What are the mechanisms by which Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) can cause kidney injury?

Mechanisms of NSAID-Induced Kidney Injury

NSAIDs cause kidney injury primarily through inhibition of prostaglandin synthesis, which leads to decreased renal blood flow, volume-dependent renal failure, interstitial nephritis, and nephrotic syndrome. 1

Primary Mechanisms of NSAID-Induced Kidney Injury

Prostaglandin Inhibition and Hemodynamic Effects

• The renal system relies on the vasodilatory effects of prostaglandins (primarily produced by COX-2) to maintain adequate renal perfusion 1
• NSAIDs inhibit both COX-1 and COX-2 enzymes, which are responsible for converting arachidonic acid to prostaglandins 1
• This inhibition reduces production of vasodilatory prostaglandins (especially PGE2 and PGI2), leading to vasoconstriction and decreased renal blood flow 2, 3
• The resulting vasoconstriction can cause acute decrements in glomerular filtration rate and renal plasma flow within hours of administration 4

Volume-Dependent Renal Failure

• In volume-contracted states or conditions with compromised renal perfusion, prostaglandins play a critical role in maintaining renal blood flow 1
• When NSAIDs block prostaglandin synthesis in these conditions, it can precipitate volume-dependent renal failure 1
• This effect is more pronounced in patients with pre-existing renal disease, congestive heart failure, or cirrhosis 1
• If NSAID use continues despite early signs of renal dysfunction, it may progress to acute tubular necrosis and permanent kidney damage 4, 5

Acute Interstitial Nephritis

• NSAIDs can cause acute interstitial nephritis, typically occurring between 2-18 months of use 6
• This is thought to be an allergic or hypersensitivity reaction rather than a direct prostaglandin-mediated effect 6
• It may present with or without nephrotic syndrome 1, 6
• Renal impairment from interstitial nephritis can be severe enough to require temporary hemodialysis 6

Nephrotic Syndrome

• NSAIDs can induce minimal change disease leading to nephrotic syndrome 5
• The mechanism involves damage to the glomerular basement membrane, reduction in pore size, and decreased podocyte density 3
• This results in proteinuria and impaired renal function 3

Risk Factors for NSAID-Induced Kidney Injury

• Pre-existing renal disease (even if mild) 2
• Advanced age (>60 years) 2
• Congestive heart failure or cirrhosis 1
• Volume depletion or compromised fluid status 2, 4
• Concurrent use of other medications that affect renal function:
  • ACE inhibitors or angiotensin receptor blockers 1, 2
  • Beta blockers 1
  • Diuretics 2
• Taking multiple NSAIDs simultaneously 2

Electrolyte and Water Disturbances

• NSAIDs can cause reduced sodium excretion, leading to:
  • Edema formation 6
  • Exacerbation of heart failure 6
  • Increased blood pressure (average increase of 5 mm Hg) 1, 6
• Hyporeninemic-hypoaldosteronism may result in hyperkalemia 6
• Reduced water excretion can rarely cause hyponatremia 6

Monitoring and Prevention

• Baseline serum creatinine measurement is recommended when starting NSAIDs in high-risk patients 1
• Some experts recommend weekly monitoring for three weeks after initiation in high-risk patients 1, 2
• NSAIDs should be avoided in patients with pre-existing renal disease, congestive heart failure, or cirrhosis 1
• Consider acetaminophen as a safer alternative for pain management in patients with renal impairment 2
• Topical NSAID preparations may provide localized pain relief with less systemic absorption 2

Clinical Significance

• Approximately 2% of patients taking NSAIDs will discontinue them due to renal complications 1, 2
• In healthy individuals with normal renal function and no risk factors, NSAIDs pose minimal risk of kidney injury 4, 6
• Most acute renal effects are reversible with prompt discontinuation of the NSAID 4, 6
• However, continued use despite early signs of renal dysfunction can lead to permanent kidney damage 4, 5