Minimal Change Disease and Acute Tubular Necrosis Caused by Diclofenac

Abstract

Renal side-effects of non-steroidal anti-inflammatory drugs (NSAID) can be divided into five clinical syndromes: (i) acute renal failure; (ii) acute interstitial nephritis with nephrotic syndrome; (iii) electrolyte and fluid disorders; (iv) hypertension; and (v) analgesic nephropathy. 1 We describe an unusual combination of minimal change disease (MCD) and acute tubular necrosis (ATN) caused by diclofenac.A 53-year-old woman with nephrotic syndrome and acute renal failure was admitted to our hospital. The patient's medical history was unremarkable except for nontreated hypertension for 5 years. The only medication was oral diclofenac for chronic muscular pain and knee arthropathy. The patient was pale, 83 kg of weight, with generalized oedema and blood pressure 130/80 mmHg. Ocular fundus showed hypertensive changes grade I/II. Erythrocyte sedimentation rate was 21 mm/h and white blood cells count 9 ¥ 10 9 /L without eosinophilia. Urine dipstick showed +++ protein. There were a few erythrocytes and leucocytes in the urine sediment, but no eosinophils. Protein urine excretion was 6.0 g/day and creatinine was 716 mmol/L. Total serum protein was 59 g/L and albumin 23 g/L. Light microscopy renal biopsy showed glomeruli with normal morphology. There was severe tubular injury ( Fig. 1). Arterioles showed mild to moderate hyaline arte-IRENA MAKULSKA, IZABELA MADER-WOŁYNSKA, DANUTA ZWOLINSKA

Minimal change nephrotic syndrome in an 82 year old patient following a tetanus-diphteria-poliomyelitis-vaccination

“…Our patient reported the occasional use of diclofenac. Non-steroidal-anti-rheumatic-drugs (NSAID's) are well known to cause MCGN as Galesic et al have recently published [10]. In our case this cause is unlikely because the patient denied the use of any NSAID four month prior to the admission.…”

Thrombosis in Nephrotic Syndrome

“…Furthermore, NS related to minimal-change nephropathy is an infrequent but possible occurrence of NSAIDs administration. 3,4 Minimal-change disease and, more frequently, MN are associated with drugs used for rheumatic diseases such as gold and penicillamine. 5 Bisphosphonates are drugs useful in the treatment of postmenopausal osteoporosis, osteolytic bone metastases, and malignancy-related hypercalcemia.…”

Nefrotoxicidade dos anti-inflamatórios não esteroidais

“…Um interessante caso foi publicado em 2008, na Croácia: uma paciente do sexo feminino, de 53 anos, desenvolveu doença de lesão mínima associada à síndrome nefrótica e necrose tubular aguda, devido ao uso crônico de diclofenaco para dores musculares e artropatias, não havendo outra causa aparente para o desenvolvimento do quadro, a não ser o uso do AINE. 15 Clinicamente, a síndrome pode se apresentar de formas bastante variadas. Os pacientes afetados evoluem com hematúria microscópica, piúria, proteinúria e níveis séricos elevados de creatinina.…”