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Diagnosis: Papillary Necrosis and Acute Tubulointerstitial Nefritis (Associated to Ibuprofen)
Renal papillary necrosis (RPN) may occur in patients with diabetes mellitus, acute pyelonephritis, urinary tract obstruction, renal tuberculosis, sickle cell disease, vasculitis, and chronic use of analgesics. In adults, RPN occurs in "classic" analgesic nephropathy, commonly after prolonged use of aspirin and phenacetin, alone or in combination. However, other nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen, tolmetin, indomethacin, benoxaprofen, and naproxen, have been also reported to cause RPN (Kovacevic L, et al. Renal papillary necrosis induced by naproxen. Pediatr Nephrol. 2003;18:826-9. [PubMed link]).
NSAIDs inhibit counterregulatory responses to vasocontriction (renal-prostaglandin-induced vasodilatation), in effect intensifying renal vasoconstriction and severely reducing renal plasma flow and glomerular filtration rate. This may result in renal failure. The inner medulla is ordinarily hypoxemic relative to the cortex, a condition aggravated by reduced blood flow. A decrease in prostaglandin-dependent blood flow in the renal papilla and a possibly direct local toxic effect of NSAIDs may cause papillary necrosis (Kovacevic L, et al. Renal papillary necrosis induced by naproxen. Pediatr Nephrol. 2003;18:826-9. [PubMed link]).
It is possible that, in our patient, the renal effect of ibuprofen was aggravated by dehydration.
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References
- Tallai B, Gulistan TG, Alrayashi MNAB, Al Mughalles SAA, Kamkoum HM, Ebrahim MAA, Abdelkarim MAA, Salah MA. A Rare Presentation of Renal Papillary Necrosis in a COVID-19-Positive Patient. Case Rep Urol. 2021;11;2021:6611861. [PubMed link]
- Panach-Navarrete J, Medina-González M, Alarcón-Molero L, Sánchez-Cano E, Pastor-Hernández F, Martínez-Jabaloyas JM. Renal papillary necrosis, an endoscopic vision. Scand J Urol. 2019;53(5):361-363. [PubMed link]
- Kawaguchi Y, Mori H, Izumi Y, Ito M. Renal Papillary Necrosis with Diabetes and Urinary Tract Infection. Intern Med. 2018;57(22):3343. [PubMed link]
- Dagrosa LM, Ghali F, Gormley EA. Renal Papillary Necrosis Appearing as Bladder Cancer on Imaging. J Endourol Case Rep. 2016;2(1):27-9. [PubMed link]
- Kovacevic L, Bernstein J, Valentini RP, Imam A, Gupta N, Mattoo TK. Renal papillary necrosis induced by naproxen. Pediatr Nephrol. 2003;18(8):826-9. [PubMed link]