginal structural models with time-updated exposures.

RESULTS

Participants were followed up for a median of 6.84 years, with 391 (9.9%) and 612 (15.5%) reporting baseline opioid and NSAID use, respectively. Time-updated opioid use was associated with the kidney disease composite outcome, kidney failure with KRT, death (HRs of 1.4 [95% CI, 1.2-1.7], 1.4 [95% CI, 1.1-1.7], and 1.5 [95% CI, 1.2-2.0], respectively), and hospitalization (rate ratio [RR], 1.7; 95% CI, 1.6-1.9) versus opioid nonusers. Similar results were found in an analysis restricted to a subcohort of participants reporting ever using other (nonopioid and non-NSAID) analgesics or tramadol. Time-updated NSAID use was associated with increased risk for the kidney disease composite (HR, 1.2; 95% CI, 1.0-1.5) and hospitalization (RR, 1.1; 95% CI, 1.0-1.3); however, these associations were not significant in the subcohort. The association of NSAID use with the kidney disease composite outcome varied by race, with a significant risk in blacks (HR, 1.3; 95% CI, 1.0-1.7). NSAID use was associated with lower risk for kidney failure with KRT in women and individuals with glomerular filtration rate<45mL/min/1.73m2 (HRs of 0.63 [95% CI, 0.45-0.88] and 0.77 [95% CI, 0.59-0.99], respectively).

LIMITATIONS

Limited periods of recall of analgesic use and potential confounding by indication.

CONCLUSIONS

Opioid use had a stronger association with adverse events than NSAIDs, with the latter's association with kidney disease outcomes limited to specific subgroups, notably those of black race.

Acetaminophen use and risk of renal impairment: A systematic review and meta-analysis

BACKGROUND

Acetaminophen is commonly used for the relief of pain and fever. Advocacy organizations recommend acetaminophen as the drug of choice in patients with kidney disease. Although some studies have suggested a risk of renal impairment after the use of acetaminophen, the effect of acetaminophen on the risk of renal impairment is unclear. The purpose of this research was to demonstrate any correlation linking acetaminophen treatment and renal impairment.

METHODS

We performed a systematic review and meta-analysis of the association between acetaminophen and renal impairment in adults by searching Cochrane Library, PubMed, and Embase databases from initiation to June 16, 2019.

RESULTS

Of 13,097 articles identified, 5 studies (2 cohort studies and 3 case-control studies) with a total of 13,114 participants were included. In the random-effects meta-analysis of the cohort study, acetaminophen use was shown to have statistically significant effects on the increased risk of renal impairment (adjusted odds ratio 1.23; 95% confidence interval, 1.07-1.40). The results of sensitivity and subgroup analyses also suggested that acetaminophen use increases the risk of renal impairment. The Egger's test (P = 0.607) and Begg's test (P = 0.732) revealed no apparent publication bias.

CONCLUSION

Acetaminophen is associated with a significantly increased risk of newly developing renal impairment in adults. Physicians who prescribe acetaminophen should be aware of potential adverse renal effects. A longitudinal study that further explores this association is warranted.

Identification of the cerebral effects of paracetamol in healthy subjects: an fMRI study

Introduction

Paracetamol is commonly used for its antipyretic properties and analgesic effects, but the central mechanism remains elusive. We designed a study in healthy volunteers to detect the central functional working mechanism of paracetamol.

Subjects material and methods

A total of 20 subjects had a baseline functional magnetic resonance imaging (fMRI) before the intake of 1000 mg paracetamol orally; 60 minutes later, a second fMRI was made aiming detection of regional blood flow differences.

Results

A decreased connectivity was observed in the ventral volume of interest (VOI), with the posterior cingulate (with both the left anterior cingulate cortex (ACC) and right ACC: respectively, Ke = 576; t = -6.8894 and Ke = 185; t = -4.8178) and the inferior temporal left (Ke = 103; t = -5.0993); in the combined ventral and dorsal VOIs, the posterior cingulate (with the left ACC; Ke = 149; t = -4.5658) and, both with the right ACC, the inferior temporal left (Ke = 88; t = -3.8456) and the inferior frontal gyrus (Ke = 86; t = -4.3937) had a decrease in connectivity. An increase was seen in other regions, including, among others, the middle frontal and temporal gyri (respectively, Ke = 85; t = 4.4256 and Ke = 85; t = 5.6851), the inferior frontal (with the left ACC: Ke = 165; t = 4.4998) and the superior frontal gyrus (with the right ACC; Ke = 281; t = 4.5992), and the post/precentral gyrus (with the right ACC, respectively, Ke = 102; t = 6.0582 and Ke = 105; t = 4.0776).

Conclusions

On fMRIs in healthy volunteers, the ingestion of paracetamol affects connections with the ACC. This suggests a central effect of paracetamol in cerebral areas known to be associated with pain. Further studies are needed to demonstrate the same effects in acute and chronic pain states.

Molecular pathways driving omeprazole nephrotoxicity

Omeprazole, a proton pump inhibitor used to treat peptic ulcer and gastroesophageal reflux disease, has been associated to chronic kidney disease and acute interstitial nephritis. However, whether omeprazole is toxic to renal cells is unknown. Omeprazole has a lethal effect over some cancer cells, and cell death is a key process in kidney disease. Thus, we evaluated the potential lethal effect of omeprazole over tubular cells. Omeprazole induced dose-dependent cell death in human and murine proximal tubular cell lines and in human primary proximal tubular cell cultures. Increased cell death was observed at the high concentrations used in cancer cell studies and also at lower concentrations similar to those in peptic ulcer patient serum. Cell death induced by omeprazole had features of necrosis such as annexin V/7-AAD staining, LDH release, vacuolization and irregular chromatin condensation. Weak activation of caspase-3 was observed but inhibitors of caspases (zVAD), necroptosis (Necrostatin-1) or ferroptosis (Ferrostatin-1) did not prevent omeprazole-induced death. However, omeprazole promoted a strong oxidative stress response affecting mitochondria and lysosomes and the antioxidant N-acetyl-cysteine reduced oxidative stress and cell death. By contrast, iron overload increased cell death. An adaptive increase in the antiapoptotic protein BclxL failed to protect cells. In mice, parenteral omeprazole increased tubular cell death and the expression of NGAL and HO-1, markers of renal injury and oxidative stress, respectively. In conclusion, omeprazole nephrotoxicity may be related to induction of oxidative stress and renal tubular cell death.

Plasma orexin-A-like immunoreactivity levels and renal function in patients in a geriatric ward

Orexin-A is a neuropeptide mainly produced by hypothalamic neurons with functions in the central nervous system such as regulation of the sleep-wake cycle. Recent studies suggest that orexin-A also plays major roles in peripheral tissues. Although a few studies have reported a role for the kidney in the dynamics of orexin-A, little is known about the association between plasma orexin-A-like immunoreactivity (orexin-A-LI) levels and renal function. We evaluated this association, and also explored other clinical characteristics associated with plasma orexin-A-LI levels. In this cross-sectional study, we included 70 consecutive patients aged ≥65 years admitted to the geriatric ward of Nagoya University Hospital from December 2017 to January 2018. Patients taking suvorexant (an orexin receptor antagonist) were excluded. On hospital days 2-4, fasting blood was collected in the morning. We evaluated associations between plasma orexin-A-LI levels and renal function and other clinical characteristics. Renal function was evaluated in two ways: the estimated glomerular filtration rate (eGFR) using serum creatinine, and estimated creatinine clearance (eCrCl) using the Cockroft-Gault formula. Pearson's correlation coefficient revealed that plasma orexin-A-LI levels were negatively correlated with the eGFR (r = -0.351, p = 0.003) and eCrCl (r = -0.342, p = 0.004). There were no significant associations between plasma orexin-A-LI levels and the primary diagnosis, body mass index, duration of fasting, or other clinical characteristics. In conclusion, plasma orexin-A-LI levels were negatively correlated with renal function in patients in a geriatric ward. Renal function may affect the study design and data interpretation in studies of plasma orexin-A-LI.

Current Management of Patients With Acquired Solitary Kidney

Persons with acquired solitary kidney, including those who have had a unilateral nephrectomy for living kidney donation, renal malignancies, or trauma, have decreased renal mass that leads to increased intraglomerular pressure and glomerular hyperfiltration. These physiologic adaptations of solitary kidney may exacerbate other preexisting and genetic conditions that could create a predisposition to or worsen glomerular pathologies, leading to unfavorable renal outcomes. Hence, these persons may benefit from special care and lifestyle modifications, including nutritional interventions. There is a lack of consensus and evidence for proper surveillance and management after nephrectomy, and misconceptions in both directions of having a “normal” versus “abnormal” kidney status may cause confusion among patients and healthcare providers pertaining to long-term kidney health monitoring and management. We have reviewed available data on the impact of lifestyle modifications, particularly nutritional measures, and pharmacologic interventions, on short- and long-term outcomes after nephrectomy. We recommend avoidance of excessively high dietary protein intake (>1 g/kg per day) and high dietary sodium intake (>4 grams/d), adequate dietary fiber intake from plant-based foods, a target body mass index of <30 kg/m² (in non-athletes and non-bodybuilders), and judicious management of risk factors of progressive chronic kidney disease (CKD), and future studies should help to better determine optimal care practices for these persons.

Pros and Cons of Aspirin Prophylaxis for Prevention of Cardiovascular Events in Kidney Transplantation and Review of Evidence

Kidney transplant recipients have traditional and nontraditional risk factors which can lead to coronary artery disease and sudden death with a functional graft loss. Aspirin has been used traditionally for prevention of cardiovascular and cerebrovascular accidents. It has beneficial effects in secondary prevention of cardiovascular events in general population. Its use for primary prophylaxis is still disputed. Bleeding and theoretical risk of nephrotoxicity are the major concerns about its use. The data on aspirin in kidney transplant population is sparse. This review will focus on various pros and cons of aspirin use for prevention of cardiovascular events in kidney transplant recipients and a way forward.

Protective effects of Gastrodia elata Blume on acetaminophen-induced liver and kidney toxicity in rats

An overdose of acetaminophen (AAP) causes hepatic and renal toxicity. This study examined the protective effects of Gastrodia elata Blume (GEB) on hepatic and renal injury induced by AAP. Rats were orally administered distilled water or GEB for 14 days and injected with AAP 1 h after the oral last administration; control rats were administered water without AAP injection. All rats were sacrificed 24 h after AAP injection. The GEB pretreatment group showed decreased necrosis and the expression of pro-inflammatory cytokines in the liver and kidney. TUNEL-positive cells and oxidative stress marker, such as malondialdehyde, were decreased. However, antioxidant enzymes, such as glutathione and superoxide dismutase, were increased. The expression of CYP2E1 and N-acetyl-beta-d-glucosaminidase was decreased in the GEB pretreatment group. This study shows that GEB prevents AAP-induced liver and kidney injury.

Pain Management in Pediatric Chronic Kidney Disease

Pain is a common problem in children with chronic kidney disease (CKD); however, limited data exist regarding its management. Although most pain is managed pharmacologically, in some instances non-pharmacologic management can aid in safely ameliorating discomfort. Because of the accumulation of toxic metabolites, many common pain medications have adverse effects on kidney function or altered pharmacokinetics in the setting of CKD. Decreased clearance impacts safe dosing of analgesics. The pain management of patients on renal replacement therapy requires an understanding of drug clearance due to the different modalities of dialysis. This educational review highlights pain medications that are safe, albeit often with adjusted dosing, as well as drugs best avoided in the management of pediatric kidney disease. Acetaminophen should be used as a first-line therapy for pain management in children with CKD. Opioids may be added to control moderate to severe pain. Although data are currently lacking, buprenorphine holds promise as a potentially useful drug for the treatment of pain in pediatric patients with CKD. The addition of adjuvant pain medications and non-pharmacologic therapies maybe also be helpful. Despite these options, pain often remains difficult to treat in children with CKD.

Population Pharmacokinetics of Finafloxacin in Healthy Volunteers and Patients with Complicated Urinary Tract Infections

Finafloxacin is a novel fluoroquinolone with increased antibacterial activity at acidic pH and reduced susceptibility to several resistance mechanisms. A phase II study revealed a good efficacy/safety profile in patients with complicated urinary tract infections (cUTIs), while the pharmacokinetics was characterized by highly variable concentration-versus-time profiles, suggesting the need for an elaborated pharmacokinetic model. Data from three clinical trials were evaluated: 127 healthy volunteers were dosed orally (n = 77) or intravenously (n = 50), and 139 patients with cUTI received finafloxacin intravenously. Plasma (2,824 samples from volunteers and 414 samples from patients) and urine (496 samples from volunteers and 135 samples patients) concentrations were quantified by liquid chromatography-tandem mass spectrometry (LC-MS/MS). NONMEM was used to build a population pharmacokinetic model, and pharmacokinetic/pharmacodynamic relationships were investigated via simulations and logistic regression. A two-compartment model with first-order elimination described the data best (central volume of distribution [Vc] and peripheral volume of distribution [Vp] of 47 liters [20%] and 43 liters [67%], respectively, and elimination clearance and intercompartmental clearance of 21 liters/h [54%] and 2.8 liters/h [57%], respectively [median bootstrap estimates {coefficients of variation}]). Vc increased with body surface area, and clearance was reduced in patients (-29%). Oral absorption was described best by parallel first- and zero-order processes (bioavailability of 75%). No pharmacodynamic surrogate parameter of clinical/microbiological outcome could be identified, which depended exclusively on the MIC of the causative pathogens. Despite the interindividual variability, the present data set does not support covariate-based dose adjustments. Based on the favorable safety and efficacy data, the clinical relevance of the observed variability appears to be limited. (This study has been registered at ClinicalTrials.gov under identifier NCT01928433.).

Pre- and perioperative aspects of dermatosurgery

Dermatosurgery occupies an exceptional position among all surgical disciplines. Above all, this includes the fact that, with very few exceptions, the vast majority of surgical interventions can be performed under local or regional anesthesia, usually in smaller procedure rooms that are spatially separated from larger operating suites. Thus, peri- and postinterventional patient monitoring is the responsibility of the dermatosurgeon and his team. Though inherently smaller, this team still has to observe numerous perioperative requirements that - in larger surgical specialties - would be attended to by a host of various specialists working in concert. Said requirements include hygienic aspects, knowledge concerning pre- and intraoperative patient monitoring, managing surgical site infections, adequate postsurgical pain management, as well as detailed pharmacological knowledge with respect to common local anesthetics and the toxic and allergic reactions associated therewith. Not only does this require interdisciplinary collaboration and shared responsibility for the patient. It also necessitates the development and implementation of quality-oriented and evidence-based guidelines that, in the dermatosurgical setting, usually extend far beyond the scope of the specialty per se. The objective of the present CME article is the condensed presentation of interdisciplinary aspects relating to the most important perioperative issues.

Use of anti-inflammatory analgesics in sickle-cell disease

WHAT IS KNOWN AND OBJECTIVE

Non-steroidal anti-inflammatory drugs (NSAIDs) have been commonly used to treat pain in sickle-cell disease (SCD), but NSAID use is associated with renal, gastrointestinal and cardiovascular toxicities. Our objective was to evaluate the use of aspirin and non-aspirin NSAIDs in SCD.

COMMENT

Despite analgesic and anti-inflammatory benefits in SCD, non-aspirin NSAIDs are associated with renal, cardiovascular and gastrointestinal toxicities in this patient population. Aspirin may have less renal and cardiovascular toxicities. The different side effect profile of NSAIDs is related to the COX-1/COX-2 selectivity at their therapeutic doses. Individual risk factors and genetic biomarkers should be considered when selecting appropriate NSAIDs and their dose.

WHAT IS NEW AND CONCLUSION

NSAIDs have the potential to be an important component of pain regimens in SCD, but the use of NSAIDs should be individualized based on potential side effects and patient risk factors and the lowest effective dose should be prescribed with proper monitoring in patients with SCD.

Post Hoc Analyses of Randomized Clinical Trial for the Effect of Clopidogrel Added to Aspirin on Kidney Function

BACKGROUND AND OBJECTIVES

Despite the high burden of CKD, few specific therapies are available that can halt disease progression. In animal models, clopidogrel has emerged as a potential therapy to preserve kidney function. The effect of clopidogrel on kidney function in humans has not been established.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The Secondary Prevention of Small Subcortical Strokes Study randomized participants with prior lacunar stroke to treatment with aspirin or aspirin plus clopidogrel. We compared annual eGFR decline and incidence of rapid eGFR decline (≥30% from baseline) using generalized estimating equations and interval-censored proportional hazards regression, respectively. We also stratified our analyses by baseline eGFR, systolic BP target, and time after randomization.

RESULTS

At randomization, median age was 62 (interquartile range, 55-71) years old; 36% had a history of diabetes, 90% had hypertension, and the median eGFR was 81 (interquartile range, 65-94) ml/min per 1 m2. Persons receiving aspirin plus clopidogrel had an average annual change in kidney function of -1.39 (95% confidence interval, -1.15 to -1.62) ml/min per 1.73 m2 per year compared with -1.52 (95% confidence interval, -1.30 to -1.74) ml/min per 1.73 m2 per year among persons receiving aspirin only (P=0.42). Rapid kidney function decline occurred in 21% of participants receiving clopidogrel plus aspirin compared with 22% of participants receiving aspirin plus placebo (hazard ratio, 0.94; 95% confidence interval, 0.79 to 1.10; P=0.42). Findings did not vary by baseline eGFR, time after randomization, or systolic BP target (all P values for interaction were >0.3).

CONCLUSIONS

We found no effect of clopidogrel added to aspirin compared with aspirin alone on kidney function decline among persons with prior lacunar stroke.

Prä- und perioperative Aspekte der Versorgung dermatochirurgischer Patienten

Die Dermatochirurgie nimmt hinsichtlich vieler Punkte eine Sonderstellung unter den operativen Fächern ein. Hierzu gehört in erster Linie die Tatsache, dass bis auf wenige Ausnahmen fast alle Eingriffe traditionell in Lokal- bzw. Regionalanästhesie und oft auch in räumlich-infrastruktureller Trennung von den großen Zentral-Operationssälen stattfinden können. Die peri- und postoperative Überwachung obliegt dabei dem dermatochirurgischen Operationsteam. Das sui generis kleinere OP-Team hat somit eine ganze Reihe perioperativer Notwendigkeiten zu beachten, um die sich in den "großen" chirurgischen Fächern eine Vielzahl verschiedener beteiligter Fachgruppen gemeinsam kümmern. Hierzu gehören neben Hygieneaspekten, Kenntnissen in der Überwachung der Patienten sowie dem Aspekt der surgical site infections auch Fragen zur postoperativen Schmerztherapie sowie detailliertes pharmakologisches Wissen über die zur Anwendung kommenden Lokalanästhetika und das Handling der damit assoziierten toxischen und allergischen Reaktionen. Eine interdisziplinäre Zusammenarbeit und Verantwortung für den Patienten ist notwendig und erfordert die Erarbeitung und Umsetzung qualitätsorientierter und evidenzbasierter Handlungsanweisungen, die im dermatochirurgischen OP-Setting meist weit über das eigentliche Fach hinausgehen. Ziel dieses Weiterbildungsartikels soll die komprimierte Darstellung der genannten fachübergreifenden Standpunkte bezüglich der wichtigsten perioperativen Aspekte sein.

Short-Term Non-Steroid Anti-Inflammatory Drug Use in Spondyloarthritis Patients Induces Subclinical Acute Kidney Injury: Biomarkers Study

BACKGROUND

Non-steroid anti-inflammatory drug (NSAID) usage is associated with kidney injury. Rise in serum creatinine (sCr) often represents irreversible process. Thus to assess the early effects of regular NSAID use, we studied sensitive serum and urine biomarkers of kidney injury.

METHODS

In a protocol-based intervention study, 103 subjects were enrolled in 3 mutually exclusive groups. Group 1 included 37 healthy controls having minimal baseline NSAID exposure as per a definition, and group 2 had 41 spondyloarthritis (SpA) patients on regular NSAID therapy for >3 months. Group 3 included 25 SpA patients having minimal NSAID exposure at baseline. Blood and urine samples were collected from all the 3 groups at baseline. Furthermore, group 3 was started on 6-week regular NSAID therapy, and blood and urine samples were re-collected at 1, 6, and 12 weeks. Baseline normal kidney function as per the definition was ensured in all the subjects. Creatinine, neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), cystatin-C, and microalbumin were measured in urine and serum samples to assess kidney injury.

RESULTS

Kidney injury biomarkers were 2-3-fold higher in SpA patients using regular NSAID therapy compared to healthy controls and SpA patients having minimal NSAID exposure (uKIM-1 and uNGAL p < 0.0001, sKIM-1 and sNGAL p = 0.001). There was no difference in sCr and estimated glomerular filtration rate using Cockcroft-Gault equation between the groups. In SpA patients started on 6 weeks of regular NSAID (group 3), biomarker levels started rising at week 1 and showed a significant rise at week 6. The levels in the patients that stopped NSAID use at 6 weeks showed reversibility at 12 weeks.

CONCLUSIONS

Regular NSAID use in SpA patients induces subclinical kidney injury represented by rise in biomarkers. These levels start rising as early as 7 days of regular NSAID use and are reversible on stopping the drug.

Common Analgesic Agents and Their Roles in Analgesic Nephropathy: A Commentary on the Evidence

An association between non-opioid analgesic agents and chronic kidney disease has long been suspected. The presumed development of chronic renal impairment following protracted and excessive use of non-opioid analgesia is known as analgesic nephropathy. Many clinicians accept analgesic nephropathy as a real entity despite the paucity of scientific evidence. This narrative review aims to summarize the literature in the field. The weight of available observational literature suggests that long-term ingestion of paracetamol and combination mixtures of aspirin and paracetamol are likely to contribute to chronic renal impairment. However, there is no convincing data to implicate non-steroidal anti-inflammatory drugs or aspirin monotherapy in the development of analgesic nephropathy. In the absence of high-level evidence, while controversy persists, it may be prudent for physicians to consider all non-narcotic analgesics to be nephrotoxic with long-term use.

Analgesic Nephropathy–-A Painful Progression

One of the dreaded complications of long term analgesic intake is nephrotoxicity characterized by chronic interstitial nephritis and papillary necrosis. Much of the literature of its epidemiology dates back to 1960s and its impact on present day society is not well documented. Non steroidal anti inflammatory agents reduce pain by blocking prostaglandin generation. Prostaglandins have renal vaso dilatory effects in states of volume depletion to counteract the vasoconstrictive pressor hormones. Earlier analgesic tablets contained a mixture of aspirin, phenacetin and caffeine. Phenacetin and its metabolites have nephrotoxic potential and incidence of analgesic nephropathy was brought down in countries where it was banned. The concentration of phenacetin and its metabolite acetaminophen is increased at the tip of renal papilla due to counter current concentrating mechanism of the loop of henle. These are potent oxidants leading to cell injury due to lipid peroxidation, though their effects are normally counterbalanced by anti oxidant glutathione. Glutathione deficiency at the medulla can be precipitated by co ingestion of aspirin. The exact dose of analgesics which needs to be ingested is unclear but a daily ingestion of 5–8 tablets over 5 years results in clinical nephrotoxicity. The histopathology is one of chronic interstitial nephritis with renal fibrosis. Clinically the patient presents with polyuria, asthenia and anemia. The diagnosis is suspected in a patient with progressive chronic kidney disease without proteinuria. CT imaging of the kidneys show irregular scarred kidneys with papillary calcification and necrosis. Recently, COX-2 inhibitors are promoted as renal safe drugs, but may not be so given the multiple case reports of renal toxicity in post marketing surveys. The treatment of analgesic nephropathy includes discontinuation of offending drug, protein restricted diet, control of blood pressure and statins. In conclusion analgesic nephropathy is a preventable cause of chronic kidney disease and both the patients and treating physicians should be mindful of the potential nephrotoxcity of nonsteroidal anti inflammatory agents when administered for prolonged periods without monitoring renal function.

THE PURVIEW OF PHYTOTHERAPY IN THE MANAGEMENT OF KIDNEY DISORDERS: A SYSTEMATIC REVIEW ON NIGERIA AND SOUTH AFRICA

BACKGROUND

The kidney is tasked with a number of metabolic functions in the body. In its role as a detoxifier and primary eliminator of xenobiotics, it becomes vulnerable to developing injuries. Currently, over 1 million people in the world are living on renal replacement therapies (RRTs). The case in sub-Sahara African countries like Nigeria and South Africa is not any better than the global trend.

MATERIALS AND METHODS

A systematic review of medicinal plants used in the treatment of kidney disorders was conducted. Information were gathered from published scientific journals, books, reports from national, regional and international institutions, conference proceedings and other high profile intellectual resources. MeSH words like 'prevalence of kidney disorders in Africa', 'renal replacement therapy', 'nephrotoxins or nephrotoxicants', 'nephroprotective plants', 'nephroprotective plants in Nigeria or South Africa' and 'nephroprotective phytocompounds' were used to retrieve information from online databases (Google, Pubmed, MEDLINE, Science Direct, Scopus and SID).

RESULTS

Interestingly, our findings revealed that phytotherapy has emerged and is being employed to protect renal functions and delay progression of renal pathological conditions into end episodes where the last resort is RRT. In fact, in recent times, Phytotherapists are not only interested in developing relatively safe, more affordable, easily accessible and potent nephroprotective formulations but also increasing awareness on the prevalence of the disease and educating the populace on the probable preventive measures. More importantly, efforts at scientifically elucidating the pharmacological efficacy of the identified nephroprotective plants yet to be validated must be intensified through informed expert opinions. Till date, there is paucity of information on the concept of nephroprotection in most developing countries where kidney disorder is a major threat. Although, the concept is just emerging in South Africa, evidences have given credence to its application in complementary and alternative system of medicine in Nigeria.

CONCLUSION

This review, therefore, reawaken researchers' consciousness in the continuous search for auspicious nephroprotective plants that could potentially be excellent candidates in developing new lead drugs to manage and treat renal disorders.

Is Long-Term Low-Dose Aspirin Therapy Associated with Renal Dysfunction in Patients with Type 2 Diabetes? JPAD2 Cohort Study

Background

Low-dose aspirin is widely recommended for patients at high risk for cardiovascular disease (CVD); however, it remains uncertain whether long-term treatment adversely affects renal function in patients with diabetes.

We investigated whether long-term low-dose aspirin affects renal dysfunction in patients with diabetes.

Methods

We conducted a randomized controlled trial (RCT), the Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) trial, to evaluate low-dose aspirin as primary prevention for CVD in patients with type 2 diabetes. We followed the patients with negative urine dipstick albumin of the JPAD trial in a cohort study after the RCT period was completed. Patients were randomly allocated to receive aspirin (81 mg or 100 mg daily, aspirin group) or no aspirin (no aspirin group). After the RCT, the treating physician decided whether to administer aspirin. We evaluated the incidence of positive urine dipstick albumin and annual changes in estimated glomerular filtration rate (eGFR).

Results

Positive urine dipstick albumin developed in 297 patients in the aspirin group (n = 1,075) and 270 patients in the no aspirin group (n = 1,098) during follow-up (median, 8.5 years). Intention-to-treat analysis showed low-dose aspirin did not increase the incidence of positive urine dipstick albumin (hazard ratio [HR], 1.17; 95% confidence interval [CI], 0.995–1.38). On-treatment analysis yielded similar results (HR, 1.08; 95% CI, 0.92–1.28). Multivariable analysis showed the incidence of positive urine dipstick albumin was higher among the elderly and those with elevated serum creatinine, high hemoglobin A1c, or high blood pressure; however, low-dose aspirin did not increase the risk of positive urine dipstick albumin. There were no significant differences in annual changes in eGFR between the groups (aspirin, −0.8 ± 2.9; no aspirin, −0.9 ± 2.5 ml/min/1.73m²/year).

Conclusion

Long-term low-dose aspirin does not affect eGFR and positive urine dipstick albumin in patients with type 2 diabetes.

Causes of end stage renal failure among haemodialysis patients in Khartoum State/Sudan

Background

End stage renal failure (ESRF) has become a major health problem in Sub Saharan Africa (SSA). There were limited data about causes of ESRF in the Sudan.

Methods

This is a cross sectional hospital based descriptive study. The subjects of the study are ESRF adults’ patients on regular haemodialysis treatment in 15 haemdoialysis centres in Khartoum State—Sudan. Clinical and epidemiological data were obtained from 1583 patients. The medical files of each patient were reviewed to identify the cause of ESRF. Concerning the causes of ESRF, diabetes was diagnosed based on the past medical history and result of the glucose tolerance test, hypertension was diagnosed based on past history of hypertension based on blood pressure of more than 140/90 mmHg, glomerulonephritis was diagnosed based on results of previous kidney biopsies and on clinical grounds, polycystic kidney disease and obstructive uropathy were diagnosed based on abdominal ultrasound and other imaging modalities, sickle cell anaemia was diagnosed based on the result of haemoglobin electrophoresis, systemic lupus erythematosus was diagnosed based on the clinical criteria in addition to lab results of auto antibodies, and analgesic nephropathy was diagnosed based on past medical history of chronic analgesic drugs usage with no other identifiable risk factors. We included all ESRF patients on regular haemodialysis treatment. We excluded ESRF patients less than 18 years old.

Results

The results showed that the mean age of ESRF Patients was 49 ± 15.8 (years) and 63.4 % were male and 76.3 % were unemployed. The mean duration of haemodialysis is 4.38 ± 4.24 (years). The most common cause of ESRF in our patients was hypertension (34.6 %) followed by chronic glomerulonephritis (17.6 %), diabetes mellitus (12.8 %), obstructive uropathy (9.6 %), autosomal dominant poly cystic kidney disease (ADPKD) (4.7 %), chronic pyelonephritis (4.6 %), analgesic nephropathy (3.5 %). However in (10.7 %) no cause was found. In patient aged less than 40 years old the leading cause of ESRF was glomerulonephritis (29.3 %) followed by hypertension (25 %). In patient aged between 40 to 60 years old the leading cause of ESRF was hypertension (38.5 %) followed by diabetes mellitus (14 %). In patient aged older than 60 years the leading cause of ESRF was hypertension (38.4 %) followed by diabetes mellitus (23.3 %).

Conclusions

ESRF in Sudan affects the economically productive age group; unemployment rate among ESRF patients is high. The study showed that hypertension is a leading cause of ESRF in Sudan followed by chronic glomerulonephritis. Hypertension and diabetes mellitus are the leading causes of ESRF among patients over 40 years old.

Severe hepatoxicity caused by aspirin overdose: a case report

We report here the rare case of a 61-year-old man with multiple organ dysfunction caused by an aspirin overdose (4 g orally). The patient presented with a fever that reached 39.2 °C, a peptic ulcer, and massive upper gastrointestinal bleeding. His blood test results were as follows: white blood cell count, 1.8 × 10(9)/L; absolute lymphocytes, 0.4 × 10(9)/L; absolute neutrophils, 1.2 × 10(9)/L; and electrolyte disturbances. A computed tomography (CT) scan showed evidence of bilateral inferior pulmonary infection and acute pancreatitis. Thick dark bile with visible floccule was drawn via a percutaneous transhepatic cholangiodrainage (PTCD). Klebsiella pneumoniae was detected in microbiological bile tests. Two years later, the patient died of chronic liver failure.

Status of non-steroidal anti-inflammatory drugs use and its association with chronic kidney disease: a cross-sectional survey in China

AIM

Non-steroidal anti-inflammatory drugs (NSAIDs) have been reported to be associated with adverse effects including kidney injury, while relevant studies from developing countries are limited. We aimed to explore the status of NSAIDs use in China, as well as cross-sectional association between NSAIDs intake and presence of chronic kidney disease (CKD).

METHODS

A national representative sample of 47,204 adults in China was used. Prevalence of regular NSAIDs use was reported. Age- and sex- matched controls of NSAIDs users were then selected. The association between NSAIDs use and kidney injury were analyzed using logistic regression.

RESULTS

Altogether 1129 participants reported regular use of NSAIDs, with the adjusted prevalence of 3.6% (95% CI, 3.2%-3.9%). And 76.9% of them (n = 868) had taken phenacetin-containing analgesics, with an adjusted prevalence of 3.2% (95% CI, 2.9%-3.5%). After adjusting for potential confounders, long-term NSAIDs intake (≥ 48 months) was associated with eGFR < 60 mL/min per 1.73 m2, with an OR of 2.36 (95% CI, 1.28-4.37).

CONCLUSION

Regular use of NSAIDs, especially phenacetin-containing drugs, is prevalent in China. And long-term NSAIDs intake (≥ 48 months) was independently associated with reduced renal function.