Clinicopathologic characteristics, treatment, and outcomes of tubulointerstitial nephritis and uveitis syndrome in adults: A national retrospective strobe-compliant study

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.

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.

Tubulointerstitial Nephritis and Uveitis Syndrome in Pediatric Patients

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.

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.

Renal outcomes in tubulointerstitial nephritis and uveitis (TINU) syndrome: a systematic review and meta-analysis

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.

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.

Tubulointerstitial Nephritis and Uveitis Syndrome (TINU): A Case Series in a Tertiary Care Uveitis Setting

Background: Tubulointerstitial nephritis and uveitis syndrome (TINU) is a rare disorder typically characterized by sudden-onset non-granulomatous anterior uveitis associated with tubulointerstitial nephritis (TIN). However, the prevalence and clinical features of TINU are still a matter of debate. To add information about TINU, we describe here the clinical features of a series of patients affected by TINU in a retrospective study. Methods: A total of 9358 clinical records of both adult and pediatric patients up to 21 years of age, referred to the Uveitis Center of the Sapienza University of Rome, were examined. The medical records covered a period from 1990 to 2020. Various demographic and clinical features were analyzed in patients who met the criteria for TINU. Results: Twenty-one patients with TINU were identified. TINU was classified as definite, possible, or probable by the currently recognized international criteria. The median age at diagnosis was 14 years (interquartile range 12–35). Females were predominant (15/21, 71.4%). In most cases (14/21, 66.6%), patients developed ocular disease concurrently with renal disease. The most frequent type of ocular involvement was bilateral anterior uveitis (9/21, 42.8%). In two cases, patients presented with bilateral intermediate uveitis; in three cases, they presented with bilateral or unilateral alternating posterior uveitis; and in four cases, they presented with bilateral panuveitis. In one case, the uveitis was anterior in the right eye (OD) and posterior in the left eye (OS), and two cases presented with bilateral asynchronous or unilateral alternating anterior uveitis. All patients received treatment with systemic corticosteroids and topical ocular therapy. At the end of the follow-up, a significant improvement in ocular signs and symptoms with a return to normal visual acuity was generally observed. In all patients, acute kidney injury (AKI) reverted completely and none progressed to chronic kidney disease (CKD). Conclusions: Patients with TINU may often present with atypical uveitis. We suggest that patients with sudden-onset uveitis, even if not bilateral anterior, should be referred to a nephologist for an assessment of the possible presence of renal disease.

Tubulointerstitial nephritis and uveitis syndrome: a systematic review

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.

Renal Prognosis in Children With Tubulointerstitial Nephritis and Uveitis Syndrome

Introduction

Tubulointerstitial nephritis (TIN) and uveitis (TINU) syndrome is a rare disease. The renal prognosis is generally thought to be better in children with TINU syndrome than in adults. However, data are scarce. We aimed to investigate the long-term renal prognosis in a French cohort of children with TINU syndrome.

Methods

We performed a national retrospective study including 23 French pediatric nephrology centers enrolling patients with TINU syndrome diagnosed between January 2000 and December 2018.

Results

A total of 46 patients were included (52% female, median age 13.8 years). At diagnosis of TIN, the median estimated glomerular filtration rate (eGFR) was 30.6 ml/min per 1.73 m² (4.9–62.8). The median time between diagnosis of uveitis and TIN was 0.4 months (−4.1; +17.1). All patients had anterior uveitis, but 12 (29%) were asymptomatic. Nearly all patients (44 of 46) received steroid treatment, and 12 patients (26%) received a second-line therapy. At last follow-up (median 2.8 years), the median eGFR was 87.5 ml/min per 1.73 m² (60.3–152.7) and <90 ml/min per 1.73 m² in 20 patients.

Conclusion

In our study, nearly half of the patients had renal sequelae at last follow-up. Given the possible progression to chronic kidney disease, long-term monitoring of children with TINU syndrome is mandatory. Approximately a quarter of the children had asymptomatic uveitis suggesting all children presenting with TIN should undergo systematic ophthalmologic screening even in the absence of ocular signs.

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.

Classification Criteria for Tubulointerstitial Nephritis With Uveitis Syndrome

PURPOSE

To determine classification criteria for tubulointerstitial nephritis with uveitis (TINU).

DESIGN

Machine learning of cases with TINU and 8 other anterior uveitides.

METHODS

Cases of anterior uveitides were collected in an informatics-designed preliminary database, and a final database was constructed of cases achieving supermajority agreement on the diagnosis, using formal consensus techniques. Cases were split into a training set and a validation set. Machine learning using multinomial logistic regression was used on the training set to determine a parsimonious set of criteria that minimized the misclassification rate among the anterior uveitides. The resulting criteria were evaluated on the validation set.

RESULTS

One thousand eighty-three cases of anterior uveitides, including 94 cases of TINU, were evaluated by machine learning. The overall accuracy for anterior uveitides was 97.5% in the training set and 96.7% in the validation set (95% confidence interval 92.4, 98.6). Key criteria for TINU included anterior chamber inflammation and evidence of tubulointerstitial nephritis with either (1) a positive renal biopsy or (2) evidence of nephritis (elevated serum creatinine and/or abnormal urine analysis) and an elevated urine β-2 microglobulin. The misclassification rates for TINU were 1.2% in the training set and 0% in the validation set.

CONCLUSIONS

The criteria for TINU had a low misclassification rate and seemed to perform well enough for use in clinical and translational research.

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 a female adult

Tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare disease characterised by the association of acutetubulointerstitial nephritis and uveitis. It affects mainly children and young women. Drugs and infections may be precipitating factors. It is a diagnosis of exclusion. The mainstays of treatment are topical and systemic corticosteroids. Prognosis is usually favourable. We report a case of TINU which occurred in our unit. A 37-year-old woman presented with an influenza-like illness, bilateral ocular pain and blurred vision. Ophthalmological evaluation revealed bilateral anterior uveitis and later renal involvement was seen as acute tubulointerstitial nephritis. A diagnosis of TINU was assumed after exclusion of other systemic diseases. She was treated with topical corticosteroids for the uveitis and evolved favourably, with resolution of ocular symptoms and normalisation of serum creatinine and proteinuria. This case highlights the importance of a high degree of clinical suspicion to make the diagnosis of TINU syndrome.

Urinary β2-microglobulin and disease activity in patients with tubulointerstitial nephritis and uveitis syndrome

Background

Urinary β2-microglobulin (Uβ2M) is elevated in tubulointerstitial nephritis and uveitis (TINU) syndrome and has emerged as an important diagnostic tool. This study aims to determine whether Uβ2M correlates with uveitis activity in TINU.

Methods

Retrospective observational case series of nine patients with TINU and ≥ 30 days follow-up. Presenting symptoms, visual acuity, uveitis characteristics, follow-up, Uβ2M, serum creatinine (SCr), urinalysis, and renal biopsy results were collected.

Results

A correlation between Uβ2M and anterior chamber (AC) cell (r = 0.69, 95% CI 0.46–0.84), flare (r = 0.65, 95% CI 0.39–0.81), trended toward a stronger correlation than SCr and AC cell (r = 0.59, 95% CI 0.29–0.79), flare (r = 0.52, 95% CI 0.19–0.75). Uβ2M decreased over 1–2 years while SCr returned to normal within a few months.

Conclusions

Uβ2M correlate with uveitis activity and trend down over the course of TINU. Uβ2M may serve as a useful tool in determining where patients are in their systemic disease course.

TINU-associated Fanconi syndrome: a case report and review of literature

Background

Tubulo-interstitial Nephritis and Uveitis (TINU) syndrome is a rare oculo-renal inflammatory disease. Renal tubular defects are usually found, but full proximal tubular abnormalities have rarely been described.

Case presentation

We report the case of a 55-year old woman, native from Morocco, presenting with bilateral, non-granulomatous, anterior uveitis, mild renal insufficiency, leucocyturia and glycosuria. Further work-up showed hypophosphatemia and hyperphosphaturia, hypouricemia and hyperuricosuria, and hyper aminoaciduria, consistent with Fanconi syndrome. A kidney biopsy was obtained and showed diffuse interstitial infiltrates with tubular necrosis. The patient improved after the initiation of a corticosteroid therapy, with tapering dose.

Conclusions

We reviewed the literature and found nine similar cases. This association mostly occurs in adult woman, without current evidence for an ethnic predilection, unlike previously reported. The renal prognosis seems favorable after corticosteroid therapy, even in case of severe renal injury. Nonetheless mild tubular defects may persist after treatment or spontaneous remission.

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.

Measurement of urinary biomarkers in a case of tubulointerstitial nephritis and uveitis syndrome during glucocorticoid treatment

Tubulointerstitial nephritis and uveitis (TINU) is a rare syndrome in which idiopathic interstitial nephritis coexists with chronic recurrent uveitis. This syndrome often represents systemic disorders such as arthralgia, rash, prolonged fever, anaemia and ocular symptoms that require medication including glucocorticoid administration. Recently, novel urinary biomarkers, such as kidney injury molecule-1, neutrophil gelatinase-associated lipocalin and liver-type fatty acid-binding protein, were shown to be associated with tubulointerstitial damage and were elevated in interstitial nephritis. We evaluated these urinary biomarkers in a case of TINU syndrome before and during treatment and found that their levels were elevated at onset and decreased during treatment, especially NGAL. We conclude that these urinary biomarkers are useful to evaluate and predict prognosis in interstitial nephritis.

Progressive renal insufficiency related to ALK inhibitor, alectinib

Alectinib is a second generation anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitor and is generally effective and tolerated in patients who have demonstrated disease progression or adverse effects while on the first generation inhibitor, crizotinib. ALK inhibitors can cause a reversible chronic increase of serum creatinine concentration; however, they rarely induce progressive renal insufficiency. We herein report a case of a 68-year-old woman diagnosed with ALK-positive advanced non-small cell lung cancer and who received ALK inhibitors. Due to dysgeusia and transaminitis, her medication was switched from crizotinib to alectinib. Rapid progressive glomerulonephritis developed 1 year after the initiation of alectinib treatment. A renal biopsy revealed unique kidney lesions in both tubules and glomeruli. Glucocorticoid therapy partially reversed kidney impairment. However, re-administration of alectinib caused kidney dysfunction, which was improved by the cessation of alectinib. Our case suggests that much attention should be paid to kidney function when using ALK inhibitors.

Tubulointerstitial nephritis and uveitis

PURPOSE OF REVIEW

Tubulointerstitial nephritis and uveitis (TINU) is an important yet underrecognized ocular inflammatory syndrome. This review summarizes key historical publications that identified and defined the syndrome, and more recent literature that reveal the importance of urinary β2-microglobulin testing and kidney biopsy in the diagnostic evaluation of patients with TINU. Additionally, research studies providing new insights into disease pathogenesis are highlighted.

RECENT FINDINGS

In contrast with initial reports of TINU manifesting exclusively as an anterior uveitis in pediatric patients, more recent reports have identified TINU in patients of all ages with a wide range of ocular manifestations. Urinary β2-microglobulin has emerged as a sensitive and specific laboratory screening test, and the role of kidney biopsy in differentiating TINU from sarcoidosis continues to evolve. Genetic studies have identified HLA-DQA101, HLA-DQB105, and HLA-DRB101 as high-risk alleles and the identification of antimonomeric C-reactive protein antibodies suggests a role for humoral immunity in disease pathogenesis. Management strategies have evolved to include systemic anti-inflammatory treatment as a result of important outcome studies in patients with significant renal and ocular disease.

SUMMARY

With greater recognition, understanding, and treatment of this syndrome, both ocular inflammation and renal disease can be better addressed.

Treatment recommendations for non-infectious anterior uveitis

BACKGROUND AND OBJECTIVE

To develop recommendations on the use of immunodepressors in patients with non-infectious, non-neoplastic anterior uveitis (AU) based on best evidence and experience.

MATERIAL AND METHODS

A multidisciplinary panel of five experts was established, who, in the first nominal group meeting defined the scope, users, and chapters of the document. A systematic literature review was performed to assess the efficacy and safety of immunosuppressors in patients with non-infectious, non-neoplastic AU. All the above was discussed in a second nominal group meeting and 33 recommendations were generated. Through the Delphi methodology, the degree of agreement with the recommendations was tested also by 25 more experts. Recommendations were voted on from one (total disagreement) to 10 (total agreement). We defined agreement if at least 70% voted ≥7. The level of evidence and degree of recommendation was assessed using the Oxford Centre for Evidence-based Medicine's Levels of Evidence.

RESULTS

The 33 recommendations were accepted. They include specific recommendations on patients with non-infectious, non-neoplastic AU, as well as different treatment lines.

CONCLUSIONS

In patients with non-infectious, non-neoplastic AU, these recommendations on the use of immunosuppressors might be a guide in order to help in the treatment decision making, due to the lack of robust evidence or other globally accepted algorithms.