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NSAID Nephropathy — SCE Rheumatology MCQ

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ModerateRheumatology PharmacologyNSAID NephropathySCE Rheumatology

A 48-year-old woman with seropositive rheumatoid arthritis has taken naproxen 500 mg twice daily on most days for 10 years. Her inflammatory arthritis is currently well controlled. Over 18 months, she develops hypertension and her serum creatinine rises from 85 to 130 µmol/L. Urinalysis shows low-grade proteinuria and persistent sterile pyuria without dysmorphic erythrocytes or cellular casts. CT urography demonstrates bilateral papillary calcification with irregularity and blunting of the renal calyces. What is the most likely renal diagnosis?

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Correct answer: A — Chronic tubulointerstitial nephritis with papillary necrosis

The correct answer is A. Prolonged NSAID exposure, progressive renal impairment, sterile pyuria and low-grade proteinuria indicate chronic tubulointerstitial injury. Papillary calcification and irregular, blunted calyces provide the decisive evidence of papillary necrosis. The naproxen SmPC recognises interstitial nephritis, proteinuria, raised creatinine and papillary necrosis as renal adverse effects. AA amyloidosis is associated with sustained uncontrolled inflammation and usually causes predominantly glomerular, often heavy proteinuria rather than sterile pyuria and papillary abnormalities. Membranous nephropathy also typically presents with nephrotic-range proteinuria. IgA nephropathy would more often produce glomerular haematuria, while lupus nephritis requires clinical or serological evidence of SLE and commonly has an active urinary sediment.

Reference: Electronic Medicines Compendium, Naprosyn 500 mg Tablets Summary of Product Characteristics, sections 4.4 and 4.8, revised 2024. https://www.medicines.org.uk/emc/product/13238/smpc