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Muhammad A, Zhang Y, Huang L, Yuan Q, Wang W, Pu J, Lin W, Tang R, Xiao X. The diagnosis of acute interstitial nephritis caused by infection versus antibiotic-induced interstitial nephritis: a narrative review. Clin Kidney J 2024; 17:sfae054. [PMID: 38572500 PMCID: PMC10986214 DOI: 10.1093/ckj/sfae054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Indexed: 04/05/2024] Open
Abstract
Acute interstitial nephritis (AIN) is a significant contributor to acute kidney injury and can be attributed to a variety of factors, including but not limited to allergens or drugs, infections, autoimmune or systemic diseases, and idiopathic forms of the disease. In some cases, AIN requires a therapeutic action according to a single specific etiology by handling the offending agent and applying an immunosuppressant. Although AIN can be diagnosed through renal biopsy, it is not able to pinpoint the precise cause when multiple causes are suspected to be present simultaneously. Such situations arise when a patient suffering from infection develops AIN during antibiotic therapy, the exact causative factor of which becomes a challenge for the clinicians to determine. This is attributed to the different approaches employed in different etiologies, wherein clinicians are required to maintain the current antibiotic therapy or augment the dose in cases of infection as AIN etiology, without resorting to immunosuppressant therapy as the primary objective is infection killing. In contrast, antibiotics as an etiology for AIN require an alternative drug from the antibiotics group, along with an immunosuppressant. In the interim, delaying the identification of the precise cause may result in interstitial fibrosis and chronic kidney disease. This narrative review highlights certain findings that can be typical of infection-associated ATIN compared with antibiotic-associated ATIN based on clinical history and physical examination, clinical presentation of different antibiotic drug classes, histopathological features, classical and novel biomarkers, serum and urine cytokines and chemokines, cellular biomarkers, and genetic biomarkers. Although these findings cannot provide conclusive and clear recommendations that can be useful in the clinical practice, they can entice researchers to conduct original research on these features to discover clear recommendations.
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Affiliation(s)
- Amir Muhammad
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Yingli Zhang
- Department of Nephrology, Third Hospital of Changsha, Changsha, China
| | - Ling Huang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Qiongjing Yuan
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Wang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Jiaxi Pu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Lin
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, China
| | - Rong Tang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangcheng Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
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Mose FH, Birn H, Hoffmann-Petersen N, Bech JN. Prednisolone treatment in acute interstitial nephritis (PRAISE) - protocol for the randomized controlled trial. BMC Nephrol 2021; 22:161. [PMID: 33933012 PMCID: PMC8088674 DOI: 10.1186/s12882-021-02372-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/22/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Acute interstitial nephritis (AIN) is an important and common cause of acute renal failure. There are no generally accepted guidelines for the treatment of AIN, due to the lack of prospective randomized trials. Since AIN is characterized by an enhanced immune response, immunosuppressive treatment could potentially improve prognosis by attenuating inflammation and subsequent fibrosis. Despite the limited evidence of effects of steroids and potential adverse effects, prednisolone is frequently used in the treatment of AIN and there is a strong need for clinical trials on the effects of immunosuppression, including steroids, in the treatment of AIN. We aimed to evaluate the effectiveness of prednisolone treatment in AIN, and hypothesized a positive effect of prednisolone treatment on renal function in AIN. METHODS The study is a randomized, controlled, prospective, open label multicenter study, including incident adult patients with biopsy proven AIN. Patients will be randomized 1:1 to one of 2 treatment regimens: A. No prednisolone treatment (control group) and B. B) Oral prednisolone treatment staring with 60 mg daily tapered over 8 weeks. One hundred ten patients (55 in each group) are planned to be included and followed for 1 year. Primary outcome is renal function estimated by eGFR 3 months after inclusion. Secondary outcomes are renal function after 12 months and need for renal replacement therapy and quality of life after 3 and 12 months. In addition, with-in prednisolone group analysis are performed to estimate the importance of treatment delay. Exploratory analyses include analysis of biomarkers in urine and plasma and the evaluation of these biomarkers in relation to renal prognosis and re-evaluation of renal biopsies to identify possible renal prognostic factors. DISCUSSION Strengths and possible limitations in the design are evaluated. The study will provide important information on the effects of prednisolone treatment in AIN and as well as prognostic information relevant for future use of biomarkers and histology. Ultimately, this would lead to improved and evidence based clinical guidelines for the treatment of AIN. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT04376216 (Retrospectively registered on May 6, 2020).
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Affiliation(s)
- Frank H. Mose
- University Clinic in Nephrology and Hypertension, Aarhus University and Gødstrup Hospital, Herning, Denmark
- Department of Medicine, Gødstrup Hospital, Herning, Denmark
| | - Henrik Birn
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | | | - Jesper N. Bech
- University Clinic in Nephrology and Hypertension, Aarhus University and Gødstrup Hospital, Herning, Denmark
- Department of Medicine, Gødstrup Hospital, Herning, Denmark
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Drug-induced tubulointerstitial nephritis: hypersensitivity and necroinflammatory pathways. Pediatr Nephrol 2020; 35:547-554. [PMID: 30820701 DOI: 10.1007/s00467-019-04207-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 01/11/2019] [Accepted: 01/25/2019] [Indexed: 02/08/2023]
Abstract
More than 250 drugs carry a small but important dose-independent risk of initiating a delayed-type hypersensitivity reaction that leads to acute tubulointerstitial nephritis (TIN). Clinical manifestations are often non-specific, making epidemiological studies challenging. In severe cases, if cessation of the offending drug is not followed by a prompt improvement in renal function, corticosteroid therapy appears to enhance renal recovery rates. Other drugs, classified as potential nephrotoxins, may induce dose-dependent acute tubular necrosis. Studies over the past decade have identified a unique form of tubular cell death called "necroptosis" that is accompanied by a specific and significant interstitial inflammatory response to certain insults, including some nephrotoxins. Insights into the molecular basis of this necroinflammatory pathway have emerged. There is still a paucity of pediatric data on these two distinct types of drug-induced TIN. Early recognition is essential to minimize the risk of chronic kidney damage.
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Boffa JJ, Esteve E, Buob D. Renal involvement in IgG4-related disease. Presse Med 2020; 49:104017. [PMID: 32234380 DOI: 10.1016/j.lpm.2020.104017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 05/04/2019] [Accepted: 07/04/2019] [Indexed: 10/24/2022] Open
Abstract
IgG4-RD may affect several organs including kidneys. The kidney is involved in approximately 20% of patient with IgG4-RD. The most common intrinsic kidney disease is tubulointerstitial nephritis (IgG4-TIN). Retroperitoneal fibrosis (IgG4-RPF) may induce obstructive acute renal failure. More rarely, IgG4-RKD can manifest as a glomerular disease, in particular as a membranous nephropathy (MN). It mostly affects middle-aged to elderly men and causes acute or chronic renal dysfunction, multiple hypodense lesions on CT-Scan and various extra-renal lesions. Increased serum IgG4 and hypocomplementemia are the most important serological findings for the diagnosis of IgG4-RD and thus should be systematically assessed when IgG4-RKD is suspected. Specific diagnosis criteria for IgG4-TIN including interstitial infiltration of IgG4-positive plasma cells, storiform fibrosis and tubular basement membrane immune complex deposits have been proposed. Corticosteroids are effective and remain the first-line therapy but relapses or severe forms could respond to immunosuppressive therapy.
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Affiliation(s)
- Jean-Jacques Boffa
- Inserm UMRS 1155, department of nephrology, Sorbonne université, hôpital Tenon, AP-HP, 75020 Paris, France.
| | - Emmanuel Esteve
- Inserm UMRS 1155, department of nephrology, Sorbonne université, hôpital Tenon, AP-HP, 75020 Paris, France
| | - David Buob
- Inserm UMRS 1155, department of pathology, Sorbonne université, hôpital Tenon, AP-HP, 75020 Paris, France
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Chen H, Lin H, Xu M, Xu G, Fang X, He L, Chen Z, Wu Z, Geng H. Quantitative Urinary Proteome Reveals Potential Biomarkers for Ureteropelvic Junction Obstruction. Proteomics Clin Appl 2018; 13:e1800101. [PMID: 30471240 DOI: 10.1002/prca.201800101] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 11/08/2018] [Indexed: 01/07/2023]
Affiliation(s)
- Honghao Chen
- Department of Pediatric UrologyXinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine 200092 Shanghai China
| | - Houwei Lin
- Department of Pediatric UrologyXinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine 200092 Shanghai China
| | - Maosheng Xu
- Department of Pediatric UrologyXinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine 200092 Shanghai China
| | - Guofeng Xu
- Department of Pediatric UrologyXinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine 200092 Shanghai China
| | - Xiaoliang Fang
- Department of Pediatric UrologyXinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine 200092 Shanghai China
| | - Lei He
- Department of Pediatric UrologyXinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine 200092 Shanghai China
| | - Zhoutong Chen
- Department of Pediatric UrologyXinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine 200092 Shanghai China
| | - Zhixiang Wu
- Department of Pediatric SurgeryXinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine Shanghai China
| | - Hongquan Geng
- Department of Pediatric UrologyXinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine 200092 Shanghai China
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Salihu S, Tosheska K, Aluloska N, Gucev Z, Cekovska S, Tasic V. The Spectrum of Kidney Diseases in Children Associated with Low Molecular Weight Proteinuria. Open Access Maced J Med Sci 2018; 6:814-819. [PMID: 29875851 PMCID: PMC5985860 DOI: 10.3889/oamjms.2018.221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/23/2018] [Accepted: 04/30/2018] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Proteinuria, in addition to haematuria, is the most important laboratory parameter in patients with nephro-urological diseases. Low molecular weight proteinuria (LMWP) is of particular importance because some diseases genetic and tubulointerstitial are diagnosed based on its presence. AIM The purpose of this study is to describe the clinical features, the course and outcome of pediatric patients with a renal disease associated with LMWP. MATERIAL AND METHODS This retrospective observational study included 250 pediatric patients with various kidney diseases in which the type of proteinuria was defined by 4-20% gradient gel sodium dodecyl sulphate polyacrylamide gel (SDS-PAG) electrophoresis. RESULTS Isolated LMWP was detected in 12% of patients, while mixed glomerulotubular proteinuria was detected in 18% of patients. It was detected in all patients with the Dent-1/2 disease, Lowe's syndrome and secondary Fanconi syndrome. Transient LMWP was also detected in a series of 12 patients with distal renal tubular acidosis. In patients with nephrotic syndrome, it was associated with corticoresistence and unfavourable clinical course. CONCLUSION This study contributes to the understanding of the clinical spectrum of various kidney diseases associated with LMWP, their natural course, and the effect of therapy.
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Affiliation(s)
- Shpetim Salihu
- Department of Neonatology, University Clinical Center, Prishtina, Kosovo
| | - Katerina Tosheska
- Institute of Medical and Experimental Biochemistry, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Natasa Aluloska
- University Children's Hospital, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Zoran Gucev
- University Children's Hospital, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Svetlana Cekovska
- Institute of Medical and Experimental Biochemistry, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Velibor Tasic
- University Children's Hospital, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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Joyce E, Glasner P, Ranganathan S, Swiatecka-Urban A. Tubulointerstitial nephritis: diagnosis, treatment, and monitoring. Pediatr Nephrol 2017; 32:577-587. [PMID: 27155873 PMCID: PMC5099107 DOI: 10.1007/s00467-016-3394-5] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/15/2016] [Accepted: 04/04/2016] [Indexed: 12/15/2022]
Abstract
Tubulointerstitial nephritis (TIN) is a frequent cause of acute kidney injury (AKI) that can lead to chronic kidney disease (CKD). TIN is associated with an immune-mediated infiltration of the kidney interstitium by inflammatory cells, which may progress to fibrosis. Patients often present with nonspecific symptoms, which can lead to delayed diagnosis and treatment of the disease. Etiology can be drug-induced, infectious, idiopathic, genetic, or related to a systemic inflammatory condition such as tubulointerstitial nephritis and uveitis (TINU) syndrome, inflammatory bowel disease, or immunoglobulin G4 (IgG4)-associated immune complex multiorgan autoimmune disease (MAD). It is imperative to have a high clinical suspicion for TIN in order to remove potential offending agents and treat any associated systemic diseases. Treatment is ultimately dependent on underlying etiology. While there are no randomized controlled clinical trials to assess treatment choice and efficacy in TIN, corticosteroids have been a mainstay of therapy, and recent studies have suggested a possible role for mycophenolate mofetil. Urinary biomarkers such as alpha1- and beta2-microglobulin may help diagnose and monitor disease activity in TIN. Screening for TIN should be implemented in children with inflammatory bowel disease, uveitis, or IgG4-associated MAD.
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Affiliation(s)
- Emily Joyce
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
| | - Paulina Glasner
- Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk and Department of Ophthalmology, Medical University of Gdansk, 80-299, Gdańsk, Poland
| | - Sarangarajan Ranganathan
- Department of Pediatric Pathology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA 15224, USA
| | - Agnieszka Swiatecka-Urban
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15224, USA
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