Acute kidney injury after treatment of paracetamol overdose using new N-acetylcysteine guideline.
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Authors
Strehle, Eugen-Matthias
Haar, Ivonne
Issue Date
2023
Type
Article
Language
en
Keywords
acute kidney injury (AKI) , paracetamol
Alternative Title
Abstract
Objectives: For several decades UK children and young people (CYP) have been treated with the standard N-acetylcysteine (NAC) protocol following a paracetamol overdose (POD). In 2021, the Scottish Newcastle Acetylcysteine Protocol (SNAP) was introduced in our Trust, and since then we have seen 3 cases of AKI after paracetamol overdose which is unusual. This regimen has not been studied in children and not been approved by the MHRA.
Methods: Case note review of 3 CYP with POD presenting to a paediatric department.
Results: CYP1 took a staggered paracetamol overdose of 10 and 5 grams 10 hours apart, and presented to the paediatric emergency department. Her paracetamol blood level was raised, and she was treated with NAC according to the SNAP guideline (3 bags). Two days after discharge she re-attended with right-sided abdominal pain and right renal angle tenderness.
CYP2 presented to the paediatric department with a 2-day-history of vomiting, loose stools, abdominal pain and backache. Physical examination revealed diffuse abdominal pain and self-harm marks. Next morning, he disclosed taking 25 grams of paracetamol 48 hours prior to admission. He was started on NAC 66 hours post ingestion and received 5 bags.
CYP3 attended the A&E department 12 hours after taking 7.5 grams of paracetamol. Her paracetamol level was raised, and she was prescribed NAC (3 bags). She re-attended 36 hours after discharge complaining of abdominal pain and backache.
Table 1 and figure 1 show the laboratory parameters of the 3 teenagers (peak values).
Conclusions: It cannot be excluded that in all 3 patients AKI was caused by paracetamol toxicity but their serum creatinine dropped initially and increased during/after treatment with NAC. Paracetamol overdoses can lead to AKI in isolation or as hepatorenal syndrome. In our patients AKI occurred ca. 48 � 84 hours after paracetamol ingestion and resolved ca. 2 � 3 weeks later without renal replacement therapy. In SNAP NAC is infused more quickly (12 versus 21 hours) and in a smaller fluid volume (1200 ml vs 1700 ml) compared to standard treatment. It has been reported that NAC can have a damaging effect on renal tissue.1�3 We propose that our anecdotal observation is investigated in a larger paediatric cohort to avoid potential iatrogenic harm. CYP may develop transient AKI at home which may go unnoticed. We advise renal function testing after completion of SNAP. CYP should report symptoms of abdominal pain, backache and reduced urination after discharge.
Description
Citation
Strehle, E-M. and Haar, I. (2023) 20 Acute kidney injury after treatment of paracetamol overdose using new N-acetylcysteine guideline. Archives of Disease in Childhood; 108 (5) : 416-417.
Publisher
License
Journal
Archives of Disease in Childhood
Volume
Issue
ISSN
1468-2044