Analgesic nephropathy: etiology, clinical syndrome, and clinicopathologic correlations in Australia

Analgesic abuse is a major public health hazard in Australia, and analgesic nephropathy with consequent terminal renal failure is the underlying cause in 20% of the patients requiring dialysis and transplantation. Analgesics are invariably taken in the form of compounds and mixtures. In the aspirin-phenacetin-caffeine (APC) mixture, aspirin appears to be the major nephrotoxic agent and phenacetin appears to play a secondary and synergistic role. The renal disease associated with abuse of analgesics is characteristic and is part of a much wider clinical syndrome, the analgesic syndrome, which includes peptic ulcer disease (35%), anemia (60 to 90%), hypertension (15 to 70%), ischemic heart disease (35%), psychological and psychiatric manifestations, pigmentation, and possible gonadal- and pregnancy-related effects. The primary lesion in analgesic nephropathy is renal papillary necrosis (RPN), and this is a nephrotoxic effect common to all nonsteroid antiinflammatory agents. The most important factor in the management of patients with analgesic nephropathy is the cessation of analgesic abuse, and this leads to improvement and stabilization of renal function. A small proportion of patients will, however, deteriorate in relation to accelerated hypertension, persistent proteinuria, ischemic heart disease, and complications leading to nephrectomy. Patients with analgesic nephropathy are poor risk patients and have a poor prognosis, even after dialysis and transplantation.

Genesis of analgesic nephropathy in the United Kingdom

Analgesic nephropathy is more common in Western Scotland than elsewhere in the United Kingdom. This appears to be a consequence of the frequency with which local people take Askit, a preparation different from most other British analgesics in that they contain more caffeine and in their presentation as powders. Surveys of different populations in Glasgow suggest that while aspirin and paracetamol tend to be taken relatively infrequently and for appropriate reasons such as pain, Askit is more likely to be taken with excessive frequency for its supposed mood-altering properties. Working-class women with psychiatric problems are especially prone to daily self-medication. Study of individuals with analgesic nephropathy reveals that in Western Scotland, at least, the cause is dependence on analgesics. The characteristics of this include a need to continue taking and to slowly increase the dose of analgesics, partly owing to tolerance and partly to treat symptoms the analgesic ingestion has caused, as well as a psychic dependence resulting from appreciation of the psychotropic effects of the compound analgesics. When compared with matched controls, those who develop the "analgesic abuse syndrome" are more likely to have a family history of analgesic abuse, alcoholism, and psychiatric disorder. They tend to be introverted and neurotic, are prone to abuse other drugs and many have had previous psychiatric treatment.

Abuse of amphetamine and amphetamine-like drugs

The present use of amphetamine-type compounds in a large city is examined carefully. The authors conclude that we are not well prepared to cope effectively with the increasing abuse of amphetamines and similar compounds.