Acute and chronic acetaminophen use and renal disease: a case-control study using pharmacy and medical claims

Evaluating a Living Donor With Rheumatoid Arthritis for a Recipient With End-Stage Renal Disease From Antineutrophil Cytoplasmic Antibodies Associated Vasculitis

A 60-year-old Caucasian female with sero-positive rheumatoid arthritis (RA) was evaluated as a potential kidney donor for her brother-in-law with end-stage kidney disease (ESKD) secondary to c-antineutrophil cytoplasmic antibody (c-ANCA) associated vasculitis (AAV) and membranous nephropathy (MN). With little to no data supporting or contradicting this unique scenario, in addition to the varying viewpoints expressed by the different specialists, our multidisciplinary transplant committee encountered a difficult decision of whether to approve a candidate with RA for a living kidney donation or not. As a result, we carried out a careful literature review addressing aspects of recipients' outcomes following kidney transplants from a living donor with RA, especially when the recipient has AAV, living donor's short- and long-term outcomes post kidney donation, renal disease in AAV and RA, and maintenance of disease remission.

Therapeutic Use of Acetaminophen and Light to Moderate Alcohol: Are There Early Disparate Risks for Kidney Disease?

Introduction: Acetaminophen (APAP) is the most common medication taken in the United States. Using the 2003-2004 U.S. National Health and Nutrition Examination Survey (NHANES), the authors previously explored and reported the relationship of concomitant consumption of light to moderate alcohol (LMA) and therapeutic doses of APAP to early risk of renal dysfunction among adults in the United States. Statistically significant increased odds of renal dysfunction were noted among respondents who reported use of therapeutic doses of APAP and LMA by adjusting for hypertension, diabetes, and obesity. In this study the authors explored further on of potential disparities in the above relationship in the population. The relationship was verified with the 2009 Chronic Kidney Disease-Epidemiology Collaboration creatine-based estimated Glomerular Filtration Rate (GFR). Methods: Subgroup logistic regression analyses to assess disparities based on gender, race, age, education, and income were performed for renal dysfunction measured in terms of serum creatinine (SCr) directly as well as self-report using NHANES 2003-2004 data. Results: Early stage renal dysfunction, as determined by self-reports, and SCr and GFR values may occur among those who concomitantly ingested therapeutic doses of APAP and described alcohol use when compared to those who do not. Risks were more profound among females, particularly in minority racial groups, below legal drinking age of 21, and with household income below $25K. Conclusion: Potential risks for renal dysfunction are apparent in a disparate manner resulting in possible health inequity. Further research could increase the sample size of minority groups and specifically assess for effect modifiers that NHANES does not include for assessment.

Influence of acetaminophen on renal function: a longitudinal descriptive study using a real-world database

PURPOSE

Long-term acetaminophen (APAP) use has poorly defined effects on renal function. We investigated these effects using a real-world database.

METHODS

We used a database of health data routinely collected from 185 hospitals serving 20 million patients in Japan. Individuals with chronic pain were selected for the study. The primary outcome was the change in renal function, as measured by 1/serum creatinine (SCr) during the postindex period.

RESULTS

After excluding individuals who did not meet the inclusion criteria, 241,167 patients were included in the analysis (median age 79.0, range 65-101 years; 111,252 were men). APAP was prescribed significantly more frequently to patients with a low renal function (P < 0.001). The annual changes in 1/SCr median and interquartile range (IQR) were - 0.038 (- 0.182 to 0.101) in patients receiving APAP, - 0.040 (- 0.187 to 0.082) in patients receiving non-steroidal anti-inflammatory drugs (NSAIDs), and - 0.025 (- 0.142 to 0.079) in nonmedicated control patients (P < 0.001). These changes were not significantly different among patients with a low renal function, with 0.003 (- 0.066 to 0.113) in the APAP group, 0.000 (- 0.089 to 0.090) in the NSAID group, and - 0.009 (- 0.086 to 0.089) in the control group (P = 0.327).

CONCLUSION

Physicians tended to select APAP for individuals with a low renal function. The annual changes in 1/SCr were significantly different based on APAP and NSAID use or no analgesia, but the differences were not significant among patients with a low renal function. Overall, long-term use of APAP does not appear to exacerbate the renal function in a clinical setting.

Acetaminophen use and risk of renal impairment: A systematic review and meta-analysis

BACKGROUND

Acetaminophen is commonly used for the relief of pain and fever. Advocacy organizations recommend acetaminophen as the drug of choice in patients with kidney disease. Although some studies have suggested a risk of renal impairment after the use of acetaminophen, the effect of acetaminophen on the risk of renal impairment is unclear. The purpose of this research was to demonstrate any correlation linking acetaminophen treatment and renal impairment.

METHODS

We performed a systematic review and meta-analysis of the association between acetaminophen and renal impairment in adults by searching Cochrane Library, PubMed, and Embase databases from initiation to June 16, 2019.

RESULTS

Of 13,097 articles identified, 5 studies (2 cohort studies and 3 case-control studies) with a total of 13,114 participants were included. In the random-effects meta-analysis of the cohort study, acetaminophen use was shown to have statistically significant effects on the increased risk of renal impairment (adjusted odds ratio 1.23; 95% confidence interval, 1.07-1.40). The results of sensitivity and subgroup analyses also suggested that acetaminophen use increases the risk of renal impairment. The Egger's test (P = 0.607) and Begg's test (P = 0.732) revealed no apparent publication bias.

CONCLUSION

Acetaminophen is associated with a significantly increased risk of newly developing renal impairment in adults. Physicians who prescribe acetaminophen should be aware of potential adverse renal effects. A longitudinal study that further explores this association is warranted.

What Can We Learn About Drug Safety and Other Effects in the Era of Electronic Health Records and Big Data That We Would Not Be Able to Learn From Classic Epidemiology?

As more and more health systems have converted to the use of electronic health records, the amount of searchable and analyzable data is exploding. This includes not just provider or laboratory created data but also data collected by instruments, personal devices, and patients themselves, among others. This has led to more attention being paid to the analysis of these data to answer previously unaddressed questions. This is especially important given the number of therapies previously found to be beneficial in clinical trials that are currently being re-scrutinized. Because there are orders of magnitude more information contained in these data sets, a fundamentally different approach needs to be taken to their processing and analysis and the generation of knowledge. Health care and medicine are drivers of this phenomenon and will ultimately be the main beneficiaries. Concurrently, many different types of questions can now be asked using these data sets. Research groups have become increasingly active in mining large data sets, including nationwide health care databases, to learn about associations of medication use and various unrelated diseases such as cancer. Given the recent increase in research activity in this area, its promise to radically change clinical research, and the relative lack of widespread knowledge about its potential and advances, we surveyed the available literature to understand the strengths and limitations of these new tools. We also outline new databases and techniques that are available to researchers worldwide, with special focus on work pertaining to the broad and rapid monitoring of drug safety and secondary effects.

Joint effects of advancing age and number of potentially inappropriate medication classes on risk of falls in Medicare enrollees

Background

Injurious falls among older adults are both common and costly. The prevalence of falls is known to increase with age and with use of fall-risk drugs/potentially inappropriate medications (FRD/PIM). Little is known about the joint effects of these two risk factors.

Methods

Data for 2013–2015 were obtained from the Truven Health MarketScan® Medicare database comprising utilization and eligibility (enrollment) data for approximately 4 million enrollees annually. A case-control design was used to compare enrollees aged 65–99 years diagnosed with > 1 fall event (n = 110,625) with enrollees without falls (n = 1,567,412). An exploratory analysis of joint age-FRD/PIM effects on fall risks was based on number needed to harm (NNH) calculations for each FRD/PIM therapy class count (compared with 0 FRD/PIMs), stratified by age group. Logistic regression analyses adjusted for demographics, comorbidities, and fracture history, measured in the 1 year prior to the fall date (cases) or a randomly assigned date (controls).

Results

For each FRD/PIM class count, NNH values decreased with older age (e.g., for 1 FRD/PIM class: from NNH = 333 for ages 65–74 years to NNH = 83 for ages 90–99 years; for 2 FRD/PIM classes: from NNH = 91 for ages 65–74 years to NNH = 38 for ages 90–99 years). NNH decreased to < 15 patients at > 6 classes for age 65–74 years, > 5 classes for age 75–84 years, and > 4 classes for age 85–99 years. Adjusted odds of falling were increased for age-FRD/PIM combinations with smaller NNH values: adjusted odds ratio (AOR) = 1.127 (95% confidence interval [CI] = 1.098–1.156) for NNH = 83–91; AOR = 1.427 (95% CI = 1.398–1.456) for NNH = 17–48; AOR = 1.983 (1.9034–2.032) for NNH < 15.

Conclusion

FRD/PIM use and age appear to have joint effects on fall risk. Older adults at high risk, indicated by small NNH, may be appropriate for fall prevention initiatives, and clinicians may wish to consider decreasing the number of FRD/PIMs utilized by these patients.

Electronic supplementary material

The online version of this article (10.1186/s12877-019-1202-3) contains supplementary material, which is available to authorized users.

Should a patient with rheumatoid arthritis be a kidney donor?

We cared for a woman with sero-positive rheumatoid arthritis (RA), in clinical remission on oral methotrexate (MTX) and hydroxychloroquine, who wished to donate a kidney to a brother with end-stage renal disease (ESRD). We could find scant literature about this unusual clinical circumstance, and therefore review pertinent aspects of renal disease in RA, perioperative medical management, maintenance of disease remission, outcomes for RA patients who have donated kidneys, and relevant ethical issues. Renal complications in RA are not uncommon, with as many as 50% of patients at risk of reduced eGFR. This reflects anti-rheumatic and analgetic medication use (non-steroidal anti-inflammatory drugs, acetaminophen, DMARDs [cyclosporine and, historically, D-penicillamine and gold compounds], and others), glomerulitis, interstitial nephritis, complicating Sjogren's syndrome, vasculitis, or amyloidosis, and/or emergence of an "overlap" syndrome or other rheumatic disorder. The literature suggests that MTX need not be interrupted for surgery. The risk of perioperative infection to our patient would be low and remission should be sustained. We are aware of one study of six patients with RA who donated kidneys; they experienced no complications, ESRD, or deaths after a median follow-up of 8.2 years. Our ethical responsibilities are to balance patient autonomy of decision-making while assuring clinical beneficence and minimizing potential maleficence. Our perspective was that it would not be unreasonable to support this patient donating a kidney if, when fully informed, that remained her wish.

Light to moderate drinking and therapeutic doses of acetaminophen: An assessment of risks for renal dysfunction

This study investigated the potential effect of therapeutic doses of acetaminophen (APAP) in combination with light-moderate amounts of alcohol on kidney functions controlling for factors such as hypertension, diabetes and obesity that may predispose the kidney to APAP and/or alcohol toxicity. Secondary analysis of the 2003–2004 National Health and Nutrition Examination Survey data was performed using SAS 9.4. Odds ratios (OR) and 95% confidence intervals (CI) comparing the likelihood that individuals who ingested therapeutic doses of APAP and light-moderate amount of alcohol, compared to those who did not, would have kidney dysfunction were generated from multiple logistics regression models by further controlling for potential predisposing factors namely hypertension, diabetes and obesity. Kidney dysfunction was defined based on self-reports and laboratory examination of serum creatinine (SCr), blood urea nitrogen (BUN), glomerular filtration rate (GFR) and albumin creatinine ratio (ABCR). Statistically significant increased odds of renal dysfunction were noted among respondents who reported use of therapeutic doses of APAP and light-moderate amount of alcohol [OR(95% CI) = 1.64(1.28–2.10) self-report, 2.18(1.81–2.63) SCr, 4.60(3.03–7.00) BUN, 3.14(2.42–4.07) GFR, and 1.71(1.36–2.14) ALBCR)] even after adjusting for hypertension, diabetes and obesity [Adjusted OR (95% CI) = 1.78 (1.22–2.58) self-report, 2.05 (1.07–3.92) GFR]. The toxic effects of APAP and alcohol on the kidney were hypothesized. The threshold doses at which these effects begin to occur are unknown. The findings of this study suggest that even therapeutic doses of APAP and light-moderate amount of alcohol could be health problematic if consumed concomitantly.

•

Even therapeutic doses of acetaminophen may be associated with renal dysfunction.

•

Light-moderate drinking alone may be protective of renal dysfunction.

•

Light-moderate alcohol may enhance effect of therapeutic doses of APAP on kidney.

•

Hypertension, obesity & diabetes may strengthen effect of APAP & alcohol on kidney.

Acetaminophen administration and the risk of acute kidney injury: a self-controlled case series study

Background

Acetaminophen (APAP) is frequently used for analgesia and is considered safer than nonsteroidal anti-inflammatory drugs (NSAIDs) for the kidneys. However, there is little epidemiological evidence of the association between APAP and acute kidney injury (AKI).

Objectives

To examine the association between APAP and AKI using the self-controlled case series (SCCS) method, which is a novel strategy to control between-person confounders by comparing the risk and reference periods in each patient.

Methods

We performed SCCS in 1,871 patients (39.9% female) who were administered APAP and subsequently developed AKI, by reviewing electronically stored hospital information system data from May 2011 to July 2016. We used conditional Poisson regression to compare each patient’s risk and reference period. As a time-varying confounder, we adjusted the status of liver and kidney functions, systemic inflammation, and exposure to NSAIDs.

Results

We identified 5,650 AKI events during the 260,549 person-day observation period. The unadjusted incidences during the reference and exposure periods were 2.01/100 and 3.12/100 person-days, respectively. The incidence rate ratio adjusted with SCCS was 1.03 (95% confidence interval [CI]: 0.95–1.12). When we restricted endpoints as stage 2 AKI- and stage 3 AKI-level creatinine elevations, the incidence rate ratios were 1.20 (95% CI 0.91–1.58) and 1.20 (95% CI 0.62–2.31), respectively, neither of which was statistically significant.

Conclusion

Our findings added epidemiological information for the relationship between APAP administration and AKI development. The results indicated scarce association between APAP and AKI, presumably supporting the general physicians’ impression that APAP is safer for kidney.

Association of non-allopathic drugs and dietary factors with chronic kidney disease: A matched case-control study in South India

Background:

The multifactorial etiology of chronic kidney disease (CKD) is known to vary with geographical region. Although diabetes and hypertension are the major known contributors for CKD, the role of other risk factors relevant to India needs to be explored. This study was done to find out the role of dietary factors and nonallopathic drugs in CKD.

Materials and Methods:

A hospital-based individual pair-matched case–control study was conducted in a tertiary care center in South India. The sample included 80 incident cases of CKD matched with 80 controls. Factors assessed in the study include sociodemographic factors, medical history, dietary factors, nonallopathic drugs, substance use, and other possible confounders. Univariate analysis was performed using McNemar's test and multivariate analysis was done using conditional logistic regression.

Results:

On multivariate analysis, lifetime exposure to nonallopathic drugs increased risk of CKD by approximately five times [odds ratio (OR): 5.15, confidence interval (CI): 1.27–20.87] and chicken intake (two to three times a month to once a week) had an increased risk by approximately four times (OR = 4.23, CI: 1.13–15.80). Fish intake at a frequency of two to three times or more reduced the risk of CKD by 94% (OR = 0.06, CI: 0.01–0.43).

Conclusion:

Chicken intake and lifetime exposure to nonallopathic drugs could increase risk for CKD in South India. Increased fish intake was found to be protective for CKD.

Common Analgesic Agents and Their Roles in Analgesic Nephropathy: A Commentary on the Evidence

An association between non-opioid analgesic agents and chronic kidney disease has long been suspected. The presumed development of chronic renal impairment following protracted and excessive use of non-opioid analgesia is known as analgesic nephropathy. Many clinicians accept analgesic nephropathy as a real entity despite the paucity of scientific evidence. This narrative review aims to summarize the literature in the field. The weight of available observational literature suggests that long-term ingestion of paracetamol and combination mixtures of aspirin and paracetamol are likely to contribute to chronic renal impairment. However, there is no convincing data to implicate non-steroidal anti-inflammatory drugs or aspirin monotherapy in the development of analgesic nephropathy. In the absence of high-level evidence, while controversy persists, it may be prudent for physicians to consider all non-narcotic analgesics to be nephrotoxic with long-term use.

Paracetamol and analgesic nephropathy: Are you kidneying me?

INTRODUCTION

Analgesic nephropathy is a disease resulting from the frequent use of combinations of analgesic medications over many years, leading to significant impairment of renal function. The observation of a large number of cases of renal failure in patients abusing analgesic mixtures containing phenacetin led to the initial recognition of the nephrotoxicity from the use of analgesics. Phenacetin was subsequently exclusively blamed for this disease. However, the role of a single analgesic as a sole cause of analgesic nephropathy was challenged, and a number of researchers have since attempted to determine the extent of involvement of other analgesics including nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and paracetamol.

CASE PRESENTATION

We present the case of an 83-year-old woman with a history of NSAID-induced nephropathy with poor pain control and reluctance to use paracetamol. We attempt to briefly review the evidence of paracetamol being implicated in the development of analgesic-induced nephropathy.

CONCLUSION

There is a lack of concrete data regarding causative analgesics, including paracetamol. Patients should therefore not be withheld paracetamol, an effective and commonly recommended agent, for fear of worsening renal function.

Towards a Consistent and Scientifically Accurate Drug Ontology

Our use case for comparative effectiveness research requires an ontology of drugs that enables querying National Drug Codes (NDCs) by active ingredient, mechanism of action, physiological effect, and therapeutic class of the drug products they represent. We conducted an ontological analysis of drugs from the realist perspective, and evaluated existing drug terminology, ontology, and database artifacts from (1) the technical perspective, (2) the perspective of pharmacology and medical science (3) the perspective of description logic semantics (if they were available in Web Ontology Language or OWL), and (4) the perspective of our realism-based analysis of the domain. No existing resource was sufficient. Therefore, we built the Drug Ontology (DrOn) in OWL, which we populated with NDCs and other classes from RxNorm using only content created by the National Library of Medicine. We also built an application that uses DrOn to query for NDCs as outlined above, available at: http://ingarden.uams.edu/ingredients. The application uses an OWL-based description logic reasoner to execute end-user queries. DrOn is available at http://code.google.com/p/dr-on.

Prescription-acquired acetaminophen use and the risk of asthma in adults: a case-control study

BACKGROUND

Studies have examined the association between acetaminophen use and asthma; however, their interpretation is limited by several methodologic issues.

OBJECTIVE

To investigate the association between recent and chronic prescription-acquired acetaminophen use and asthma.

METHODS

This retrospective case-control study used a 10% random sample of the IMS LifeLink commercial claims data from 1997 to 2009. Cases had to have at least 1 incident claim of asthma; 3:1 controls matched on age, sex, and region were randomly chosen. Acetaminophen exposure, dose, and duration were measured in the 7- and 30-day (recent) and the 1-year (chronic) look-back periods. Multivariable conditional logistic regression was used to estimate the risk of asthma associated with acetaminophen use adjusted for comorbidities, other drugs increasing asthma risk, and health system factors.

RESULTS

There were 28,892 cases and 86,676 controls, with mean age of 42.8 years; 37.7% were males, and 22.6% of cases and 18.2% of controls had acetaminophen exposure in the pre-index year, with mean cumulative doses of 78.7 g and 59.8 g, respectively. There was no significant association between recent prescription acetaminophen exposure and asthma (7 days: OR 1.02, p = 0.74; 30 days: OR 0.97, p = 0.38). Cumulative prescription acetaminophen dose in the year prior increased asthma risk compared to acetaminophen nonusers (≤1 kg: OR 1.09, p < 0.001 and >1 kg: OR = 1.60, p = 0.02). Duration of prescription acetaminophen use greater than 30 days was associated with elevated asthma risk (OR 1.39, p < 0.001).

CONCLUSIONS

Chronic prescription-acquired acetaminophen use was associated with an increased risk of asthma, while recent use was not. However, over-the-counter acetaminophen use was not captured in this study and further epidemiologic research with complete acetaminophen exposure ascertainment and research on pathophysiologic mechanisms is needed to confirm these relationships.