An Uncommon Cause of End-Stage Renal Disease

\s=b\The frequency of analgesic nephropathy as a cause of end-stage renal disease varies considerably, not only between countries but also between different areas In the same country. We questioned 277 hemodialysis patients in the Washington, DC, area regarding the consumption of analgesic preparations. Only eight (2.8%) of the patients consumed excessive quantities of analgesic compounds prior to institution of hemodialysis. In addition, three of the eight patients had other causes for their end-stage renal disease. We conclude that analgesic nephropathy is an unusual cause of end-stage renal disease in the greater Washington, DC, area. (Arch Intern Med 1983;143:1897-1899) Opuhler and Zollinger1 first described the association ^ between renal papillary necrosis and chronic interstitial nephritis with excessive analgesic use, and many studies have since confirmed their findings. Despite these studies, however, many unanswered questions remain with particu¬ lar regard to the geographic variation in the prevalence of analgesic nephropathy between countries and even be¬ tween different areas in the same country. In Australia, 20% to 25%2 of patients entering dialysis programs with end-stage renal disease (ESRD) are diagnosed as having analgesic nephropathy, with Queensland and New South Wales having a higher proportion than other states.3 In Europe, 2.5% of patients with ESRD have analgesic ne¬ phropathy,4 while in the United Kingdom only about 1%5 and in Belgium 44%6 have that diagnosis. In the United States the proportion of patients with ESRD with the diagnosis of analgesic nephropathy varies considerably from region to region. In California, only 2% of patients carried the diagnosis,7 while in the Philadelphia region 20% of patients with tubulointerstitial disease8 and "by inference" about 6% to 7% of patients with ESRD9 have the disease, whereas in North Carolina the proportion of patients with ESRD with analgesic nephropathy ap¬ proaches 10%.10 The large numerical differences in the proportion of patients with ESRD with analgesic nephropathy may be ex¬ plained by the type of drugs ingested, a true geographic variation, variations in criteria for diagnosis (including the definition of "excessive" analgesic use), a true difference in individual susceptibility, or a low risk for development of ESRD in habitual analgesic users. There is now consider¬ able evidence that in autopsy studies of renal papillary necrosis the proportion resulting from excessive analgesic use varies from only 15%" to 24%.12 Moreover, several studies have cast doubt on the strength of the causal rela¬ tionship between analgesic use and chronic renal dis¬