Tubulointerstitial nephritis and uveitis

Tubulointerstitial Nephritis and Uveitis Syndrome Presenting with Scleritis

PURPOSE

To report two patients who presented with scleritis associated with tubulointerstitial nephritis and uveitis syndrome (TINU).

RESULTS

A 13-year-old male initially presenting with unilateral panuveitis with scleritis in the fellow eye was ultimately diagnosed with TINU. A 33-year-old male previously diagnosed with TINU presented with recurrent bilateral episcleritis as well as bilateral scleritis eight years after his first episode of bilateral anterior uveitis. Both patients' scleritis responded to local corticosteroids and systemic immunosuppression.

CONCLUSIONS

Scleritis should be considered among the ocular manifestations of TINU.

Clinical outcomes in paediatric tubulointerstitial nephritis and uveitis syndrome (TINU)

PURPOSE

To evaluate the clinical presentation, course, and outcomes of uveitis in paediatric patients with tubulointerstitial nephritis and uveitis syndrome (TINU).

METHODS

Multicentric Retrospective Cohort Study 110 patients ≤21 years of age diagnosed with TINU from 10 sites across the United States and Canada. Clinical diagnosis of TINU required uveitis diagnosed by an ophthalmologist, elevated serum creatinine (SCr) and elevated urine β2-microglobulin (β2M) or abnormal urinalysis. Renal biopsy and systemic illness were not mandatory. Univariate and multivariate analysis was performed to analyse risk factors and treatment modalities.

RESULTS

Median age was 13 years (Range (5.9-18.4); 52% male); median follow-up, 1.6 years (IQR 0.98-4.02). Uveitis was symptomatic in 90%, with bilateral anterior uveitis in 94%. Ninety-two (84%) patients required immunomodulatory treatment (IMT). Methotrexate (n = 44) and mycophenolate mofetil (n = 39) were the first agents after oral corticosteroids. 45% required addition of biologic agents (Adalimumab [n = 33], Infliximab [n = 8]). Younger age (p = 0.018), male sex (p = 0.011), and higher uveitis grade at presentation (p = 0.031) were associated with greater IMT ( ≥ 2) requirement. 53% had uveitis recurrence compared to 16% with nephritis recurrence. At the most recent visit, nephritis was controlled in 90%, while uveitis in 74%. Four (4%) patients required glaucoma surgery. Nine (8%) patients had renal complications.

CONCLUSIONS

Most patients with TINU require steroid-sparing IMT for control of uveitis, with nearly half requiring addition of biologic agents. Urinalysis, urine β2M and SCr testing should be considered in children presenting with uveitis, especially when the disease is bilateral and anterior.

TINU: A Multisystemic Inflammatory Disorder-Case Report and Literature Review

Background. The syndrome of tubulointerstitial nephritis and uveitis (TINU) is a rare oculorenal condition, mainly seen in children and women. The underlying cause of this disease is unknown. Case Presentation. We report a 24-year-old male without any past medical history, diagnosed with bilateral uveitis and azotemia. Biopsy revealed tubulointerstitial nephritis, consistent with TINU syndrome. Fluorescein angiogram revealed peripheral retinal vasculitis. Discussion. TINU is a rare disorder that needs to be distinguished from sarcoidosis, Sjogren's disease, and tuberculosis. Treatment is indicated in patients with progressive renal insufficiency, consisting of steroid therapy. Most patients recover kidney function. Its early recognition is important to offer the best chance of organ preservation.

Mimickers of anterior uveitis, scleritis and misdiagnoses- tips and tricks for the cornea specialist

BACKGROUND

Anterior uveitis, inflammation of the anterior chamber and related structures, is a cohort of diseases that can present to almost any general or sub-specialty Ophthalmology practice. Its features classically involve anterior chamber cell and flare. Below the surface of these two signs exist a panoply of diagnoses. BODY: The purpose of this review is to provide a general framework for diagnoses of anterior uveitis that are often missed as well as non-uveitic pathologies that often mimic anterior uveitis. Diagnostic deviation in either direction can have vision-threatening and rarely life-threatening consequences for patients. Using a comprehensive literature review we have collected a broad spectrum of etiologies of anterior uveitis that are easily missed and non-uveitic pathologies that can masquerade as anterior uveitis.

CONCLUSIONS

We present a focused review on specific misdiagnosed anterior uveitis pathologies and some of the conditions that can masquerade as anterior uveitis and scleritis.

Ocular manifestations and clinical outcomes in Tubulointerstitial Nephritis and Uveitis Syndrome (TINU)

PURPOSE

To describe the various ocular clinical features and visual outcomes in Tubulointerstitial Nephritis and Uveitis Syndrome (TINU).

METHODS

The medical records of 13 patients (26 eyes) diagnosed with TINU were reviewed.

RESULTS

Twenty-six (26) eyes of 13 patients with TINU were reviewed in this study. The median age at onset of uveitis was 14 (range, 9-45). Eight (61.5%) subjects were female. The median follow-up of patients was 30 months (range, 6-89 months). Posterior segment findings were seen in 18 eyes of 9 patients (69.2%). The most common posterior findings were optic nerve head inflammation (16 eyes, 88.8%) and retinal vasculitis (13 eyes, 72.2%). Other posterior findings included vitritis (8 eyes, 44.4%), macular edema (6 eyes, 33.3%), snowball (4 eyes, 22.2%), and chorioretinal lesions (2 eye, 11.1%). Eight patients had fluorescein angiography (FA) data available and most eyes had retinal capillary leakage (13 eyes, 81.2%) followed by optic disc staining/leakage (12 eyes, 75%). Twelve (12) patients (92.3%) were treated with immunomodulatory treatment (IMT) and/or biologics. Five patients (%38.4) required biologics to control intraocular inflammation.

CONCLUSION

Posterior segment involvement may be common in patients with TINU syndrome. FA provides significant information for detecting posterior segment involvement and disease activity in TINU. The majority of patients required systemic treatment in order to control intraocular inflammation and prevent relapses.

Clinical Features of Pediatric Uveitis at a Tertiary Referral Center in the Western Region of Japan

PURPOSE

This study aimed to assess the clinical features of pediatric uveitis at a tertiary referral center in Western Japan.

METHODS

One hundred forty eyes of 80 patients aged <20 years at the time of uveitis onset, who visited Kyushu University Hospital between January 2010 and December 2019 were included in this study. Clinical records were retrospectively reviewed. Demographics, clinical findings, treatments, and visual prognoses were compared between the disease groups.

RESULTS

Of 80 patients, 32 were males and 48 were females. The average age of onset was 12.5 ± 4.8 (0-19) years. Tubulointerstitial nephritis and uveitis (TINU) and juvenile idiopathic arthritis (JIA) were the most frequent causes, accounting for 11.3% and 10% of cases, respectively, followed by sarcoidosis (5%), Behçet's disease, acute anterior uveitis, Vogt-Koyanagi-Harada disease, and juvenile chronic iridocyclitis (3.8% each). Infectious uveitis accounted for 7.6% of the cases: cytomegalovirus was the most frequent agent. Of these cases, 43.8% were unclassified. Systemic therapies were administered to 87.5% of the patients with JIA, 33.3% of those with TINU, and 28.6% of the other diagnostic groups. In the unclassified group, 80% of the patients were followed up with only topical corticosteroids. LogMAR visual acuity of 0 or less accounted for more than 80% in the final examination.

CONCLUSION

TINU and JIA were the most common causes of pediatric uveitis. Although each required systemic therapy, most unclassified cases of pediatric uveitis were managed by topical corticosteroids alone with good visual prognosis. Accurate diagnosis is important for pediatric uveitis management.

Diagnostic and Management Strategies of Tubulointerstitial Nephritis and Uveitis Syndrome (TINU): Current Perspectives

Tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare autoimmune disease with unclear pathogenesis but probably related to a combination of genetic predisposition and environmental triggers. Diagnosis is challenging due to the asynchronous onset of renal and ocular symptoms, and it is necessary to exclude other causes of nephritis and uveitis. It affects both sexes, with an overall predominance of females and a median age of onset of 15 years. TINU syndrome is characterized by bilateral, non-granulomatous anterior uveitis and tubulointerstitial nephritis, which can cause acute renal failure in severe cases. Several triggers have been identified including concurrent infections, medications, or endocrine diseases. The diagnosis of TINU is mainly based on clinical and analytical findings, and although urinary β2-microglobulin is a useful parameter no specific diagnostic test is available. Current perspectives intend to facilitate its diagnosis identifying susceptibility HLA genotypes, serologic markers and imaging tools to avoid renal biopsy. Treatment options for TINU syndrome include corticosteroids, immunosuppressive agents, and intravenous immunoglobulins, but relapses are frequent, and management can be challenging. The purpose of this review is to provide an updated summary of the diagnostic and treatment strategies of TINU syndrome, helping clinicians recognize and manage this rare autoimmune disorder.

Ocular images-based artificial intelligence on systemic diseases

PURPOSE

To provide a summary of the research advances on ocular images-based artificial intelligence on systemic diseases.

METHODS

Narrative literature review.

RESULTS

Ocular images-based artificial intelligence has been used in a variety of systemic diseases, including endocrine, cardiovascular, neurological, renal, autoimmune, and hematological diseases, and many others. However, the studies are still at an early stage. The majority of studies have used AI only for diseases diagnosis, and the specific mechanisms linking systemic diseases to ocular images are still unclear. In addition, there are many limitations to the research, such as the number of images, the interpretability of artificial intelligence, rare diseases, and ethical and legal issues.

CONCLUSION

While ocular images-based artificial intelligence is widely used, the relationship between the eye and the whole body should be more clearly elucidated.

Sarcoid-like Uveitis with or without Tubulointerstitial Nephritis during COVID-19

PURPOSE

To report sarcoid-like uveitis with or without tubulointerstitial nephritis (TIN) during coronavirus disease 2019 (COVID-19) and to discuss diagnostic evaluation and treatment.

METHODS

Detailed information on the subject's demographics, medical history, ophthalmic examination findings, and laboratory results were obtained from medical records. Fluorescein angiography (FA) and indocyanine green angiography (ICGA) images were evaluated.

RESULTS

All seven patients aged between 8 and 17 had bilateral granulomatous panuveitis. TIN preceded in four patients. Thorax computed tomography of patient 1 was found to be compatible with COVID-19, patients 2 and 3 were in contact with Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive parents, patients 4 and 5 were found to be SARS-CoV-2 PCR positive, and patients 6 and 7 were positive for SARS-CoV-2 IgG antibodies. ICGA revealed hypofluorescent dots in six patients. Intraocular inflammation was controlled with corticosteroid and/or immunomodulatory therapy. Visual acuity was maintained or improved in all.

CONCLUSION

SARS-CoV-2 infection may be related to sarcoid-like uveitis and acute tubulointerstitial nephritis.

Clinical Features and Outcomes of Tubulointerstitial Nephritis and Uveitis Syndrome in Spain and Portugal: The IBERTINU Project

PURPOSE

To assess the clinical features, management and prognosis of patients diagnosed with tubulointerstitial nephritis and uveitis (TINU) syndrome in Spain and Portugal.

METHODS

Retrospective multicenter study, which included all patients diagnosed with TINU syndrome managed in 15 uveitis referral centers from Spain and Portugal.

RESULTS

Forty-eight subjects with a mean age at diagnosis of 25.0 [14.8; 49.5] years were included. Both eyes were affected in 43 patients (89.6%). The visual outcome was favorable, but immunosuppressive systemic therapy (IST) was needed in 26 (54.16%) due to relapses. Renal function normalized in 35 patients (72.9%). HLA-DQB1*05 was the most common genetic typing (57.1%). The mean follow-up time was 22.5 [11.0; 48.0] months.

CONCLUSIONS

Both visual and renal outcomes were favorable, although IST was frequently used. TINU is under- diagnosed, so further prospective studies would provide more knowledge about its recognition and management.

EXPERT OPINION

TINU Syndrome is underdiagnosed because ocular and renal disease are asynchronous. Outcomes are favorable so it has to be highly suspected in cases of bilateral anterior uveitis. According to literature and our experience, systemic immunosuppressive therapy is often required because of ocular relapses.This study adds to the previous knowledge that HLA-DQB1*05 could be an important HLA type amongst the TINU Syndrome Iberian population. HLA typing should be assessed in these patients in order to describe its phenotype-genotype relationship better. A considerable number of patients in our series were diagnosed in their sixties, so TINU Syndrome should also be suspected in elderly patients.

Chronic Kidney Disease as A Potential Risk Factor for Uveitis: A 13-Year Nationwide Population-Based Cohort Study in Taiwan

PURPOSE

To investigate whether patients with chronic kidney disease (CKD) are at increased risk of uveitis.

METHODS

Data was collected from the Taiwan National Health Insurance system and included patients newly diagnosed with CKD between 2000 and 2012. The endpoint of interest was a diagnosis of uveitis.

RESULTS

30,256 CKD patients and 121,024 matched comparisons were analyzed. CKD patients were found to have a significantly higher cumulative uveitis incidence. Through multivariate Cox regression analysis, the CKD group was found to have higher risk of developing uveitis (adjusted hazard ratio 1.51). After stratified by gender, age, and comorbidities (hypertension, diabetes, and hyperlipidemia), the increased risk of uveitis in CKD patients remained significant.

CONCLUSIONS

Patients with CKD were found to have higher risk of developing uveitis. For patients over 18 years old and with hypertension, diabetes, or hyperlipidemia, the presence of CKD was demonstrated as an additional crucial factor for uveitis development.

Subclinical Choroidal Inflammation Revealed by Indocyanine Green Angiography in Tubulointerstitial Nephritis and Uveitis Syndrome

PURPOSE

To describe subclinical chorioretinal lesions revealed by indocyanine green angiography (ICGA) and their evolution under systemic treatment in tubulointerstitial nephritis and uveitis (TINU) patients.

METHODS

Retrospective case series of three patients with TINU syndrome. Choroidal and retinal involvement were assessed by fluorescein angiography (FA) and ICGA.

RESULTS

Three patients were analyzed. FA demonstrated hot disc, associated in two cases with retinal vascular leakage, and ICGA revealed subclinical chorioretinal dots in all three cases. Given the presence of posterior uveitis and deterioration of kidney function, asystemic treatment by oral methylprednisolone was started. Persistence of retinal and choroidal inflammations under systemic corticosteroids required association with immunosuppressive agent to control the disease activity.

CONCLUSION

Multimodal imaging and more precisely ICGA is useful to assess subclinical choroidal inflammation and monitor treatment response in TINU syndrome. Immunosuppression needs to be revised and adapted when uveitis and/or kidney function are unresponsive to systemic steroids.

ABBREVIATIONS

TINU: tubulointerstitial nephritis and uveitis; TIN: tubulointerstitial nephritis; ACE: angiotensin-converting enzyme; RF: rheumatoid factor; Uβ2M: urinary β-2microglobulin; AMPPE: acute multifocal placoid pigment epitheliopathy; FA: fluorescein angiography; ICGA: indocyanine green angiography; CT: computed tomography.

Intermediate Uveitis: A Review

PURPOSE

This review aims to provide an update on the clinical presentation, etiologies, complications, and treatment options in intermediate uveitis (IU).

METHODS

Narrative literature review.

RESULTS

IU affects all age groups with no clear gender predominance and has varied etiologies including systemic illnesses and infectious diseases, or pars planitis. In some instances, IU may be the sole presentation of an underlying associated condition or disease. Management of IU and its complications include administration of corticosteroids, antimetabolites, T-cell inhibitors, and/or biologics, along with surgical interventions, with varying degrees of effectiveness across literature. In particular, increasing evidence of the safety and efficacy of immunomodulatory agents and biologics has seen greater adoption of these therapies in clinical practice.

CONCLUSIONS

IU is an anatomical description of uveitis, involving intraocular inflammation of the vitreous, peripheral retinal vasculature, and pars plana. Various treatment options for intermediate uveitis are currently used in practice.

Pediatric uveitis: Role of the pediatrician

The challenges of childhood uveitis lie in the varied spectrum of its clinical presentation, the often asymptomatic nature of disease, and the evolving nature of the phenotype alongside normal physiological development. These issues can lead to delayed diagnosis which can cause significant morbidity and severe visual impairment. The most common ocular complications include cataracts, band keratopathy, glaucoma, and macular oedema, and the various associated systemic disorders can also result in extra-ophthalmic morbidity. Pediatricians have an important role to play. Their awareness of the various presentations and etiologies of uveitis in children afford the opportunity of prompt diagnosis before complications arise. Juvenile Idiopathic Arthritis (JIA) is one of the most common associated disorders seen in childhood uveitis, but there is a need to recognize other causes. In this review, different causes of uveitis are explored, including infections, autoimmune and autoinflammatory disease. As treatment is often informed by etiology, pediatricians can ensure early ophthalmological referral for children with inflammatory disease at risk of uveitis and can support management decisions for children with uveitis and possible underling multi-system inflammatory disease, thus reducing the risk of the development of irreversible sequelae.

Immunomodulation and TNF-α inhibition for tubulointerstitial nephritis and uveitis syndrome: a case series

BACKGROUND

Tubulointerstitial nephritis and uveitis (TINU) syndrome combines acute inflammatory nephritis (AIN) and uveitis. Uveitis in TINU often requires systemic immunomodulatory therapy (IMT), including steroid-sparing agents. Although common for other noninfectious uveitides, the use of tumor necrosis factor-α inhibitors (TNFi) in TINU has seldom been described.

METHODS

This retrospective case series included patients <18 years of age with TINU followed at our tertiary care pediatric hospital. Disease characteristics at time of diagnosis and subsequent ophthalmological and rheumatologic evaluations were extracted from the record. AIN was defined as the presence of abnormal renal function and urinalysis or renal biopsy findings consistent with TINU. Uveitis grading, site of inflammation, inactivity, and flare were defined according to Standardization of Uveitis Nomenclature.

RESULTS

A total of 10 patients (median age, 12.3 years; 6 females) were included. AIN preceded uveitis onset in 6 patients. Uveitis was bilateral at onset in 7 patients. Uveitis inactivity was achieved with systemic corticosteroids (CS) in 2 and with mycophenolate mofetil (MMF) in 3 patients. Because of persistent ocular inflammation, despite CS and IMT, 4 patients were treated with TNFi. All rapidly achieved uveitis quiescence and maintained prolonged inactivity under combined treatment with TNFi and MMF.

CONCLUSIONS

Most patients in our study cohort required a steroid-sparing immunomodulator to achieve and maintain uveitis control. In the 50% of the cohort in whom conventional IMTs were inadequate, TNFi were able to maintain quiescence. TNF inhibition might be a useful treatment in IMT-refractory uveitis in TINU patients.

Tubulointerstitial nephritis and uveitis syndrome in an adolescent female: a case report

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.

Long-term clinical characteristics and renal prognosis of children with tubulointerstitial nephritis and uveitis syndrome

BACKGROUND

Tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare disease, especially in children. Owing to the short-term observational period and the small number of patients analyzed in previous reports, the long-term clinical and laboratory characteristics and renal prognosis of children with TINU syndrome remain unclear.

METHODS

In this retrospective observational study, we enrolled 29 children with TINU syndrome from February 1990 to February 2019.

RESULTS

During the median follow-up duration of 38 months, the kidney function, urinary β2 microglobulin-creatinine ratio (U-β2MG/Cr), and uveitis in the patients had significantly improved at 24, 6, and 36 months after diagnosis. Higher U-β2MG/Cr was associated with longer duration of kidney function normalization. Half of the patients required uveitis treatment for 5 years after the diagnosis.

CONCLUSIONS

Patients with severe low-molecular weight proteinuria at diagnosis needed a longer duration to achieve improvements in kidney function. Uveitis has a much longer treatment period than tubulointerstitial nephritis. This study demonstrates the good prognosis of children with TINU syndrome in terms of their long-term clinical and laboratory characteristics.

Tubulointerstitial nephritis and uveitis in Northern Ireland

Objectives

This paper looks at patients with a diagnosis of tubulointerstitial nephritis and uveitis (TINU) presenting to the Northern Ireland regional adult and paediatric uveitis service in the Belfast Health and Social Care Trust. The demographic distribution, treatment required and the visual and renal outcomes of these patients are documented.

Methods

Data were collected retrospectively on 24 patients with TINU using the Northern Ireland Electronic Care Record, central pathology records alongside the adult and paediatric uveitis databases from 2011 to 2021. Patients were categorised into two groups using the Mandeville classification system. Standard Uveitis Nomenclature (SUN) was used to classify the uveitis.

Results

The population prevalence is at least 12.6 cases per million based on a population of 1.9 million. Nineteen of 24 cases were definite TINU and five of 24 probable. Seventeen out of 24 had biopsy-positive TIN, all of which met all of the Mandeville clinical diagnostic features required for a definite diagnosis. All but one presented with acute bilateral anterior uveitis. The paediatric cases ranged from age 12 to 18 at age of onset with a mean age of 14. Of the 18 adult onset cases, the age ranged from 20 to 76 years. The mean age of onset for the adult cases was 53 years. Of these patients 71% were female; 42% required second-line immunosuppression for ocular disease. Visual acuity was maintained. Follow-up time ranged from 3 months to 16 years. No patient developed long-term renal impairment.

Conclusions

TINU is a cause of uveitis in both the paediatric and adult populations. In Northern Ireland average age with TINU was older than much of the published literature. Long-term immunosuppression for uveitis may be required as ongoing ocular, rather than renal inflammation seemed to require treatment.

Tubulointerstitial Nephritis and Uveitis Syndrome: Case Series and Literature Review

Tubulointerstitial nephritis and uveitis syndrome (TINU) is a rare oculorenal inflammatory entity with a probable autoimmune etiology. Interstitial nephritis may be asymptomatic and usually has a benign course with spontaneous resolution. Uveitis, instead, is classically anterior, bilateral, and nongranulomatous, but it can be unilateral and presents as posterior uveitis or panuveitis, sometimes with a chronic or recurrent evolution. The frequent time lag of ocular and renal manifestations makes this diagnosis particularly challenging. The authors describe four cases of this rare entity, two with tubulointerstitial nephritis preceding ocular manifestations and the remaining, instead, with uveitis preceding renal involvement. The therapeutic approach included systemic corticosteroids in all cases. The addition of immunosuppressive therapy was required in three patients to achieve uveitis control. TINU is probably an underrecognized entity and should always be considered in the differential diagnosis of a chronic or recurrent idiopathic uveitis, especially in young patients who may have mild and asymptomatic renal disease.

Tubulointerstitial nephritis and uveitis: The first report from the ophthalmology perspective in India

A 16-year-old boy presented with uveitis in both eyes with recurrent febrile illness and renal ailments. The patient was referred to a nephrologist. Subsequent investigations revealed acute tubulointerstitial nephritis in a renal biopsy and raised urinary beta-2 microglobulin (B2M). Based on his clinical findings and laboratory investigations, a diagnosis of tubulointerstitial nephritis and uveitis (TINU) syndrome was made. Since, the literature on TINU through India is sparse, the two available case reports were published through nephrology setup. Our case illustrates how ophthalmologist can aid in the diagnosis of such a rare clinical entity using interdisciplinary approach.

Rational laboratory testing in uveitis: A Bayesian analysis

Uveitis encompasses a heterogeneous group of clinical entities with the common feature of intraocular inflammation. In addition to patient history and examination, a focused set of laboratory investigations is frequently necessary to establish a specific diagnosis. There is limited consensus among uveitis specialists regarding appropriate laboratory evaluation for many distinct patient presentations. The appropriateness of a laboratory test for a given case of uveitis will depend on patient-specific as well as epidemiologic factors. Bayesian analysis is a widely used framework for the interpretation of laboratory testing, but is seldom adhered to in clinical practice. Bayes theorem states that the predictive value of a particular laboratory test depends on the sensitivity and specificity of that test, as well as the prevalence of disease in the population being tested. In this review we will summarize the performance of commonly-utilized laboratory tests for uveitis, as well as the prevalence of uveitic diagnoses in different geographic practice settings. We will propose a logical framework for effective laboratory testing in uveitic disease through rigorous application of Bayesian analysis. Finally, we will demonstrate that while many highly sensitive laboratory tests offer an effective means to rule out associated systemic disease, limited test specificity and low pretest probability often preclude the diagnosis of systemic disease association with any high degree of certainty, even in the face of positive testing.

Tubulointerstitial nephritis and uveitis syndrome: Our experience

Tubulointerstitial nephritis and uveitis (TINU) syndrome is a distinct oculorenal disorder of immune origin and accounts for some cases of unexplained recurrent uveitis. We report three cases of TINU syndrome, one of which had primarily come to us with uveitis. It is the occurrence of tubulointerstitial nephritis and uveitis in a patient in the absence of other systemic diseases that can cause either interstitial nephritis or uveitis. TINU syndrome is a diagnosis of exclusion. Our aim in reporting these cases is to highlight the association of nephritis and uveitis, which together form a distinct clinical disorder called the TINU syndrome.

A case of adult-onset tubulointerstitial nephritis and uveitis syndrome presenting with granulomatous panuveitis

The tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare disorder that is probably underdiagnosed in clinical practice. Ocular involvement in TINU syndrome not only presents with the nongranulomatous anterior uveitis in 80% of patients but also manifests as intermediate, posterior, or panuveitis. This case report mentions an adult male patient who presented with granulomatous iridocyclitis with panuveitis and mild renal insufficiency. Workup for connective tissue and infectious diseases was negative for the patient. He was diagnosed with TINU syndrome based on the findings of renal biopsy. Both the uveitis and nephritis promptly responded well to steroid treatment, and there was no recurrence during the follow-up of 24 months.

The genetic contribution of HLA-E*01:03 and HLA-E*01:03-G*01:01 to Posner-Schlossman syndrome in southern Chinese

Background

The polymorphisms of classical HLA-Ia and HLA-II loci have been associated with Posner-Schlossman syndrome (PSS) in the southern Chinese population. However, the associations of non-classical HLA-Ib (e.g., HLA-E and HLA-G) loci with PSS have not been reported for in the southern Chinese population. This study aimed to evaluate the associations of the HLA-E and HLA-G loci with PSS in a southern Chinese Han population group.

Methods

Ninety-seven unrelated patients with PSS and 90 ethnically matched control subjects were recruited from the Shenzhen Eye Hospital in China. The full-length sequences of HLA-E and HLA-G genes were amplified by long-range high-fidelity PCR, and the third exon of the HLA-E gene and the coding region of the HLA-G gene were sequenced.

Results

The allele frequency of HLA-E*01:03 in patients with PSS was significantly higher than that in the control group (P=0.017, corrected P=0.034, OR =1.66). The genotype frequencies of HLA-E*01:01/01:03 and HLA-E*01:03/01:03 in the PSS group were significantly higher than that in the control group (P=0.027, OR =2.62; P=0.011, OR =3.05; respectively). There were no significant differences in the frequency of HLA-G alleles and genotypes between the two groups (all P>0.05). The haplotype frequency of HLA-E*01:03-G*01:01 in the PSS group was significantly higher than that in the control group (P=0.019, OR =1.63), although this association did not survive the Bonferroni correction (corrected P=0.13).

Conclusions

This study proved for the first time that HLA-E*01:03 and HLA-E*01:03-G*01:01 might be risk factors for PSS.

Tubulointerstitial nephritis and uveitis (TINU) syndrome: a review

Inflammation of renal interstitium and uveal tissue establishes the two components of tubulointerstitial nephritis and uveitis (TINU) syndrome. Although believed to occur more frequently in young females, a broad spectrum of patients can be affected. Both renal and eye disease can be asymptomatic and may not manifest simultaneously, having independent progressions. Renal disease manifests as acute kidney injury and may cause permanent renal impairment. Eye inflammation can manifest in different anatomical forms, most commonly as bilateral anterior uveitis and may progress to a chronic course. TINU syndrome accounts for approximately 1%–2% of uveitis in tertiary referral centres. A literature review covering the clinical features, pathogenesis, diagnosis and treatment is presented.

Tubulointerstitial nephritis and uveitis syndrome in children: report of three cases

Tubulointerstitial nephritis and uveitis syndrome is a rare and probably underdiagnosed condition. Renal and ocular manifestations may not occur simultaneously, making the diagnosis more difficult. Nephritis may be asymptomatic; therefore, renal function evaluation is essential for diagnosis. Urinary β2-microglobulin levels may be particularly useful. Uveitis, mostly anterior, nongranulomatous and bilateral, occurs usually after the onset of nephritis. Treatment includes corticosteroids and, eventually, other immunosuppressant agents. Renal disease is usually benign and resolves spontaneously or after treatment with systemic corticosteroids. Uveitis, however, may be chronic or recurrent. The authors described the cases of three pediatric patients diagnosed with tubulointerstitial nephritis and uveitis syndrome. The goal of this paper was to warn the medical community over the need to screen patients with uveitis for renal disease.

Treatment challenges in an atypical presentation of tubulointerstitial nephritis and uveitis (TINU)

PURPOSE

To describe an atypical presentation of Tubulointerstitial Nephritis and Uveitis (TINU), with challenges in treatment course.

OBSERVATIONS

A 12-year-old Hispanic female presented to the National Eye Institute's Uveitis clinic with bilateral blurred vision, red eyes and photophobia, not responsive to topical steroids. On exam, she had bilateral severe panuveitis with areas of subretinal fluid. During her evaluation, she was noted to have elevated serum creatinine. A kidney biopsy confirmed the presence of severe tubulointerstitial nephritis and interstitial fibrosis. She was treated with oral steroids with excellent resolution of symptoms and subretinal fluid. She continued to have anterior segment flares with attempts to taper oral prednisone which lead to treatment with multiple immunomodulatory agents. Associated hypertension and kidney damage complicated the choice of a secondary immunosuppressive agent.

CONCLUSIONS AND IMPORTANCE

Although rare, TINU can present as panuveitis with choroidal involvement which may or may not be preceded by tubulointerstitial nephritis. A renal biopsy is required for definitive diagnosis, but abnormal urinalysis or renal function should raise suspicion for TINU.

Clinical and Genetic Features of Tubulointerstitial Nephritis and Uveitis Syndrome with Long-Term Follow-Up

Purpose

To investigate the clinical manifestations, prognosis, and HLA-type of tubulointerstitial nephritis and uveitis syndrome (TINU) with long-term follow-up.

Methods

Clinical data of five patients with TINU were retrospectively reviewed.

Results

The mean age was 15.8 years. The mean follow-up periods were 54.0 months. The initial subjective symptoms were bulbar injection (100%), ocular pain (80%), and blurred vision (60%). The medical department that the patients visited first was ophthalmology in 4 (80%) cases. Urinalysis showed the characteristic increase of the β2 microglobulin in all (100%) patients. Uveitis and nephritis were diagnosed within 1 week from each other. Although two showed recurrences, the topical and systemic steroid treatment with mean duration of 14.1 months brought the resolution of nephritis and uveitis in all patients. Recurrence-free periods ranged from 12 to 71 months. The final visual outcome was 20/20 or better in all cases. HLA-DR4 or the allele of DRB1^∗04 was present in all (100%) patients.

Conclusions

TINU should be considered in the differential diagnosis in young patients with uveitis of unknown origin and renal dysfunction. Urinary β2 microglobulin level and HLA typing may help in the diagnosis of TINU. The prognosis for patients with TINU is generally good with steroid treatment.