From the Research
Paracetamol (acetaminophen) is generally considered safe for patients with acute kidney injury (AKI) caused by NSAIDs, and it is often the preferred analgesic in this situation. Standard dosing of paracetamol (up to 4 grams per day in adults with normal liver function, divided into doses of 500-1000 mg every 6 hours) can be used in most patients with AKI. However, dose reduction may be necessary in patients with severe kidney impairment, especially if it's chronic. When treating patients with NSAID-induced AKI, it's essential to immediately discontinue the offending NSAID, ensure adequate hydration, and monitor kidney function closely. Paracetamol is preferred because it works primarily in the central nervous system rather than through inhibition of prostaglandin synthesis in the kidneys, which is how NSAIDs cause kidney injury. Unlike NSAIDs, paracetamol has minimal effects on renal blood flow and glomerular filtration rate, making it less likely to worsen existing kidney damage. However, caution should be exercised in patients with concurrent liver disease, as paracetamol is metabolized by the liver and can cause hepatotoxicity at high doses or in vulnerable individuals 1.
Key Considerations
- The most recent study on NSAID-associated AKI in hospitalized children found that AKI usually occurs with recommended NSAID dosing in the setting of dehydration, and follow-up after AKI showed a substantial rate of CKD 2.
- Another study highlighted the importance of avoiding NSAIDs in patients with CKD, as their use is associated with a higher risk of kidney damage and other complications 3.
- A systematic review and meta-analysis comparing the efficacy of NSAIDs, opioids, and paracetamol in the treatment of acute renal colic found that NSAIDs were equivalent to opioids or paracetamol in relieving pain, but had fewer side effects 4.
- A case report described two children who developed acute nonoliguric renal failure after taking analgesic-antipyretic drugs, including paracetamol, at therapeutic doses, highlighting the need for caution when using these medications in children 5.
Recommendations
- Use paracetamol with caution in patients with AKI caused by NSAIDs, and monitor kidney function closely.
- Discontinue the offending NSAID and ensure adequate hydration.
- Consider dose reduction in patients with severe kidney impairment.
- Avoid using NSAIDs in dehydrated children, as recommended by the most recent study 2.