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Huang L, Kim DT, Rosenberg CR, Lin P, Suhler E. Diagnosis and Characteristics of Presentation of Tubulointerstitial Nephritis and Uveitis Syndrome During the COVID-2019 Pandemic. Ocul Immunol Inflamm 2024; 32:1351-1358. [PMID: 37699166 PMCID: PMC10927609 DOI: 10.1080/09273948.2023.2244077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 07/12/2023] [Accepted: 07/30/2023] [Indexed: 09/14/2023]
Abstract
PURPOSE To compare the diagnosis and clinical features of tubulointerstitial nephritis and uveitis syndrome (TINU) before and during the COVID-19 pandemic. METHODS Retrospective chart review. RESULTS Before the COVID-19 pandemic (March 2017 to March 2019), 1/561 (0.18%) new patient was diagnosed with TINU. During the pandemic (March 2020 to March 2022), 15/581 (2.58%) new patients were diagnosed with TINU. We found a significant increase in TINU cases during the pandemic (P=0.0005). Various posterior segment findings were observed in 2/3 (66.7%) patients before the pandemic and 13/15 (86.7%) patients during the pandemic, including disc edema, chorioretinal scars, disc leakage, and peripheral vascular leakage. CONCLUSION This is the first study reporting an increased number of TINU during the COVID-19 pandemic. With most of the American population now exposed to COVID-19, a large multi-center epidemiological study would be helpful to investigate any association of COVID-19 disease or vaccination with TINU in recent years.
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Affiliation(s)
- Lingling Huang
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
| | - David Ta Kim
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Phoebe Lin
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
- Cole Eye Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eric Suhler
- Casey Eye Institute, Oregon Health & Science University, Portland, OR, USA
- VA Portland Health Care System, Portland, OR, USA
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2
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Mandel M, Elhusseiny AM, Davidson SL, Rockter A, Levin AV, Huang LC, Cheung CSY, Stahl ED, Cooper AM, Jin J, Inger HE, Jordan CO, Jung JL, Utz VM, Angeles-Han ST, Oke I, Nihalani BR. Clinical outcomes in paediatric tubulointerstitial nephritis and uveitis syndrome (TINU). Eye (Lond) 2024:10.1038/s41433-024-03286-9. [PMID: 39085599 DOI: 10.1038/s41433-024-03286-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 07/14/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024] Open
Abstract
PURPOSE To evaluate the clinical presentation, course, and outcomes of uveitis in paediatric patients with tubulointerstitial nephritis and uveitis syndrome (TINU). METHODS Multicentric Retrospective Cohort Study 110 patients ≤21 years of age diagnosed with TINU from 10 sites across the United States and Canada. Clinical diagnosis of TINU required uveitis diagnosed by an ophthalmologist, elevated serum creatinine (SCr) and elevated urine β2-microglobulin (β2M) or abnormal urinalysis. Renal biopsy and systemic illness were not mandatory. Univariate and multivariate analysis was performed to analyse risk factors and treatment modalities. RESULTS Median age was 13 years (Range (5.9-18.4); 52% male); median follow-up, 1.6 years (IQR 0.98-4.02). Uveitis was symptomatic in 90%, with bilateral anterior uveitis in 94%. Ninety-two (84%) patients required immunomodulatory treatment (IMT). Methotrexate (n = 44) and mycophenolate mofetil (n = 39) were the first agents after oral corticosteroids. 45% required addition of biologic agents (Adalimumab [n = 33], Infliximab [n = 8]). Younger age (p = 0.018), male sex (p = 0.011), and higher uveitis grade at presentation (p = 0.031) were associated with greater IMT ( ≥ 2) requirement. 53% had uveitis recurrence compared to 16% with nephritis recurrence. At the most recent visit, nephritis was controlled in 90%, while uveitis in 74%. Four (4%) patients required glaucoma surgery. Nine (8%) patients had renal complications. CONCLUSIONS Most patients with TINU require steroid-sparing IMT for control of uveitis, with nearly half requiring addition of biologic agents. Urinalysis, urine β2M and SCr testing should be considered in children presenting with uveitis, especially when the disease is bilateral and anterior.
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Affiliation(s)
- Mallory Mandel
- Department of Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Abdelrahman M Elhusseiny
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Ophthalmology, Harvey and Bernice Jones Eye Institute, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Stefanie L Davidson
- Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Adam Rockter
- Departments of Ophthalmology and Pediatrics, Flaum Eye Institute, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex V Levin
- Departments of Ophthalmology and Pediatrics, Flaum Eye Institute, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, NY, USA
| | - Laura C Huang
- Department of Ophthalmology, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Crystal Sin Yi Cheung
- Department of Ophthalmology, The Hospital for Sick Children (SickKids), Toronto, ON, Canada
| | - Erin D Stahl
- Department of Ophthalmology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Ashley M Cooper
- Division of Rheumatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Jing Jin
- Department of Ophthalmology, Nemours Children's Health, Wilmington, DE, USA
| | - Hilliary E Inger
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Catherine O Jordan
- Department of Ophthalmology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jennifer L Jung
- Department of Ophthalmology, Children's Hospital Colorado, Aurora, CO, USA
| | - Virginia Miraldi Utz
- Department of Ophthalmology, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Sheila T Angeles-Han
- Department of Ophthalmology, Cincinnati Children's Hospital, Cincinnati, OH, USA
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Isdin Oke
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bharti R Nihalani
- Department of Ophthalmology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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3
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Vazquez SE, Niemeyer K, Mentreddy A, Gonzales J, Rasool N, Acharya NR, Doan T, Shantha JG. Acute neuroretinitis as a delayed manifestation of tubulointerstitial nephritis and uveitis syndrome. Am J Ophthalmol Case Rep 2024; 34:102050. [PMID: 38665419 PMCID: PMC11043875 DOI: 10.1016/j.ajoc.2024.102050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/29/2023] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Purpose Tubulointerstitial nephritis syndrome with uveitis (TINU) is a rare, acquired syndrome characterized by interstitial nephritis with bilateral uveitis. We report a case of TINU with typical bilateral anterior uveitis complicated by an atypical, delayed-onset neuroretinitis in a 12-year old patient. Observation A 12-year-old female with a 21-month history of TINU featuring chronic bilateral anterior uveitis presented with one week of blurred vision in her left eye. On exam she was found to have new-onset disc edema in the right eye and neuroretinitis in the left eye. After a negative infectious disease workup, the patient was treated with a course of intravenous (IV) solumedrol with prednisone taper and advancement of her systemic immunosuppression. In follow up she demonstrated resolution of her disc edema and neuroretinitis with improved visual acuity and clinical exam. Conclusion This case stresses the importance of monitoring for additional ocular manifestations including neuroretinitis years after the onset of anterior uveitis in TINU. In comparison to the two published cases of TINU with neuroretinitis, this case shares features of uveitis progression, and thus highlights the value of further description of TINU-associated neuroretinitis.
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Affiliation(s)
- Sara E. Vazquez
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Katherine Niemeyer
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Akshay Mentreddy
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - John Gonzales
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Nailyn Rasool
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Nisha R. Acharya
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Thuy Doan
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
| | - Jessica G. Shantha
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
- Department of Ophthalmology, University of California San Francisco, San Francisco, CA, USA
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4
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Uludag Kirimli G, Hassan M, Onghanseng N, Or C, Yasar C, Park S, Akhavanrezayat A, Mobasserian A, Yavari N, Bazojoo V, Khojasteh H, Ghoraba H, Karaca I, Trong Tuong Than N, Zaidi M, Nguyen QD. Ocular manifestations and clinical outcomes in Tubulointerstitial Nephritis and Uveitis Syndrome (TINU). Eye (Lond) 2024; 38:349-356. [PMID: 37626158 PMCID: PMC10810898 DOI: 10.1038/s41433-023-02695-6] [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: 01/19/2023] [Revised: 06/26/2023] [Accepted: 08/02/2023] [Indexed: 08/27/2023] Open
Abstract
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.
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Affiliation(s)
- Gunay Uludag Kirimli
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Muhammad Hassan
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Neil Onghanseng
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Chris Or
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Cigdem Yasar
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Sungwho Park
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Amir Akhavanrezayat
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Azadeh Mobasserian
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Negin Yavari
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Vahid Bazojoo
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Hassan Khojasteh
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Hashem Ghoraba
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Irmak Karaca
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Ngoc Trong Tuong Than
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Moosa Zaidi
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA
| | - Quan Dong Nguyen
- Spencer Center for Vision Research, Byers Eye Institute, Stanford University, Palo Alto, CA, USA.
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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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6
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Tubulointerstitial Nephritis and Uveitis Syndrome (TINU): A Case Series in a Tertiary Care Uveitis Setting. J Clin Med 2022; 11:jcm11174995. [PMID: 36078924 PMCID: PMC9457268 DOI: 10.3390/jcm11174995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 08/17/2022] [Accepted: 08/24/2022] [Indexed: 11/17/2022] Open
Abstract
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.
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Scifo L, Willermain F, Postelmans L, Pozdzik A, Lolin Sekelj K, Zampieri M, de Jong C, Makhoul D. Subclinical Choroidal Inflammation Revealed by Indocyanine Green Angiography in Tubulointerstitial Nephritis and Uveitis Syndrome. Ocul Immunol Inflamm 2022; 30:1190-1198. [PMID: 34191677 DOI: 10.1080/09273948.2020.1869267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/28/2020] [Accepted: 12/21/2020] [Indexed: 10/21/2022]
Abstract
PURPOSE To describe subclinical chorioretinal lesions revealed by indocyanine green angiography (ICGA) and their evolution under systemic treatment in tubulointerstitial nephritis and uveitis (TINU) patients. METHODS Retrospective case series of three patients with TINU syndrome. Choroidal and retinal involvement were assessed by fluorescein angiography (FA) and ICGA. RESULTS Three patients were analyzed. FA demonstrated hot disc, associated in two cases with retinal vascular leakage, and ICGA revealed subclinical chorioretinal dots in all three cases. Given the presence of posterior uveitis and deterioration of kidney function, asystemic treatment by oral methylprednisolone was started. Persistence of retinal and choroidal inflammations under systemic corticosteroids required association with immunosuppressive agent to control the disease activity. CONCLUSION Multimodal imaging and more precisely ICGA is useful to assess subclinical choroidal inflammation and monitor treatment response in TINU syndrome. Immunosuppression needs to be revised and adapted when uveitis and/or kidney function are unresponsive to systemic steroids. ABBREVIATIONS TINU: tubulointerstitial nephritis and uveitis; TIN: tubulointerstitial nephritis; ACE: angiotensin-converting enzyme; RF: rheumatoid factor; Uβ2M: urinary β-2microglobulin; AMPPE: acute multifocal placoid pigment epitheliopathy; FA: fluorescein angiography; ICGA: indocyanine green angiography; CT: computed tomography.
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Affiliation(s)
- Lisa Scifo
- Department of Ophthalmology, CHU St-Pierre, Université Libre de Bruxelles, Brussels, Belgium
- Department of Ophthalmology, Hôpital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - François Willermain
- Department of Ophthalmology, CHU St-Pierre, Université Libre de Bruxelles, Brussels, Belgium
- Department of Ophthalmology, Hôpital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Laurence Postelmans
- Department of Ophthalmology, Hôpital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Agnieszka Pozdzik
- Department of Nephrology and Dialysis, Hôpital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Ksenija Lolin Sekelj
- Department of Pediatric Nephrology, Hôpital Universitaire des Enfants - Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Monalisa Zampieri
- Department of Pediatrics, CHU St-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Casper de Jong
- Department of Ophthalmology, Hôpital Universitaire des Enfants - Reine Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Dorine Makhoul
- Department of Ophthalmology, CHU St-Pierre, Université Libre de Bruxelles, Brussels, Belgium
- Department of Ophthalmology, Hôpital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
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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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9
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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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10
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Koreishi AF, Zhou M, Goldstein DA. Tubulointerstitial Nephritis and Uveitis Syndrome: Characterization of Clinical Features. Ocul Immunol Inflamm 2020; 29:1312-1317. [DOI: 10.1080/09273948.2020.1736311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Anjum F. Koreishi
- Department of Ophthalmology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mei Zhou
- 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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11
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Cao JL, Srivastava SK, Venkat A, Lowder CY, Sharma S. Ultra-widefield Fluorescein Angiography and OCT Findings in Tubulointerstitial Nephritis and Uveitis Syndrome. ACTA ACUST UNITED AC 2020; 4:189-197. [DOI: 10.1016/j.oret.2019.08.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 07/04/2019] [Accepted: 08/30/2019] [Indexed: 10/26/2022]
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12
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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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Caplash S, Gangaputra S, Kodati S, Tuchman S, Srinivasalu H, Sen HN. Treatment challenges in an atypical presentation of tubulointerstitial nephritis and uveitis (TINU). Am J Ophthalmol Case Rep 2018; 10:253-256. [PMID: 29780945 PMCID: PMC5956714 DOI: 10.1016/j.ajoc.2018.03.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 02/27/2018] [Accepted: 03/05/2018] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Sonny Caplash
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, MD, 20814, United States
| | - Sapna Gangaputra
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, MD, 20814, United States
| | - Shilpa Kodati
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, MD, 20814, United States
| | - Shamir Tuchman
- Division of Pediatric Nephrology, Children's National Medical Center, Washington DC, 20010, United States
| | - Hemalatha Srinivasalu
- Division of Rheumatology, Children's National Medical Center, Washington DC, 20010, United States
| | - H. Nida Sen
- Laboratory of Immunology, National Eye Institute, National Institutes of Health, Bethesda, MD, 20814, United States
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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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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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Sobolewska B, Bayyoud T, Deuter C, Doycheva D, Zierhut M. Long-term Follow-up of Patients with Tubulointerstitial Nephritis and Uveitis (TINU) Syndrome. Ocul Immunol Inflamm 2016; 26:601-607. [PMID: 27937079 DOI: 10.1080/09273948.2016.1247872] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To evaluate the response to treatment in patients with tubulointerstitial nephritis and uveitis (TINU) syndrome over a long-term follow-up period. METHODS Nine patients with TINU syndrome were retrospectively reviewed. The mean follow-up was 54.8 months (range: 24-133 months). RESULTS The mean number of recurrences per year declined from 1.7 in the 1st year to 0.66 in the 2nd year of treatment. The ocular inflammation responded to local corticosteroids in two patients, systemic corticosteroids in two patients, immunosuppressive therapy in four patients, and anti-TNF-α blocking agent in one patient. The therapy could be discontinued in six (67%) patients after a mean treatment period of 29.5 months. In five patients, remission with the recurrence-free period of 12.8 months was achieved. CONCLUSIONS TINU syndrome was characterized by limited responsiveness to corticosteroid therapy and less by severe complications. A long-term course of immunosuppressants or biologics was necessary to control the uveitis and led to induction of remission.
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Affiliation(s)
- Bianka Sobolewska
- a Center for Ophthalmology , Eberhard-Karls University Tübingen , Germany
| | - Tarek Bayyoud
- a Center for Ophthalmology , Eberhard-Karls University Tübingen , Germany
| | - Christoph Deuter
- a Center for Ophthalmology , Eberhard-Karls University Tübingen , Germany
| | - Deshka Doycheva
- a Center for Ophthalmology , Eberhard-Karls University Tübingen , Germany
| | - Manfred Zierhut
- a Center for Ophthalmology , Eberhard-Karls University Tübingen , Germany
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Three cases of tubulointerstitial nephritis and uveitis syndrome with different clinical manifestations. Int Ophthalmol 2016; 37:753-759. [PMID: 27511057 PMCID: PMC5440544 DOI: 10.1007/s10792-016-0321-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 08/03/2016] [Indexed: 11/22/2022]
Abstract
We here describe three different clinical manifestations of tubulointerstitial nephritis and uveitis (TINU) syndrome. We examined and diagnosed the following 3 patients: a 15-year-old boy with bilateral anterior uveitis (Case 1), a 14-year-old girl with bilateral papilledema (Case 2), and a 49-year-old woman with panuveitis (Case 3). The findings are presented herein. Case 1: The patient had bilateral anterior uveitis. Urinalysis revealed markedly increased β2-microglobulin and N-acetyl-β-d-glucosaminidase levels. As the patient was pathologically diagnosed with tubulointerstitial nephritis (TIN), we diagnosed TINU based on the presence of both uveitis and TIN. He was treated with oral corticosteroids. Case 2: This patient showed anterior uveitis and papilledema in both eyes. On initial examination, the urine test results did not show any abnormality. Three months later, high β2-microglobulin and N-acetyl-β-d-glucosaminidase levels were detected. As the patient was clinically diagnosed with TIN, we subsequently diagnosed TINU. Both the ocular and renal findings improved without treatment. Case 3: The patient developed bilateral panuveitis, retinal vasculitis, and macular edema, which were initially suspected to be sarcoidosis. However, she was pathologically diagnosed with TIN 12 months before the onset of uveitis; therefore, she was finally diagnosed with TINU. She recovered with local corticosteroid administration only. TINU may present with fundal features in addition to anterior uveitis. Detailed history taking and urinalysis are important to determine the presence of tubular disorders in similar patients.
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Aguilar MC, Lonngi M, de-la-Torre A. Tubulointerstitial Nephritis and Uveitis Syndrome: Case Report and Review of the Literature. Ocul Immunol Inflamm 2015; 24:415-21. [PMID: 26400208 DOI: 10.3109/09273948.2015.1034374] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE To review the literature on tubulointerstitial nephritis and uveitis (TINU) syndrome, and to report a case of a patient with relapsing polychondritis (RP) and TINU syndrome. METHOD TINU syndrome is a rare oculorenal inflammatory disorder. It is more common in young women with autoimmune conditions, infections, systemic disease, and previous use of medications. We report the case of a 62-year-old woman with relapsing polychondritis and a 2-year history of acute, recurrent, asymmetric, bilateral, anterior, non-granulomatous uveitis accompanied by tubulointerstitial nephritis. RESULTS The patient was diagnosed with TINU syndrome associated with relapsing polychondritis. No cases of this association have been reported in the literature. The clinical features of TINU syndrome are discussed based on the published works. CONCLUSIONS TINU is an uncommon syndrome; only about 200 cases have been reported in the literature related to infections, systemic disease, and previous use of medications such as antibiotics and non-steroidal anti-inflammatory drugs (NSAIDs). We found that it can be associated with relapsing polychondritis; therefore, it is important to investigate symptoms of this disease since TINU syndrome can co-exist with it.
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Affiliation(s)
- María Camila Aguilar
- a Uveitis Service, Fundación Oftalmológica Nacional, Rosario University , Bogotá , Colombia and
| | - Marcela Lonngi
- a Uveitis Service, Fundación Oftalmológica Nacional, Rosario University , Bogotá , Colombia and
| | - Alejandra de-la-Torre
- a Uveitis Service, Fundación Oftalmológica Nacional, Rosario University , Bogotá , Colombia and.,b School of Medicine and Health Science, Study Group on Public Health, Immunology Service, Rosario University , Bogotá , Colombia
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Acute granulomatous iridocyclitis in a child with tubulointerstitial nephritis and uveitis syndrome. J Ophthalmic Inflamm Infect 2015; 5:3. [PMID: 25861394 PMCID: PMC4384971 DOI: 10.1186/s12348-015-0035-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 01/31/2015] [Indexed: 11/15/2022] Open
Abstract
Background Tubulointerstitial nephritis and uveitis [TINU] syndrome is a rare disorder that may also be underdiagnosed. Patients with TINU syndrome typically present with an acute bilateral nongranulomatous anterior uveitis following symptoms of systemic illness. Findings We report the case of a 15-year-old girl who presented with acute granulomatous iridocyclitis and was diagnosed with TINU syndrome based on renal biopsy findings. Both her uveitis and interstitial nephritis promptly responded to high-dose corticosteroid treatment, and there were no relapses during follow-up of 20 months. Conclusions TINU should be included in the differential diagnosis of patients who present with acute granulomatous uveitis.
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