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Chung-Hsin Chang, Chiu-Jong Hung, Shou-Shan Chian, An-Hang Yang, Acute renal failure in a young man, 9 days after a 5-h persisting erection following Viagra™: is there a causal relationship?, Nephrology Dialysis Transplantation, Volume 14, Issue 8, August 1999, Pages 2045–2047, https://doi.org/10.1093/ndt/14.8.2045
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Sir,
Since its approval by the US Food and Drug Administration as the first safe and effective oral agent for the treatment of erectile dysfunction in late March 1998, sildenafil citrate (Viagra™) has been widely used in USA [1] and the rest of the world, even in the black market in Taiwan. Sildenafil (Viagra™) is a selective inhibitor of cyclic guanosine monophosphate (cGMP)-specific phosphadiesterase type 5 (PDE 5), the predominant isoenzyme which metabolises cGMP in human corpus cavernosum. Cyclic GMP is the second messenger of nitric oxide (NO) and the principal mediator of smooth-muscle relaxation and vasodilatation in the penis. In general, sildenafil is safe with only mild adverse reactions of headache, flushing, nasal congestion, dyspepsia, and mild visual disturbances reported by less than 20% of over 3700 patients who were evaluated [23]. Here we report a case of acute renal failure following the use of sildenafil.
Case.
An otherwise healthy 39-year-old man without drug using history was referred to our hospital on August 6, 1998 because of epigastric fullness, bilateral flank soreness for 5 days and dysuria, tenesmus, and anorexia for 1 day. Nine days before admission, he took one tablet of Viagra™ (100 mg) for 2 consecutive days, and his erection persisted for 4–5 h after the last dose. During hospitalization, he was shown to be a physically well nourished man without hypertension, oedema, hypovolaemia or anaemia, his blood pressure was 140/90 mmHg, pulse rate was 82/min, serum creatinine and BUN were 9.9 mg/dl and 53 mg/dl, respectively. Urinalysis revealed nothing particular. During the third day of admission he developed oliguria (300 ml/day), serum Na was 142 mEq/l, K 6.5 mEq/l, iCa 4.10 mg/dl, P 4.7 mg/dl. Arterial pH was 7.385, pCO2 32.1 mmHg and [HCO3] 19.3 mmol/l. Haematological evaluation revealed a Hct 45%, Hb 14.9 gm/dl and leukocyte count of 9800/mm3 with normal classification. Serological studies i.e. C3, C4, ANA were within normal limits. Virological screening for anti-HAV IgM, HbsAg, anti-HCV and anti-HIV were negative. On the fourth day of admission, he developed diuresis (4050 ml/day), serum creatinine was 4.9 mg/dl, K 5.2 mEq/l, and creatinine clearance was 36 ml/min. Renal sonogram showed bilaterally normal renal size (~10 cm in length), shape and cortical echogenecity. A percutaneous renal biopsy was performed 5 days after admission, the specimen revealed 14 glomeruli with prominent capillary dilatation and congestion. There was prominent dilatation of cortical tubules and flattening of tubular epithelial cells, segmental regeneration of tubular epithelial cells and moderate interstitial oedema (Figure 1). A diagnosis of acute tubular necrosis was made. His renal function progressively improved after supportive treatment. Serum creatinine decreased to 2.7 mg/dl 7 days after admission and he was discharged. On August 17, his serum creatinine was 1.9 mg/dl. On September 21, his serum BUN was 16 mg/dl, creatinine was 1.3 mg/dl, potassium 4.2 mEq/l and he is doing well.
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