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Moss JG, Parry CM, Holt RCL, McWilliam SJ. 5-ASA induced interstitial nephritis in patients with inflammatory bowel disease: a systematic review. Eur J Med Res 2022; 27:61. [PMID: 35488310 PMCID: PMC9052675 DOI: 10.1186/s40001-022-00687-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/09/2022] [Indexed: 01/04/2023] Open
Abstract
Background Acute interstitial nephritis (AIN) is an important cause of kidney injury accounting for up to 27% of unexplained renal impairment. In up to 70% of cases, drugs, including aminosalicylates, are reported as the underlying cause. Following two recent paediatric cases of suspected mesalazine induced AIN within our own department, we performed a systematic review of the literature to address the following question: In patients with inflammatory bowel disease (IBD), is interstitial nephritis associated with 5-aminosalicylate (5-ASA) treatment? Our primary objective was to identify the number of cases reported in the literature of biopsy-proven 5-ASA induced interstitial nephritis, in children and adults with IBD. We also aimed to identify which variables influence the onset, severity and recovery of 5-ASA interstitial nephritis. Methods Embase and PubMed databases were searched from inception to 07/10/20. Search terms had three main themes: “inflammatory bowel disease”, “interstitial nephritis” and “aminosalicylates”. Studies were included if they reported an outcome of AIN, confirmed on biopsy, suspected to be secondary to a 5-ASA drug in those with IBD. A narrative synthesis was performed. Results Forty-one case reports were identified. Mesalazine was the most frequently reported aminosalicylate associated with AIN (95%). The median duration of treatment before AIN was diagnosed was 2.3 years (Interquartile Range (IQR) 12–48 months). The median rise in creatinine was 3.3 times the baseline measurement (IQR 2.5–5.5). Aminosalicylate withdrawal and steroids were the most frequently used treatments. Despite treatment, 15% of patients developed end-stage renal failure. Conclusions AIN is a serious adverse drug reaction associated with aminosalicylates, with mesalazine accounting for most reports. The current guidance of annual monitoring of renal function may not be sufficient to identify cases early. Given the severity of AIN and reports in the literature that early treatment with steroids may be beneficial, we would recommend at least 6 monthly monitoring of renal function. PROSPERO registration number CRD42020205387. Supplementary Information The online version contains supplementary material available at 10.1186/s40001-022-00687-y.
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Affiliation(s)
- James G Moss
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK. .,Institute in the Park, National Institute for Health Research Alder Hey Clinical Research Facility, Alder Hey Children's Hospital, East Prescot Road, Liverpool, UK.
| | - Christopher M Parry
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Institute in the Park, National Institute for Health Research Alder Hey Clinical Research Facility, Alder Hey Children's Hospital, East Prescot Road, Liverpool, UK
| | - Richard C L Holt
- Department of Paediatric Nephrology, Alder Hey Children's Hospital, Liverpool, UK
| | - Stephen J McWilliam
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Institute in the Park, National Institute for Health Research Alder Hey Clinical Research Facility, Alder Hey Children's Hospital, East Prescot Road, Liverpool, UK
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Magalhães-Costa P, Matos L, Chagas C. Chronic tubulointerstitial nephritis induced by 5-aminosalicylate in an ulcerative colitis patient: a rare but serious adverse event. BMJ Case Rep 2015; 2015:bcr-2014-207928. [PMID: 25935912 DOI: 10.1136/bcr-2014-207928] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The 5-aminosalicylate is widely prescribed in inflammatory bowel disease patients. Its potential for renal damage has been seldom described. We report a case of a 23-year-old man who started 5-aminosalicylate after being diagnosed with ulcerative colitis. One year after, a significant decline on his creatinine clearance was noted, however, at that time, he was on an acute flare of his bowel disease and the 5-aminosalicylate dose was increased. Six months later, his renal function kept worsening and, on drug-induced toxicity suspicion, 5-aminosalicylate was halted and a kidney biopsy demonstrated a chronic tubulointerstitial nephritis. Steroids and azathioprine were started leading to partial recovery and stabilisation of his renal function. Physicians who prescribe 5-aminosalicylate to patients with inflammatory bowel disease should be aware of this adverse event.
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Affiliation(s)
- Pedro Magalhães-Costa
- Department of Gastroenterology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Leopoldo Matos
- Department of Gastroenterology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
| | - Cristina Chagas
- Department of Gastroenterology, Hospital Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisboa, Portugal
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Colvin RB, Traum AZ, Taheri D, Jafari M, Dolatkhah S. Granulomatous Interstitial Nephritis as a Manifestation of Crohn Disease. Arch Pathol Lab Med 2014; 138:125-7. [DOI: 10.5858/arpa.2012-0224-cr] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Granulomatous interstitial nephritis is a rare extraintestinal manifestation of Crohn disease that has been described previously in 4 patients. We report a 23-year-old man with a history of Crohn disease since age 6 years who was admitted to the hospital for weight loss, fever, and bloody diarrhea in the midst of a recent flare up during the past 2 months. Investigations revealed anemia, high erythrocyte sedimentation rate, high C-reactive protein level, and an elevated serum creatinine level. Histopathologic examination of tissue specimens obtained at renal biopsy demonstrated granulomatous interstitial nephritis. Crohn disease needs to be in the differential diagnosis of granulomatous interstitial nephritis and can be a manifestation of drug allergy or the Crohn disease itself.
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Affiliation(s)
- Robert B. Colvin
- From the Departments of Pathology (Drs Colvin and Taheri) and Nephrology (Dr Traum), Massachusetts General Hospital, Harvard Medical School, Boston; the Isfahan Kidney Disease Research Center, Isfahan, Iran (Dr Taheri); and the Department of Pathology, School of Medicine (Drs Taheri and Jafari), and the Faculty of Medicine (Dolatkhah), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Avram Z. Traum
- From the Departments of Pathology (Drs Colvin and Taheri) and Nephrology (Dr Traum), Massachusetts General Hospital, Harvard Medical School, Boston; the Isfahan Kidney Disease Research Center, Isfahan, Iran (Dr Taheri); and the Department of Pathology, School of Medicine (Drs Taheri and Jafari), and the Faculty of Medicine (Dolatkhah), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Diana Taheri
- From the Departments of Pathology (Drs Colvin and Taheri) and Nephrology (Dr Traum), Massachusetts General Hospital, Harvard Medical School, Boston; the Isfahan Kidney Disease Research Center, Isfahan, Iran (Dr Taheri); and the Department of Pathology, School of Medicine (Drs Taheri and Jafari), and the Faculty of Medicine (Dolatkhah), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Jafari
- From the Departments of Pathology (Drs Colvin and Taheri) and Nephrology (Dr Traum), Massachusetts General Hospital, Harvard Medical School, Boston; the Isfahan Kidney Disease Research Center, Isfahan, Iran (Dr Taheri); and the Department of Pathology, School of Medicine (Drs Taheri and Jafari), and the Faculty of Medicine (Dolatkhah), Isfahan University of Medical Sciences, Isfahan, Iran
| | - Shahaboddin Dolatkhah
- From the Departments of Pathology (Drs Colvin and Taheri) and Nephrology (Dr Traum), Massachusetts General Hospital, Harvard Medical School, Boston; the Isfahan Kidney Disease Research Center, Isfahan, Iran (Dr Taheri); and the Department of Pathology, School of Medicine (Drs Taheri and Jafari), and the Faculty of Medicine (Dolatkhah), Isfahan University of Medical Sciences, Isfahan, Iran
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Oikonomou KA, Kapsoritakis AN, Stefanidis I, Potamianos SP. Drug-induced nephrotoxicity in inflammatory bowel disease. Nephron Clin Pract 2011; 119:c89-94; discussion c96. [PMID: 21677443 DOI: 10.1159/000326682] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Conservative management of inflammatory bowel disease (IBD) is based on a combination of drugs, including aminosalicylates (ASAs), steroids, antibiotics, immunosuppressives and biologic agents. Although various side effects have been related to treatment regimens, drug-induced nephrotoxicity is rather uncommon. Furthermore, it is often underestimated since renal function deterioration may be attributed to the underlying disease. The nephrotoxicity of ASAs and cyclosporine A seems well established, but recent data have suggested a possible role of biologic agents such as infliximab and adalimubab in renal impairment. The aim of this review is to summarize the nephrotoxic effects of medical treatment as well as to express possible caveats in the administration of novel agents in IBD.
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Oikonomou K, Kapsoritakis A, Eleftheriadis T, Stefanidis I, Potamianos S. Renal manifestations and complications of inflammatory bowel disease. Inflamm Bowel Dis 2011; 17:1034-45. [PMID: 20842645 DOI: 10.1002/ibd.21468] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Accepted: 07/29/2010] [Indexed: 12/11/2022]
Abstract
Renal manifestations and complications are not rare in patients with inflammatory bowel disease (IBD) and may present as nephrolithiasis, amyloidosis, tubulointerstitial nephritis, and glomerulonephritis. Symptoms of renal impairment are not always specific and since the underlying bowel disease is preponderant, renal function deterioration may be underestimated. Additionally, medical treatment of patients with IBD such as aminosalicylates, cyclosporine, and tumor necrosis factor-α inhibitors can cause renal complications, although direct correlation to bowel disease is not always clear. The well-documented renal manifestations and complications of IBD, as well as the possible renal side effects of new drugs, emphasize the need for periodic evaluation of renal function. New markers of renal function may facilitate early diagnosis and unravel the complex mechanisms responsible for kidney damage. The purpose of this review is to summarize the renal manifestations and complications as well as the markers of renal function utilized in IBD, attempting to shed more light on the pathophysiology of renal damage in IBD.
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Affiliation(s)
- Konstantinos Oikonomou
- Department of Gastroenterology, University of Thessaly, School of Medicine, Larissa, Greece.
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Gisbert JP, Luna M, González-Lama Y, Pousa ID, Velasco M, Moreno-Otero R, Maté J. Effect of 5-aminosalicylates on renal function in patients with inflammatory bowel disease: 4-year follow-up study. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 31:477-84. [PMID: 18928745 DOI: 10.1157/13127088] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Nephrotoxicity has been described in some patients with inflammatory bowel disease (IBD) treated with 5-aminosalicylates (5-ASA). Our aim was to conduct a retrospective study of IBD patients, both with and without 5-ASA treatment, who underwent regular evaluation of renal function over a 4-year period. METHODS Serum creatinine was measured before the start of 5-ASA therapy, and thereafter yearly up to 4 years. Creatinine clearance (Cl(Cr)) was estimated from serum creatinine (Cockroft and Gault formula). The influence of 5-ASA treatment on renal function was assessed by univariate and multivariate analysis. RESULTS A total of 150 IBD patients (ulcerative colitis in 45%, Crohn's disease in 55%) were included. Sixty-two patients were receiving 5-ASAs (95% coated mesalazine, mean dose 1.9 +/- 0.8 g/day). Both serum creatinine levels and ClCr were similar in patients with and without 5-ASA treatment, and remained stable throughout the 4-year follow-up in patients taking 5-ASAs. In the multivariate analysis, 5-ASA treatment (or its dose) was not correlated with serum creatinine levels or Cl(Cr). No interstitial nephritis was reported during follow-up. CONCLUSION 5-ASA-related renal disease was not found in our series, suggesting that the occurrence of renal impairment in IBD patients receiving these drugs is exceptional. Our results do not support the recommendation of serum creatinine monitoring in patients receiving 5-ASA treatment.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain.
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Tubulointerstitial nephritis as an extraintestinal manifestation of Crohn's disease. ACTA ACUST UNITED AC 2008; 4:693-7. [PMID: 18838984 DOI: 10.1038/ncpneph0955] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Accepted: 08/26/2008] [Indexed: 01/22/2023]
Abstract
BACKGROUND A 12-year-old boy presented to hospital with a 6-month history of crampy pre-defecation abdominal pain, non-bloody diarrhea, anorexia and weight loss. Investigations revealed hypochromic microcytic anemia, a low serum iron level, a low serum ferritin level and an elevated serum creatinine level. Histopathological examination of tissue specimens obtained at esophagogastroduodenoscopy and colonoscopy revealed features of Crohn's disease, and a renal biopsy demonstrated tubulointerstitial nephritis. A second case of tubulointerstitial nephritis in a patient with Crohn's disease, is also presented. INVESTIGATIONS Physical examination, laboratory tests including full blood count, electrolytes, renal function, serum albumin, urinalysis and 24 h urinary protein, esophagogastroduodenoscopy, colonoscopy, abdominal ultrasonography, dimercaptosuccinic acid scan, renal diethylene triamine pentaacetic acid clearance study and renal biopsy. DIAGNOSIS Tubulointerstitial nephritis secondary to Crohn's disease. MANAGEMENT Prednisone therapy (60 mg/day) for 1 month followed by a tapering schedule over 3 months.
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Gisbert JP, González-Lama Y, Maté J. 5-Aminosalicylates and renal function in inflammatory bowel disease: a systematic review. Inflamm Bowel Dis 2007; 13:629-38. [PMID: 17243140 DOI: 10.1002/ibd.20099] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nephrotoxicity has been described in some patients with inflammatory bowel disease (IBD) treated with 5-aminosalicylic acid (5-ASA). Studies with 5-ASA treatment in which serum creatinine or creatinine clearance was measured regularly show that nephrotoxicity is exceptional (mean rate of only 0.26% per patient-year). There have been several case reports, including 46 patients, of renal disease associated with 5-ASA treatment in patients with IBD. 5-ASA treatment-related nephrotoxicity is reported most often within the first 12 months, but also delayed presentation after several years has been shown. The absence of a clear relationship between 5-ASA dose and the risk of nephrotoxicity suggests that this complication is idiosyncratic rather than dose-related. Most of the patients with renal disease associated with 5-ASA treatment suffered interstitial nephritis, with symptoms and signs being nonspecific, which may delay detection for many months. The nephrotoxicity potential of mesalazine and sulfasalazine seems to be similar. The risk with different oral preparations of 5-ASA is probably too small to influence the choice of agent. Mesalazine should be withdrawn when renal impairment manifests in a patient with IBD; if this does not result in a fall in serum creatinine, then renal biopsy should be considered. A trial of high-dose steroid may be recommended in patients whose renal function does not respond to drug withdrawal. The optimal monitoring schedule of serum creatinine in patients receiving 5-ASA treatment remains to be established, as there is no evidence to date that either the test, or the frequency of testing, improves patient outcomes.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de la Princesa, Universidad Autónoma, Madrid, Spain.
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9
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Muller AF, Stevens PE, McIntyre AS, Ellison H, Logan RF. Experience of 5-aminosalicylate nephrotoxicity in the United Kingdom. Aliment Pharmacol Ther 2005; 21:1217-24. [PMID: 15882242 DOI: 10.1111/j.1365-2036.2005.02462.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
AIM To study 5-aminosalicylate nephrotoxicity in patients with inflammatory bowel disease in the UK. METHODS A detailed postal questionnaire was sent to all 1298 names in the British Society of Gastroenterology database and 290 consultant members of the Renal Association. The British Society of Gastroenterology reported new cases monthly, the Renal Association 6 monthly. Results were expressed as estimated glomerular filtration rate. RESULTS Retrospective study: cases--British Society of Gastroenterology:Renal Association 202:87, aged 15-76 years. Median peak (range) creatinine (British Society of Gastroenterology:Renal Association) - 300:301 (78-1200) micromol/L. Prospective study - 59 cases, median age 52 years (M:F ratio: 47:12). Median pre-treatment estimated glomerular filtration rate: 76.9 (123.9-39), at diagnosis 28.4 (80.5-3.6, creatinine range: 92-1361 micromol/L), recovery 46.8 [111.2-end stage renal failure] mL/min/1.73 m2. Recovery of renal function was significantly improved for patients treated for < 12 months [n = 10, median recovery estimated glomerular filtration rate 70.5 (92-26.9) vs. > 12 months 38.4 (111.2-end stage renal failure) mL/min/1.73 m2, P = 0.028]. CONCLUSIONS Regular monitoring of renal function may allow earlier detection of nephrotoxicity, particularly during the first year of therapy. Based on an inflammatory bowel disease prevalence in the United Kingdom of 412 x 10(5) with about 50% on treatment, we estimate that the incidence of clinical nephrotoxicity in patients taking 5-aminosalicylate therapy is approximately one in 4000 patients/year.
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Affiliation(s)
- A F Muller
- Department of Medicine, The Kent and Canterbury Hospital, Canterbury, Kent, UK.
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Abstract
Sterile pyuria is not an uncommon laboratory finding. This article explores the major causes of sterile pyuria, including infectious, systemic, structural and physiologic, and drug-related causes. It also discusses the differential diagnosis of eosinophiluria and the basic workup of sterile pyuria.
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Affiliation(s)
- R S Dieter
- Department of Medicine, University of Wisconsin, Madison 53562, USA
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Margetts PJ, Churchill DN, Alexopoulou I. Interstitial nephritis in patients with inflammatory bowel disease treated with mesalamine. J Clin Gastroenterol 2001; 32:176-8. [PMID: 11205659 DOI: 10.1097/00004836-200102000-00019] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Mesalamines are slow-release formulations of 5-aminosalicylic acid (5-ASA) and are effective as primary treatment and maintenance therapy in inflammatory bowel disease. Interstitial nephritis is a recognized side effect. We report two cases of biopsy-confirmed interstitial nephritis in patients being treated with 5-ASA. Both had a trial of steroid therapy. One patient had partial recovery of renal function but the other patient was in chronic renal failure and likely was approaching the need for dialysis. Interstitial nephritis is an under-recognized complication of 5-ASA therapy. Early identification and withdrawal of this drug can lead to a partial or complete reversal of renal dysfunction.
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Affiliation(s)
- P J Margetts
- Division of Nephrology, Faculty of Health Sciences, McMaster University Hamilton, Ontario, Canada
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Corrigan G, Stevens PE. Review article: interstitial nephritis associated with the use of mesalazine in inflammatory bowel disease. Aliment Pharmacol Ther 2000; 14:1-6. [PMID: 10632639 DOI: 10.1046/j.1365-2036.2000.00683.x] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
5-Aminosalicylic acid (5-ASA) has replaced sulphasalazine as first line therapy for mild to moderately active inflammatory bowel disease and is widely used. A number of reports have linked oral 5-ASA therapy to chronic tubulo-interstitial nephritis and this relationship is now well established. Despite increasing recognition of the potential for this serious adverse event, guidelines for monitoring renal function in patients prescribed 5-ASA preparations are not widely employed. Whilst the incidence of this adverse event in the population of patients with inflammatory bowel disease treated with mesalazine is low, the morbidity in an affected individual is high with some cases progressing to end-stage renal disease. Routine monitoring of renal function is simple and inexpensive and could prevent this outcome. Based on the available data, serum creatinine should be estimated prior to commencing treatment, monthly for the first 3 months, 3-monthly for the next 9 months, 6-monthly thereafter and annually after 5 years of treatment.
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Affiliation(s)
- G Corrigan
- Kent and Canterbury Hospital, Canterbury, UK
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Abstract
Renal and urologic complications are not uncommon in patients with inflammatory bowel disease, and can be directly or indirectly related to the underlying disease process or its treatment. Many of these patients have asymptomatic disease, or the urinary symptoms are nonspecific or overshadowed by bowel symptoms. By the time a urinary complication is considered, significant disease progression or renal damage may have occurred. These risks necessitate a high degree of diligence and periodic urologic evaluation as part of the long-term management of patients with inflammatory bowel disease.
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Affiliation(s)
- D S Pardi
- Inflammatory Bowel Disease Clinic, Division of Gastroenterology, Mayo Clinic and Foundation, Rochester, Minnesota, USA
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