AKI with drug interactions

 Case: 54 years old male with past medical history only significant for hypertension (HTN) stable over years with lisinopril, brought to ED with mental status change. The patient is found to be in Acute Kidney Failure. History is negative for any recreational drug abuse, though wife acknowledges he was in a motor vehicle accident (MVA) 8 weeks ago and was lately using over-the-counter pain killers. Which drug interaction is suspected to cause his AKF?

Answer: nonsteroidal anti-inflammatory drug (NSAID) and angiotensin-converting enzyme (ACE) inhibitors

The objective of this question is to identify the risk factors which can quickly culminate in renal injury. One of the biggest risk factors is the drug-interaction. Over-use of NSAID itself is one of the leading causes of Acute Kidney Injury (AKI) and the risk multiplies when combined with other drugs or clinical conditions. AKI due to NSAID gets exacerbated when used with diuretics, CHF, nephrotic syndrome, cirrhosis, hypercalcemia, ACE inhibitors, angiotensin receptor blockers (ARBs), or calcineurin inhibitors (CNIs). 

The AKI due to NSAID is dose-dependent, and usually reversible when NSAID is discontinued.

#pharmacology

References:

1.  Huerta C, Castellsague J, Varas-Lorenzo C, García Rodríguez LA. Nonsteroidal anti-inflammatory drugs and risk of ARF in the general population. Am J Kidney Dis 2005; 45:531. 

2. Lapi F, Azoulay L, Yin H, et al. Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study. BMJ 2013; 346:e8525. 

3. Delzer LM, Golightly LK, Kiser TH, et al. Calcineurin Inhibitor and Nonsteroidal Anti-inflammatory Drug Interaction: Implications of Changes in Renal Function Associated With Concurrent Use. J Clin Pharmacol 2018; 58:1443.