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Urinary enzyme excretion after a single dose of phenacetin and paracetamol (acetaminophen) during antidiuresis and during water diuresis
151
Clinicu Chrmicu ACM, 160 (1986) 151-155 Elsevier
Urinary enzyme excretion after a single dose of phenacetin and paracetamol (aceta~inophen~ during antidiuresis and during water diuresis Ulrike Metz, Nikolaus Graben, Dieter Maruhn and Klaus Dietrich Bock
(Received
1 May 1986; revision received 25 June 1986; accepted
26 June 1986)
Kg words: Urinan, cvrq~mc~;Phenocetin; Purucercrmoi;Antidiuresis; Wuter diuresis
2 g phenacetin or paxacetamol in a single oral dose were administered to five healthy persons under the conditions of antidiuresis and subsequent water diuresis. Excretion of the brush border enzyme GGT, the cytoplasm enzyme LDH, and the lysosomal enzymes, NAG and GAL, was analysed before, during and after ingestion of the analgesics. Increased excretion of LDH and GCT indicated a similar moderate damage of the tubular epithelia after phenacetin and paracetamol. The state of diuresis appeared to have no influence.
More than 30 years ago Spuehler and Zollinger [l] first described the features of analgesic nephropathy. Hawever, the nature of the causative agent is still controversial. The analysis of the drug histories of 287 patients with analgesic nephropathy observed in our department since 1362 supports our opinion that phenacetin or its metabolites are the decisive factors in the pathogenesis of analgesic nephro~a~y t21. However, since not alf patients with severe abuse of anatgesies devdop nephropathy and since no significant correlation between the amount of phenacetin intake and impairment of renal function exists, individual factors might possibly prevent or induce the development of renal impairment. For example, differences in fluid intake may result in different locai concentration of phenacetin in the kidney. On the other hand, phenacetin is mainly metabolized to paraeetamol ~a&etamino~hen~~ which has been substituted for phenacetin in many modern analgesic mixtures. The aim of this study was to investigate the acute nephrotoxicity of phenacetin or its main metabolite paracetamol under the conditions of antidiuresis and water diuresis. As sensitive parameters of acute renal toxicity, we determined five urinary
152
enzymes: lactate dehydrogenase (LDH), gamma-glutamyltransferase (GGT), leucine-aminopeptidase (LAP), N-acetylglucosaminidase (NAG) and /3-galactosidase (GAL). LDH is a cytoplasm enzyme, GGT and LAP are localized to the brush border and NAG and GAL are lysosomal enzymes. Probands and methods 10 voluntary and healthy participants were randomly allocated into two groups (5/5). None had a history or clinical signs of renal disease or chronic intake of any nephrotoxic drug. Group 1 received phenacetin, group 2 paracetamol. Both drugs were given orally in a single dose of 2 g at 9 a.m.. Each subject underwent two tests: 1. Fluid intake was stopped from 7 p.m. the day before the trial for at least 16 hours. 2. Between 9 a.m. and 12 p.m. the subjects drank 2-3 1 water. Urine samples for enzyme analysis were collected on day 1 from 6 to 9 a.m. before drug intake and then from 9 a.m. to 12 p.m. and 3 to 6 p.m.. On day 2 urine was collected from 6 to 9 a.m.. Immediately after collection periods urines were prepared by gel filtration on Sephadex G 50 fine. Enzymes were determined as described by Maruhn et al [3]. Urinary excretion of enzymes was calculated as mU/3 h, corrected for the average adult body surface of 1,73 m2. Normal limits of urinary enzyme excretion refer to results of our laboratory obtained in a selected group of 100 healthy subjects [3]. Results Phenacetin Urinary antidiuresis
oJL,,,
LDH there
I
36
12
excretion rose in all subjects during water diuresis. During was an increase in three subjects, one showing a doubling of
24
Fig, 1. Excretion of LDH during nr, normal range.
11,
I
36
12
water diuresis
24 hrs
and antidiuresis
after administration
of 2 g of phenacetin.
153
X103
,f-GTI Phenacetln
12-
Ant,d,ures,s
Woterdlures,s
Pheoacetm.
,#I
36
Fig. 2. Excretion nr, normal
I
12
of GGT
24
during
($1
29 orolly
I
36
12
24 hrs
water diuresis
and antidiuresis
after administration
of 2 g phenacetin.
range.
excretion, while two subjects demonstrated an increase about 50% above the normal range (Fig. 1). The excretion of GGT increased slightly in all subjects, with the exception of one during antidiuresis. However, the peak values were in the upper range of normal or only slightly above (Fig. 2). Urinary excretion of NAG, GAL and LAP showed no change at all. Paracetamol Following paracetamol intake all subjects showed a rise in the excretion of LDH during water diuresis, and three during antidiuresis (Fig. 3). Excretion of GGT was
LOH /Paracetamol
x103
Pvxetomol,
O-1
2g orally
c
4-
III
I
36
12
24
Fig, 3. Excretion of LDH during paracetamol. nr, normal range.
36 water
12 diuresis
24 hrs and
antidiuresis
after
administration
of 2 g of
III
36
12
24
I
36
Fig. 4. Excretion of GGT during paracetamol. nr, normal range.
12
water
24 hrs
diuresis
and
antidiuresis
after
administration
of 2
g of
considerably enhanced in all persons during water diuresis and in four during antidiuresis (Fig. 4). There was no change in the excretion of the lysosomal enzymes NAG and GAL or the brush border enzyme LAP after administration of paracetamol. In a subsequent cross-over study under the same conditions there was no increase of enzyme excretion after paracetamol in the two persons who showed normal enzyme excretion after phenacetin. In all ten test persons enzyme activities had returned into the normal range after 24 hours. In all persons the urinary sediment remained normal, proteinuria was not detected. Discussion Recently, the determination of urinary enzymes has proven to be an early indicator of nephrotoxicity before the onset of clinical deterioration [4]. In previous investigations LDH was described as a sensitive indicator of renal injury [5]. In our study we found an increased excretion of the cytoplasm enzyme LDH and the brush border enzyme GGT following application of a single dose of phenacetin and paracetamol in the majority of ten healthy volunteers. The increased excretion of LDH is suggestive of a tubular lesion caused by the two analgesics. The hypothesis is supported by the slight rise in GGT after phenacetin and its distinct increase after paracetamol. GGT is a brush border enzyme, but compared to LAP it is localized more deeply in the membrane and it is less sensitive to toxic events. Whether the more distinct increase of LDH and GGT after paracetamol compared to phenacetin means a higher toxic potential of this first metabolite of phenacetin cannot be answered. The unchanged excretion of the second brush border enzyme LAP also remained unexplained. A similar result was found by Raab [6] after application of acetylsalicylic acid. The excretion of the lysosomal enzymes NAG and GAL was also unchanged.
155
Excretion of lysosomal enzymes would indicate release as a result of cell necrosis. Previous investigations have showed a rapid increase of LDH immediately after application of toxic agents, followed by an intense desquamation of tubular epithelia in the urine only 2 or 3 days later [7]. At this time an increased output of lysosomal enzymes should also be expected; the observation period in our study may have been too short to detect this. A difference in urinary enzyme output under antidiuresis as opposed to water diuresis was not detectable. It also did not matter whether the enzyme excretion was calculated as mU/3 h or U/ml. In summary, a single oral dose of 2 g phenacetin or paracetamol, respectively, increases transiently the excretion of the cytoplasm enzyme LDH and the brush border enzyme GGT, but not of LAP and the lysosomal enzymes NAG and GAL. The diuretic state did not influence these results. Acknowledgement This work was supported Forschung.
by a grant
of the Sandoz-Stiftung
fiir therapeutische
References 1 Sptihler 0, Zollinger HU. Die chronische interstitielle Nephritis. Z Klin Med 1953; 151: 1. 2 Bock KD, Nitzsche T. Haufig, aber vermeidbar, Nierenschaden durch Schmenmittel. Med Klin 79: 308. 3 Maruhn D, Fuchs I, Mues G, Bock KD. Normal limits of urinary excretion of eleven enzymes. Chem 1976; 22: 1567. 4 Price RG. Urinary enzymes, Nephrotoxicity and renal disease. Toxicology 1982; 23: 99. 5 Dubach UC, Josch W. Urinenzyme nach medikamentoser Nierenreizung durch Salicylat. Schweiz Wschr 1967; 40: 97. 6 Raab W. Analgetika und renale Enzymausscheidung: Harnenzymaktivitaten bei Ratten Verabreichung von hohen Dosen Acetylsalicylslure. Clin Chim Acta 1968; 22: 535. 7 Raab W. Renal enzyme excretion following ingestion of salicylates, increased by caffeine. Helv Acta 1969/70; 35: 290.
1984; Clin
Med nach Med
Clinicu Chrmicu ACM, 160 (1986) 151-155 Elsevier
Urinary enzyme excretion after a single dose of phenacetin and paracetamol (aceta~inophen~ during antidiuresis and during water diuresis Ulrike Metz, Nikolaus Graben, Dieter Maruhn and Klaus Dietrich Bock
(Received
1 May 1986; revision received 25 June 1986; accepted
26 June 1986)
Kg words: Urinan, cvrq~mc~;Phenocetin; Purucercrmoi;Antidiuresis; Wuter diuresis
2 g phenacetin or paxacetamol in a single oral dose were administered to five healthy persons under the conditions of antidiuresis and subsequent water diuresis. Excretion of the brush border enzyme GGT, the cytoplasm enzyme LDH, and the lysosomal enzymes, NAG and GAL, was analysed before, during and after ingestion of the analgesics. Increased excretion of LDH and GCT indicated a similar moderate damage of the tubular epithelia after phenacetin and paracetamol. The state of diuresis appeared to have no influence.
More than 30 years ago Spuehler and Zollinger [l] first described the features of analgesic nephropathy. Hawever, the nature of the causative agent is still controversial. The analysis of the drug histories of 287 patients with analgesic nephropathy observed in our department since 1362 supports our opinion that phenacetin or its metabolites are the decisive factors in the pathogenesis of analgesic nephro~a~y t21. However, since not alf patients with severe abuse of anatgesies devdop nephropathy and since no significant correlation between the amount of phenacetin intake and impairment of renal function exists, individual factors might possibly prevent or induce the development of renal impairment. For example, differences in fluid intake may result in different locai concentration of phenacetin in the kidney. On the other hand, phenacetin is mainly metabolized to paraeetamol ~a&etamino~hen~~ which has been substituted for phenacetin in many modern analgesic mixtures. The aim of this study was to investigate the acute nephrotoxicity of phenacetin or its main metabolite paracetamol under the conditions of antidiuresis and water diuresis. As sensitive parameters of acute renal toxicity, we determined five urinary
152
enzymes: lactate dehydrogenase (LDH), gamma-glutamyltransferase (GGT), leucine-aminopeptidase (LAP), N-acetylglucosaminidase (NAG) and /3-galactosidase (GAL). LDH is a cytoplasm enzyme, GGT and LAP are localized to the brush border and NAG and GAL are lysosomal enzymes. Probands and methods 10 voluntary and healthy participants were randomly allocated into two groups (5/5). None had a history or clinical signs of renal disease or chronic intake of any nephrotoxic drug. Group 1 received phenacetin, group 2 paracetamol. Both drugs were given orally in a single dose of 2 g at 9 a.m.. Each subject underwent two tests: 1. Fluid intake was stopped from 7 p.m. the day before the trial for at least 16 hours. 2. Between 9 a.m. and 12 p.m. the subjects drank 2-3 1 water. Urine samples for enzyme analysis were collected on day 1 from 6 to 9 a.m. before drug intake and then from 9 a.m. to 12 p.m. and 3 to 6 p.m.. On day 2 urine was collected from 6 to 9 a.m.. Immediately after collection periods urines were prepared by gel filtration on Sephadex G 50 fine. Enzymes were determined as described by Maruhn et al [3]. Urinary excretion of enzymes was calculated as mU/3 h, corrected for the average adult body surface of 1,73 m2. Normal limits of urinary enzyme excretion refer to results of our laboratory obtained in a selected group of 100 healthy subjects [3]. Results Phenacetin Urinary antidiuresis
oJL,,,
LDH there
I
36
12
excretion rose in all subjects during water diuresis. During was an increase in three subjects, one showing a doubling of
24
Fig, 1. Excretion of LDH during nr, normal range.
11,
I
36
12
water diuresis
24 hrs
and antidiuresis
after administration
of 2 g of phenacetin.
153
X103
,f-GTI Phenacetln
12-
Ant,d,ures,s
Woterdlures,s
Pheoacetm.
,#I
36
Fig. 2. Excretion nr, normal
I
12
of GGT
24
during
($1
29 orolly
I
36
12
24 hrs
water diuresis
and antidiuresis
after administration
of 2 g phenacetin.
range.
excretion, while two subjects demonstrated an increase about 50% above the normal range (Fig. 1). The excretion of GGT increased slightly in all subjects, with the exception of one during antidiuresis. However, the peak values were in the upper range of normal or only slightly above (Fig. 2). Urinary excretion of NAG, GAL and LAP showed no change at all. Paracetamol Following paracetamol intake all subjects showed a rise in the excretion of LDH during water diuresis, and three during antidiuresis (Fig. 3). Excretion of GGT was
LOH /Paracetamol
x103
Pvxetomol,
O-1
2g orally
c
4-
III
I
36
12
24
Fig, 3. Excretion of LDH during paracetamol. nr, normal range.
36 water
12 diuresis
24 hrs and
antidiuresis
after
administration
of 2 g of
III
36
12
24
I
36
Fig. 4. Excretion of GGT during paracetamol. nr, normal range.
12
water
24 hrs
diuresis
and
antidiuresis
after
administration
of 2
g of
considerably enhanced in all persons during water diuresis and in four during antidiuresis (Fig. 4). There was no change in the excretion of the lysosomal enzymes NAG and GAL or the brush border enzyme LAP after administration of paracetamol. In a subsequent cross-over study under the same conditions there was no increase of enzyme excretion after paracetamol in the two persons who showed normal enzyme excretion after phenacetin. In all ten test persons enzyme activities had returned into the normal range after 24 hours. In all persons the urinary sediment remained normal, proteinuria was not detected. Discussion Recently, the determination of urinary enzymes has proven to be an early indicator of nephrotoxicity before the onset of clinical deterioration [4]. In previous investigations LDH was described as a sensitive indicator of renal injury [5]. In our study we found an increased excretion of the cytoplasm enzyme LDH and the brush border enzyme GGT following application of a single dose of phenacetin and paracetamol in the majority of ten healthy volunteers. The increased excretion of LDH is suggestive of a tubular lesion caused by the two analgesics. The hypothesis is supported by the slight rise in GGT after phenacetin and its distinct increase after paracetamol. GGT is a brush border enzyme, but compared to LAP it is localized more deeply in the membrane and it is less sensitive to toxic events. Whether the more distinct increase of LDH and GGT after paracetamol compared to phenacetin means a higher toxic potential of this first metabolite of phenacetin cannot be answered. The unchanged excretion of the second brush border enzyme LAP also remained unexplained. A similar result was found by Raab [6] after application of acetylsalicylic acid. The excretion of the lysosomal enzymes NAG and GAL was also unchanged.
155
Excretion of lysosomal enzymes would indicate release as a result of cell necrosis. Previous investigations have showed a rapid increase of LDH immediately after application of toxic agents, followed by an intense desquamation of tubular epithelia in the urine only 2 or 3 days later [7]. At this time an increased output of lysosomal enzymes should also be expected; the observation period in our study may have been too short to detect this. A difference in urinary enzyme output under antidiuresis as opposed to water diuresis was not detectable. It also did not matter whether the enzyme excretion was calculated as mU/3 h or U/ml. In summary, a single oral dose of 2 g phenacetin or paracetamol, respectively, increases transiently the excretion of the cytoplasm enzyme LDH and the brush border enzyme GGT, but not of LAP and the lysosomal enzymes NAG and GAL. The diuretic state did not influence these results. Acknowledgement This work was supported Forschung.
by a grant
of the Sandoz-Stiftung
fiir therapeutische
References 1 Sptihler 0, Zollinger HU. Die chronische interstitielle Nephritis. Z Klin Med 1953; 151: 1. 2 Bock KD, Nitzsche T. Haufig, aber vermeidbar, Nierenschaden durch Schmenmittel. Med Klin 79: 308. 3 Maruhn D, Fuchs I, Mues G, Bock KD. Normal limits of urinary excretion of eleven enzymes. Chem 1976; 22: 1567. 4 Price RG. Urinary enzymes, Nephrotoxicity and renal disease. Toxicology 1982; 23: 99. 5 Dubach UC, Josch W. Urinenzyme nach medikamentoser Nierenreizung durch Salicylat. Schweiz Wschr 1967; 40: 97. 6 Raab W. Analgetika und renale Enzymausscheidung: Harnenzymaktivitaten bei Ratten Verabreichung von hohen Dosen Acetylsalicylslure. Clin Chim Acta 1968; 22: 535. 7 Raab W. Renal enzyme excretion following ingestion of salicylates, increased by caffeine. Helv Acta 1969/70; 35: 290.
1984; Clin
Med nach Med