Treatment of acute interstitial nephritis
- Abhijit V Kshirsagar, MD, MPH
Abhijit V Kshirsagar, MD, MPH
- Associate Professor of Medicine
- University of North Carolina at Chapel Hill
- Ronald J Falk, MD
Ronald J Falk, MD
- Allan Brewster Distinguished Professor of Medicine
- Chair, Department of Medicine
- Director, UNC Kidney Center
- Director, Center for Transplant Care
- University of North Carolina-Chapel Hill
Acute interstitial nephritis (AIN) classically presents as acute renal failure (ARF) after the use of known offending drugs and is associated with the typical urinary findings of pyuria, hematuria, and white cell casts [1-4]. Less frequently, AIN is secondary to infection or sarcoidosis. Signs of systemic allergy, such as a maculopapular rash, peripheral eosinophilia, and eosinophiluria, are present in some patients [5,6].
Proteinuria is common, but excretion is usually <1 g/day. However, nephrotic-range proteinuria may occur and presumably reflects cytokine-induced injury to the glomerulus. It is most often seen with AIN caused by nonsteroidal anti-inflammatory drugs (NSAIDs) [7,8]. Histologically, AIN is characterized by the infiltration of T cells, macrophages, and plasma cells in the interstitial compartment.
The treatment of AIN due to drugs will be reviewed here. The manifestations and diagnosis of AIN and the approach to the management of patients diagnosed with infection-induced AIN, tubulointerstitial nephritis and uveitis, and renal sarcoidosis are presented separately. (See "Clinical manifestations and diagnosis of acute interstitial nephritis" and "Tubulointerstitial nephritis and uveitis (TINU syndrome)" and "Renal disease in sarcoidosis".)
For drug-induced AIN, prognostic data are most available for methicillin, which is no longer available because it was estimated to cause AIN in up to 17 percent of patients who were treated for more than 10 days [2,9].
Recovery of renal function was observed in the great majority of cases of AIN due to methicillin, either with discontinuation of the offending drug or with glucocorticoid therapy [2,9,10]. The proportion recovering kidney function appears to be lower in AIN due to drugs other than methicillin [2,10-12]. The prognosis of AIN due to other inciting factors (eg, sarcoidosis, infection) is not well described. Acute dialysis is often required [13-15], but only approximately 10 percent of patients remain dialysis dependent [3,4,11].
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