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Su T, Gu Y, Sun P, Tang J, Wang S, Liu G, Li X, Yang L. Etiology and renal outcomes of acute tubulointerstitial nephritis: a single-center prospective cohort study in China. Nephrol Dial Transplant 2019; 33:1180-1188. [PMID: 28992223 DOI: 10.1093/ndt/gfx247] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 06/25/2017] [Indexed: 12/18/2022] Open
Abstract
Background The aim of this study was to explore the etiology, long-term renal outcomes and affecting factors of acute tubulointerstitial nephritis (ATIN). Methods Patients with biopsy-proven ATIN from 1 January 2005 to 31 December 2013 at Peking University First Hospital were enrolled in the study and received scheduled follow-up for at least 24 months. The causes of ATIN were defined at biopsy and reclassified during follow-up. Factors affecting renal recovery at 6 months post-biopsy and estimated glomerular filtration rate (eGFR) at 12 months post-biopsy and at the end of follow-up were analyzed. Results A total of 157 ATIN patients were enrolled, with an average follow-up of 48 months (range 24-108 months). A modified etiology spectrum was identified, with a decreased proportion of drug-induced ATIN (D-ATIN, 64% at biopsy to 50% after follow-up) and an increase in autoimmune-related ATIN (22-41%) with late-onset systemic manifestations in patients who had been classified as D-ATIN or ATIN of unknown cause. Recurrent kidney injury was observed in 51% of the patients with tubulointerstitial nephritis and uveitis syndrome (TINU), 53% of those with an autoimmune disease and 8% of those with D-ATIN, resulting in prolonged immunosuppressive treatment. By 12 months, decreased eGFR (<60 mL/min/1.73 m2) was observed in 47% of the patients with D-ATIN, 74% of those with TINU and 57% of those with other autoimmune diseases. In multivariable analysis, female sex, older age, presence of hypertension and recurrent kidney injury were independent risk factors for worse renal outcomes. Conclusions Our data demonstrate that autoimmune-related ATIN may present with systemic manifestations after kidney injury and is, therefore, commonly misdiagnosed. Repeated kidney injury is not uncommon in patients with ATIN. Scheduled follow-up is, therefore, critical for defining the exact etiology and proper management of ATIN.
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Affiliation(s)
- Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, P.R. China.,Peking University Institute of Nephrology, Beijing, P.R. China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, P.R. China
| | - Yanghui Gu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, P.R. China.,Peking University Institute of Nephrology, Beijing, P.R. China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, P.R. China.,Renal Division, Department of Medicine, Second Clinical Medical College, Guangzhou University of Traditional Chinese Medicine, Guangzhou, P.R. China
| | - Pingping Sun
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, P.R. China.,Peking University Institute of Nephrology, Beijing, P.R. China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, P.R. China
| | - Jiawei Tang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, P.R. China.,Peking University Institute of Nephrology, Beijing, P.R. China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, P.R. China
| | - Suxia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, P.R. China.,Peking University Institute of Nephrology, Beijing, P.R. China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, P.R. China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, P.R. China
| | - Gang Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, P.R. China.,Peking University Institute of Nephrology, Beijing, P.R. China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, P.R. China
| | - Xiaomei Li
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, P.R. China.,Peking University Institute of Nephrology, Beijing, P.R. China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, P.R. China
| | - Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, P.R. China.,Peking University Institute of Nephrology, Beijing, P.R. China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, P.R. China
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Zhao WT, Huang JW, Sun PP, Su T, Tang JW, Wang SX, Liu G, Yang L. Diagnostic roles of urinary kidney injury molecule 1 and soluble C5b-9 in acute tubulointerstitial nephritis. Am J Physiol Renal Physiol 2019; 317:F584-F592. [PMID: 31291122 DOI: 10.1152/ajprenal.00176.2019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Acute tubulointerstitial nephritis (ATIN) is a common cause of acute kidney injury characterized by inflammatory cells infiltrating in the interstitium. The present study aimed to explore noninvasive biomarkers that might indicate activity of pathological injuries and help direct treatment. Fifty-four patients with clinical-pathologically diagnosed ATIN from January 1, 2014, to June 30, 2016, at Peking University First Hospital were enrolled. Urine samples were collected on the morning of renal biopsy and assessed for urinary kidney injury molecule-1 (KIM-1) and urinary soluble C5b-9 (sC5b-9). Immunofluorescence staining for KIM-1 and C5b-9 was performed in biopsied kidney sections from ATIN cases. The clinical and pathological relevance of the two urinary biomarkers was analyzed. Both urinary KIM-1 and sC5b-9 values were significantly elevated in patients with ATIN compared with healthy controls. The urinary KIM-1 level positively correlated with urinary N-acetyl-β-d-glucosaminidase (r = 0. 542, P = 0.001) and the pathological tubular injury score (r = 0.469, P < 0.001), whereas the urinary sC5b-9 level was related to pathological activity scores for tubular injury (r = 0.413, P = 0.002), interstitial inflammation (r = 0.388, P = 0.004), and treatment response (r = 0.564, P < 0.001). Urinary KIM-1 tended to have better diagnostic value for tubular injury than urinary sC5b-9, whereas only urinary sC5b-9 was able to demonstrate severe interstitial inflammation. A combination of urinary KIM-1 and sC5b-9 had an area under the receiver-operating characteristic curve of 0.864 (95% confidence interval: 0.766-0.963, P < 0.001, sensitivity: 75%, specificity: 88%) for acute tissue injury in ATIN. KIM-1 expression was markedly increased in renal tubular cells in both ATIN and acute tubular necrosis conditions, whereas a significant upregulation of C5b-9 was only detected in the tubular cells and interstitial cells in ATIN cases. Urinary KIM-1 is a specific biomarker for renal tubular injury in ATIN, whereas urinary sC5b-9 is valuable in demonstrating severe interstitial inflammation. The combination of these two biomarkers helps identify patients at an acute injury stage and, therefore, might facilitate clinical evaluation and guide immunosuppressive therapy.
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Affiliation(s)
- Wen-Ting Zhao
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
| | - Jun-Wen Huang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
| | - Ping-Ping Sun
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
| | - Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
| | - Jia-Wei Tang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Renal Pathology Room, Peking University First Hospital, Beijing, People's Republic of China.,Laboratory of Electron Microscopy, Peking University First Hospital, Beijing, People's Republic of China
| | - Gang Liu
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Renal Pathology Room, Peking University First Hospital, Beijing, People's Republic of China
| | - Li Yang
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Renal Pathology Room, Peking University First Hospital, Beijing, People's Republic of China
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Norden AGW, Lapsley M, Unwin RJ. Urine retinol-binding protein 4: a functional biomarker of the proximal renal tubule. Adv Clin Chem 2014; 63:85-122. [PMID: 24783352 DOI: 10.1016/b978-0-12-800094-6.00003-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Measurement of retinol-binding protein 4 in urine (uRBP4) is arguably the most sensitive biomarker for loss of function of the human proximal renal tubule. Megalin- and cubilin-receptor-mediated endocytosis normally absorbs > 99% of the approximately 1.5 g/24 h of protein filtered by the renal glomerulus. When this fails there is "tubular proteinuria," comprising uRBP4, albumin, and many other proteins and peptides. This tubular proteinuria is a consistent feature of the renal Fanconi syndrome (FS) and measurement of uRBP4 appears to be an excellent screening test for FS. FS occurs in rare inherited renal diseases including cystinosis, Dent disease, Lowe syndrome, and autosomal dominant FS. Acquired FS occurs in paraproteinemias, tubulointerstitial renal disease, oncogenic osteomalacia, Chinese herbs nephropathy, and Balkan endemic nephropathy. Though poorly understood, FS may be associated with HIV disease and antiretroviral treatment; cadmium poisoning may cause FS. In addition to FS, uRBP4 measurement has a different role: the early detection of acute kidney injury. Urine RBP4 comprises several isoforms, including intact plasma RBP4, MW 21.07 kDa, and C-terminal truncated forms, des-L- and des-LL-RBP4, also probably plasma derived. In FS, uRBP4 levels are about 104-fold above the upper limit of normal and small increments are frequently seen in carriers of some inherited forms of FS and in acquired disease. The very high levels in disease, frequent assay nonlinearity, lack of defined calibrants, and multiple uRBP4 isoforms make accurate assay challenging; top-down mass spectrometry has brought advances. Assays for uRBP4 with defined molecular targets allowing good interlaboratory comparisons are needed.
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Chang CH, Chen YF, Wu VC, Shu CC, Lee CH, Wang JY, Lee LN, Yu CJ. Acute kidney injury due to anti-tuberculosis drugs: a five-year experience in an aging population. BMC Infect Dis 2014; 14:23. [PMID: 24410958 PMCID: PMC3898246 DOI: 10.1186/1471-2334-14-23] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Accepted: 01/08/2014] [Indexed: 11/25/2022] Open
Abstract
Background Patients on anti-tuberculosis treatment may develop acute kidney injury (AKI), but little is known about the renal outcome and prognostic factors, especially in an aging population. This study aimed to calculate the incidence of AKI due to anti-TB drugs and analyze the outcomes and predictors of renal recovery. Methods From 2006 to 2010, patients on anti-TB treatment were identified and their medical records reviewed. Acute kidney injury was defined according to the criteria established by the AKI Network, while renal recovery was defined as a return of serum creatinine to baseline. Predictors of renal recovery were identified by Cox regression analysis. Results Ninety-nine out of 1394 (7.1%) patients on anti-TB treatment had AKI. Their median age was 68 years and there was male predominance. Sixty (61%) developed AKI within two months of anti-TB treatment, including 11 (11%) with a prior history of rifampin exposure. Thirty (30%) had co-morbid chronic kidney disease or end-stage renal disease. The median time of renal recovery was 39.6 days (range, 1–180 days). Factors predicting renal recovery were the presence of fever, rash, and gastro-intestinal disturbance at the onset of AKI. Sixty-two of the 71 (87%) patients who recovered from AKI had successful re-introduction or continuation of rifampin. Conclusions Renal function impairment is not a rare complication during anti-TB treatment in an elderly population. The presence of fever and rash may be associated with renal recovery. Rifampin can still be used in most patients who recover from AKI.
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Affiliation(s)
| | | | | | | | | | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
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