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Non–Contrast-Enhanced Computerized Tomography and Analgesic-Related Kidney Disease: Report of the National Analgesic Nephropathy Study

William L. Henrich^*, Richard L. Clark, Judith P. Kelly, Vardaman M. Buckalew, Andrew Fenves^||, William F. Finn^¶, Joseph I. Shapiro^**, Paul L. Kimmel, Paul Eggers, Larry E. Agodoa, George A. Porter, Samuel Shapiro, Robert Toto^||||, Theresa Anderson, L. Adrienne Cupples^¶¶ and David W. Kaufman

^* Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland; Departments of Radiology and ^¶ Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Slone Epidemiology Center, Boston University School of Medicine; ^¶¶ Boston University School of Public Health, Boston, Massachusetts; Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina; ^|| Dallas Nephrology Associates, Dallas, Texas; ^** Department of Medicine, Medical College of Ohio, Toledo, Ohio; National Institutes of Health, Bethesda, Maryland; Department of Medicine, Oregon Health Sciences University, Portland, Oregon; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York; and ^|||| University of Texas Southwestern Medical Center Dallas, Dallas, Texas

Address correspondence to: Dr. William L. Henrich, University of Texas Health Science Center, MSC 7790, 7703 Floyd Curl Drive, San Antonio, TX 78229. Phone: 210-567-0612; Fax: 210-567-4418; E-mail: henrich{at}uthscsa.edu

Received for publication October 21, 2005. Accepted for publication February 15, 2006.

Previous studies suggested that the non–contrast-enhanced computerized tomography (CT) scan is a highly reliable tool for the diagnosis of analgesic-associated renal disease. However, this issue has not been addressed in the US population. A total of 221 incident patients with ESRD from different regions of the United States underwent a helical CT scan and detailed questioning about drug history. Specific renal anatomic criteria were developed to determine whether a constellation of CT findings (small indented calcified kidneys [SICK]) is linked to analgesic ingestion. For approximating use before the onset of renal disease, only analgesic ingestion at least 9 yr before starting dialysis was considered relevant. Fifteen patients met the criteria for SICK. This represented 7% of the enrolled patients and approximately 1% of the total ESRD population. There was a significant increase in the estimated risk among patients with a history of heavy aspirin ingestion (odds ratio [OR] 7.4 [95% confidence interval (CI) 1.2 to 43] for 1 kg lifetime; OR 8.8 [95% CI 1.2 to 66] for 0.3 kg/yr). Total analgesic ingestion of 0.3 kg/yr also was significantly associated with SICK (OR 8.2; 95% CI 1.5 to 45). These findings were accounted for largely by combination products that contained aspirin and phenacetin (used by three patients with SICK), which are no longer available. In addition, the CT finding of SICK was present only in a minority of heavy analgesic users, yielding a sensitivity of 5 to 26%. Findings of SICK are infrequent in the US ESRD population and do not occur among a sufficient proportion of heavy analgesic users to render the non–contrast-enhanced CT scan a sensitive tool to detect analgesic-associated kidney injury.

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