A patient has undergone donor nephrectomy. The drug will not begiven:

AIIMS Delhi NO- 2019

Pharmacology

Medium

Appeared in: AIIMS Delhi NO- 2019

Explanation

Diclofenac is a Non-Steroidal Anti-Inflammatory Drug (NSAID).
NSAIDs inhibit the synthesis of prostaglandins, which are vital for maintaining renal blood flow by causing vasodilation of the afferent arterioles.
In a patient with a single kidney (reduced renal mass), this inhibition can lead to renal vasoconstriction, decreased glomerular filtration, and acute kidney injury.
Due to this significant risk of nephrotoxicity, NSAIDs like Diclofenac are contraindicated in patients who have undergone a nephrectomy.

Option A: Morphine is an opioid analgesic. While its active metabolites are cleared renally and can accumulate in patients with kidney disease, it is not absolutely contraindicated. It can be used for severe pain if administered cautiously with dose adjustments and close monitoring.
Option B: Fentanyl is a synthetic opioid that is primarily metabolized by the liver into inactive metabolites. Its clearance is not significantly affected by renal function, making it a much safer opioid option than morphine for patients with renal impairment or a single kidney.
Option C: Paracetamol (acetaminophen) is an analgesic and antipyretic that is metabolized primarily by the liver. It does not interfere with renal prostaglandins or blood flow, making it a safe and appropriate choice for mild to moderate pain relief in patients with kidney disease, provided it is used at therapeutic doses.

Clinical Relevance

Nursing practice connection: Use the key finding related to Pharmacological contraindications after donor nephrectomy to guide bedside assessment, documentation, and the next nursing action.
Nurses must be vigilant in reviewing medication orders for post-nephrectomy patients to identify and question prescriptions for nephrotoxic drugs like NSAIDs.
Patient education is a key nursing responsibility. Nurses should teach patients with a single kidney to avoid over-the-counter NSAIDs (e.g., ibuprofen, naproxen, diclofenac) and to always consult a healthcare provider before taking any new medication.
What if the patient had chronic liver disease in addition to the single kidney? In this scenario, Paracetamol would become a high-risk drug due to its liver metabolism, and dosing would need to be significantly reduced or avoided. Pain management would become very complex, likely relying on cautious use of opioids like Fentanyl.

How to Approach the Question

First, identify the patient's core clinical condition: The patient has undergone a donor nephrectomy, meaning they have only one functioning kidney.
Recognize that a single kidney has reduced renal reserve, making it highly susceptible to damage from nephrotoxic substances.
The question asks which drug 'will not be given,' which directs you to find the drug with a significant risk of harming the kidney (a contraindication).
Systematically evaluate each drug option based on its mechanism of action and route of elimination, specifically considering its effect on the kidneys.
Recall the primary mechanism of NSAID-induced nephrotoxicity: inhibition of renal prostaglandins, which leads to reduced renal blood flow.
Compare this high-risk mechanism with the other options: Morphine (caution needed), Fentanyl (safer opioid), and Paracetamol (generally safe).

Concept Tested & Keywords

Concept Tested: Pharmacological contraindications after donor nephrectomy
Stem keywords: donor nephrectomy, drug will not be given
Lead-in keywords: not
Clinical cues: The patient's history of donor nephrectomy is the critical cue, indicating a single functioning kidney and heightened risk for nephrotoxicity.
Negative lead-in flag: The question asks which drug will NOT be given, requiring identification of the contraindicated medication.

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