Pathophysiological aspects of nephropathy caused by non-steroidal anti-inflammatory drugs

In silico prediction of drug-induced nephrotoxicity: current progress and pitfalls

INTRODUCTION

Due to its role in absorption and metabolism, the kidney is an important target for drug toxicity. Drug-induced nephrotoxicity (DIN) presents a significant challenge in clinical practice and drug development. Conventional methods for assessing nephrotoxicity have limitations, highlighting the need for innovative approaches. In recent years, in silico methods have emerged as promising tools for predicting DIN.

AREAS COVERED

A literature search was performed using PubMed and Web of Science, from 2013 to February 2023 for this review. This review provides an overview of the current progress and pitfalls in the in silico prediction of DIN, which discusses the principles and methodologies of computational models.

EXPERT OPINION

Despite significant advancements, this review identified issues accentuates the pivotal imperatives of data fidelity, model optimization, interdisciplinary collaboration, and mechanistic comprehension in sculpting the vista of DIN prediction. Integration of multiple data sources and collaboration between disciplines are essential for improving predictive models. Ultimately, a holistic approach combining computational, experimental, and clinical methods will enhance our understanding and management of DIN.

Design, classification, and adverse effects of NSAIDs: A review on recent advancements

Inflammation is a hallmark of many diseases, including cancer, neurodegenerative diseases like Alzheimer's, type II diabetes, rheumatoid arthritis, and asthma. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been a cornerstone in the management of various inflammatory, pain, and fever-related conditions. As a result, NSAIDs have found their applications in new therapeutic areas. NSAIDs are known to act by inhibiting the cyclooxygenase (COX) pathway. In recent years, new strategies have been proposed to counter inflammation and develop safer COX inhibitors. This review discusses the design of new COX inhibitors, the derivatization of conventional NSAIDs, and their biological applications. The review also presents an integrated classification of NSAIDs incorporating both traditional chemical-based and function-based approaches, including a brief overview of the NSAIDs of natural origins. Additionally, the review addresses adverse effects associated with different NSAIDs, including effects associated with cardiovascular, renal, and hepatic complications emphasizing the need for the development of new and safer COX inhibitors.

Study on the Consumption of Non-Steroidal Anti-Inflammatory Drugs and Antibiotics by the Brazilian Adult Population: A Cohort Study

Self-medication without a medical or dental prescription is an action that leads to a significant problems associated with the overuse of medication in Brazil. The inappropriate use of antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs) leads to problems related to microbial agent resistance and gastrointestinal complications. The purpose of this study was to elucidate the patterns of antibiotic and NSAIDs consumption among the adult population of Brazil. The questionnaire was answered by 400 people residing in Brazil who had access to the link in the year 2023. The findings showed that approximately 89.5% of the volunteers had used NSAIDs, and 32.2% had used antibiotics whether or not these medications had been prescribed by doctors or dentists. It was noted that a large proportion of the adverse effects reported by the volunteers involved symptoms related to gastrointestinal complaints. There was a high prevalence of NSAIDs consumption in the studied population, which is consistent with the high frequency of risk of adverse reactions caused by these drugs, particularly in the gastrointestinal tract. In relation to antibiotics, it was observed that the non-prescription consumption of these medications by the population was considered high, reaching one-third of the total number of volunteers who consumed such medications.

The nephroprotective potential of selected synthetic compound against gentamicin induced nephrotoxicity

BACKGROUND

Nephrotoxicity, the rapid impairment of kidney function caused by harmful drugs and chemicals, affects about 20% of cases and is projected to become a leading cause of death by reactive oxygen species (ROS). Gentamicin (GM), an aminoglycoside antibiotic is one of the well know drugs/chemicals to cause nephrotoxicity both in humans and animals.

METHODS

A study on the effects of a synthetic phenolic compound, called 5-a, on GM-induced nephrotoxicity in male Wistar albino rats was conducted. The rats were grouped into five groups: normal control (NC), GM control (GM), positive control (GM + Dexa), treatment I (GM + 5-a 5 mg/kg) and treatment II (GM + 5-a 10 mg/kg). Throughout the experiment, the rats' weights were monitored, and at its conclusion, their serum and kidney tissues were analyzed for renal function indicators and inflammatory markers. The study also included histopathological evaluations, molecular docking studies, blood and urine analyses for electrolyte changes, and behavioural assessments for central nervous system impact.

RESULTS

2-{5-[(2-hydroxyethyl)-sulfanyl]-1,3,4-oxadiazol-2-yl} phenol (5-a) significantly protected against renal damage by reducing inflammatory markers, improving antioxidant defences, and decreasing kidney injury, particularly at higher doses. The findings suggest that compound 5-a, due to its anti-inflammatory and antioxidant properties, could be a promising therapeutic option for reducing gentamicin-induced nephrotoxicity and potentially for other kidney disorders in the future.

CONCLUSION

These findings highlight the therapeutic effects of compound 5-a in alleviating gentamicin-induced nephrotoxicity.

Drug-Drug Interactions in Nosocomial Infections: An Updated Review for Clinicians

Prevention, assessment, and identification of drug-drug interactions (DDIs) represent a challenge for healthcare professionals, especially in nosocomial settings. This narrative review aims to provide a thorough assessment of the most clinically significant DDIs for antibiotics used in healthcare-associated infections. Complex poly-pharmaceutical regimens, targeting multiple pathogens or targeting one pathogen in the presence of another comorbidity, have an increased predisposition to result in life-threatening DDIs. Recognising, assessing, and limiting DDIs in nosocomial infections offers promising opportunities for improving health outcomes. The objective of this review is to provide clinicians with practical advice to prevent or mitigate DDIs, with the aim of increasing the safety and effectiveness of therapy. DDI management is of significant importance for individualising therapy according to the patient, disease status, and associated comorbidities.

Lupus Nephritis from Pathogenesis to New Therapies: An Update

Lupus Nephritis (LN) still represents one of the most severe complications of Systemic Lupus Erythematosus (SLE) and a major risk factor for morbidity and mortality. However, over the last few years, several studies have paved the way for a deeper understanding of its pathogenetic mechanisms and more targeted treatments. This review aims to provide a comprehensive update on progress on several key aspects in this setting: pathogenetic mechanisms of LN, including new insight into the role of autoantibodies, complement, vitamin D deficiency, and interaction between infiltrating immune cells and kidney resident ones; the evolving role of renal biopsy and biomarkers, which may integrate information from renal histology; newly approved drugs such as voclosporin (VOC) and belimumab (BEL), allowing a more articulate strategy for induction therapy, and other promising phase III-immunosuppressive (IS) agents in the pipeline. Several adjunctive treatments aimed at reducing cardiovascular risk and progression of chronic renal damage, such as antiproteinuric agents, represent an important complement to IS therapy. Furthermore, non-pharmacological measures concerning general lifestyle and diet should also be adopted when managing LN. Integrating these therapeutic areas requires an effort towards a holistic and multidisciplinary approach. At the same time, the availability of an increasingly wider armamentarium may translate into improvements in patient's renal outcomes over the next decades.

Pathogenesis of Sarcopenia in Chronic Kidney Disease-The Role of Inflammation, Metabolic Dysregulation, Gut Dysbiosis, and microRNA

Chronic kidney disease (CKD) is a progressive disorder associated with a decline in kidney function. Consequently, patients with advanced stages of CKD require renal replacement therapies, such as dialysis and kidney transplantation. Various conditions lead to the development of CKD, including diabetes mellitus, hypertension, and glomerulonephritis, among others. The disease is associated with metabolic and hormonal dysregulation, including uraemia and hyperparathyroidism, as well as with low-grade systemic inflammation. Altered homeostasis increases the risk of developing severe comorbidities, such as cardiovascular diseases or sarcopenia, which increase mortality. Sarcopenia is defined as a progressive decline in muscle mass and function. However, the precise mechanisms that link CKD and the development of sarcopenia are poorly understood. Knowledge about these linking mechanisms might lead to the introduction of precise treatment strategies that could prevent muscle wasting. This review discusses inflammatory mediators, metabolic and hormonal dysregulation, gut microbiota dysbiosis, and non-coding RNA alterations that could link CKD and sarcopenia.

Do the high-protein recommendations for athletes set some on a path to kidney injury and dialysis?

Athletes and fitness enthusiasts are often encouraged to follow high-protein diets to optimize muscle protein synthesis, modify body composition, and enhance performance, yet the safety of these higher protein intakes has been debated. Many people with kidney dysfunction are unaware of their condition, and the potential harm of excess protein intake on the kidneys may not be adequately reported in the sports nutrition literature. Studies suggesting that high-protein intake may be associated with incident kidney disease have led the nephrology community to make conservative recommendations. In contrast, the fitness community suggests that high dietary protein intake is safe and poses no risk of kidney injury. These claims often fail to acknowledge limitations in the internal validity and generalizability of the study results, despite many studies not being adequately powered to support such claims. It is essential to make dietary recommendations that consider the totality of the data and follow the ethical norm of "do no harm." Studies that evaluate the use of high-protein diets among athletes must consider the balance of efficacy with safety. While an intervention may be safe in one population, it does not mean that safety can be assumed for all groups.

Safety of Oral and Topical Nonsteroidal Anti-Inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used to manage mild to moderate pain. While limited use is appropriate for many patients, there are safety concerns with use in certain patient populations or with long-term use of these agents. Topical NSAIDs may provide analgesic benefits while decreasing the overall risks of adverse effects. This article will review safety information for both oral and topical NSAIDs.

Management of patients with chronic kidney disease: a French medical centre database analysis

OBJECTIVE(S)

Chronic kidney disease (CKD) is an insidious disease that requires early nephroprotective measures to delay progression to end-stage kidney disease. The objective of this study was to describe the management of patients with CKD in primary care, including clinical and biological monitoring and prescribed treatments. A retrospective, single-centre study was conducted on adult patients who were treated in the Maison de Neufchâtel (France) between 2012 and 2017 at least once a year. The inclusion criteria were 2 estimated glomerular filtration rate (eGFR) measurements <60 mL/min more than 3 months apart. Two subgroups were constituted according to whether CKD was coded in the electronic medical records (EMRs).

RESULTS

A total of 291 (6.7%, CI95% 5.9-7.4) patients with CKD were included. The mean eGFR was 51.0 ± 16.4 mL/min. Hypertension was the most frequent health problem reported (n = 93, 32%). Nephrotective agents were prescribed in 194 (66.7%) patients, non-steroidal anti-inflammatory drugs (NSAIDs) in 22 (8%) patients, and proton-pump inhibitors (PPIs) in 147 (47%) patients. CKD coding in EMRs was associated with dosage of natraemia (n = 34, 100%, P < 0.01), albuminuria (n = 20, 58%, P < 0.01), vitamin D (n = 14, 41%, P < 0.001), and phosphorus (n = 11, 32%, P < 0.001). Eighty-one patients (31.5%) with low eGFR without an entered code for CKD were prescribed an albuminuria dosage. Clinical monitoring could not be analysed due to poor coding.

CONCLUSION

This pilot study reinforces the hypothesis that CKD is underscreened and undermanaged. More systematic coding of medical information in EMRs and further studies on medical centre databases should improve primary care practices.

Pain Assessment in Patients during Hemodialysis Treatment: Quality Improvement Project

Pain is a prevalent symptom in patients with chronic kidney disease, related to disease progression, comorbidities, and required immobility during dialysis treatment. Nurses must perform detailed pain assessments to manage pain effectively during hemodialysis treatment. This quality improvement project, reported using SQUIRE 2.0, aims to describe pain characteristics in chronic kidney disease patients in a hemodialysis unit clinic in Portugal, implement strategies to improve the pain assessment process in patients with chronic kidney disease during hemodialysis treatment, and assess nurses' satisfaction with the implemented strategies. The study was conducted in a Portuguese hemodialysis clinic, with patients and nurses, in three phases: diagnostic study, protocol implementation, and a descriptive study to assess nurse satisfaction. Seventy-five patients (mean age 71 ± 12.6 years) participated, with 64% reporting moderate chronic pain daily and 48% during hemodialysis treatment. Thirteen nurses considered the pain assessment protocol important, rating their satisfaction at 7.92 ± 1.32 (0-10). Standardizing practices through protocol implementation is likely to improve care and increase nurse satisfaction.

Effects of Empagliflozin in Type 2 Diabetes With and Without Chronic Kidney Disease and Nondiabetic Chronic Kidney Disease: Protocol for 3 Crossover Randomized Controlled Trials (SiRENA Project)

BACKGROUND

Sodium-glucose-cotransporter 2 inhibitors (SGLT2is) have revolutionized the treatment of type 2 diabetes mellitus (DM2) and chronic kidney disease (CKD), reducing the risk of cardiovascular and renal end points by up to 40%. The underlying mechanisms are not fully understood.

OBJECTIVE

The study aims to examine the effects of empagliflozin versus placebo on renal hemodynamics, sodium balance, vascular function, and markers of the innate immune system in patients with DM2, DM2 and CKD, and nondiabetic CKD.

METHODS

We conducted 3 double-blind, crossover, randomized controlled trials, each with identical study protocols but different study populations. We included patients with DM2 and preserved kidney function (estimated glomerular filtration rate >60 mL/min/1.73 m2), DM2 and CKD, and nondiabetic CKD (both with estimated glomerular filtration rate 20-60 mL/min/1.73 m2). Each participant was randomly assigned to 4 weeks of treatment with either 10 mg of empagliflozin once daily or a matching placebo. After a wash-out period of at least 2 weeks, participants were crossed over to the opposite treatment. End points were measured at the end of each treatment period. The primary end point was renal blood flow measured with 82Rubidium positron emission tomography-computed tomography (82Rb-PET/CT). Secondary end points include glomerular filtration rate measured with 99mTechnetium-diethylene-triamine-pentaacetate (99mTc-DTPA) clearance, vascular function assessed by forearm venous occlusion strain gauge plethysmography, measurements of the nitric oxide (NO) system, water and sodium excretion, body composition measurements, and markers of the complement immune system.

RESULTS

Recruitment began in April 2021 and was completed in September 2022. Examinations were completed by December 2022. In total, 49 participants completed the project: 16 participants in the DM2 and preserved kidney function study, 17 participants in the DM2 and CKD study, and 16 participants in the nondiabetic CKD study. Data analysis is ongoing. Results are yet to be published.

CONCLUSIONS

This paper describes the rationale, design, and methods used in a project consisting of 3 double-blind, crossover, randomized controlled trials examining the effects of empagliflozin versus placebo in patients with DM2 with and without CKD and patients with nondiabetic CKD, respectively.

TRIAL REGISTRATION

EU Clinical Trials Register 2019-004303-12; https://www.clinicaltrialsregister.eu/ctr-search/search?query=2019-004303-12, EU Clinical Trials Register 2019-004447-80; https://www.clinicaltrialsregister.eu/ctr-search/search?query=2019-004447-80, EU Clinical Trials Register 2019-004467-50; https://www.clinicaltrialsregister.eu/ctr-search/search?query=and+2019-004467-50.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56067.

Increased risk of acute kidney injury in the first part of an ultra-trail-Implications for abandonment

Acute kidneys injuries (AKIs) have been described in marathon and trail running. The currently available data allows assessment of before/after comparisons but does not allow an analysis of what happens during the race. A multidisciplinary assessment protocol was performed during the first trail of Clécy (Normandy France) in November 2021. This allowed an initial assay to be carried out, then at the end of each of the 6 loops of 26 km, and finally after 24 h of recovery. The race extends over 156 km in hilly terrain and 6000 m of elevation gain (D+). The level of impairment according to the RIFLE classification was defined for each runner at each assay. Fifty-five runners were at the start, and the per protocol analysis involved 36 runners (27 men and 9 women, 26 finishers). Fifteen (41.7%) of the riders presented at least one result corresponding to a "RIFLE risk" level. After 24 h of rest, only one runner still had a "RIFLE Risk". The distance around the marathon seems to be the moment of greatest risk. For the first time, we find an association between this renal risk and the probability of abandonment. Many runners are vulnerable to kidney damage during long-duration exercise, which is why it's important to limit risk situations, such as the use of potentially toxic drugs or hydration disorders. The consumption of NSAIDs (nonsteroidal anti-inflammatory drugs) before or during an ultra-distance race should therefore be prohibited. Attention should be paid to hydration disorders.

Duloxetine protected indomethacin-induced gastric mucosal injury by increasing serotonin-dependent RANTES expression and activating PI3K-AKT-VEGF pathway

Antidepressant duloxetine has been shown protective effect on indomethacin-induced gastric ulcer, which was escorted by inflammation in the gastric mucosa. Cytokines are the principal mediators of inflammation. Thus, by screening the differential expression of cytokines in the gastric mucosa using cytokine array at 3 h after indomethacin exposure, when the gastric ulcer began to format, we found that indomethacin increased cytokines which promoted inflammation responses, whereas duloxetine decreased pro-inflammatory cytokines increased by indomethacin and increased RANTES expression. RANTES was consistently increased by pretreated with both 5 mg/kg and 20 mg/kg duloxetine at 3 h and 6 h after indomethacin exposure in male rats. Selective blockade of RANTES-CCR5 axis by a functional antagonist Met-RANTES or a CCR5 antagonist maraviroc suppressed the protection of duloxetine. Considering the pharmacologic action of duloxetine on reuptake of monoamine neurotransmitters, we examined the serotonin (5-HT), norepinephrine and dopamine contents in the blood and discovered 20 mg/kg duloxetine increased 5-HT levels in platelet-poor plasma, while treatment with 5-HT promoted expression of RANTES in the gastric mucosa and alleviated the indomethacin-induced gastric injury. Furthermore, duloxetine activated PI3K-AKT-VEGF signaling pathway, which was regulated by RANTES-CCR5, and selective inhibitor of VEGF receptor axitinib blocked the prophylactic effect of duloxetine. Furthermore, duloxetine also protected gastric mucosa from indomethacin in female rats, and RANTES was increased by duloxetine after 6 h after indomethacin exposure too. Together, our results identified the role of cytokines, particularly RANTES, and the underlying mechanisms in gastroprotective effect of duloxetine against indomethacin, which advanced our understanding in inflammatory modulation by monoamine-based antidepressants.

Acute kidney injury in hospitalized patients with nonmalignant pleural effusions: a retrospective cohort study

BACKGROUND

Nonmalignant pleural effusion (NMPE) is common and remains a definite health care problem. Pleural effusion was supposed to be a risk factor for acute kidney injury (AKI). Incidence of AKI in NMPE patients and whether there is correlation between the size of effusions and AKI is unknown.

OBJECTIVE

To assess the incidence of AKI in NMPE inpatients and its association with effusion size.

STUDY DESIGN AND METHOD

We conducted a retrospective cohort study of inpatients admitted to the Chinese PLA General Hospital with pleural effusion from 2018-2021. All patients with pleural effusions confirmed by chest radiography (CT or X-ray) were included, excluding patients with diagnosis of malignancy, chronic dialysis, end-stage renal disease (ESRD), community-acquired AKI, hospital-acquired AKI before chest radiography, and fewer than two serum creatinine tests during hospitalization. Multivariate logistic regression and LASSO logistic regression models were used to identify risk factors associated with AKI. Subgroup analyses and interaction tests for effusion volume were performed adjusted for the variables selected by LASSO. Causal mediation analysis was used to estimate the mediating effect of heart failure, pneumonia, and eGFR < 60 ml/min/1.73m2 on AKI through effusion volume.

RESULTS

NMPE was present in 7.8% of internal medicine inpatients. Of the 3047 patients included, 360 (11.8%) developed AKI during hospitalization. After adjustment by covariates selected by LASSO, moderate and large effusions increased the risk of AKI compared with small effusions (moderate: OR 1.47, 95%CI 1.11-1.94 p = 0.006; large: OR 1.86, 95%CI 1.05-3.20 p = 0.028). No significant modification effect was observed among age, gender, diabetes, bilateral effusions, and eGFR. Volume of effusions mediated 6.8% (p = 0.005), 4.0% (p = 0.046) and 4.6% (p < 0.001) of the effect of heart failure, pneumonia and low eGFR on the development of AKI respectively.

CONCLUSION

The incidence of AKI is high among NMPE patients. Moderate and large effusion volume is independently associated with AKI compared to small size. The effusion size acts as a mediator in heart failure, pneumonia, and eGFR.

Long-term dietary exposure to the non-steroidal anti-inflammatory drugs diclofenac and ibuprofen can affect the physiology of common carp (Cyprinus carpio) on multiple levels, even at "environmentally relevant" concentrations

The aim of the study was to evaluate the effects of emerging environmental contaminants, the non-steroidal anti-inflammatory drugs (NSAIDs) diclofenac (DCF) and ibuprofen (IBP), on physiological functions in juvenile common carp (Cyprinus carpio). Fish were exposed for 6 weeks, and for the first time, NSAIDs were administered through diet. Either substance was tested at two concentrations, 20 or 2000 μg/kg, resulting in four different treatments (DCF 20, DCF 2000, IBP 20, IBP 2000). The effects on haematological and biochemical profiles, the biomarkers of oxidative stress, and endocrine disruption were studied, and changes in RNA transcription were also monitored to obtain a comprehensive picture of toxicity. Fish exposure to high concentrations of NSAIDs (DCF 2000, IBP 2000) elicited numerous statistically significant changes (p < 0.05) in the endpoints investigated, with DCF being almost always more efficient than IBP. Compared to control fish, a decrease in total leukocyte count attributed to relative lymphopenia was observed. Plasma concentrations of total proteins, ammonia, and thyroxine, and enzyme activities of alanine aminotransferase (ALT), aspartate aminotransferase, and alkaline phosphatase (ALP) were significantly elevated in either group, as were the activities of certain hepatic antioxidant enzymes (superoxide dismutase, glutathione-S-transferase) in the DCF 2000 group. The transcriptomic profile of selected genes in the tissues of exposed fish was affected as well. Significant changes in plasma total proteins, ammonia, ALT, and ALP, as well as in the transcription of genes related to thyroid function and the antioxidant defense of the organism, were found even in fish exposed to the lower DCF concentration (DCF 20). As it was chosen to match DCF concentrations commonly detected in aquatic invertebrates (i.e., the potential feed source of fish), it can be considered "environmentally relevant". Future research is necessary to shed more light on the dietary NSAID toxicity to fish.

Latest Concepts in the Endodontic Management of Kidney Patients

Doubtlessly, kidney patients present a common challenge in endodontic practice, so specialists in this field should know and follow several key points regarding this group of medically compromised patients. This review paper aims to explain kidney disease and its complications, as well as notify and discuss the latest concepts on anesthesia, pain management, antibiotic prophylaxis/stewardship, and the risk of viral diseases for these patients, and also the oral manifestations of kidney diseases that may guide endodontists to diagnose kidney intervention and prevent hazardous consequences that may happen during or following endodontic practice on these patients. For this purpose, relevant keywords were searched on Scopus, PubMed, Medline, and Web of Science to find published papers from 1980 to July 2023. Based on the quality, validity, and novelty 57 published articles were selected to provide this review to notify the most important concepts and considerations regarding endodontic management of kidney patients. Overall, it is concluded that training and education of general dentists, as well as endodontic specialists with strong technical, scientific, human, and moral knowledge about kidney patients, with emphasis on the philosophy of prevention of common dangerous systemic consequences originating from endodontic treatments, is the responsibility of dental schools in undergraduate as well as post-graduate programs.

Unveiling drug induced nephrotoxicity using novel biomarkers and cutting-edge preventive strategies

Drug-induced nephrotoxicity is still a significant obstacle in pharmacotherapy of various diseases and it accounts for around 25 % of serious side-effects reported after drug administration. Furthermore, some groups of drugs such as nonsteroidal anti-inflammatory drugs, antibiotics, antiviral drugs, antifungal drugs, immunosuppressants, and chemotherapeutic drugs have the "preference" for damaging the kidney and are often referred to as the kidney's "silent killer". Clinically, the onset of acute kidney injury associated with drug administration is registered in approximately 20 % of patients and many of them develop chronic kidney disease vulnerability. However, current knowledge about the mechanisms underlying this dangerous phenomenon is still insufficient with many unknowns. Hence, the valuable use of these drugs in clinical practice is significantly limited. The main aim of this study is to draw attention to commonly prescribed nephrotoxic drugs by clinicians or drugs bought over the counter. In addition, the complex relationship between immunological, vascular and inflammatory events that promote kidney damage is discussed. The practical use of this knowledge could be implemented in the engineering of novel biomarkers for early detection of drug-associated kidney damage such as Kidney Injury Molecule (KIM-1), lipocalin associated with neutrophil gelatinase (NGAL) and various microRNAs. In addition, the utilization of artificial intelligence (AI) for the development of computer algorithms that could detect kidney damage at an early stage should be further explored. Therefore, this comprehensive review provides a new outlook on drug nephrotoxicity that opens the door for further clinical research of novel potential drugs or natural products for the prevention of drug-induced nephrotoxicity and accessible education.

Evaluation of an Intravenous Acetaminophen Protocol in the Emergency Department

BACKGROUND

Acute pain is a leading reason for Emergency Department (ED) evaluation, accounting for nearly half of all ED visits. Therefore, providing effective non-opioid analgesics in the ED is critical. Oral acetaminophen (APAP) is commonly administered in the ED but is limited to patients tolerating oral intake. Intravenous (IV) APAP provides significant pain reduction parenterally. The purpose of this quality assessment project was to evaluate the frequency of opioid use in patients receiving IV APAP, the safety of IV APAP, and compliance with an ED IV APAP protocol.

METHODS

This study included all patients who received IV APAP in the ED of a tertiary care, level I trauma center, during a three-month period. The protocol required ED patients to be NPO (nil per os), 18 years or older, and administered with a single 1000 mg dose. The adverse reactions within 24 hours post-IV APAP, ED length of stay (LOS), and opioid administration within four hours post-IV APAP were assessed.

RESULTS

Ninety-four patients received IV APAP. All patients received a 1000 mg dose. One patient received more than one dose, but this patient had a 22-hour ED LOS. Two patients received oral medications within one hour of IV APAP (one received an antacid, and the other received carbamazepine and lamotrigine). An opioid was administered to 22 of the 94 (23.4%) patients during the four-hour protocol period. There were no reports of adverse reactions.

CONCLUSIONS

The results show excellent compliance with the protocol. IV APAP was safe and well-tolerated. Notably, most patients did not receive an opioid within four hours of IV APAP. IV APAP can be safely and effectively utilized as an analgesic and lessen ED opioid use.

Cardiometabolic comorbidities in autosomal dominant polycystic kidney disease: a 16-year retrospective cohort study

BACKGROUND

Autosomal-dominant polycystic kidney disease (ADPKD) is the most prevalent hereditary kidney disease and the fourth leading cause of end-stage renal disease (ESRD) requiring renal replacement therapy (RRT). Nevertheless, there is a paucity of epidemiological research examining the risk factors and survival on RRT for ADPKD. Thus, we aimed to investigate the cumulative effects of cardiometabolic comorbidities, including hypertension (HTN), type 2 diabetes mellitus (DM), and dyslipidemia (DLP) to clinical outcomes in ADPKD.

METHODS

We identified 6,142 patients with ADPKD aged ≥ 20 years from 2000 to 2015 using a nationwide population-based database. HTN, DM, and DLP diagnoses before or at the time of ADPKD diagnosis and different combinations of the three diagnoses were used as the predictors for the outcomes. Survival analyses were used to estimate the adjusted mortality risk from cardiometabolic comorbidities and the risk for renal survival.

RESULTS

Patients with ADPKD who developed ESRD had the higher all-cause mortality (HR, 5.14; [95% CI: 3.88-6.80]). Patients with all three of the diseases had a significantly higher risk of entering ESRD (HR:4.15, [95% CI:3.27-5.27]), followed by those with HTN and DM (HR:3.62, [95% CI:2.82-4.65]), HTN and DLP (HR:3.54, [95% CI:2.91-4.31]), and HTN alone (HR:3.10, [95% CI:2.62-3.66]) compared with those without any three cardiometabolic comorbidities.

CONCLUSIONS

Our study discovered the cumulative effect of HTN, DM, and DLP on the risk of developing ESRD, which reinforces the urgency of proactive prevention of cardiometabolic comorbidities to improve renal outcomes and overall survival in ADPKD patients.

Postoperative Complications Associated with Non-Steroidal Anti-Inflammatory Combinations Used Status-Post Total Hip and Knee Arthroplasty

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in multimodal pain control following total joint arthroplasty (TJA). However, few studies have assessed the complications associated with the combinations of NSAIDs in this population despite the known risks associated with this class of medications. The Premier Healthcare Database was queried to identify adults who underwent primary total hip or knee arthroplasty from 2005-2014. The following most common inpatient combinations of NSAIDs were chosen for analysis: aspirin + celecoxib (A + C), toradol + aspirin (T + A), toradol + ibuprofen (T + I), celecoxib + ibuprofen (C + I), ibuprofen + aspirin (I + A), and toradol + celecoxib (T + C). Primary outcomes included acute kidney injury (AKI), gastrointestinal bleed, and stroke. Secondary outcomes included periprosthetic joint infection (PJI), deep vein thrombosis, and pulmonary embolism. Univariate and multivariate regression analyses were used to compare differences and address confounds. Overall, 195,833 patients were identified. After controlling for confounds, increased odds of AKI was associated with A + C (adjusted odds ratio [aOR]: 1.20, 95% confidence interval [CI]: 1.09-1.34, p < 0.001) and decreased odds was associated with T + A (aOR 0.76, 95% CI: 0.69-0.83, p < 0.001). Increased odds of stroke was associated with A + C (aOR: 1.80, 95% CI: 1.15-2.84, p = 0.011); T + I (aOR 3.48, 95% CI: 1.25-9.73, p = 0.017); and I + A (aOR 4.29, 95% CI: 1.06-17.9, p = 0.046). Increased odds of PJI was associated with C + I (aOR: 10.3, 95% CI: 1.35-78.3, p = 0.024). In the TJA patient population, NSAID pairings should be regarded as distinct entities. Our results suggest that combinations including A + C, T + I, I + A, and C + I should be used cautiously. With this knowledge, providers should consider tailoring NSAID prescriptions appropriately.

New Insights into the Nephroprotective Potential of Lercanidipine

Kidneys are responsible for many crucial biological processes in the human body, including maintaining the water-electrolyte balance, pH, and blood pressure (BP), along with the elimination of toxins. Despite this, chronic kidney disease (CKD), which affects more and more people, is a disease that develops insidiously without causing any symptoms at first. The main purpose of this article is to summarize the existing literature on lercanidipine, with a particular focus on its nephroprotective properties. Lercanidipine is a third-generation dihydropyridine (DHP) blocker of calcium channels, and as such it possesses unique qualities such as high lipophilicity and high vascular selectivity. Furthermore, it acts by reversibly inhibiting L-type and T-type calcium channels responsible for exerting positive renal effects. It has been shown to reduce tissue inflammation and tubulointerstitial fibrosis, contributing to a decrease in proteinuria. Moreover, it exhibited antioxidative effects and increased expression of molecules responsible for repairing damaged tissues. It also decreased cell proliferation, preventing thickening of the vascular lumen. This article summarizes studies simultaneously comparing the effect of lercanidipine with other antihypertensive drugs. There is still a lack of studies on the medications used in patients with CKD, and an even greater lack of studies on those used in patients with concomitant hypertension. Therefore, further studies on lercanidipine and its potential in hypertensive patients with coexisting CKD are required.

Killing pain? A prospective population-based study on trauma exposure in childhood as predictor for frequent use of over-the-counter analgesics in young adulthood. The HUNT study

Frequent and increasing use of over-the-counter analgesics (OTCA) is a public health concern. Pain conditions and psychological distress are related to frequent OTCA use, and as exposure to potentially traumatic events (PTE) in childhood appears to increase risk of experiencing such symptoms, we aimed to assess childhood PTEs and related symptoms in adolescence as predictors for frequent OTCA use in young adulthood. Prospective population survey data were used (n = 2947, 59.1% female, 10-13 years follow-up). Exposure to PTEs, symptoms of post-traumatic stress, anxiety and depression, musculoskeletal pain and headache were assessed in adolescence (13-19 years). Use of OTCA was assessed in young adulthood (22-32 years) and use of OTCA to treat musculoskeletal pain and headache served as separate outcomes in ordinal logistic regression analyses. Overall, exposure to childhood PTEs, particularly direct interpersonal violence, was significantly and consistently related to more frequent use of OTCA to treat musculoskeletal pain and headaches in young adulthood. Adjusting for psychological symptoms and pain attenuated associations, indicating that these symptoms are of importance for the relationship between traumatic events and OTCA use. These findings emphasize the need to address symptomatology and underlying causes at an early age.

Evaluation of Glomerular Filtration Rate Trends in People Living With HIV Corrected by the Baseline Glomerular Filtration Rate

BACKGROUND

Chronic kidney disease, for which estimated glomerular filtration rate (eGFR) trajectories are early markers, is frequent in people living with HIV.

SETTING

Identify eGFR trajectory patterns according to kidney function and assess associated factors over a 13-year follow-up period.

METHODS

We evaluated longitudinal changes and its associated factors in eGFR of 3366 participants according to kidney function with a 2-level, linear, mixed model.

RESULTS

Participants with initial kidney dysfunction experienced a slight eGFR increase, whereas others showed a slight decrease. A weak relationship was observed between baseline eGFR and its variation over time. Baseline eGFR was affected by age, CD4 + count, viral load, hypertension, hyperlipidemia, AIDS-defining illness and tenofovir (TDF) with integrase inhibitor (INSTI) or efavirenz. Significant factors for eGFR change included the following: in kidney dysfunction, CD4 + cell count of >350 cells per cubic millimeter and undetectable viral load increased eGFR, whereas TDF + protease inhibitor decreased eGFR; in mildly decreased kidney function, CD4 + cell count of >350 cells per cubic millimeter, AIDS-defining illness, and TDF + efavirenz increased eGFR, whereas age, hypertension, hyperlipidemia, and TDF + INSTI decreased eGFR; in normal kidney function, age, CD4 + cell count of > 350 cells per cubic millimeter, undetectable viral load, hypertension, hyperlipidemia, and TDF + INSTI decreased eGFR, whereas TDF + efavirenz increased eGFR (all P value for interaction < 0.05).

CONCLUSION

Our findings suggest that eGFR trajectories varied widely between individuals in people living with HIV. In the lower eGFR group, virus-related factors were more relevant, whereas traditional risk factors for renal dysfunction were more prominent in the highest eGFR group.

Renal Function Underpins the Cyclooxygenase-2: Asymmetric Dimethylarginine Axis in Mouse and Man

Introduction

Through the production of prostacyclin, cyclooxygenase (COX)-2 protects the cardiorenal system. Asymmetric dimethylarginine (ADMA), is a biomarker of cardiovascular and renal disease. Here we determined the relationship between COX-2/prostacyclin, ADMA, and renal function in mouse and human models.

Methods

We used plasma from COX-2 or prostacyclin synthase knockout mice and from a unique individual lacking COX-derived prostaglandins (PGs) because of a loss of function mutation in cytosolic phospholipase A2 (cPLA2), before and after receiving a cPLA2-replete transplanted donor kidney. ADMA, arginine, and citrulline were measured using ultra-high performance liquid-chromatography tandem mass spectrometry. ADMA and arginine were also measured by enzyme-linked immunosorbent assay (ELISA). Renal function was assessed by measuring cystatin C by ELISA. ADMA and prostacyclin release from organotypic kidney slices were also measured by ELISA.

Results

Loss of COX-2 or prostacyclin synthase in mice increased plasma levels of ADMA, citrulline, arginine, and cystatin C. ADMA, citrulline, and arginine positively correlated with cystatin C. Plasma ADMA, citrulline, and cystatin C, but not arginine, were elevated in samples from the patient lacking COX/prostacyclin capacity compared to levels in healthy volunteers. Renal function, ADMA, and citrulline were returned toward normal range when the patient received a genetically normal kidney, capable of COX/prostacyclin activity; and cystatin C positively correlated with ADMA and citrulline. Levels of ADMA and prostacyclin in conditioned media of kidney slices were not altered in tissue from COX-2 knockout mice compared to wildtype controls.

Conclusion

In human and mouse models, where renal function is compromised because of loss of COX-2/PGI2 signaling, ADMA levels are increased.

Non-steroidal Anti-inflammatory Drugs: Clinical Implications, Renal Impairment Risks, and AKI

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most common class of drugs utilized for a variety of disorders, including headaches, pain states, fever, and other common conditions. In recent years, a link between NSAIDs and adverse effects has been identified, including renal, heart, and liver disease, bleeding, and increased mortality. NSAID-mediated renal disease is associated with interference with the cyclooxygenase enzyme. Literature evaluating NSAID renal effects has indicated that a number of factors are associated with acute and chronic kidney injury (AKI). Early diagnosis can identify changes in renal function and allow for cessation of NSAID use, limiting the risk for long-term chronic renal disease and in some cases reversal of renal injury. Alternative medications should be considered in those patients identified with morbidity linked to NSAID use. Nephrotoxicity is increased in the elderly population and in hypovolemia, high dose exposure, use of vasoconstrictors such as calcineurin inhibitors, and use of renin-angiotensin-aldosterone system (RAAS) inhibitors or diuretics. Careful risk/benefit considerations from healthcare professionals can limit the incidence and degree of morbidity and mortality, including in NSAID-mediated renal disease. Selective NSAID cyclooxygenase-2 inhibitors also possess risks and therefore clinicians should always recommend short-term courses of this class of drugs versus long-term dosing because of the risk of morbidity and mortality. Given that these drugs are available over the counter as well by prescribing, clinicians must communicate the risks and benefits of NSAIDs and provide sound recommendations to their patients regarding use short and long term.

Provider-directed analgesia for dental pain

INTRODUCTION

Extraction of impacted molar teeth is a common procedure performed by oral surgeons and general dentists, with postoperative pain being a significant adverse event post-surgery. If mismanaged, pain can lead to complications that impact oral and systemic health. The current scourge of the opioid epidemic has ushered in a new era of provider-directed analgesic (PDA) therapy in dentistry.

AREAS COVERED

This article provides an in-depth review on the major pharmacological and therapeutic properties of established and alternative analgesics used to manage dental pain.

EXPERT OPINION

Substantial evidence-based literature shows combination of a non-steroidal anti-inflammatory drug (NSAID; e.g. ibuprofen) and acetaminophen provides superior pain relief than single-agent or combination opioid regimens. However, there are clinical scenarios (e.g. severe pain) when short-course opioid prescription is appropriate in select patients, in which a 2-3-day treatment duration is typically sufficient. Alternative agents (e.g. caffeine, gabapentin, phytotherapies), typically in combination with established agents, can mitigate postoperative dental pain. Some evidence suggests preemptive therapies (e.g. corticosteroids, NSAIDs) reduce amounts of postsurgical analgesic consumption and might lessen opioid prescription burden. In summary, this comprehensive review provides an opportune update on the evolving landscape of pharmacotherapy for acute postsurgical dental pain, informing best practices for PDA in the dental setting.

Potential therapeutic effects of Chinese meteria medica in mitigating drug-induced acute kidney injury

Drug-induced acute kidney injury (DI-AKI) is one of the leading causes of kidney injury, is associated with high mortality and morbidity, and limits the clinical use of certain therapeutic or diagnostic agents, such as antineoplastic drugs, antibiotics, immunosuppressants, non-steroidal anti-inflammatory drugs, and contrast media. In recent years, numerous studies have shown that many Chinese meteria medica, metabolites derived from botanical drugs, and Chinese medicinal formulas confer protective effects against DI-AKI by targeting a variety of cellular or molecular mechanisms, such as oxidative stress, inflammatory, cell necrosis, apoptosis, and autophagy. This review summarizes the research status of common DI-AKI with Chinese meteria medica interventions, including cisplatin, gentamicin, contrast agents, methotrexate, and acetaminophen. At the same time, this review introduces the metabolites with application prospects represented by ginseng saponins, tetramethylpyrazine, panax notoginseng saponins, and curcumin. Overall, this review provides a reference for the development of promising nephroprotectants.

Nanodrugs alleviate acute kidney injury: Manipulate RONS at kidney

Currently, there are no clinical drugs available to treat acute kidney injury (AKI). Given the high prevalence and high mortality rate of AKI, the development of drugs to effectively treat AKI is a huge unmet medical need and a research hotspot. Although existing evidence fully demonstrates that reactive oxygen and nitrogen species (RONS) burst at the AKI site is a major contributor to AKI progression, the heterogeneity, complexity, and unique physiological structure of the kidney make most antioxidant and anti-inflammatory small molecule drugs ineffective because of the lack of kidney targeting and side effects. Recently, nanodrugs with intrinsic kidney targeting through the control of size, shape, and surface properties have opened exciting prospects for the treatment of AKI. Many antioxidant nanodrugs have emerged to address the limitations of current AKI treatments. In this review, we systematically summarized for the first time about the emerging nanodrugs that exploit the pathological and physiological features of the kidney to overcome the limitations of traditional small-molecule drugs to achieve high AKI efficacy. First, we analyzed the pathological structural characteristics of AKI and the main pathological mechanism of AKI: hypoxia, harmful substance accumulation-induced RONS burst at the renal site despite the multifactorial initiation and heterogeneity of AKI. Subsequently, we introduced the strategies used to improve renal targeting and reviewed advances of nanodrugs for AKI: nano-RONS-sacrificial agents, antioxidant nanozymes, and nanocarriers for antioxidants and anti-inflammatory drugs. These nanodrugs have demonstrated excellent therapeutic effects, such as greatly reducing oxidative stress damage, restoring renal function, and low side effects. Finally, we discussed the challenges and future directions for translating nanodrugs into clinical AKI treatment.

•

AKI is a common clinical acute syndrome with high morbidity and mortality but without effective clinical drug available.

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Hypoxia and accumulation of toxic substances are key pathological features of various heterogeneous AKI.

•

Excessive RONS is the core of the pathological mechanism of AKI.

•

The development of nanodrugs is expected to achieve successful treatment in AKI.

Comparative Efficacy of Analdent (Herbal Analgesic Preparation) and Aceclofenac on Pain Intensity After Tooth Extraction: A Split-Mouth Randomized Clinical Trial

Background and Aim

Pain management following tooth extraction is crucial in minimizing patient suffering and risk of infection and hastening the recovery. Safety issues with routinely prescribed drugs such as NSAIDs for pain management call for search of an effective and safe alternative. Advances in the field of alternative medicine have led to the use of various natural products for pain management in the field of dentistry. The aim of the study was to compare the efficacy between the analdent and aceclofenac in terms of alleviation of post-operative pain and facial swelling after extraction of tooth.

Methods

A split-mouth randomized clinical trial was conducted on 22 participants in the age range of 13-25 years requiring extraction of first permanent premolars for orthodontic reason. The extraction sites were randomized to receive either analdent or aceclofenac post-orthodontic extraction. Post-extraction dental pain was assessed after 8 h, 24 h, 48 h and 72 h post-operatively using a visual analog scale, and incidence of swelling was recorded.

Results

Pain score showed a significant reduction (p = 0.001) post-operatively within analdent (herbal drug) group as well as Zerodol (aceclofenac) group. However, there was no significant difference in pain intensity between the two groups at each interval. Two participants in analdent group and one participant in aceclofenac group reported swelling after 8 h of extraction which subsided after cold pack application.

Conclusion

Analdent was found to be equally effective as aceclofenac in managing pain after the tooth extraction with relatively no side effects.CTRI Registration Number: CTRI/2020/ 03/024296 dated 27/03/2020.

A Synopsis of Current Theories on Drug-Induced Nephrotoxicity

The overriding goal of the treatment of patients is its effectiveness and safety. However, all medications currently being used also exert some adverse pharmaceutical reactions, which may be regarded as an unintended but inevitable cost of pharmacotherapy. The kidney, as the main organ that eliminates xenobiotics, is an organ especially predisposed and vulnerable to the toxic effects of drugs and their metabolites during their excretion from the body. Moreover, some drugs (e.g., aminoglycosides, cyclosporin A, cisplatin, amphotericin B, and others) have a "preferential" nephrotoxicity potential, and their use is associated with an increased risk of kidney damage. Drug nephrotoxicity is, therefore, both a significant problem and a complication of pharmacotherapy. It should be noted that, currently, there is no generally recognized definition of drug-induced nephrotoxicity and no clear criteria for its diagnosis. This review briefly describes the epidemiology and diagnosis of drug-induced nephrotoxicity and characterizes its pathomechanisms, including immunological and inflammatory disturbances, altered kidney blood flow, tubulointerstitial injury, increased lithogenesis-crystal nephropathy, rhabdomyolysis, and thrombotic microangiopathy. The study also lists the basic drugs with nephrotoxicity potential and provides a short overview of the preventive methods for reducing the risk of drug-related kidney damage developing.

Exploration of the Antioxidant and Anti-inflammatory Potential of Cassia sieberiana DC and Piliostigma thonningii (Schumach.) Milne-Redh, Traditionally Used in the Treatment of Hepatitis in the Hauts-Bassins Region of Burkina Faso

Inflammation is the supreme biological response to illness. In the Hauts-Bassins region, in traditional medicine, all parts of Cassia sieberiana and Piliostigma thonningii are used to treat hepatitis and inflammation. The aim of this study was to evaluate the in vitro antioxidant and anti-inflammatory activities of their aqueous extracts. High performance liquid chromatography with photodiode array (HPLC-DAD) and ultra-high-performance liquid chromatography coupled with high-resolution mass spectrometry (UHPLC-MS/MS) analyses highlighted the presence of polyphenols and flavonoids. Antioxidant and anti-inflammatory activities were measured by various methods such as DPPH (2,2-diphenyl-1-picrylhydrazyl), ABTS 2,2'-azino-bis(3-ethylbenzothiazoline-6-sulfonic acid), TAC (total antioxidant capacity), anti-protease, anti-lipoxygenase, and membrane stabilization. The best antioxidant activity was observed in the bark (DPPH: IC50 = 13.45 ± 0.10 µg/mL) and roots (TAC = 29.68 ± 1.48 mg AAE/g DW) of Piliostigma thonningii and in the roots (ABTS: IC50 = 1.83 ± 0.34 µg/mL) of Cassia sieberiana. The best anti-inflammatory activity was observed in the bark (anti-lipoxygenase: IC50 = 13.04 ± 1.99 µg/mL) and leaves (anti-proteases: IC50 = 75.74 ± 1.07 µg/mL, membrane stabilization: IC50 = 48.32 ± 6.39 µg/mL) of Cassia sieberiana. Total polyphenols (ABTS: r = -0.679, TAC: r = 0.960) and condensed tannins (ABTS: r = -0.702, TAC: r = 0.701) were strongly correlated with antioxidant activity. Total flavonoids (anti-proteases: r = -0.729), condensed tannins (anti-proteases: r = 0.698), and vitamin C (anti-proteases: r = -0.953) were strongly correlated with anti-inflammatory activity. Total polyphenols, flavonoids, condensed tannins, and vitamin C could contribute to the antioxidant and anti-inflammatory activities of the two studied plants. These results could validate the traditional use of these plants to treat various inflammatory diseases.

Integration of Chinese Herbal Medicine into Routine Care Was Related to Lower Risk of Chronic Kidney Disease in Patients with Rheumatoid Arthritis: A Population-Based Nested Case-Control Study in Taiwan

Objective

Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently used as the first-line agents for the symptomatic relief of rheumatoid arthritis (RA), but it may insidiously provoke the onset of renal diseases, especially chronic kidney disease (CKD). While Chinese herbal medicine (CHM) has become an increasingly popular adjunctive therapy among RA groups, there are currently no available data on the effect of CHM use towards risk of CKD. This study aimed to explore on a population-level whether CHM use decreases sequent CKD risk among them.

Methods

In this nested case-control study retrieved from the nationwide insurance database of Taiwan from 2000 to 2012, we looked at the association between CHM use and the likelihood of developing CKD, with a focus on usage intensity. Cases with CKD claims were defined and matched to one randomly selected control case. Conditional logistic regression was then applied to estimate odds ratio (OR) of CKD from CHM treatment measured before the index date. For each OR, we calculated a 95% confidence interval for CHM use relative to the matched control.

Results

This nested case-control study included 5464 patients with RA, where after matching comprised 2712 cases and 2712 controls. Among them, there were 706 and 1199 cases that ever received CHM treatment, respectively. After the adjustment, CHM use in RA individuals was related to a lower likelihood of CKD, with an adjusted OR of 0.49 (95% CI: 0.44-0.56). Additionally, a dose-dependent, reverse association was found between the cumulative duration of CHM use and risk of CKD.

Conclusion

Integrating CHM into conventional therapy may reduce the likelihood of developing CKD, which could be a reference in instituting novel preventive strategies to improve treatment outcomes and reduce related fatalities for RA subjects.

Use of non-steroidal anti-inflammatory drugs in renal transplant patients: A retrospective study

BACKGROUND

Renal transplants are often prescribed non-steroidal anti-inflammatory drugs (NSAIDs) for analgesic purposes.

OBJECTIVE

Considering the dearth of data, we carried out the present study to evaluate the use of various NSAIDs and the incidence of acute kidney injury (AKI) in transplant patients.

METHODS

A retrospective study amongst renal transplant patients prescribed at least one dose of NSAID was carried between January and December 2020 at the Department of Nephrology, Salmaniya Medical Complex, Kingdom of Bahrain. The patients' demographic details, serum creatinine values, and drug-related details were obtained. The Kidney Disease Improving Global Outcomes (KDIGO) criteria were used for defining AKI.

RESULTS

Eighty-seven patients were included. Forty-three patients were prescribed diclofenac, 60 received ibuprofen, six received indomethacin, 10 were administered mefenamic acid, and 11 received naproxen. Due to multiple courses of NSAID prescription, a total of 70 prescriptions were identified for diclofenac, 80 for ibuprofen, six for indomethacin, 11 for mefenamic acid, and 16 for naproxen. No significant differences were observed in the absolute (p = 0.08) and percent changes in serum creatinine (p = 0.1) between the NSAIDs. Twenty-eight (15.2%) courses of NSAID therapy met the KDIGO criteria for AKI. Age (OR: 1.1, 95% CI: 1.007, 1.2; p = 0.02), concomitant everolimus (OR: 483, 95% CI: 4.3, 54407; p = 0.01), and mycophenolate + cyclosporine + azathioprine (OR: 63.4E+006, 95% CI: 203.2157 to 19.8E+012; p = 0.005) administration were observed with significant risk of NSAID-induced AKI.

CONCLUSION

We observed possible NSAID-induced AKI to an extent of around 15.2% in our renal transplant patients. No significant differences were observed in the incidence of AKI between various NSAIDs and none of them had either graft failure or death.

Dehydration risk factors and outcomes in older people in rural areas

Objective: To determine the risk factors for dehydration in elderly people in one of Elbehira Governorate’s villages.

Methods: A descriptive correlational design was utilized in this study. The study was conducted at Elnemaria village, Markaz Abo Elmatamir, Elbehira Governorate, Egypt. Data were collected using 3 tools: a structured interviewing questionnaire, a dehydration knowledge questionnaire, and a dehydration risk appraisal checklist.

Results: The study found that 29.5% of the participants were aged between 65 and 70. Males constituted 51% of the study participants. The majority of the study participants regularly took anti-acids, anti-inflammatory drugs, and diuretics. Among the elderlies comprising the respondents, 40% had a low level of knowledge regarding dehydration. More than half of the study subjects were at moderate risk for dehydration.

Conclusions: The study showed that half of the participants had diabetes and a medium level of information about dehydration. The study also showed in general that the elderly in the village are exposed to a moderate dehydration rate, and there is also a strong relationship between taking different types of medication and the occurrence of dehydration.

Association between intraoperative oliguria and postoperative acute kidney injury in non-cardiac surgical patients: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis aimed to evaluate the association between intraoperative oliguria and the risk of postoperative acute kidney injury (AKI) in patients undergoing non-cardiac surgery.

METHODS

The MEDLINE and EMBASE databases were searched up to August 2022 for studies in adult patients undergoing non-cardiac surgery, where the association between intraoperative urine output and the risk of postoperative AKI was assessed. Both randomised and non-randomised studies were eligible for inclusion. Study selection and risk of bias assessment were independently performed by two investigators. The risk of bias was evaluated using the Newcastle-Ottawa scale. We performed meta-analysis of the reported multivariate adjusted odds ratios for the association between intraoperative oliguria (defined as urine output < 0.5 mL/kg/hr) and the risk of postoperative AKI using the inverse-variance method with random effects models. We conducted sensitivity analyses using varying definitions of oliguria as well as by pooling unadjusted odds ratios to establish the robustness of the primary meta-analysis. We also conducted subgroup analyses according to surgery type and definition of AKI to explore potential sources of clinical or methodological heterogeneity.

RESULTS

Eleven studies (total 49,252 patients from 11 observational studies including a post hoc analysis of a randomised controlled trial) met the selection criteria. Seven of these studies contributed data from a total 17,148 patients to the primary meta-analysis. Intraoperative oliguria was associated with a significantly elevated risk of postoperative AKI (pooled adjusted odds ratio [OR] 1.74; 95% confidence interval [CI] 1.36-2.23, p < 0.0001, 8 studies). Sensitivity analyses supported the robustness of the primary meta-analysis. There was no evidence of any significant subgroup differences according to surgery type or definition of AKI.

CONCLUSIONS

This study demonstrated a significant association between intraoperative oliguria and the risk of postoperative AKI, regardless of the definitions of oliguria or AKI used. Further prospective and multi-centre studies using standardised definitions of intraoperative oliguria are required to define the thresholds of oliguria and establish strategies to minimise the risk of AKI.

Perinatal Tissue-Derived Allografts and Stromal Cells for the Treatment of Knee Osteoarthritis: A Review of Preclinical and Clinical Evidence

OBJECTIVE

The use of perinatal-derived tissues and mesenchymal stromal cells (MSCs) as alternative treatment options to corticosteroid and hyaluronic acid injections has been gaining popularity. However, their ability to attenuate osteoarthritic (OA) symptoms while also slowing the progression of the disease remains controversial. Thus, the objective of this article is to summarize the results from both preclinical and clinical studies evaluating the efficacy of perinatal-derived tissue allografts and MSCs for the treatment of OA.

DESIGN

A comprehensive literature search was conducted on databases including Pubmed, ScienceDirect, and Google Scholar beginning in March 2020 for both preclinical and clinical studies evaluating perinatal-derived tissues and MSCs in OA. Eighteen studies met the inclusion criteria and were used for this review.

RESULTS

Both animal models and early human clinical trials demonstrated that perinatal tissues could reduce joint inflammation and pain as well as improve range of motion and function in OA. Perinatal tissue-derived MSCs in animal studies have shown the potential to support chondrocyte proliferation while also decreasing inflammatory gene and protein expression. Limited clinical results suggest perinatal tissue-derived MSC sources may also be a viable alternative or adjunct to hyaluronic acid in reducing pain and symptoms in an arthritic joint.

CONCLUSIONS

Perinatal tissue-derived allografts and MSCs have promise as potential therapeutics for mitigating OA progression. However, further research is warranted to fully define the therapeutic mechanism(s) of action and safety of these biological therapies.

Neocinnamomum caudatum Essential Oil Ameliorates Lipopolysaccharide-Induced Inflammation and Oxidative Stress in RAW 264.7 Cells by Inhibiting NF-κB Activation and ROS Production

Neocinnamomum caudatum (Lauraceae) plant is used in the traditional system of medicine and is considered a potential source of edible fruits, spices, flavoring agents and biodiesel. The leaves, bark and roots of the species are used by local communities for the treatment of inflammatory responses, such as allergies, sinusitis and urinary tract infections. However, there is no scientific evidence to support the molecular mechanism through which this plant exerts its anti-inflammatory effect. The aim of the current research was to characterize the chemical constituents of bark (NCB) and leaf (NCL) essential oil of N. caudatum and to elucidate its anti-inflammatory action in lipopolysaccharide (LPS)-treated RAW 264.7 cells. Essential oils extracted by hydrodistillation were further subjected to gas chromatography mass spectrometry (GC-MS) analysis. The major constituents in bark essential oil identified as β-pinene (13.11%), α-cadinol (11.18%) and α-pinene (10.99%), whereas leaf essential oil was found to be rich in β-pinene (45.21%), myrcene (9.97%) and α-pinene (9.27%). Treatment with NCB and NCL at a concentration of 25 µg/mL exerted significant anti-inflammatory activity by significantly reducing LPS-triggered nitric oxide (NO) production to 45.86% and 61.64%, respectively, compared to the LPS-treated group. In the LPS-treated group, the production of proinflammatory cytokines, such as tumor necrosis factor (TNF)-α, interleukin (IL)-6 and IL-1β, decreased after treatment with essential oil, alleviating the mRNA levels of inducible nitric oxide synthase (iNOS) and cyclooxygenase (COX)-2. The essential oil also inhibited the production of intracellular ROS and attenuated the depletion of mitochondrial membrane potential in a concentration-dependent manner. Pretreatment with NCB also reduced nuclear factor kappa-B (NF-κB)/p65 translocation and elevated the levels of endogenous antioxidant enzymes in LPS-induced macrophages. The present findings, for the first time, demonstrate the anti-inflammatory potential of both bark and leaf essential oils of N. caudatum. The bark essential oil exhibited a significantly more important anti-inflammatory effect than the leaf essential oil and could be used as a potential therapeutic agent for the treatment of inflammatory diseases.

Renal arcuate vein thrombosis-induced acute kidney injury: a rare multiple-Hit-mediated disease

Background

Renal arcuate vein thrombosis (RAVT) is a rare and recently recognized cause of acute kidney injury (AKI) in young adults. However, the precise incidence and underlying pathophysiologic mechanisms leading to AKI in these patients remain elusive.

Methods

This study included all patients who underwent a kidney biopsy over a 40-month period sent to the pathology department of Necker-Enfants Malades Hospital, with evidence of RAVT. We performed coagulation tests, genetic testing for thrombophilia, complete urine toxicologic screening and kidney metagenomic sequencing to identify an underlying cause of thrombosis.

Results

We report five pediatric cases of RAVT discovered on kidney biopsy performed in the setting of unexplained AKI. Investigations did not reveal an underlying cause of thrombosis but only a significant nonsteroidal anti-inflammatory drugs (NSAIDs) use was reported in 4/5 patients, supporting a potential link between NSAIDs use and RAVT. By performing metagenomic sequencing on kidney biopsy samples, we detected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in the kidney of one patient. These results suggest that systemic SARS-CoV-2 infection may also be a key contributing factor of renal thrombosis, particularly by inducing potential endothelial disruption.

Conclusions

In conclusion, RAVT-induced AKI appears to be a multiple hit-mediated disease in which NSAIDs consumption and viral infection such as SARS-CoV-2 may be crucial contributing factors. These findings may have significant public health implications given the prevalence of NSAIDs use in the general population. Increased awareness and additional study of future cases may lead to a better understanding of this rare cause of AKI in children and young adults.

Acute, chronic, and genotoxic studies on the protopine total alkaloids of the Macleaya cordata (willd.) R. Br. in rodents

The protopine alkaloids are widely distributed within the opium poppy family and have a wide range of pharmacological effects. MPTA is a product of the protopine total alkaloids extracted from the Macleaya cordata (Willd.) R. Br. Previously, we reported good anti-inflammatory activity of MPTA as well as oral acute and sub-chronic toxicity studies in rats. In order to perform a systematic toxicological safety assessment of MPTA, oral acute toxicity, genotoxicity (bone marrow cell chromosome aberration test, sperm abnormality test, bone marrow cell micronucleus test, and rat teratogenicity test), and chronic toxicity in mice were performed in this study. In the oral acute toxicity test, the LD₅₀ in ICR mice was 481.99 mg/kg, with 95% confidence limits ranging from 404.27 to 574.70 mg/kg. All three mutagenicity tests tested negative in the range of 60.25–241.00 mg/kg. The results of the teratogenicity test in rats showed no reproductive or embryonic developmental toxicity at only 7.53 mg/kg, which can be considered as a no observed effect level (NOEL) for the teratogenicity test. Therefore, MPTA is safe for use at the doses tested, but attention should be paid to the potential risk to pregnant animals and the safety evaluation and toxicity mechanisms in target animals should be further investigated.

Practice guidelines for the treatment of acute migraine and chronic knee osteoarthritis with paracetamol: an expert appraisal on evolution over time between scientific societies

BACKGROUND

Paracetamol is the commonest analgesic worldwide in primary care. Despite evidence-based recommendations for management of acute and chronic pain with paracetamol, practices seem to vary considerably in its modalities of use, with or without restrictions, between renowned scientific societies and over time.

OBJECTIVE

Qualitative assessment of similarities, differences, and changes over time in guidelines for paracetamol use in acute and chronic pain.

METHODS

We focused on two common pain conditions for which paracetamol is widely used: acute migraine and chronic knee osteoarthritis (OA). In 19 guidelines (10 for acute migraine, 9 for chronic knee OA) from 10 scientific societies (AAN/AHS, ACR/AF, CHS, EFNS, EHF/LTB, ESCEO, EULAR, SFEMC, SRF, OARSI) published between 1997 and 2021, methods, results and conclusions were compared, between guidelines and over time.

RESULTS

In acute migraine, there was a shift from no recommendation for paracetamol or recommendation only for mild attacks to recommendation for mild to moderate attacks in updated guidelines, without restriction for use for four of the five scientific societies. In knee OA, although updated guidelines generally used the GRADE system, recommendations remained heterogeneous between scientific societies: recommendation without or with restrictions, or not recommended. Consensus is lacking regarding long-course safety and efficacy in acute pain and pain at mobilization.

CONCLUSIONS

Most migraine guidelines now recommend paracetamol for mild to moderate pain. Knee OA guidelines vary on the use of paracetamol: a more holistic approach is needed for this condition, considering patient profile, disease stage, and pain management during physical activity to clarify its appropriate use.

Preterm Birth Therapies to Target Inflammation

Preterm birth (PTB; defined as delivery before 37 weeks of pregnancy) is the leading cause of morbidity and mortality in infants and children aged <5 years, conferring potentially devastating short- and long-term complications. Despite extensive research in the field, there is currently a paucity of medications available for PTB prevention and treatment. Over the past few decades, inflammation in gestational tissues has emerged at the forefront of PTB pathophysiology. Even in the absence of infection, inflammation alone can prematurely activate the main components of parturition resulting in uterine contractions, cervical ripening and dilatation, membrane rupture, and subsequent PTB. Mechanistic studies have identified critical elements of the complex inflammatory molecular pathways involved in PTB. Here, we discuss therapeutic options that target such key mediators with an aim to prevent, postpone, or treat PTB. We provide an overview of more traditional therapies that are currently used or being tested in humans, and we highlight recent advances in preclinical studies introducing novel approaches with therapeutic potential. We conclude that urgent collaborative action is required to address the unmet need of developing effective strategies to tackle the challenge of PTB and its complications.

Long-term intake of Lilium lancifolium mitigated osteoarthritic effects by suppressing inflammatory cytokines in a dog model

Background and Aim: Osteoarthritis (OA) is a chronic, painful, degenerative inflammatory disease of the synovial joints. Regular use of nonsteroidal anti-inflammatory drugs to decrease OA pain can have severe side effects, such as gastric irritation, ulcers, and heart problems. Natural products are extensively used to minimize OA-associated pain and inflammatory reactions. Lilium lancifolium is commonly used to alleviate several diseases through its anti-inflammatory effects. This study examined the impact of L. lancifolium extract on alleviating pain and inflammation associated with articular cartilage damage. Materials and Methods: Hydro-ethanol extracts of the L. lancifolium bulb were used. The experimental animals (adult beagle dogs) were divided into four groups: sham, which received neither treatment nor surgery; placebo, which received an empty gelatin capsule; glucosamine, which received glutamine (60 mg/kg); and L. lancifolium, which received an L. lancifolium extract-filled (60 mg/kg) gelatin capsule for 8 weeks. OA was induced by an expert orthopedic surgeon in 2-year-old dogs through resection of cranial cruciate ligament and lateral collateral ligament. Inflammatory cytokines, enzymes, lameness score, radiology, and histological changes were assessed. Results: Our experiments showed that long-term oral therapy with L. lancifolium alleviated inflammation and increased histological damage. L. lancifolium treatment effectively reduced cytokines, such as interleukin-6, metalloproteinase-9, leukotriene-4, prostaglandin, and cyclo-oxygenase in dogs with OA, suggesting the potential to minimize inflammatory reactions in OA. L. lancifolium showed anti-inflammatory qualities in dogs with OA. This effect was comparable with that of glucosamine OA treatment. Conclusion: L. lancifolium supplementation represents a possible therapeutic and management option in this model of OA.

Non-steroidal anti-inflammatory drugs in the era of the Covid-19 pandemic in the context of the human and the environment

From 2019, life in the world has mainly been determined by successive waves of the COVID-19 epidemic. During this time, the virus structure, action, short- and long-term effects of the infection were discovered, and treatments were developed. This epidemic undoubtedly affected people's lives, but increasing attention is also being paid to the effects of the epidemic on the environment. Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, a global scoping review of peer-reviewed information has been conducted on the use of over-the-counter non-steroidal anti-inflammatory drugs in the treatment of symptoms of SARS-CoV-2 infections and their positive and negative effects on the human body, the effects of non-steroidal anti-inflammatory drugs (NSAIDs) on aquatic organisms, and their adverse effects on non-target organisms. The literature from 1998 to 2021 was analysed using the Scopus®, Web of Science™ (WoS) and Google Scholar databases. As non-steroidal anti-inflammatory drugs place a heavy burden on the environment, all reports of the presence of these drugs in the environment during the pandemic period have been thoroughly analysed. Of the 70 peer-reviewed records within the scope, only 14% (n = 10) focussed on the analysis of non-steroidal anti-inflammatory drugs concentrations in wastewater and surface waters during the pandemic period. The percentage of these works indicates that it is still an open topic, and this issue should be supplemented with further reports in which the results obtained during the pandemic, which has been going on for several years, will be published. The authors hope this review will inspire scientists to investigate the problem of non-steroidal anti-inflammatory drugs in the environment to protect them for the next generation.

Clinical management of fever in children in Brazil: practical recommendations from an expert panel

The objective of this study was to answer several questions related to the assessment and treatment of fever, as well as other controversies that exist during its management in pediatric patients. First, an advisory board with medical experts was conducted to discuss the clinical journey of these patients, considering the main challenges and possible solutions. After this discussion, a non-systematic literature review was performed, between November 2019 and January 2020, to collect the most relevant evidence available in the scientific databases MEDLINE, Lilacs, and SciELO. A narrative review was carried out based on scientific evidence and on extensive experience of experts in clinical practice. The experts developed a set of recommendations and clarifications about the assessment of the severity of fever in pediatrics, the need for treatment and the choice of the most appropriate antipyretic. The most common controversies in the management of fever in pediatric patients were also addressed, such as alternating antipyretics, persistent fever, and dose equivalence. In primary management of pediatric patients, fever should be seen as a relevant symptom that requires treatment with antipyretics in potentially more complex or severe cases, when it causes discomfort to children or is associated with infectious diseases.

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.

The Flavonoid Hesperidin Methyl Chalcone Targets Cytokines and Oxidative Stress to Reduce Diclofenac-Induced Acute Renal Injury: Contribution of the Nrf2 Redox-Sensitive Pathway

Hesperidin is derived from citrus fruits among other plants. Hesperidin was methylated to increase its solubility, generating hesperidin methyl chalcone (HMC), an emerging flavonoid that possess anti-inflammatory and antioxidant properties. The nuclear factor erythroid 2-related factor 2 (Nrf2) is a powerful regulator of cellular resistance to oxidant products. Previous data evidenced HMC can activate Nrf2 signaling, providing antioxidant protection against diverse pathological conditions. However, its effects on kidney damage caused by non-steroidal anti-inflammatory drugs (NSAIDs) have not been evaluated so far. Mice received a nephrotoxic dose of diclofenac (200 mg/kg) orally followed by intra-peritoneal (i.p.) administration of HMC (0.03–3 mg/kg) or vehicle. Plasmatic levels of urea, creatinine, oxidative stress, and cytokines were assessed. Regarding the kidneys, oxidative parameters, cytokine production, kidney swelling, urine NGAL, histopathology, and Nrf2 mRNA expression and downstream targets were evaluated. HMC dose-dependently targeted diclofenac systemic alterations by decreasing urea and creatinine levels, and lipid peroxidation, as well as IL-6, IFN-γ, and IL-33 production, and restored antioxidant properties in plasma samples. In kidney samples, HMC re-established antioxidant defenses, inhibited lipid peroxidation and pro-inflammatory cytokines and upregulated IL-10, reduced kidney swelling, urine NGAL, and histopathological alterations. Additionally, HMC induced mRNA expression of Nrf2 and its downstream effectors HO-1 and Nqo1, as well as reduced the levels of Keap1 protein detected in renal tissue. The present data demonstrate HMC is a potential compound for the treatment of acute renal damage caused by diclofenac, a routinely prescribed non-steroidal anti-inflammatory drug.

NSAID Treatment Before and on the Early Onset of Acute Kidney Injury Had an Opposite Effect on the Outcome of Patients With AKI

Background: NSAIDs are one of the most frequently used medications and a risk factor for AKI. However, the optimal time of NSAIDs in patients with AKI is unknown. Methods: A secondary analysis of a multicenter, randomized clinical trial including adult inpatients with acute kidney injury was performed. Univariate, multivariate, and subgroup analyses were used to explore the impact of NSAIDs during the early onset of AKI on the outcome of patients with AKI. Results: A total of 6,030 patients with AKI were enrolled in the study. Following are the findings of the multi-factor analysis: NSAID treatments within 72 and 24 h before the onset of AKI were not associated with AKI progression, dialysis, or discharge from dialysis; only NSAID treatment within the 24-h onset of AKI was associated with these outcomes, and their OR values were independently 1.50 (95% CI: 1.02-2.19, p = 0.037), 4.20 (95% CI: 1.47-11.97, p = 0.007), and 0.71 (95% CI: 0.54-0.92, p = 0.011); only NSAID treatment within the 24-h onset of AKI would decrease the 14-day mortality, and the OR value was 0.52 (95% CI: 0.33-0.82, p = 0.005). The subgroup analysis revealed that in patients with age ≥65 years, CKD (chronic kidney disease), congestive heart failure, hypertension, and liver disease, NSAID treatments within the 24-h onset of AKI would deteriorate the outcome of patients with AKI. Conclusion: Before an early onset of AKI, NSAID treatment might be safe, but during the onset of AKI, even early NSAID treatment would deteriorate the outcome of patients with AKI.