Nonsteroidal antiinflammatory drug-induced renal dysfunction related to inhibition of renal prostaglandins

Drug-Induced Nephrotoxicity and Dose Adjustment Recommendations: Agreement Among Four Drug Information Sources

Hospitalized patients require the use of a variety of drugs, many of which individually or in combination have the potential to cause kidney damage. The use of potentially nephrotoxic drugs is often unavoidable, and the need for dose adjustment should be evaluated. This study is aimed at assessing concordance in information on drug-induced nephrotoxicity and dose adjustment recommendations by comparing four drug information sources (DRUGDEX^®, UpToDate^®, Medscape^® and the Brazilian Therapeutic Formulary) using the formulary of a Brazilian public hospital. A total of 218 drugs were investigated. The global Fleiss’ kappa coefficient was 0.265 for nephrotoxicity (p < 0.001; CI 95%, 0.211–0.319) and 0.346 for recommendations (p < 0.001; CI 95%, 0.292–0.401), indicating fair concordance among the sources. Anti-infectives and anti-hypertensives were the main drugs cited as nephrotoxic by the different sources. There were no clear definitions for qualitative data or quantitative values for dose adjustments among the four information sources. There was no advice for dosing for a large number of the drugs in the international databases. The National Therapeutic Formulary offered imprecise dose adjustment recommendations for many nephrotoxic drugs. Discrepancies among information sources may have a clinical impact on patient care and contribute to drug-related morbidity and mortality.

Renal effects of over-the-counter analgesics

Recent case reports have shown that over-the-counter (OTC) analgesics, which are generally considered to be a safe treatment for minor aches and pains and fever, may cause adverse renal effects. Many renal syndromes induced by nonsteroidal antiinflammatory drugs (NSAIDs) can be attributed to prostaglandin inhibition. Fluid and electrolyte disturbances, acute renal failure, and acute interstitial nephritis also occur predominantly with NSAIDs. Acetaminophen lacks significant peripheral prostaglandin inhibition and may be a preferred first-line agent, particularly in patients susceptible to the induction of renal impairment. Apart from obvious clinical overdosage situations, limited reports of adverse renal effects exist with acetaminophen. Some studies have reported an association between analgesic nephropathy, one of the most severe analgesic-related adverse renal effects, and long-term abuse of phenacetin, acetaminophen, aspirin, ibuprofen, analgesic combinations, or other NSAIDs, although for some of these agents, this relationship is controversial. The overall risk for serious renal effects with OTC analgesics appears to be low, but given the accessibility and vast number of persons taking these agents, the absolute number of patients affected may be substantial. Therefore, it is important that healthcare providers recognize the risk factors for adverse analgesic-related renal effects.

Acute renal failure in an elderly woman following intramuscular ketorolac administration

OBJECTIVE

To report a case of ketorolac tromethamine-induced acute renal failure and to discuss the risk factors that make patients more susceptible to the renal effects of nonsteroidal antiinflammatory drugs (NSAIDs).

DATA SOURCES

Case reports and review articles identified by MEDLINE. Indexing terms included ketorolac, renal failure, and NSAIDs.

DATA EXTRACTION

Data were abstracted from pertinent published English-language sources and were reviewed by all authors.

DATA SYNTHESIS

Ketorolac is an intramuscularly administered NSAID with many of the same adverse effects associated with other oral NSAIDs. Although reversible depression of renal function has been associated with several NSAIDs, to date there have been no published reports of acute renal failure secondary to ketorolac administration. A 71-year-old woman received three doses of ketorolac to control the pain associated with pelvic and T11-T12 compression fractures. Over the next two days, the patient developed signs and symptoms of acute renal failure, including significant increases in blood urea nitrogen, serum creatinine, and peripheral edema. These signs and symptoms resolved over the next three to four days. Certain risk factors, several of which were present in this woman, make individual patients more susceptible to the renal affects of NSAIDs. These risk factors include advanced age, cirrhosis, volume depletion, congestive heart failure, gastrointestinal bleeding, and preexisting mild renal dysfunction.

CONCLUSIONS

Caution should be taken when initiating ketorolac or any NSAID therapy with specific attention to risk factors that predispose a patient to renal dysfunction.

Effects of eicosanoids on the water and sodium balance of the neonate

Experimental and clinical evidence support the assumption that eicosanoids affect the morphological development and the functional behaviour of the kidney during the intra-uterine and newborn periods. Inhibition of prostaglandin (PG) synthesis in the pregnant rhesus monkey resulted in renal hypoplasia in the offspring. The plasma levels of PGs are high in the newborn. Production of PGE2 by the cortical collecting duct was found to be similar in newborn and adult rabbit but the affinity of the renal tissue of the newborn for this eicosanoid was higher than that of the renal tissue of the adult rat. Based on findings in adult animals this would be expected to blunt the effect of antidiuretic hormone and account, in part, for the limited ability of the newborn to concentrate the urine. Yet, administration to unanaesthetized newborn rats of acetaminophen, a drug that inhibits the synthesis of PGE2 and thromboxane B2, blocked, rather than enhanced, the increment in urine osmolality produced by 1 h of water deprivation. The effect was absent in weaning and adult rats. A similar experimental manoeuvre increased sodium excretion in newborn but not in weaning or adult rats. Age-related differences are also evident with regard to side effects of PG synthesis inhibition.(ABSTRACT TRUNCATED AT 250 WORDS)