PUID: 63 || PLAB 2 Mock 2 :: Nephropathy3: Analgesic Nephropathy Ibuprofen Adverse Effect

Practice a case with the AI patient 🤖

Summary

This station focuses on a patient with acute kidney injury (AKI) secondary to prolonged NSAID (ibuprofen) use. The key task is to identify the cause and prioritise stopping the offending drug while managing patient concerns about pain.

Key Points

Renal System (AKI / CKD)

• AKI likely secondary to analgesic nephropathy (NSAIDs like ibuprofen)

• eGFR <60 = abnormal → must be taken seriously

• Creatinine may be raised (indicator of AKI)

• Always look for cause of renal impairment (not idiopathic in PLAB scenarios)

Medication History

• Important drugs worsening AKI:

  • NSAIDs (e.g., ibuprofen)

  • Metformin

  • Diuretics

• Patient was actively taking ibuprofen → key causative factor

Symptoms Identified

• Anaemia symptoms (important clue)

• Renal failure features

• Lifestyle risk factors identified well

Interpretation of Investigations

• Focus on:

  • eGFR (low = abnormal)

  • Creatinine (may indicate AKI)

• Avoid:

  • Over-reassurance about abnormal values

  • Ignoring clearly labelled abnormal results

Important Considerations

• PLAB exams:

  • Rarely test idiopathic conditions

  • Always expect a clear cause → must identify and address

• Do NOT rely on personal clinical experiences → follow guidelines

• Prioritise main issue in station (cause + management)

• Avoid spending too long explaining normal results

Diagnostic Approach

1. Confirm patient details

2. Open-ended question:

   • “What brought you in today?” / “Any symptoms recently?”

3. Focused history:

   • Renal symptoms

   • Anaemia symptoms

4. Medication history:

   • Specifically NSAIDs, metformin, diuretics

5. Review investigations:

   • eGFR

   • Creatinine

6. Identify cause:

   • NSAID-induced AKI

Management

Immediate Management

• STOP ibuprofen (key step)

• Explain cause:

  • “Your kidney problem is likely due to this medication”

Supportive Care

• Ensure adequate hydration

• Monitor renal function

Medication Review

• Stop nephrotoxic drugs:

  • NSAIDs

  • Consider others (metformin, diuretics if relevant)

Pain Management Alternatives

• Offer safer alternatives (e.g., paracetamol)

• Consider referral:

  • Rheumatology / pain specialist

Escalation

• Refer to nephrology if needed

• Follow-up blood tests

Key Principle

• AKI management takes priority over pain control

Communication Skills

• Start with open-ended questions (missed initially)

• Avoid jumping into closed questions early

• Clearly explain:

  • Cause (NSAIDs → kidney damage)

  • Need to stop medication

• Address patient concern:

  • “How will I manage pain now?”

• Avoid:

  • Over-explaining normal results

  • False reassurance

• Use structured flow:

  • History → findings → explanation → management

Ethical Considerations

• Patient autonomy:

  • Respect concerns about stopping pain medication

• Shared decision-making:

  • Offer alternatives and involve patient

• Follow principles from :

  • Clear communication

  • Informed decisions

  • Patient safety prioritised

Additional Resources

• PLAB 2 Examiner Guidance

• GMC Good Medical Practice

• Understanding PLAB Marking Domains