Reversible renal failure following opioid administration

Abstract

SummaryA patient who received intravenous papaveretum during and after operation developed anuria and biochemical evidence of impaired renal function in the first 6 hours after surgery. Administration of naloxone 0.4 mg was associated with a sustained improvement in urine output. Mean arterial pressure did not change signijicantly. The impairment of renal function may have been related to high plasma concentrations of codeine, one of the constituents of papaveretum. Key wordsKidney; anuria. Analgesics; papaveretum.Administration of opioid drugs has been associated with a reduction in urine output in both experimental animals and man, although the exact mechanism whereby this occurs is unclear. In man, opioid abuse has been associated with both acute and chronic renal failure. There has been a report of two patients in whom dihydrocodeine in therapeutic doses precipitated acute renal failure which was reversed by the use of the specific opioid antagonist naloxone.' In this report we present a patient in whom papaveretum (a variable mixture of opioid including morphine 41.5-52.5%, codeine 2.5-5%, noscapine 16-22% and papaverine 2.5-7%) given for sedation and analgesia after aortic surgery was associated with impaired renal function which improved after treatment with naloxone. Case historyA 60-year-old male was admitted to the intensive care unit for artificial ventilation after elective aortic aneurysmectomy, which did not involve the renal arteries, with a 2.2 litre blood loss. Analgesia was provided during operation by intravenous administration of papavereturn 20 mg; after operation, a total of 30mg of papaveretum was given during the first 6 hours. There were no periods of intraoperative hypotension and postoperative hypertension was controlled with an infusion of sodium nitroprusside. Despite a mean arterial pressure (MAP) greater than 100mmHg the patient remained anuric for 6 hours. An infusion of dopamine, at a low dose, had been used throughout the peri-operative period to provide renal protection and there was no response to intravenous frusemide administration. Postoperatively, the plasma urea concentration increased from a pre-operative value of 6.8 mmol/litre to 12 mmol/litre and plasma creatinine concentration increased from 135 pmol/litre to 341 pmol/litre, reflecting poor renal function. Six hours after operation the patient was unresponsive to painful stimuli and therefore naloxone 0.4 mg was given as a slow intravenous injection which produced an improvement in his conscious level. In addition, an increase in urine output was noted without any change in MAP, central venous pressure or other therapy (such as fluid administration). No further doses of naloxone were required as urine output, once established, was maintained with the administration of dopamine and frusemide. Analgesia was provided subsequently with sublingual buprenorphine.Blood and urine samples were collected before and after naloxone treatment for subsequent analysis of codeine, morphine, morphine-3-glucuronide (M3G) and morphine-...

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