1
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Pichi F, Aljeneibi S, Neri P. Tubulointerstitial Nephritis and Uveitis Syndrome in the United Arab Emirates. Ocul Immunol Inflamm 2024; 32:578-582. [PMID: 36794345 DOI: 10.1080/09273948.2023.2178939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/01/2023] [Accepted: 02/07/2023] [Indexed: 02/17/2023]
Abstract
PURPOSE To report the first series of tubulointerstitial nephritis (TINU) syndrome from the Middle East. METHODS We retrospectively included patients with elevated urine beta-2 microglobulin, and a diagnosis of TINU based on anterior uveitis with or without posterior involvement. Multimodal imaging, duration of follow-up, local and systemic treatment used were recorded. RESULTS 24 eyes of 12 patients (8 male, mean age 20.3 years) met the criteria for TINU. The most common posterior segment clinical finding was optic nerve head edema (41.7%), while on fluorescein angiography 58.3% and 75% of eyes had peripheral vascular and optic disc leakage, respectively. The mean follow-up was 2.5 years and all patients required immunomodulatory treatment. CONCLUSIONS Middle Eastern patients with TINU seem to have a male predominance, a bimodal distribution in terms of age, and present with ocular involvement first. Multimodal imaging is paramount in detecting subclinical inflammation and tailoring immunomodulatory treatment.
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Affiliation(s)
- Francesco Pichi
- Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Shaikha Aljeneibi
- Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Piergiorgio Neri
- Eye Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
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2
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Janetos TM, Lee PHA, Goldstein DA. Tubulointerstitial Nephritis and Uveitis Syndrome in Pediatric Patients. Ocul Immunol Inflamm 2023; 31:1955-1964. [PMID: 37983806 DOI: 10.1080/09273948.2023.2279689] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 10/31/2023] [Indexed: 11/22/2023]
Abstract
Tubulointerstitial nephritis and uveitis (TINU) syndrome is a disorder that was originally described in 1975. The syndrome, although diagnosed in all age ranges, is more frequently reported in pediatric patients. Diagnosis can be difficult, and its clinical spectrum is still being defined. In this article, we review the epidemiology, diagnosis, pathogenesis, clinical findings, prognosis, and treatment of both the ocular and renal disease. We comment on the current difficulties in diagnosis and study of the disease, its expanding clinical spectrum, and treatment strategies in pediatric patients.
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Affiliation(s)
- Timothy M Janetos
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Debra A Goldstein
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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3
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Palamaris K, Stylianou K, Destouni M, Stofas A, Theodoropoulou H, Kroustalakis N, Dermitzaki EK, Petrakis I, Pleros C, Theochari I, Sarantis P, Paliouras C, Gakiopoulou H. Tubulointerstitial Nephritis and Uveitis Syndrome: A Report of 6 Cases with Renal Biopsy and Electron Microscopy Evaluation. Nephron Clin Pract 2023; 148:204-214. [PMID: 37611557 DOI: 10.1159/000533402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 06/24/2023] [Indexed: 08/25/2023] Open
Abstract
Tubulointerstitial nephritis with uveitis syndrome is a rare, immune-mediated entity, characterized by oculo-renal inflammation. Diagnosis requires the exclusion of all other causes of tubulointerstitial nephritis (TIN). We present 6 patients with clinical, laboratory, and renal biopsy findings denotative of tubulointerstitial nephritis with uveitis syndrome. All our patients experienced ocular and renal manifestations, defined by bilateral uveitis and photosensitivity, along with a decline of renal function. In some patients, increased serum creatinine was accompanied by non-nephrotic range proteinuria, glucosuria or "full-blown" Fanconi syndrome. The rest of the laboratory evaluation was normal apart from the presence of elevated erythrocyte sedimentation rate and increased urine β2-microglobulin, as well as normochromic, normocytic anemia in some cases. All patients underwent renal biopsy. Histochemical (PAS, Masson, silver, Congo-red) and immunohistochemical stains for immune cell populations (CD3, CD20, CD4, CD8, PGM1, CD138) and for the assessment of β2-microglobulin were conducted. Electron microscopy examination of the biopsies was also performed. Follow-up, ranging from 18 months to 10 years, was available for 4 patients. Histological evaluation revealed interstitial inflammatory infiltration consisting mainly of lymphocytes, with a T-cell predominance, along with several macrophages. Inflammation severity varied among different patients, with some showing scarce foci of immune cell clusters, while others demonstrated a dense, diffuse interstitial infiltration. Interestingly, in 2 cases, a granulomatous pattern, characterized by non-necrotic, ill-defined granulomas was detected. Tubulitis was also encountered in some patients. A divergence was noted regarding the chronicity index, with different levels of tubular atrophy, interstitial fibrosis, and global glomerulosclerosis among different cases. β2-Microglobulin immunohistochemical evaluation revealed a substantial diminishment of cytoplasmic staining in tubular epithelial cells compared to control kidneys. The most notable finding derived from electron microscopy examination was the presence, in 1 patient, of scattered granular electron-dense deposits along some tubular basement membranes. First-line treatment included steroids, supplemented in some cases by additional immunosuppressive agents. Three patients experienced a partial or complete response, while progressive renal damage was observed in a case with severe chronic lesions and persistence of inflammation-triggering factor. Our cases seem to represent progressive stages within the continuum of disease evolution. Patients with more prominent inflammation might represent a more initial state, while those with a more severe chronicity index, probably depict more advanced stages. While the predominance of T-cells predicates a cell-mediated autoimmune mechanism, as the driving force of the disease occurrence, the presence of immune complexes in more advanced stages might indicate the involvement of humoral immunity as a late event during the disease course.
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Affiliation(s)
- Kostas Palamaris
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece,
| | - Kostas Stylianou
- Nephrology Department, Heraklion University Hospital, Heraklion, Greece
| | - Maria Destouni
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Anastasios Stofas
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | - Ioannis Petrakis
- Nephrology Department, Heraklion University Hospital, Heraklion, Greece
| | - Christo Pleros
- Nephrology Department, Heraklion University Hospital, Heraklion, Greece
| | - Irene Theochari
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panagiotis Sarantis
- Department of Biological Chemistry, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Harikleia Gakiopoulou
- First Department of Pathology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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4
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Southgate G, Clarke P, Harmer MJ. Renal outcomes in tubulointerstitial nephritis and uveitis (TINU) syndrome: a systematic review and meta-analysis. J Nephrol 2023; 36:507-519. [PMID: 36396848 DOI: 10.1007/s40620-022-01478-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 10/01/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Tubulointerstitial nephritis and uveitis syndrome (TINU) is a rare condition characterised by bilateral uveitis and interstitial nephritis. There is no nationally, or internationally agreed upon treatment regimen. A systematic review was undertaken to report the renal outcomes in TINU, and treatments used. METHODS Medline (1969-2021) and EMBASE (1988-2021) databases were searched for primary studies, clinical practice guidelines and case reports of adult and paediatric TINU cases, as defined by Mandeville criteria. Two reviewers identified articles meeting inclusion criteria (registered with PROSPERO). Data were extracted into a synthesis table and meta-analysis performed. Quality of case series was also assessed. RESULTS One hundred twenty-two articles were identified, totalling 257 cases included in the meta-analysis. Females were more commonly affected than males (2:1), and median age was 19 years. GFR at follow-up correlated with nadir GFR, and the proportion with GFR <90 ml/min/1.73 m2 was statistically different between adult and paediatric groups. Of the entire cohort, 40% had GFR <90 ml/min/1.73 m2 at follow-up. Glucocorticoid monotherapy was the most common treatment (70%); other strategies included no treatment (9%) and immunosuppressant drugs (e.g. azathioprine), mostly in steroid-resistant cases, or as 'steroid-sparing' alternatives. CONCLUSIONS The majority of literature regarding TINU is limited to case reports and case series. There are no prospective trials assessing the effects of different treatments on renal outcomes, and currently employed treatment strategies are physician-specific without a reliable evidence-base. Prospective data collection as part of multicentre trials should be a research focus to improve the evidence-base.
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Affiliation(s)
- Genevieve Southgate
- Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Patrick Clarke
- Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK
| | - Matthew J Harmer
- Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD, UK.
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5
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Regusci A, Lava SAG, Milani GP, Bianchetti MG, Simonetti GD, Vanoni F. Tubulointerstitial nephritis and uveitis syndrome: a systematic review. Nephrol Dial Transplant 2022; 37:876-886. [PMID: 33561271 DOI: 10.1093/ndt/gfab030] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Tubulointerstitial nephritis and uveitis (TINU) syndrome is defined as the occurrence of tubulointerstitial nephritis (TIN) and uveitis in the absence of other systemic diseases. The most comprehensive review on this condition was published in 2001. METHODS We conducted a systematic review of the literature for cases of TINU syndrome. MEDLINE and Embase databases were screened. Full-length articles or letters reporting cases with both TIN and uveitis were selected. We investigated differences between males and females and paediatric and adult cases. Multivariate analysis was performed to identify potential risk factors for chronic kidney disease (CKD) development. RESULTS A total of 233 articles reporting 592 TINU cases were retained for the analysis. The median age of the included subjects was 17 years (interquartile range 13-46) with a female predominance (65%). Uveitis most frequently (52%) followed renal disease and was mostly anterior (65%) and bilateral (88%). Children tended to have more ocular relapses, while they were slightly less likely than adults to suffer from acute kidney injury and to develop CKD. Adult age as well as posterior or panuveitis were associated with an increased risk of developing CKD. CONCLUSIONS TINU affects both children and adults, with some differences between these two categories. Adult age and the presence of a posterior uveitis or panuveitis appear to be associated with the development of CKD.
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Affiliation(s)
- Alessia Regusci
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Sebastiano A G Lava
- Pediatric Cardiology Unit, Department of Pediatrics, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Gregorio P Milani
- Pediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Mario G Bianchetti
- Faculty of Biomedical Sciences, University of Southern Switzerland, Lugano, Switzerland
| | - Giacomo D Simonetti
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, University of Southern Switzerland, Lugano, Switzerland
| | - Federica Vanoni
- Pediatric Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
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6
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Petek T, Frelih M, Marčun Varda N. Tubulointerstitial nephritis and uveitis syndrome in an adolescent female: a case report. J Med Case Rep 2021; 15:443. [PMID: 34479628 PMCID: PMC8417986 DOI: 10.1186/s13256-021-03017-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/20/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Tubulointerstitial nephritis with uveitis syndrome is a rare disease affecting mainly children and young women. Tubulointerstitial nephritis with uveitis is a diagnosis of exclusion, requiring a high degree of clinical suspicion. Studies report recent infections or certain drugs as precipitating factors of a lymphocytic oculorenal immune response. The prognosis is usually favorable with topical and systemic corticosteroid therapy. CASE PRESENTATION We report a literature review and the case of a 14-year-old white girl, who presented to the ophthalmology department with features of one-sided uveitis. Upon transfer of patient to nephrological care, diagnostic work-up revealed renal involvement. Renal biopsy showed a mixed-cell and granulomatous tubulointerstitial nephritis with some noncaseating granulomas, leading to a diagnosis of tubulointerstitial nephritis with uveitis syndrome. With topical ocular and systemic corticosteroid therapy, the patients' condition improved over several weeks. CONCLUSIONS Our case highlights the importance of early recognition and treatment of this syndrome, where cross-specialty care typically leads to a favorable outcome.
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Affiliation(s)
- Tadej Petek
- Department of Pediatrics, University Medical Center Maribor, Ljubljanska ulica 5, Maribor, Slovenia.
| | - Maja Frelih
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Korytkova 2, Ljubljana, Slovenia
| | - Nataša Marčun Varda
- Department of Pediatrics, University Medical Center Maribor, Ljubljanska ulica 5, Maribor, Slovenia
- Faculty of Medicine, University of Maribor, Taborska ulica 8, Maribor, Slovenia
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7
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Long-term outcome of biopsy-proven idiopathic tubulointersitial nephritis with or without uveitis in children-a nationwide follow-up study. Pediatr Nephrol 2021; 36:3663-3671. [PMID: 34008125 PMCID: PMC8497450 DOI: 10.1007/s00467-021-05060-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/07/2021] [Accepted: 03/18/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Only a few studies reporting the long-term outcome of children with idiopathic tubulointerstitial nephritis (TIN) and uveitis syndrome (TINU) are available. We studied the long-term kidney and ocular outcome in a nationwide cohort of children with TIN or TINU. METHODS All patients followed up for a minimum of 1 year by a paediatrician and an ophthalmologist were enrolled. The data on plasma creatinine (P-Cr), estimated glomerular filtration rate (eGFR), proteinuria, hypertension and uveitis were collected retrospectively. RESULTS Fifty-two patients were studied. Median age at time of diagnosis was 13.1 (1.8-16.9) years and median follow-up time was 5.7 (1.1-21.2) years. Forty-five (87%) patients were initially treated with glucocorticoids. The median of the maximum P-Cr was 162 μmol/l (47-1,016) and that of eGFR 47 ml/min/1.73m2 (8-124). Uveitis was diagnosed in 33 patients (63%) and 21 (40%) patients developed chronic uveitis. P-Cr normalised in a median of 2 months. Eleven (21%) patients had nephritis recurrence during or after discontinuation of glucocorticoids. At the latest follow-up, 13 (25%) patients had eGFR < 90 ml/min/1.73m2 (median 83; 61-89 ml/min/1.73m2). Six patients had tubular proteinuria; all presented with TIN without uveitis. Seven (13%) patients were hypertensive. Eleven (21%) patients had uveitis. One patient developed uraemia and was later transplanted. CONCLUSIONS Our study questions the previously reported good long-term kidney and ocular outcome of patients with TIN/TINU. Decreased kidney function and/or ocular co-morbidities may persist for several years; thus, both kidney and ocular follow-up for at least 1 year is warranted. A higher resolution version of the Graphical abstract is available as Supplementary information.
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8
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Zhao Y, Huang J, Su T, Yang Z, Zheng X, Yang L, Zhou X, Yu X, Wang H, Wang S, Liu G, Yang L. Acute Kidney Injury Relevant to Tubulointerstitial Nephritis with Late-Onset Uveitis Superimposed by Thrombotic Microangiopathy: A Case Report and Review of the Literature. KIDNEY DISEASES 2020; 6:414-421. [PMID: 33313062 DOI: 10.1159/000507668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/01/2020] [Indexed: 11/19/2022]
Abstract
Background The syndrome of tubulointerstitial nephritis and uveitis (TINU) is an uncommon and multisystemic autoimmune disorder. This review reports a rare case of TINU being superimposed on thrombotic microangiopathy (TMA) and, by comparing with the available literature, also summarizes the clinical features, associated conditions, treatment, and outcome of patients with TINU. Summary Herein, we report the case of a 37-year-old male patient with acute kidney injury (AKI) clinicopathologically identified as malignant hypertension-induced TMA superimposed by acute tubulointerstitial nephritis, which was suspected to be related to drug hypersensitivity. After treatment with oral prednisone combined with a renin-angiotensin system inhibitor, the patient achieved partial renal recovery and was withdrawn from hemodialysis. Recurrent AKI concomitant with new-onset asymptomatic uveitis was detected during routine clinical follow-up after cessation of prednisone. TINU was then diagnosed, and prednisone followed by cyclophosphamide was prescribed. The patient achieved better renal recovery than in the first round of treatment and maintained stable renal function afterward. By reviewing the literature, 36 cases were reported as TINU superimposed on other conditions, including thyroiditis, osteoarthropathy, and sarcoid-like noncaseating granulomas. Key messages TINU could be complicated by many other conditions, among which TMA is very rare. When presented as AKI, kidney biopsy is important for differential diagnosis. The case also shows that recurrent AKI with concomitant uveitis after prednisone withdrawal strongly suggested the need for long-term follow-up and elongated prednisone therapy for TINU syndrome.
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Affiliation(s)
- Youlu Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Junwen Huang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Zhikai Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Xizi Zheng
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Liu Yang
- Department of Ophthalmology, Peking University First Hospital, Beijing, China
| | - Xujie Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Xiaojuan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Hui Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Suxia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Gang Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Renal Pathology Center, Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
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9
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Jia Y, Su T, Gu Y, Li C, Zhou X, Su J, Sun P, Tang J, Yang L, Liu G, Yang L. HLA-DQA1, -DQB1, and -DRB1 Alleles Associated with Acute Tubulointerstitial Nephritis in a Chinese Population: A Single-Center Cohort Study. THE JOURNAL OF IMMUNOLOGY 2018; 201:423-431. [PMID: 29858267 DOI: 10.4049/jimmunol.1800237] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/08/2018] [Indexed: 12/24/2022]
Abstract
Acute tubulointerstitial nephritis (ATIN) is a common cause of acute kidney injury with various origins. HLA-DQA1, -DQB1, and -DRB1 have been associated with development of tubulointerstitial nephritis and uveitis (TINU) syndrome in case reports and small case series, but information about HLA genetic susceptibility to drug hypersensitivity-related ATIN (D-ATIN) or other types of ATIN is limited. In this article, we genotyped 154 patients with ATIN of different causes and 200 healthy controls at HLA-DQA1, -DQB1, and -DRB1 loci. We found that there was no difference between patients with D-ATIN and TINU in the carrier's frequency of HLA-DQA1, -DQB1, or -DRB1 Patients with Sjogren's syndrome-ATIN and IgG4-related ATIN presented a different pattern of tested HLA alleles. HLA-DQA1*0104 (p value corrected by false discovery rate method [Pc] = 4.72 × 10-22, odds ratio [OR] = 13.81), -DQB1*0503 (Pc = 1.95 × 10-14, OR = 9.51), and -DRB1*1405 (Pc = 8.06 × 10-19, OR = 12.80) were significant risk alleles for the occurrence of D-ATIN and TINU. There were no significant associations between tested HLA alleles and ATIN induced by other causes. Patients with D-ATIN/TINU carrying HLA-DQA1*0104/DQB1*0503/DRB1*1405 had higher peak serum creatinine and more severe renal tubulointerstitial inflammatory impairment. They also had significantly higher levels of tubular HLA-DR and HLA-DQ expression, which were correlated with the numbers of interstitial CD4+ T lymphocytes (r = 0.975, p < 0.001 and r = 0.832, p = 0.005, respectively) and monocytes/macrophages (r = 0.721, p = 0.004 and r = 0.615, p = 0.02, respectively). In conclusion, patients with D-ATIN or TINU have genetic susceptibility in HLA-DQA1, -DQB1, and -DRB1 alleles. HLA-DQA1*0104/DQB1*0503/DRB1*1405 serves as a significant risk haplotype for development of D-ATIN and TINU, which might facilitate renal tubulointerstitial inflammation by enhancing Ag-presenting capacity of renal tubular cells.
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Affiliation(s)
- Yan Jia
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China.,Institute of Nephrology, Peking University, Beijing 100034, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China.,Institute of Nephrology, Peking University, Beijing 100034, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Yanghui Gu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China.,Renal Division, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen 518000, China; and
| | - Cui Li
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China
| | - Xujie Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China.,Institute of Nephrology, Peking University, Beijing 100034, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Jianqun Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China.,Institute of Nephrology, Peking University, Beijing 100034, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Pingping Sun
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China.,Institute of Nephrology, Peking University, Beijing 100034, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Jiawei Tang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China.,Institute of Nephrology, Peking University, Beijing 100034, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Liu Yang
- Ophthalmology Division, Peking University First Hospital, Beijing 100034, China
| | - Gang Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China.,Institute of Nephrology, Peking University, Beijing 100034, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
| | - Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing 100034, China; .,Institute of Nephrology, Peking University, Beijing 100034, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing 100034, China
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10
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Clive DM, Vanguri VK. The Syndrome of Tubulointerstitial Nephritis With Uveitis (TINU). Am J Kidney Dis 2018; 72:118-128. [PMID: 29429748 DOI: 10.1053/j.ajkd.2017.11.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 11/13/2017] [Indexed: 01/21/2023]
Abstract
The syndrome of tubulointerstitial nephritis and uveitis (TINU) is a multisystemic autoimmune disorder that may occur in response to various environmental triggers, including drugs and microbial pathogens. Evidence exists of HLA antigen-related genetic predisposition to developing TINU. The resulting inflammation affects chiefly the ocular uvea and renal tubules, although other organs may be involved. TINU is uncommon; only about 200 cases are on record since its original description 40 years ago, although it is possible that new ones are no longer being reported. Although its incidence is highest in children and adolescents, all ages may be affected. Renal and ocular inflammation may be clinically severe and persistent, but the prognosis for the majority of patients with TINU is favorable. Owing to its low prevalence, no standard therapeutic protocols have been established, but most reported cases have been treated with corticosteroids or other immunomodulatory agents. TINU has many features in common with sarcoidosis, the main clinical entity from which it must be distinguished. This article begins with an illustrative case vignette, followed by an overview of the syndrome and current theories regarding its pathogenesis.
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Affiliation(s)
- David M Clive
- Division of Renal Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, MA.
| | - Vijay K Vanguri
- Department of Pathology, University of Massachusetts Medical School, Worcester, MA
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FOXP3 + T cells are present in kidney biopsy samples in children with tubulointerstitial nephritis and uveitis syndrome. Pediatr Nephrol 2018; 33:287-293. [PMID: 28894974 DOI: 10.1007/s00467-017-3796-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 08/10/2017] [Accepted: 08/24/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Tubulointerstitial nephritis (TIN) is an inflammatory disease of unknown pathogenesis. To evaluate a possible role of regulatory T cells (Tregs) in the pathophysiology of TIN with (TINU) and without uveitis, we investigated the presence and quantity of FOXP3+ T regulatory lymphocytes in diagnostic kidney biopsies from pediatric patients. METHODS A total of 33 patients (14 TIN and 19 TINU) were enrolled. The quantity of CD4+, FOXP3+ and double-positive T cells in formalin-fixed kidney biopsies was determined using double label immunohistochemistry with anti-human CD4 and FOXP3 antibodies. RESULTS FOXP3 staining was successful in all 33 patients. In patients with chronic uveitis, the density of FOXP3+ cells was significantly lower (p = 0.046) than in TIN patients without uveitis or with uveitis lasting <3 months. CD4+ staining was successful in 23 patients. The density of all lymphocytes (CD4+, CD4+FOXP3+ and FOXP3+ cells) was significantly lower (p = 0.023) in patients with chronic uveitis than in other patients. CONCLUSIONS FOXP3+ T cells are present in kidney biopsy samples from TIN and TINU patients. In patients with chronic uveitis, the density of FOXP3+ T cells is significantly lower than in other patients, suggesting a different pathomechanism for these clinical conditions.
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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: 91] [Impact Index Per Article: 13.0] [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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Hamdan JM, Obeidat FN. Tubulo-interstitial nephritis and uveitis syndrome in a 6-year-old boy: case report. ACTA ACUST UNITED AC 2013; 26:145-8. [PMID: 16709335 DOI: 10.1179/146532806x107502] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
A 6-year-old boy presented with a 4-month history of anorexia, weight loss and fatigue and was found to have tubulo-interstitial nephritis and uveitis (TINU) syndrome. After 2 months of corticosteroid therapy, resolution of the uveitis was almost complete but renal function showed only partial improvement. He was still in renal failure 6 months after diagnosis, but there was no relapse of the uveitis. Although the prognosis of TINU in children and adults is reported to be excellent, the outcome in young children can be less favourable, probably owing to delayed diagnosis and initiation of treatment.
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Affiliation(s)
- Jahed M Hamdan
- Department of Pediatrics, King Abdullah University Hospital, Jordan University of Science and Technology, Irbid, Jordan.
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Peräsaari J, Saarela V, Nikkilä J, Ala-Houhala M, Arikoski P, Kataja J, Rönnholm K, Merenmies J, Nuutinen M, Jahnukainen T. HLA associations with tubulointerstitial nephritis with or without uveitis in Finnish pediatric population: a nation-wide study. ACTA ACUST UNITED AC 2013; 81:435-41. [PMID: 23594347 DOI: 10.1111/tan.12116] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 03/10/2013] [Accepted: 03/21/2013] [Indexed: 11/30/2022]
Abstract
The human leukocyte antigen (HLA) genotype has been shown to associate with tubulointerstitial nephritis (TIN) and tubulointerstitial nephritis with uveitis syndrome (TINU). The association of HLA genes with TIN was examined in this nation-wide study. HLA genotyping was performed in 31 pediatric patients with biopsy-proven TIN. All patients were examined by an ophthalmologist to diagnose possible uveitis. Class II HLA genotypes of TIN patients were compared with the Finnish reference population. We found a significant association between the HLA alleles DQA1*04:01 [risk ratio (RR) 5.0, 95% confidence interval (CI) 2.0-11.2], DQB1*04:02 (RR 2.7, 95% CI 1.4-5.3), and DRB1*08 (RR 3.8, 95% CI 1.5-8.4) and TIN. Uveitis was found in 20/31 (64.5%) patients. HLA genotyping of the TINU patients showed additional risk HLA alleles: DQA1*01:04 (RR 6.1, 95% CI 1.5-17.8), and DRB1*14 (RR 8.2, 95% CI 2.2-22.1). The alleles DQA1*01:04 (RR 8.8, 95% CI 2.2-26.5), DQA1*04:01 (RR 3.2, 95% CI 1.2-7.3), and DRB1*14 (RR 12.0, 95% CI 3.2-33.0) were more frequent in patients with TIN and chronic uveitis than in reference population. The HLA class II haplotype DQA1*04:01/DQB1:04:02/DRB1*08 was the most common combination in our study population (58.1%). None of the patients had haplotype DQA1*04:01/DQB1*06:02/DRB1*15, which is common in Finland. HLA genotype did not predict the renal outcome. We found a strong association between certain HLA genotypes both in TIN and TINU patients. The TIN/TINU-associated HLA alleles appear to vary depending on study population.
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Affiliation(s)
- J Peräsaari
- Clinical Laboratory, Finnish Red Cross Blood Service, Helsinki, Finland
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Saarela V, Nuutinen M, Ala-Houhala M, Arikoski P, Rönnholm K, Jahnukainen T. Tubulointerstitial nephritis and uveitis syndrome in children: a prospective multicenter study. Ophthalmology 2013; 120:1476-81. [PMID: 23511116 DOI: 10.1016/j.ophtha.2012.12.039] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 12/14/2012] [Accepted: 12/19/2012] [Indexed: 12/31/2022] Open
Abstract
PURPOSE To evaluate the occurrence and characteristics of uveitis related to tubulointerstitial nephritis (TIN) in children. DESIGN Prospective, observational, multicenter, partly placebo-controlled treatment trial. PARTICIPANTS Nineteen children with a biopsy-proven TIN. METHODS Patients were treated with prednisone or followed without treatment. In addition to the nephrologic evaluations, the prospective follow-up included structured ophthalmological examinations at the onset of TIN and at 3 and 6 months after the diagnosis. MAIN OUTCOME MEASURES Occurrence, clinical features, and outcome of uveitis. RESULTS Some 84% (16/19) of the patients had uveitis, 83% (5/6) in the nontreatment group and 82% (9/11) in the prednisone-treated group. The remaining 2 patients, originally in the nontreatment group, were switched to the prednisone group after 2 weeks. Both of them developed uveitis. Altogether, 3 patients developed uveitis during prednisone treatment and 2 patients showed worsening of uveitis despite the systemic corticosteroid. Some 50% (8/16) of the patients with uveitis presented with no ocular symptoms; 88% (14/16) of the patients had a chronic course of uveitis. Two patients were diagnosed with uveitis before nephritis; nephritis and uveitis were diagnosed within 1 week from each other in 7 patients, and uveitis developed 1 to 6 months after the diagnosis of TIN in 7 patients. CONCLUSIONS There was no statistically significant difference in the occurrence of uveitis in patients with TIN in the prednisone and nontreatment groups. In this study, the occurrence of uveitis associated with TIN was considerably higher than previously reported. Uveitis related to TIN may develop late and is often asymptomatic. The ophthalmological follow-up of all patients with TIN is warranted for at least 12 months starting with 3-month intervals. FINANCIAL DISCLOSURE(S) The authors have no proprietary or commercial interest in any material discussed in this article.
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Affiliation(s)
- Ville Saarela
- Department of Ophthalmology, Oulu University Hospital, Oulu, Finland.
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Ulinski T, Sellier-Leclerc AL, Tudorache E, Bensman A, Aoun B. Acute tubulointerstitial nephritis. Pediatr Nephrol 2012; 27:1051-7. [PMID: 21638156 DOI: 10.1007/s00467-011-1915-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2011] [Revised: 04/29/2011] [Accepted: 05/04/2011] [Indexed: 12/27/2022]
Abstract
Acute tubulointerstitial nephritis (TIN) is a frequent cause of acute renal failure, characterised by the presence of inflammatory cell infiltrate in the interstitium of the kidney. Immuno-allergic reaction to certain medications, mainly non-steroidal anti-inflammatory drugs and antibiotics are by far the most important etiology for TIN today, but other situations such as infections, toxins, and vasculitis are known to induce TIN. Incidence of TIN is increasing, probably due to prescription habits and NSAID overuse, representing 3-7% of acute kidney injury in biopsies in children. Avoidance of the causal substance and rapid steroid therapy are hallmarks for patient care, but spontaneous initial recovery is very frequent and the general prognosis seems satisfactory. However, development of chronic TIN, without response to steroid or other immunosuppressive treatment, is possible. As the largest part of TIN is secondary to certain drugs, clear indications in particular for NSAID or antibiotics should be respected to reduce the number of TIN cases.
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Affiliation(s)
- Tim Ulinski
- Department of Pediatric Nephrology, Armand Trousseau Hospital (APHP), University Pierre & Marie Curie, Paris 6, 26, Avenue du Docteur Arnold Netter, 75012, Paris, France.
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Martin TM, Rosenbaum JT. An update on the genetics of HLA B27-associated acute anterior uveitis. Ocul Immunol Inflamm 2011; 19:108-14. [PMID: 21428748 DOI: 10.3109/09273948.2011.559302] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The discovery of the association of HLA B27 with spondyloarthropathy led to more questions than answers about the role of this gene in disease susceptibility. The realization that HLA B27 was not responsible for all of the genetic effects helped to lay a foundation for further investigation into the genetics of uveitis. Over several decades, genetic findings have provided clues to advance the understanding of mechanisms of uveitis and to catalyze new research on diagnostics, animal models, and therapies. From the early candidate gene studies on immune mediators to the recent genome-wide investigations, much has been discovered. However, these discoveries have come with the caveat that a genetic finding does not automatically reveal the disease-relevant functional effect of the associated variant.
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Affiliation(s)
- Tammy M Martin
- Department of Ophthalmology, Casey Eye Institute, Oregon Health & Science University, Portland, OR 97239, USA
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Liakopoulos V, Ioannidis I, Zengos N, Karabatsas CH, Karasavvidou F, Salmas M, Kanelaki E, Eleftheriadis T, Stefanidis I. Tubulointerstitial Nephritis and Uveitis (TINU) Syndrome in a 52-Year-Old Female: A Case Report and Review of the Literature. Ren Fail 2009; 28:355-9. [PMID: 16771253 DOI: 10.1080/08860220600577775] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare entity first described in 1975, affecting mainly young women and adolescents. We present a case of a 52-year-old female patient (one of the oldest in the literature) who complained of fever, anorexia, nausea, and vomiting. After she was admitted to our hospital, laboratory tests revealed tubular proteinuria, elevated erythrocyte sedimentation rate (ESR), anemia, and renal insufficiency (serum creatinine 4.2 mg/dL) with metabolic acidosis. Ophthalmologic examination revealed anterior uveitis (iritis) and renal biopsy showed acute tubulointerstitial nephritis. The diagnosis of TINU syndrome was established and the patient was treated with oral corticosteroids. All symptoms and ophthalmologic abnormalities disappeared after 6 weeks of treatment. Renal function also recovered completely and remained stable at follow-up. TINU syndrome should be considered in the differential diagnosis of unexplained tubulointerstitial nephritis, especially in the presence of ocular findings. Corticosteroid therapy is still controversial, but it helps in the quick resolution of renal and mainly eye abnormalities.
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Affiliation(s)
- Vassilios Liakopoulos
- Department of Nephrology, Medical School, University of Thessaly, 41221 Larissa, Greece
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Li JY, Yong TY, Bennett G, Barbara JA, Coates PTH. Human leucocyte antigen DQ alpha heterodimers and human leucocyte antigen DR alleles in tubulointerstitial nephritis and uveitis syndrome. Nephrology (Carlton) 2009; 13:755-7. [PMID: 19154326 DOI: 10.1111/j.1440-1797.2008.00984.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Jordan Yz Li
- Department of Nephrology, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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Dusek J, Urbanova I, Stejskal J, Seeman T, Vondrak K, Janda J. Tubulointerstitial nephritis and uveitis syndrome in a mother and her son. Pediatr Nephrol 2008; 23:2091-3. [PMID: 18528711 DOI: 10.1007/s00467-008-0879-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 04/30/2008] [Accepted: 05/07/2008] [Indexed: 11/24/2022]
Abstract
A mother and her son, both with tubulointerstitial nephritis and uveitis syndrome (TINU) are reported. The nephritis presented itself at 13 years in the mother and at 10 years in her son. Glomerular filtration (GFR) decreased in both, and renal biopsies confirmed the diagnosis. Nephritis preceded the onset of uveitis in both. Clinical course and renal function improved quickly on oral steroids in the boy. The mother's hyperazotemia decreased spontaneously (without steroids), but not to normal range, and remained stable for 35 years of follow-up. Local steroids due to recurrences of uveitis were repeatedly needed in both. We believe this is the first report on familial occurrence of inherited TINU syndrome in two generations.
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Affiliation(s)
- Jiri Dusek
- Department of Pediatrics, University Hospital Motol, Charles University, 2nd Medical School, Prague, Czech Republic.
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Affiliation(s)
- L C Herlitz
- Department of Pathology, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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Mackensen F, Smith JR, Rosenbaum JT. Enhanced recognition, treatment, and prognosis of tubulointerstitial nephritis and uveitis syndrome. Ophthalmology 2007; 114:995-9. [PMID: 17383731 DOI: 10.1016/j.ophtha.2007.01.002] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2006] [Revised: 12/31/2007] [Accepted: 01/02/2007] [Indexed: 12/01/2022] Open
Abstract
PURPOSE Tubulointerstitial nephritis and uveitis syndrome (TINU) is a specific form of uveitis that is unfamiliar to most ophthalmologists. Thus, it is frequently overlooked in differential diagnosis. We hypothesized that recognition of subsets of uveitis can facilitate the diagnosis of rare entities such as TINU. DESIGN Retrospective case series. PARTICIPANTS One thousand nine hundred eighty-five patients with uveitis. METHODS We performed a computerized database analysis of patients evaluated for uveitis at the Casey Eye Institute from September 1985 until May 2005. The database includes details about ocular inflammation, including specific diagnosis, anatomic location, laterality, continuity, onset, complications, HLA-B27 status, and relative diagnostic certainty. Additionally, we reviewed all charts of patients diagnosed with TINU or with a presentation of uveitis that was typical of TINU (i.e., bilateral sudden-onset anterior uveitis). MAIN OUTCOME MEASURES Prevalence of TINU in identifiable subsets of patients with uveitis, visual acuity (VA), and renal function. RESULTS Individuals with TINU (n = 33) represented 1.7% of all patients with uveitis. However, TINU was diagnosed in 32 of the 316 patients (10%) presenting with bilateral sudden-onset anterior uveitis and in 20 of 62 of these patients (32%) who were younger than 20 years. Creatinine levels were more likely to be elevated in patients older than 40. Most patients maintained excellent VA and did not develop clinically significant renal impairment. CONCLUSION Tubulointerstitial nephritis and uveitis syndrome is a common cause of uveitis among patients who present with bilateral sudden-onset anterior uveitis. The size of this series clarifies the understanding of the relationship between renal and ocular disease; facilitates recognition of the syndrome; and adds to the knowledge on prognosis, complications, and role of antecedent medications.
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Dincer AP, Dincer HE, Model A. A Case of Tubulointerstitial Nephritis and Uveitis in an Adult Male. Int Urol Nephrol 2005; 37:123-7. [PMID: 16132774 DOI: 10.1007/s11255-004-2357-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We report a case of tubulointerstitial nephritis and uveitis (TINU) syndrome in an adult male. A 40-year-old man was found to have bilateral anterior uveitis and mild renal insufficiency with high urinary beta-2 microglobulin. Work up for connective tissue and infectious diseases were negative. His kidney function normalized spontaneously and remained normal at 1 year without intervention. Uveitis responded completely to local corticosteroid treatment and has not recurred.
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Affiliation(s)
- Ayse P Dincer
- Division of Neoplastic Diseases and Related Disorders, Medical College of Wisconsin, 9200 W Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Kadanoff R, Lipps B, Khanna A, Hou S. Tubulointerstitial Nephritis With Uveitis (TINU): A Syndrome Rheumatologists Should Recognize. J Clin Rheumatol 2004; 10:25-7. [PMID: 17043457 DOI: 10.1097/01.rhu.0000111313.32464.a6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Patients with uveitis such as the patient whose case is reported here are often referred to rheumatologists for investigation of possible underlying systemic diseases. This patient presented with decreased vision, photophobia, weight loss, and fevers and was found to have uveitis, elevated creatinine, and interstitial nephritis. This raised consideration of a variety of systemic diseases before she was determined to have the tubulointerstitial nephritis with uveitis (TINU) syndrome. The TINU syndrome, although known to some ophthalmologists and nephrologists, is still rather obscure. Uncommon but not rare with 133 cases in the literature, TINU syndrome should be one more diagnosis to be considered in patients with uveitis. The median age of onset is 15, but it ranges from 9 to 74. There is a 3:1 female preponderance. Response to corticosteroids, which are used in 80% of reported cases, is rapid. The prognosis for the renal disorder is excellent, although the uveitis often recurs or remains chronic.
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Affiliation(s)
- Ruth Kadanoff
- From the Sections of *Rheumatology and †Nephrology, Department of Medicine, and the ‡Section of Ophthalmology, Department of Surgery, Loyola University, Maywood, Illinois
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