OSCE questions

https://soumyamenda80.blogspot.com/2023/11/29-year-old-with-bilateral-lower-limb.html

1.How NSAID abuse effects on kidney leading to renal injury and How long exposure and dosage can cause injury

The main mechanism of NSAID action is cyclooxygenase (COX) enzyme inhibition, interfering on arachidonic acid conversion into E2 prostaglandins E2, prostacyclins and thromboxanes. Within the kidneys, prostaglandins act as vasodilators, increasing renal perfusion. This vasodilatation is a counter regulation of mechanisms, such as the renin-angiotensin-aldosterone system works and that of the sympathetic nervous system, culminating with compensation to ensure adequate flow to the organ. NSAIDs inhibit this mechanism and can lead to acute kidney injury (AKI).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534025/


2.What other drugs or treatment modalities could be possible other than NSAIDs for pain?
He had history of Rat poison ,does it have any significance in etiopathogenesis of the condition

https://pubmed.ncbi.nlm.nih.gov/28545504/
This is a case report showing renal damage  of 35 year old female consume rat poison - zinc phosphide compound
She developed severe acute kidney injury with acute tubular necrosis, subnephrotic ranged proteinuria and tubulointerstitial nephritis for which she underwent haemodialysis three times along with other measures of resuscitation.
Here Zinc phosphide poisoning caused severe acute kidney injury, abnormal liver profile, pancreatitis and possible myocarditis. The patient improved with repeated haemodialysis. The renal biopsy revealed acute tubulointerstitial nephritis with acute tubular necrosis


3.Previous his leg pain was relieved on medication ,recently no pain relief even after NSAID 
Now after dialysis the pain is relived ,is it due
Decreased uric acid levels? If so how much uric acid can be eliminated by dialysis and what could be long term treatment for the pain (which is one of his problem to be addressed in long term)

Here is link of study of NSAIDs exposure effects 
https://bpspubs.onlinelibrary.wiley.com/doi/10.1002/prp2.817

There are not many studies showing the long-term effects of NSAIDs on the development of CKD. However, Melgaco et al. reported, that daily use of NSAIDs for over a year increases the risk of developing CKD.Patients who continue to use NSAIDs may progress to the already existing weakened kidney function, contributing to their fibrosis. A recent cohort study by Chiu et al. published in 2015 showed that in the elderly, chronically ill patients, regardless of the class and selectivity of the drug, NSAIDs increase the risk of CKD in a dose-dependent matter. Among over 12 thousand patients who had comorbidities but were using NSAIDs about 10% of them developed CKD.The result was statistically significant.

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