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Teachable Moment | Less Is More

Nonsteroidal Anti-inflammatory Drug Use in a Patient With Hypertension A Teachable Moment

Bharat Kumar, MD1; Melissa L. Swee, MD, MS2
[+] Author Affiliations
1Division of Immunology, University of Iowa, Iowa City
2Division of Nephrology, University of Iowa, Iowa City
JAMA Intern Med. 2015;175(6):892-893. doi:10.1001/jamainternmed.2015.0809.
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Article InformationCorresponding Author: Bharat Kumar, MD, Division of Immunology, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242 (bharat-kumar@uiowa.edu).

Published Online: April 13, 2015. doi:10.1001/jamainternmed.2015.0809.

Conflict of Interest Disclosures: None reported.

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Importance of Early Nephrology Referral
Posted on April 14, 2015
Ashraf El-Meanawy, MD, PhD
Medical College of Wisconsin
Conflict of Interest: None Declared
It is clear that the patient developed Acute Kidney Injury during the interval described. Although hemodynamic mediated renal damage caused by the combination of NSAID and ACEI is very likely, other mechanisms cannot be totally ruled out. Early Referral to nephrology service is critical especially in such patients. Without all the data we cannot ascertain if early referral would have changed the outcome. It is important to stress that creatinine of 0.96 mg/dl does not necessarily indicate renal structural integrity. Structure/Function relationship studies published in December 1970 showed substantial renal parenchymal damage (based on pathology scoring systems) in subjects whose Inulin clearance would be considered normal. This case presentation highlights the importance of deeper look and understanding of kidney function and renal disease progression beyond creatinine and urea.
reversible renal failure during NSAID and ACEI combination treatment
Posted on April 14, 2015
Andrea Semplicini, MD
Dept. Medicine, University of Padua (Italy)
Conflict of Interest: None Declared
I read with interest the report by Kumar and coworkers. I appreciate their caution regarding the combined use of NSAIDs and ACEI for the increased risk of kidney failure assoociated with this drug combination. I think they should add that kidney failure may be linked to impaiment of glomerular filtration rate autoregulation, particularly relevant under conditions of dehydration andhypotension (1). NSAIDs may hamper preglomerular vasodilation and ACEI postgllomerular vasoconstriction. Stopping the drug combination and a careful hydration will correct this functional renal insufficiency.Andrea Semplicini, MDDepartment of MedicineUniversity of Padua (Italy)
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