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Long Y, Aljamal AA, Bahmad HF, Yedla N, Herrera GA, Schwartz MA, Layka A. Multiple myeloma presenting as acute tubulointerstitial nephritis. Autops Case Rep 2021; 11:e2021328. [PMID: 34604122 PMCID: PMC8478360 DOI: 10.4322/acr.2021.328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 08/09/2021] [Indexed: 11/23/2022] Open
Abstract
Background Acute tubulointerstitial nephritis (ATIN) is a very rare paraneoplastic manifestation in patients with multiple myeloma (MM). It is an uncommon pattern of renal disease in such patients. Case presentation We report a case of an 82-year-old male who was admitted with acute kidney injury. Renal biopsy showed typical findings of light chain-associated ATIN with scattered inflammatory cells in the interstitium and associated active tubulitis. No other common manifestations of MM were present at the time of presentation, including hypercalcemia, hyperuricemia, proteinuria, bone pain or lytic bone lesions. Subsequent immunoassays revealed significant serum lambda light chain burden and Bence Jones protein in urine. Immunofluorescence demonstrated linear tubular basement membranes with positive staining for lambda light chain (3+). Electron microscopy (EM) further showed interstitial edema and inflammation. All the aforementioned findings are consistent with ATIN and supported the diagnosis of MM. Conclusions In conclusion, light chain-associated ATIN should be considered in the differential diagnosis of acute interstitial nephritis. Henceforth, serum free light chains as well as serum and urine protein electrophoresis should be included in the workup of such patients.
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Affiliation(s)
- Ying Long
- Mount Sinai Medical Center, Department of Internal Medicine, Miami Beach, FL, USA
| | - Abed A Aljamal
- Mount Sinai Medical Center, Department of Internal Medicine, Miami Beach, FL, USA
| | - Hisham F Bahmad
- Mount Sinai Medical Center, Arkadi M. Rywlin M.D. Department of Pathology and Laboratory Medicine, Miami Beach, FL, USA
| | - Niharika Yedla
- Mount Sinai Medical Center, Department of Internal Medicine, Miami Beach, FL, USA
| | - Guillermo A Herrera
- Louisiana State University Health, Department of Pathology Shreveport, LA, USA
| | - Michael A Schwartz
- Mount Sinai Medical Center, Department of Internal Medicine, Division of Hematology and Oncology, Miami Beach, FL, USA
| | - Ayman Layka
- Mount Sinai Medical Center, Department of Internal Medicine, Division of Nephrology, Miami Beach, FL, USA
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Anand S, Montez-Rath ME, Adasooriya D, Ratnatunga N, Kambham N, Wazil A, Wijetunge S, Badurdeen Z, Ratnayake C, Karunasena N, Schensul SL, Valhos P, Haider L, Bhalla V, Levin A, Wise PH, Chertow GM, Barry M, Fire AZ, Nanayakkara N. Prospective Biopsy-Based Study of CKD of Unknown Etiology in Sri Lanka. Clin J Am Soc Nephrol 2019; 14:224-232. [PMID: 30659059 PMCID: PMC6390926 DOI: 10.2215/cjn.07430618] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/30/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND OBJECTIVES A kidney disease of unknown cause is common in Sri Lanka's lowland (dry) region. Detailed clinical characterizations of patients with biopsy-proven disease are limited, and there is no current consensus on criteria for a noninvasive diagnosis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We designed a prospective study in a major Sri Lankan hospital servicing endemic areas to ascertain pathologic and clinical characteristics of and assess risk factors for primary tubulointerstitial kidney disease. We used logistic regression to determine whether common clinical characteristics could be used to predict the presence of primary tubulointerstitial kidney disease on kidney biopsy. RESULTS From 600 new patients presenting to a tertiary nephrology clinic over the course of 1 year, 87 underwent kidney biopsy, and 43 (49%) had a biopsy diagnosis of primary tubulointerstitial kidney disease. On detailed biopsy review, 13 (30%) had evidence of moderate to severe active kidney disease, and six (15%) had evidence of moderate to severe chronic tubulointerstitial kidney disease. Patients with tubulointerstitial kidney disease were exclusively born in endemic provinces; 91% spent a majority of their lifespan there. They were more likely men and farmers (risk ratio, 2.0; 95% confidence interval, 1.2 to 2.9), and they were more likely to have used tobacco (risk ratio, 1.7; 95% confidence interval, 1.0 to 2.3) and well water (risk ratio, 1.5; 95% confidence interval, 1.1 to 2.0). Three clinical characteristics-age, urine dipstick for protein, and serum albumin-could predict likelihood of tubulointerstitial kidney disease on biopsy (model sensitivity of 79% and specificity of 84%). Patients referred for kidney biopsy despite comorbid diabetes or hypertension did not experience lower odds of tubulointerstitial kidney disease. CONCLUSIONS A primary tubulointerstitial kidney disease occurs commonly in specific regions of Sri Lanka with characteristic environmental and lifestyle exposures.
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Affiliation(s)
| | | | - Dinuka Adasooriya
- Kandy Teaching Hospital, Kandy, Sri Lanka
- Center for Education Research and Training on Kidney Diseases, Faculty of Medicine and
| | | | | | | | | | - Zeid Badurdeen
- Center for Education Research and Training on Kidney Diseases, Faculty of Medicine and
| | | | | | | | - Penny Valhos
- Department of Marine Sciences, University of Connecticut, Groton, Connecticut; and
| | - Lalarukh Haider
- Division of Nephrology, University of Connecticut Health Center, Farmington, Connecticut
| | | | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Michele Barry
- Medicine, Stanford University School of Medicine, Palo Alto, California
| | | | - Nishantha Nanayakkara
- Kandy Teaching Hospital, Kandy, Sri Lanka
- Center for Education Research and Training on Kidney Diseases, Faculty of Medicine and
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Fernandez-Juarez G, Perez JV, Caravaca-Fontán F, Quintana L, Shabaka A, Rodriguez E, Gadola L, de Lorenzo A, Cobo MA, Oliet A, Sierra M, Cobelo C, Iglesias E, Blasco M, Galeano C, Cordon A, Oliva J, Praga M. Duration of Treatment with Corticosteroids and Recovery of Kidney Function in Acute Interstitial Nephritis. Clin J Am Soc Nephrol 2018; 13:1851-1858. [PMID: 30397027 PMCID: PMC6302327 DOI: 10.2215/cjn.01390118] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 09/06/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND OBJECTIVES Drug-induced acute interstitial nephritis represents an emerging cause of acute kidney disease, especially among polymedicated elderly patients. Although corticosteroids are frequently used, controversy exists about the timing of initiation, efficacy, safety, and duration of treatment. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a retrospective study of 182 patients with biopsy-proven drug-induced acute interstitial nephritis from 13 Spanish centers. Exposure was defined as the length of corticosteroid treatment. The main outcome was the level of serum creatinine at month 6, with respect to baseline values. RESULTS The most common offending agents were nonsteroidal anti-inflammatory drugs (27%). In 30% of patients, the offending drug could not be identified. The median time to suspected drug withdrawal was 11 days (interquartile range, 5-22). All patients presented with acute kidney disease and were treated with corticosteroids. The mean initial dose of prednisone was 0.8±0.2 mg/kg per day. High-dose corticosteroid treatment was maintained for 2 weeks (interquartile range, 1-4). After 6 months, the mean recovered GFR was 34±26 ml/min per 1.73 m2 and ten patients required maintenance dialysis. Use of high-dose corticosteroids for 3 weeks or treatment duration >8 weeks were not associated with better recovery of kidney function. In the multivariable analysis, delayed onset of steroid treatment (odds ratio, 1.02; 95% confidence interval, 1.0 to 1.04) and the presence of interstitial fibrosis of >50% on the kidney biopsy specimen (odds ratio, 8.7; 95% confidence interval, 2.7 to 27.4) were both associated with serum creatinine level at month 6 of >75%, with respect to baseline values. CONCLUSIONS High-dose corticosteroid treatment for 3 weeks or prolonged treatment for >8 weeks were not associated with greater kidney function recovery in drug-induced acute interstitial nephritis. A delay in the initiation of corticosteroids resulted in worse recovery of kidney function.
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Affiliation(s)
| | | | | | - Luis Quintana
- Department of Nephrology, Hospital Clinic i Provincial de Barcelona, Barcelona, Spain
| | - Amir Shabaka
- Department of Nephrology, Hospital Clínico San Carlos, Madrid, Spain
| | - Eva Rodriguez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Liliana Gadola
- Hospital de Clínicas Nefrología y Fisiopatología, Facultad de Medicina- UDeLaR, Universidad de la República Uruguay, Montevideo, Uruguay
| | | | - Maria Angeles Cobo
- Department of Nephrology Hospital Universitario General de Canarias, Tenerife, Spain
| | - Aniana Oliet
- Department of Nephrology, Hospital Severo Ochoa, Madrid, Spain
| | - Milagros Sierra
- Department of Nephrology, Hospital San Pedro, La Rioja, Spain
| | - Carmen Cobelo
- Department of Nephrology, Hospital Universitario Lugus Ausguti, Lugo, Spain
| | - Elena Iglesias
- Department of Nephrology, Complejo Hospitalario Universitario de Orense, Orense, Spain
| | - Miguel Blasco
- Department of Nephrology, Hospital Clinic i Provincial de Barcelona, Barcelona, Spain
| | - Cristina Galeano
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Madrid, Spain; and
| | - Alfredo Cordon
- Department of Nephrology, Hospital Fundación de Alcorcón, Madrid, Spain
| | - Jesus Oliva
- CentroNacional de Epidemilogía, Instituto de Salud Carlos III, Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - on behalf of the Spanish Group for the Study of Glomerular Diseases (GLOSEN)
- Department of Nephrology, Hospital Fundación de Alcorcón, Madrid, Spain
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Department of Nephrology, Hospital Clinic i Provincial de Barcelona, Barcelona, Spain
- Department of Nephrology, Hospital Clínico San Carlos, Madrid, Spain
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
- Hospital de Clínicas Nefrología y Fisiopatología, Facultad de Medicina- UDeLaR, Universidad de la República Uruguay, Montevideo, Uruguay
- Department of Nephrology, Hospital de Getafe, Madrid, Spain
- Department of Nephrology Hospital Universitario General de Canarias, Tenerife, Spain
- Department of Nephrology, Hospital Severo Ochoa, Madrid, Spain
- Department of Nephrology, Hospital San Pedro, La Rioja, Spain
- Department of Nephrology, Hospital Universitario Lugus Ausguti, Lugo, Spain
- Department of Nephrology, Complejo Hospitalario Universitario de Orense, Orense, Spain
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Madrid, Spain; and
- CentroNacional de Epidemilogía, Instituto de Salud Carlos III, Madrid, Spain
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Jannot AS, Burgun A, Thervet E, Pallet N. The Diagnosis-Wide Landscape of Hospital-Acquired AKI. Clin J Am Soc Nephrol 2017; 12:874-884. [PMID: 28495862 PMCID: PMC5460713 DOI: 10.2215/cjn.10981016] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 03/01/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The exploration of electronic hospital records offers a unique opportunity to describe in-depth the prevalence of conditions associated with diagnoses at an unprecedented level of comprehensiveness. We used a diagnosis-wide approach, adapted from phenome-wide association studies (PheWAS), to perform an exhaustive analysis of all diagnoses associated with hospital-acquired AKI (HA-AKI) in a French urban tertiary academic hospital over a period of 10 years. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We retrospectively extracted all diagnoses from an i2b2 (Informatics for Integrating Biology and the Bedside) clinical data warehouse for patients who stayed in this hospital between 2006 and 2015 and had at least two plasma creatinine measurements performed during the first week of their stay. We then analyzed the association between HA-AKI and each International Classification of Diseases (ICD)-10 diagnostic category to draw a comprehensive picture of diagnoses associated with AKI. Hospital stays for 126,736 unique individuals were extracted. RESULTS Hemodynamic impairment and surgical procedures are the main factors associated with HA-AKI and five clusters of diagnoses were identified: sepsis, heart diseases, polytrauma, liver disease, and cardiovascular surgery. The ICD-10 code corresponding to AKI (N17) was recorded in 30% of the cases with HA-AKI identified, and in this situation, 20% of the diagnoses associated with HA-AKI corresponded to kidney diseases such as tubulointerstitial nephritis, necrotizing vasculitis, or myeloma cast nephropathy. Codes associated with HA-AKI that demonstrated the greatest increase in prevalence with time were related to influenza, polytrauma, and surgery of neoplasms of the genitourinary system. CONCLUSIONS Our approach, derived from PheWAS, is a valuable way to comprehensively identify and classify all of the diagnoses and clusters of diagnoses associated with HA-AKI. Our analysis delivers insights into how diagnoses associated with HA-AKI evolved over time. On the basis of ICD-10 codes, HA-AKI appears largely underestimated in this academic hospital.
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Affiliation(s)
- Anne-Sophie Jannot
- Departments of Medical Informatics, Biostatistics and Public Health
- Assistance Publique Hôpitaux de Paris, Paris, France
- Paris Descartes University, Paris, France; and
- National Institute for Health and Research (INSERM) U1138, Centre de Recherche des Cordeliers, Paris, France
| | - Anita Burgun
- Departments of Medical Informatics, Biostatistics and Public Health
- Assistance Publique Hôpitaux de Paris, Paris, France
- Paris Descartes University, Paris, France; and
- National Institute for Health and Research (INSERM) U1138, Centre de Recherche des Cordeliers, Paris, France
| | - Eric Thervet
- Nephrology, and
- Assistance Publique Hôpitaux de Paris, Paris, France
- Paris Descartes University, Paris, France; and
| | - Nicolas Pallet
- Nephrology, and
- Clinical Chemistry, Hôpital Européen Georges Pompidou, Paris, France
- Assistance Publique Hôpitaux de Paris, Paris, France
- Paris Descartes University, Paris, France; and
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