Nonsteroidal Antiinflammatory Drugs (NSAIDs)-Induced Acute Renal Failure

Author: V. Dimov, M.D.
Reviewer: S. Noor, M.D.

A 46-year-old Caucasian male (CM) with chronic back pain takes large doses of over-the-counter pain medications. He works 12-hour night shifts and has to take 15-20 pills, especially Motrin (ibuprofen) and Aleve (naproxen), during the shift and about the same amount during the day in order to "function."

He went to the ER today because of his back pain. CBC and BMP are ordered.

Past medical history (PMH)

Back pain.

Medications

Motrin (ibuprofen), Aleve (naproxen), Advil (ibuprofen), Ultram (tramadol), Tylenol (acetaminophen).

Physical examination

Limited range of motion (ROM) of lower back, otherwise unremarkable.

Laboratory results

BMP showed a creatinine of 3.3 mg/dL, BUN 25 mg/dL. CBC was normal.

The patient had a normal CBC and BMP one month ago.

What is the most likely diagnosis?

NSAIDs-induced renal failure.

What tests would your order?

UA
Urine Na+ and creatinine
Urinary eosinophils
Renal ultrasound

What happened?

The patient was admitted to the hospital and IVF were started.

UA was normal. Microscopy was negative for eosinophils. Renal ultrasound was WNL.

His creatinine improved to 2.2 mg/dL over the course of 2 days. He was making 2 L of urine per day and had no complaints. Back pain was controlled with Percocet (oxycodone with acetaminophen).

The patient was discharged home with a follow up BMP in one week.

Final diagnosis

NSAIDs-Induced Acute Renal Failure (ARF).

What did we learn from this case?

NSAIDs-induced ARF is a well-known complication of NSAIDs abuse. It is described in injured athletes who have an important game and take "mega" doses of OTC pain killers to play "through the pain".

NSAIDs can induce two different forms of ARF:

- hemodynamically-mediated due to local vasoconstriction
- acute interstitial nephritis (often accompanied by nephrotic syndrome)

Patients with acute interstitial nephritis present with hematuria, pyuria, white cell casts, proteinuria (not present in our patient).

A third type of ARF is due to an allergic reaction, in this case eosinophilia and eosinophiluria are noted in the urine.

References

NSAIDs: Acute renal failure and nephrotic syndrome - UpToDate (subscription required)

Published: 03/11/2006
Updated: 10/08/2009

16 comments:

  1. renal failure with nsaids is an entity which is rarely seen these days, partly due to more awareness of the side effects of these drugs and partly because of the emergence of novel, safe painkillers. acute renal failure caused by NSAIDS is rarer still and one should be cautious while making this diagnosis. a lot of other agents and simultaneous medications which the patient is taking is usually the cause.

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  2. That is not true, it is very common!!!

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  3. I am a nephrologist. NSAID induced renal failure is still fairly common. I rarely have to dialyze people because of it, but I see ARF with recovery all the time.

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    1. hi. can you tell me which pain killers should be given to people who already have suffered from acute renal failure?

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    2. paracetamol

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  4. thanks for the case and comments :)

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  5. I have had physicians with Nsaid ATN-related, of course, to over zealous body building and the proverbial mid-life crisis.

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  6. what's more reliable parameters to check if patient is suspected a renal failure

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  7. "what's more reliable parameters to check if patient is suspected a renal failure"

    Creatinine.

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  8. Being a nephrologist, NSAID induced renal failure patients do show up for consultations from other department. It is important to remember that NSAID induced renal failure happens with both over the counter ADVIl and more fancy COX-II inhibitors. All the NSAID irrespective of their background classification cause hemodynamic failure, Acute interstitial nephritis, Type-IV RTA and GN (mostly Minimal change). The irony is despite the awareness of the side effects among the ER physicians, Toradol continues to be the weapon of kidney destruction in the ER!. It goes without saying prevention is better than cure!!!!

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  9. 55yo M with new onset A-fib w/ RVR, started anti-coag with theraputic lovenox 1mg/kg and rate control with CCB, day 2 pt c/o Right great toe pain (Cr 1.25 - baseline), given indomethicin for gout, day 3 no big toe pain, however, Cr of 2.99. I hate to wonder what would have happened if he were treated the same in an outpt setting w/out labs.

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  10. "I hate to wonder what would have happened if he were treated the same in an outpt setting w/out labs."

    It's possible that the NSAIDs-induced renal injury would have resolved on its own, even if he were an outpatient... That had happened multiple times in the past with thousands of patients before the syndrome was discovered... :) Just putting things in perspective here.

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  11. I am already on dialysis with renal failure. Can I take NSAIDs? How much worse can they make my kidneys if they already failed?

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  12. "I am already on dialysis with renal failure. Can I take NSAIDs?"

    Yes. However, have in mind the fact that NSAIDs also cause fluid retention - your blood pressure may fluctuate.

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  13. taking NSAID in patient already on dialysis has a lot of side effects & risks, importantly the the use of such agent can lead to loss of residual renal function even you're in dilaysis, salt & water retntion, increase the blood pressure, hyperkalemia, prolonging the bleeding time, and the risk of GIT bleeding is also great. the risk of ARF NSAID-induced is more with elderly people & dehyderated pt.

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  14. I don't take NSAIDS or any type of pain reliever on a regular basis. i few years back i had a bad headeach and took 3 200mg ibuprofen and suffered allergic ARF within hours. Now i take nothing for headaches, etc. not worth the risk. luckily my ARF resolved.

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