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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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2
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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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Zhou XJ, Su T, Xie J, Xie QH, Wang LZ, Hu Y, Chen G, Jia Y, Huang JW, Li G, Liu Y, Yu XJ, Nath SK, Tsoi LC, Patrick MT, Berthier CC, Liu G, Wang SX, Xu H, Chen N, Hao CM, Zhang H, Yang L. Genome-Wide Association Study in Acute Tubulointerstitial Nephritis. J Am Soc Nephrol 2023; 34:895-908. [PMID: 36749126 PMCID: PMC10125656 DOI: 10.1681/asn.0000000000000091] [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: 07/21/2022] [Accepted: 12/28/2022] [Indexed: 02/08/2023] Open
Abstract
SIGNIFICANCE STATEMENT Polymorphisms of HLA genes may confer susceptibility to acute tubulointerstitial nephritis (ATIN), but small sample sizes and candidate gene design have hindered their investigation. The first genome-wide association study of ATIN identified two significant loci, risk haplotype DRB1*14-DQA1*0101-DQB1*0503 (DR14 serotype) and protective haplotype DRB1*1501-DQA1*0102-DQB1*0602 (DR15 serotype), with amino acid position 60 in the peptide-binding groove P10 of HLA-DR β 1 key. Risk alleles were shared among different causes of ATIN and HLA genotypes associated with kidney injury and immune therapy response. HLA alleles showed the strongest association. The findings suggest that a genetically conferred risk of immune dysregulation is part of the pathogenesis of ATIN. BACKGROUND Acute tubulointerstitial nephritis (ATIN) is a rare immune-related disease, accounting for approximately 10% of patients with unexplained AKI. Previous elucidation of the relationship between genetic factors that contribute to its pathogenesis was hampered because of small sample sizes and candidate gene design. METHODS We undertook the first two-stage genome-wide association study and meta-analysis involving 544 kidney biopsy-defined patients with ATIN and 2346 controls of Chinese ancestry. We conducted statistical fine-mapping analysis, provided functional annotations of significant variants, estimated single nucleotide polymorphism (SNP)-based heritability, and checked genotype and subphenotype correlations. RESULTS Two genome-wide significant loci, rs35087390 of HLA-DQA1 ( P =3.01×10 -39 ) on 6p21.32 and rs2417771 of PLEKHA5 on 12p12.3 ( P =2.14×10 -8 ), emerged from the analysis. HLA imputation using two reference panels suggested that HLA-DRB1*14 mainly drives the HLA risk association . HLA-DRB1 residue 60 belonging to pocket P10 was the key amino acid position. The SNP-based heritability estimates with and without the HLA locus were 20.43% and 10.35%, respectively. Different clinical subphenotypes (drug-related or tubulointerstitial nephritis and uveitis syndrome) seemed to share the same risk alleles. However, the HLA risk genotype was associated with disease severity and response rate to immunosuppressive therapy. CONCLUSIONS We identified two candidate genome regions associated with susceptibility to ATIN. The findings suggest that a genetically conferred risk of immune dysregulation is involved in the pathogenesis of ATIN.
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Affiliation(s)
- Xu-Jie Zhou
- Renal Division, Peking University First Hospital, 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, Peking University First Hospital, 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
| | - Jingyuan Xie
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiong-Hong Xie
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Li-Zhong Wang
- WeGene, Shenzhen Zaozhidao Technology Co., Ltd., Shenzhen, China
- Human Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, China
- Shenzhen WeGene Clinical Laboratory, Shenzhen, China
| | - Yong Hu
- Beijing Institute of Biotechnology, Beijing, China
| | - Gang Chen
- WeGene, Shenzhen Zaozhidao Technology Co., Ltd., Shenzhen, China
- Human Provincial Key Lab on Bioinformatics, School of Computer Science and Engineering, Central South University, Changsha, China
- Shenzhen WeGene Clinical Laboratory, Shenzhen, China
| | - Yan Jia
- Renal Division, Peking University First Hospital, 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
| | - Jun-Wen Huang
- Renal Division, Peking University First Hospital, 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
| | - Gui Li
- Renal Division, Peking University First Hospital, 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
| | - Yang Liu
- Renal Division, Peking University First Hospital, 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
| | - Xiao-Juan Yu
- Renal Division, Peking University First Hospital, 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
| | - Swapan K. Nath
- Arthritis and Clinical Immunology Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma
| | - Lam C. Tsoi
- Department of Dermatology, University of Michigan Medical School, Ann Arbor, Michigan
- Center for Statistical Genetics, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Matthew T. Patrick
- Department of Dermatology, University of Michigan Medical School, Ann Arbor, Michigan
- Center for Statistical Genetics, Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan
| | - Celine C. Berthier
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Gang Liu
- Renal Division, Peking University First Hospital, 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
| | - Su-Xia Wang
- Renal Division, Peking University First Hospital, 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
| | - Huji Xu
- Department of Rheumatology and Immunology, Shanghai Changzheng Hospital, Second Military Medical University, Shanghai, China
- Peking-Tsinghua Center for Life Sciences, Tsinghua University, Beijing, China
- School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Nan Chen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chuan-Ming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, 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, Peking University First Hospital, 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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Kitamura Y, Kuraoka S, Nagano K, Tamura H. A case of tubulointerstitial nephritis and uveitis syndrome following drug-induced acute interstitial nephritis. Clin Case Rep 2022; 10:e5969. [PMID: 35765298 PMCID: PMC9207119 DOI: 10.1002/ccr3.5969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/15/2022] [Accepted: 06/03/2022] [Indexed: 11/11/2022] Open
Abstract
Distinguishing between late-onset TINU syndrome and drug-induced AIN remains difficult given that patients with TINU syndrome may develop uveitis long after the onset of AIN. Therefore, ophthalmic examination is required not only upon diagnosis but also continuously or when eye symptoms and relapse of urinary findings are observed.
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Affiliation(s)
- Yukiko Kitamura
- Department of Pediatrics, Faculty of Life SciencesKumamoto UniversityKumamotoJapan
| | - Shohei Kuraoka
- Department of Pediatrics, Faculty of Life SciencesKumamoto UniversityKumamotoJapan
| | - Koji Nagano
- Department of Pediatrics, Faculty of Life SciencesKumamoto UniversityKumamotoJapan
| | - Hiroshi Tamura
- Department of Pediatrics, Faculty of Life SciencesKumamoto UniversityKumamotoJapan
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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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Wennink RAW, de Boer JH, Hiddingh S, Haasnoot AMJW, Kalinina Ayuso V, de Hoop T, van Setten J, Spierings E, Kuiper JJW. Next-Generation HLA Sequence Analysis Uncovers Shared Risk Alleles Between Clinically Distinct Forms of Childhood Uveitis. Invest Ophthalmol Vis Sci 2021; 62:19. [PMID: 34254975 PMCID: PMC8287043 DOI: 10.1167/iovs.62.9.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Purpose Classical alleles of the human leukocyte antigen (HLA) complex have been linked to specific entities of pediatric noninfectious uveitis, yet genetic predisposition encoded by the HLA super-locus across the patient population remains understudied. Methods We performed next-generation full-length sequencing of HLA-A, HLA-B, HLA-C, HLA-DPB1, HLA-DQB1, and HLA-DRB1 in 280 cases. Dense genotype data from 499 Dutch controls from Genome of the Netherlands were imputed using an HLA-specific reference panel (n = 5225 samples from European ancestry). Cases and controls were compared using logistic regression models adjusting for sex. Results In total, 179 common and rare alleles were detected. Considering all cases and controls, HLA-DQB1*04:02 and HLA-DRB1*08:01 were identified as the principal HLA association, which was mainly driven by 92 cases with juvenile idiopathic arthritis-associated uveitis (JIA-U). The HLA-DQB1*04:02-HLA-DRB1*08:01 haplotype was also the primary association for the phenotypically similar idiopathic chronic anterior uveitis without arthritis (CAU). Also, HLA-DQB1*05:03 was an independent risk allele for CAU, but not in JIA-U. Analysis of 185 cases with other forms of uveitis revealed HLA-wide associations (P < 2.79 × 10−4) for HLA-DRB1*01:02, HLA-DRB1*04:03, and HLA-DQB1*05:03, which could be primarily attributed to cases with panuveitis. Finally, amino acid substitution modeling revealed that aspartic acid at position 57 that distinguishes the risk allele HLA-DQB1*05:03 (for CAU and panuveitis) from nonrisk alleles, significantly increased the binding capacity of naturally presented ligands to HLA-DQ. Conclusions These results uncovered novel shared HLA associations among clinically distinct phenotypes of pediatric uveitis and highlight genetic predisposition affecting the antigen presentation pathway.
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Affiliation(s)
- Roos A W Wennink
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands.,Center of Translational Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Joke H de Boer
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Sanne Hiddingh
- Center of Translational Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Anne-Mieke J W Haasnoot
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Viera Kalinina Ayuso
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Talitha de Hoop
- Center of Translational Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jessica van Setten
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Eric Spierings
- Center of Translational Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jonas J W Kuiper
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands.,Center of Translational Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands
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Agarwal M, Dutta Majumder P, Babu K, Konana VK, Goyal M, Touhami S, Stanescu-Segall D, Bodaghi B. Drug-induced uveitis: A review. Indian J Ophthalmol 2021; 68:1799-1807. [PMID: 32823396 PMCID: PMC7690475 DOI: 10.4103/ijo.ijo_816_20] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Uveitis maybe induced by the use of various medications known as drug-induced uveitis (DIU), though rare it is an important cause of uveitis which one needs to be aware of. The drugs may be administered through any route including systemic, topical, and intravitreal. Ocular inflammation can be in the form of anterior, intermediate, posterior or pan uveitis, and rarely may present as episcleritis and scleritis. Identification of drug as the offending agent of uveitis is important as many a times stopping the drug may help recover the uveitis or the concomitant use of corticosteroids. An extensive literature review was done using the Pubmed. An overview of DIU is provided as it is important for us to be aware of this clinical entity.
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Affiliation(s)
- Manisha Agarwal
- Vitreoretina and Uveitis Services, Dr. Shroff's Charity Eye Hospital, New Delhi, India
| | | | - Kalpana Babu
- Department of Uveitis and Ocular Inflammation, Vittala International Institute of Ophthalmology, Prabha Eye Clinic and Research Centre, Bangalore, Karnataka, India
| | | | - Mallika Goyal
- Department of Ophthalmology, IHU FOReSIGHT, Pitie-Salpetriere Universtiy Hospital, Paris, France
| | - Sara Touhami
- Department of Ophthalmology, IHU FOReSIGHT, Pitie-Salpetriere Universtiy Hospital, Paris, France
| | - Dinu Stanescu-Segall
- Department of Ophthalmology, IHU FOReSIGHT, Pitie-Salpetriere Universtiy Hospital, Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, IHU FOReSIGHT, Pitie-Salpetriere Universtiy Hospital, Paris, France
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9
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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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10
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A rare case of tubulointerstitial nephritis and uveitis (TINU) syndrome: Answers. Pediatr Nephrol 2020; 35:2269-2274. [PMID: 32440946 DOI: 10.1007/s00467-020-04590-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 04/22/2020] [Indexed: 10/24/2022]
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11
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Amaro D, Carreño E, Steeples LR, Oliveira-Ramos F, Marques-Neves C, Leal I. Tubulointerstitial nephritis and uveitis (TINU) syndrome: a review. Br J Ophthalmol 2019; 104:742-747. [DOI: 10.1136/bjophthalmol-2019-314926] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 10/11/2019] [Accepted: 10/30/2019] [Indexed: 11/04/2022]
Abstract
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.
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12
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Rytkönen S, Ritari J, Peräsaari J, Saarela V, Nuutinen M, Jahnukainen T. IL-10 polymorphisms +434T/C, +504G/T, and -2849C/T may predispose to tubulointersititial nephritis and uveitis in pediatric population. PLoS One 2019; 14:e0211915. [PMID: 30779760 PMCID: PMC6380573 DOI: 10.1371/journal.pone.0211915] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 01/22/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Tubulointerstitial nephritis (TIN) and uveitis syndrome (TINU) are likely to be autoimmune diseases. Based on previous studies, adults with isolated idiopathic uveitis have polymorphisms in interleukin 10 (IL-10) and tumor necrosis factor α (TNF-α) genes. We aimed to evaluate the presence of IL-10 and TNF-α polymorphisms in a nationwide cohort of pediatric TIN/TINU patients. METHODS Single nucleotide polymorphisms in IL-10 (+434T/C, +504G/T, -1082G/A, -2849C/T) and in TNFα (-308G/A, -238G/A, -857C/T) genes were genotyped in 30 well-defined pediatric patients with idiopathic TIN/TINU syndrome. Control group frequencies for these SNPs were obtained from 393 independent Finnish subjects. RESULTS The homozygous minor allele in IL-10 +434T (rs2222202) and IL-10+504G (rs3024490) was found in all patients with TIN or TINU syndrome while the frequency of these minor alleles in the control population was 44% and 23%, respectively (p <0.001). In IL-10 SNP -2849 (rs6703630) a significant difference was found with genotype TT in all patients (p = 0.004) and in subgroups with TINU syndrome (p = 0.017) and TINU syndrome with chronic uveitis (p = 0.01) compared to reference population. There were no statistical differences in any of the studied TNF-α genotypes between TIN/TINU patients and control population. CONCLUSIONS A significant difference in the frequency of IL-10+434T and +504G alleles was found between TIN/TINU patients and control population. Genotype -2849TT was more frequently present in patients with TINU syndrome than in the reference subjects. Genetic variation in the inflammatory mediators may predispose to autoimmune nephritis and uveitis.
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Affiliation(s)
- Sari Rytkönen
- PEDEGO Research Unit and Medical Research Center (MRC), University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Jarmo Ritari
- Clinical Laboratory, Finnish Red Cross Blood Service, Helsinki, Finland
| | - Juha Peräsaari
- Clinical Laboratory, Finnish Red Cross Blood Service, Helsinki, Finland
| | - Ville Saarela
- Ville Saarela, Department of Ophthalmology, Oulu University Hospital, Finland
| | - Matti Nuutinen
- PEDEGO Research Unit and Medical Research Center (MRC), University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Timo Jahnukainen
- Timo Jahnukainen, Department of Pediatric Nephrology and Transplantation, New Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- * E-mail:
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13
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Gauckler P, Shin JI, Mayer G, Kronbichler A. Eosinophilia and Kidney Disease: More than Just an Incidental Finding? J Clin Med 2018; 7:E529. [PMID: 30544782 PMCID: PMC6306805 DOI: 10.3390/jcm7120529] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 11/29/2018] [Accepted: 12/05/2018] [Indexed: 02/07/2023] Open
Abstract
Peripheral blood eosinophilia (PBE), defined as 500 eosinophils or above per microliter (µL) blood, is a condition that is not uncommon but often neglected in the management of patients with chronic kidney disease (CKD), acute kidney injury (AKI), or patients on renal replacement therapy (RRT). The nature of PBE in the context of kidney diseases is predominantly secondary or reactive and has to be distinguished from primary eosinophilic disorders. Nonetheless, the finding of persistent PBE can be a useful clue for the differential diagnosis of underdiagnosed entities and overlapping syndromes, such as eosinophilic granulomatosis with polyangiitis (EGPA), IgG4-related disease (IgG4-RD), acute interstitial nephritis (AIN), or the hypereosinophilic syndrome (HES). For patients on RRT, PBE may be an indicator for bio-incompatibility of the dialysis material, acute allograft rejection, or Strongyloides hyperinfection. In a subset of patients with EGPA, eosinophils might even be the driving force in disease pathogenesis. This improved understanding is already being used to facilitate novel therapeutic options. Mepolizumab has been licensed for the management of EGPA and is applied with the aim to abrogate the underlying immunologic process by blocking interleukin-5. The current article provides an overview of different renal pathologies that are associated with PBE. Further scientific effort is required to understand the exact role and function of eosinophils in these disorders which may pave the way to improved interdisciplinary management of such patients.
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Affiliation(s)
- Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Korea.
- Department of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Korea.
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Korea.
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30322, USA.
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, 6020 Innsbruck, Austria.
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14
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Sarri CA, Papadopoulos GE, Papa A, Tsakris A, Pervanidou D, Baka A, Politis C, Billinis C, Hadjichristodoulou C, Mamuris Z. Amino acid signatures in the HLA class II peptide-binding region associated with protection/susceptibility to the severe West Nile Virus disease. PLoS One 2018; 13:e0205557. [PMID: 30379846 PMCID: PMC6209194 DOI: 10.1371/journal.pone.0205557] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 09/27/2018] [Indexed: 12/23/2022] Open
Abstract
The MHC class II region in humans is highly polymorphic. Each MHC molecule is formed by an α and a β chain, produced by different genes, creating an antigen-binding groove. In the groove there are several pockets into which antigens anchor and fit. The affinity of this fitting determines the recognition specificity of a given peptide. Here, based on our previous results about the association of MHC class II with the WNV disease, we examined the role of the binding pockets of HLA-DPA1, -DQA1 and-DRB1 in the severe form of the disease. In HLA-DQA1, variants in all pockets 1, 6 and 9 were found to be associated with either protection and/or susceptibility to neuroinvasion caused by WNV. Similarly, pockets 7, 9 and 10 in HLA-DRB1 were associated with severe disease. Protein modeling of these molecules revealed structural and functional differences among alleles with opposite roles concerning the development of the disease. Different amino acids in positions α52 and α66 (HLA-DQA1) significantly influenced the peptide binding while DYWLR/EFA combination (HLA-DRB1) was associated with neuronal damage. Further studies could help us understand the selectivity of pocket variants in order to create suitable peptides for an effective response.
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Affiliation(s)
- Constantina A. Sarri
- Department of Biochemistry and Biotechnology, University of Thessaly, Larissa, Greece
| | | | - Anna Papa
- 1st Microbiological Laboratory, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasios Tsakris
- Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Danai Pervanidou
- Hellenic Centre for Disease Control and Prevention (HCDCP), Athens, Greece
| | - Agoritsa Baka
- Hellenic Centre for Disease Control and Prevention (HCDCP), Athens, Greece
| | | | | | | | - Zissis Mamuris
- Department of Biochemistry and Biotechnology, University of Thessaly, Larissa, Greece
- * E-mail:
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15
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Robson KJ, Ooi JD, Holdsworth SR, Rossjohn J, Kitching AR. HLA and kidney disease: from associations to mechanisms. Nat Rev Nephrol 2018; 14:636-655. [DOI: 10.1038/s41581-018-0057-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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16
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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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17
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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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18
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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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19
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Abstract
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.
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Affiliation(s)
- Kaivon Pakzad-Vaezi
- Department of Ophthalmology, University of Washington, Seattle, Washington, USA
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20
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Okafor LO, Hewins P, Murray PI, Denniston AK. Tubulointerstitial nephritis and uveitis (TINU) syndrome: a systematic review of its epidemiology, demographics and risk factors. Orphanet J Rare Dis 2017; 12:128. [PMID: 28709457 PMCID: PMC5513333 DOI: 10.1186/s13023-017-0677-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 06/19/2017] [Indexed: 01/22/2023] Open
Abstract
Tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare oculorenal inflammatory condition that was first described in 1975. In 2001 a major review identified 133 cases in the world literature and proposed key diagnostic criteria for the condition. Although acknowledged as rare, the limited data available prevented reliable estimates of the prevalence of the condition, and hampered elucidation of the relationship between genetic and environmental factors that contribute to its pathogenesis.In this review we have performed a systematic search on the epidemiology, demographics and proposed risk factors for TINU. Estimates of prevalence based on studies that explicitly report TINU cases suggest that it is diagnosed in 0.2-2% of patients attending specialist uveitis services, with variation reflecting a number of factors including level of diagnostic certainty required. The prevalence of uveitis in patients with tubulointerstitial nephritis (TIN) may be higher than currently recognised, particularly in the paediatric population.The prevalence of TINU is higher in younger age groups and there is a female preponderance although this gender effect appears weaker than suggested by early studies. Although important genetic contributions have been proposed, the small size of studies and variation between reports currently preclude identification of a 'pro-TINU' haplotype. Drugs and infections have been proposed as the leading acquired risk factors for the development of TINU; whilst the small size of TINU cohorts and issues of study design limit interpretation of many studies. Larger datasets from the renal literature suggest that the majority of these cases are precipitated by a drug-induced hypersensitivity reaction; however in many ophthalmic cases no clear precipitant is identified.
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Affiliation(s)
- Linda O. Okafor
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Peter Hewins
- Department of Renal Medicine, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Translational Medicine, Centre for Rare Diseases, Birmingham Health Partners, Birmingham, UK
| | - Philip I. Murray
- Birmingham & Midland Eye Centre, Sandwell & West Birmingham Hospitals NHS Trust, Birmingham, UK
- Institute of Inflammation and Ageing, Academic Unit of Ophthalmology, University of Birmingham, Birmingham, B15 2WB UK
| | - Alastair K. Denniston
- Department of Ophthalmology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Translational Medicine, Centre for Rare Diseases, Birmingham Health Partners, Birmingham, UK
- Institute of Inflammation and Ageing, Academic Unit of Ophthalmology, University of Birmingham, Birmingham, B15 2WB UK
- NIHR Biomedical Research Centre at Moorfields Eye Hospital and UCL Institute of Ophthalmology, London, UK
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21
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Ramanathan ASK, Senguttuvan P, Chinniah R, Vijayan M, Thirunavukkarasu M, Raju K, Mani D, Ravi PM, Rajendran P, Krishnan JI, Karuppiah B. Association of HLA-DR/DQ alleles and haplotypes with nephrotic syndrome. Nephrology (Carlton) 2017; 21:745-52. [PMID: 26566811 DOI: 10.1111/nep.12669] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/21/2015] [Accepted: 11/09/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Nephrotic syndrome (NS) is a debilitating renal problem in children resulting from an interaction between environmental and genetic factors including human leukocyte antigen genes (HLA). The aim of this work was to study the probable link between HLA alleles/haplotypes and NS in south India. METHODS HLA DRB1*/DQB1* alleles were genotyped in 183 NS (76 steroid sensitive-SSNS; 107 steroid resistant-SRNS) and paediatric healthy controls (PHCs; n = 91) using polymerase chain reaction-sequence specific primers (PCR-SSP). HLA-A/-B genotyping was performed for patients (n = 70) positive for DRB1*07-DQB1*02 haplotype to identify four locus extended haplotype. RESULTS The following alleles and haplotypes were strongly associated with NS (P < 0.05 as significant): DRB1*07 (SSNS, P < 7.98 × 10(-6) ; SRNS, P < 0.008), DQB1*02 (SSNS, P < 3.99 × 10(-6) ; SRNS, P < 0.002), DRB1*07-DQB1*02 (SSNS, P < 1.32 × 10(-4) ; SRNS, P < 0.010), DRB1*07-DQB1*0301,0304 (DQ7) (SSNS, P < 0.001) and DRB1*03-DQB1*02 (SRNS, P < 0.048). Protective associations were observed for alleles DRB1*10 (SRNS, P < 0.013), DQB1*05 (SSNS, P < 4.34 × 10(-6) ; SRNS, P < 0.01), DQB1*06 (SSNS, P < 0.003), and haplotypes DRB1*10-DQB1*06 (SSNS, P < 0.046; SRNS, P < 0.032) and DRB1*15-DQB1*05 (SSNS, P < 0.018). HLA-A/-B typing of 70 NS cases with two locus haplotype DRB1*07-DQB1*02 (70/183; 38.25%) revealed the presence of an extended haplotype 'A*03-B*07-DRB1*07-DQB1*02' (n = 35; 50%). CONCLUSION Our study revealed strong susceptible association of DRB1*07 with SRNS and DQB1*02 with SSNS. A gender predominant protective association was observed for DRB1*10 with SRNS females; DQB1*05 with SSNS and SRNS males. Further, the study documented the presence of an extended haplotype and pleiotropic action of DRB1*/DQB1* alleles in immune-mediated aetiology of NS in south India.
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Affiliation(s)
- Aravind Selvin Kumar Ramanathan
- Department of Pediatric Nephrology, Institute of Child Health & Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | - Prabha Senguttuvan
- Department of Pediatric Nephrology, Institute of Child Health & Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India.,Department of Pediatric Nephrology, Dr. Mehta's Children's Hospital, Chennai, Tamil Nadu, India
| | - Rathika Chinniah
- Department of Immunology, School of Biological Sciences, Madurai Kamaraj University, Madurai, Tamil Nadu, India
| | - Murali Vijayan
- Department of Biotechnology & Genetic Engineering, School of Biotechnology, Bharathidasan University, Tiruchirappalli, Tamil Nadu, India
| | - Manikandan Thirunavukkarasu
- Department of Biotechnology & Genetic Engineering, School of Biotechnology, Bharathidasan University, Tiruchirappalli, Tamil Nadu, India
| | - Kamaraj Raju
- Department of Immunology, School of Biological Sciences, Madurai Kamaraj University, Madurai, Tamil Nadu, India
| | - Dhivakar Mani
- Department of Immunology, School of Biological Sciences, Madurai Kamaraj University, Madurai, Tamil Nadu, India
| | - Padma Malini Ravi
- Department of Immunology, School of Biological Sciences, Madurai Kamaraj University, Madurai, Tamil Nadu, India
| | - Padmaraj Rajendran
- Department of Pediatric Nephrology, Institute of Child Health & Hospital for Children, Madras Medical College, Chennai, Tamil Nadu, India
| | | | - Balakrishnan Karuppiah
- Department of Immunology, School of Biological Sciences, Madurai Kamaraj University, Madurai, Tamil Nadu, India
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22
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Legendre M, Devilliers H, Perard L, Groh M, Nefti H, Dussol B, Trad S, Touré F, Abad S, Boffa JJ, Frimat L, Torner S, Seidowsky A, Massy ZA, Saadoun D, Rieu V, Schoindre Y, Heron E, Frouget T, Lionet A, Glowacki F, Arnaud L, Mousson C, Besancenot JF, Rebibou JM, Bielefeld P. Clinicopathologic characteristics, treatment, and outcomes of tubulointerstitial nephritis and uveitis syndrome in adults: A national retrospective strobe-compliant study. Medicine (Baltimore) 2016; 95:e3964. [PMID: 27367994 PMCID: PMC4937908 DOI: 10.1097/md.0000000000003964] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Tubulointerstitial nephritis and uveitis (TINU) syndrome is a rare disease, defined by the association of idiopathic acute TINU. The aim of our work was to determine the characteristics of adult TINU syndrome in France, and to assess factors (including treatment) influencing medium-term prognosis.We conducted a nationwide study including 20 French hospitals. Clinical, laboratory, and renal histopathologic data of 41 biopsy-proven TINU syndromes were retrospectively collected. The patients were diagnosed between January 1, 1999 and December 1, 2015.Twenty-five females and 16 males were included (F/M ratio: 1.6:1). The median age at disease onset was 46.8 years (range 16.8-77.4) with a median serum creatinine level at 207 μmol/L (range 100-1687) and a median estimated glomerular filtration rate (eGFR) at 27 mL/min per 1.73 m (range 2-73). Twenty-nine patients (71%) had a bilateral anterior uveitis and 24 (59%) had deterioration in general health at presentation. Moderate proteinuria was found in 32 patients (78%) (median proteinuria 0.52 g/24 h; range 0.10-2.10), aseptic leukocyturia in 25/36 patients (70%). The evaluation of renal biopsies revealed 41 patients (100%) with an acute tubulointerstitial nephritis, 19/39 patients (49%) with light to moderate fibrosis and 5 patients (12%) with an acute tubular necrosis. Thirty-six patients (88%) were treated with oral corticosteroids. After 1 year of follow-up, the median eGFR was 76 mL/min per 1.73 m (range 17-119) and 32% of the patients suffered from moderate to severe chronic kidney disease. Serum creatinine (P < 0.001, r = -0.54), serum bicarbonate and phosphate levels (respectively, P = 0.01, r = 0.53; and P = 0.04, r = 0.46), and age (P = 0.03, r = -0.37) at the 1st symptoms were associated with eGFR after 1 year. During the 1st year 40% of patients had uveitis relapses. The use of oral corticosteroids was not associated with a better kidney function but was associated with fewer uveitis relapses (P = 0.44 and 0.02, respectively).In our study, 32% of patients were suffering from moderate to severe chronic kidney disease after 1 year of follow-up, and 40% had uveitis relapses during this follow-up. This work also suggests that oral corticosteroids are effective for the treatment of TINU syndrome's uveitis.
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Affiliation(s)
| | - Hervé Devilliers
- Internal Medicine and Systemic Diseases Department, Bocage University Hospital, Dijon
| | - Laurent Perard
- Internal Medicine Department, Edouard Herriot University Hospital and University Claude Bernard Lyon 1, Lyon
| | - Matthieu Groh
- Internal Medicine Department, National Referral Center for Rare Autoimmune and Systemic Diseases, Cochin University Hospital and University Paris Descartes, Paris
| | | | - Bertrand Dussol
- Nephrology Department, La Conception University Hospital and University Aix-Marseille, Marseille
| | - Salim Trad
- Internal Medicine Department, Ambroise-Paré University Hospital, Paris
| | - Fatouma Touré
- Nephrology Department, Maison Blanche University Hospital, Reims
| | - Sébastien Abad
- Internal Medicine Department, University Hospital Avicenne and University Sorbonne, Paris
| | | | - Luc Frimat
- Nephrology Department, Brabois University Hospital and INSERM CIC-EC CIE6, Nancy
| | | | - Alexandre Seidowsky
- Nephrology Department, Ambroise-Paré University Hospital, Boulogne-Billancourt
| | - Ziad André Massy
- Nephrology Department, Ambroise-Paré University Hospital, Boulogne-Billancourt
| | - David Saadoun
- Internal Medicine and Clinical Immunology Department, Pitié Salpetriere University Hospital and DHU Inflammation, Immunopathology, Biotherapy, Paris VI
| | - Virginie Rieu
- Internal Medicine Department, University Hospital Clermont Ferrand, Clermont-Ferrand
| | - Yoland Schoindre
- Internal Medicine and Clinical Immunology Department, Pitié Salpetriere University Hospital and DHU Inflammation, Immunopathology, Biotherapy, Paris VI
| | - Emmanuel Heron
- Internal Medicine Department, Quinze-Vingts Ophthalmogy Hospital, Paris
| | | | - Arnaud Lionet
- Nephrology Department, University Hospital Claude Huriez, Lille
| | | | - Laurent Arnaud
- Rheumatology Department, National Referral Center for Rare Autoimmune Diseases, Strasbourg University Hospital, and UMR 1109, Strasbourg, France
| | | | | | | | - Philip Bielefeld
- Internal Medicine and Systemic Diseases Department, Bocage University Hospital, Dijon
- Correspondence: Philip Bielefeld, Internal Medicine and Systemic Diseases Department, Bocage University Hospital, Service de Médecine 2, 14 rue Paul Gaffarel, CHU Dijon, 21033 Dijon Cedex, France (e-mail: )
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Reddy AK, Hwang YS, Mandelcorn ED, Davis JL. HLA-DR, DQ class II DNA typing in pediatric panuveitis and tubulointerstitial nephritis and uveitis. Am J Ophthalmol 2014; 157:678-86.e1-2. [PMID: 24321473 DOI: 10.1016/j.ajo.2013.12.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Revised: 11/30/2013] [Accepted: 12/02/2013] [Indexed: 10/25/2022]
Abstract
PURPOSE To describe chorioretinal lesions in pediatric uveitis that are associated strongly with the HLA-DR, DQ class II type associated with tubulointerstitial nephritis and uveitis (TINU). DESIGN Retrospective, observational case series. METHODS SETTING University-based clinic. PATIENT POPULATION Fifteen consecutive patients with onset of bilateral panuveitis at less than 16 years of age who were seen between September 2004 and October 2012 and 6 pediatric patients with confirmed TINU. OBSERVATION PROCEDURE HLA-DR, DQ class II DNA typing. MAIN OUTCOME MEASURE Detection of the HLA-DRB1*01 and HLA-DQB1*05 risk alleles for TINU. RESULTS Fourteen (93%) of the 15 patients with otherwise unexplained pediatric panuveitis typed HLA-DRB1*01-HLA-DQB1*05. Eleven (73.3%) of 15 patients had bilateral sharply demarcated, usually inferior, 200- to 300-μm spots of chorioretinal atrophy, and 4 (27.7%) of 15 patients had bilateral clusters of 500- to 750-μm poorly defined orange choroidal lesions without overlying atrophy of the retinal pigment epithelium. None had interstitial nephritis. Four of the 6 definite TINU cases had class II typing and TINU risk alleles; all 6 had bilateral panuveitis. The frequency of risk alleles was statistically higher in those with pediatric panuveitis than in the North American population and in nonpanuveitis pediatric uveitis patients assumed to have the North American HLA distribution (P < .0001, Fischer exact test). Positive likelihood ratios were 9.92 to 5.18, depending on assumptions regarding pretest probability of disease. CONCLUSIONS Recognition of characteristic chorioretinal lesions in otherwise unexplained pediatric panuveitis, supported by selective HLA class II DNA typing, is useful in narrowing diagnostic possibilities and directing further evaluations. Panuveitis is underappreciated as a manifestation of TINU.
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