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
- Nan and Hugh Cullman Eminent Professor of Nephrology
- Chair, Department of Medicine
- Director, UNC Kidney Center
- 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].To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Davison AM, Jones CH. Acute interstitial nephritis in the elderly: a report from the UK MRC Glomerulonephritis Register and a review of the literature. Nephrol Dial Transplant 1998; 13 Suppl 7:12.
- Rossert J. Drug-induced acute interstitial nephritis. Kidney Int 2001; 60:804.
- Baker RJ, Pusey CD. The changing profile of acute tubulointerstitial nephritis. Nephrol Dial Transplant 2004; 19:8.
- Clarkson MR, Giblin L, O'Connell FP, et al. Acute interstitial nephritis: clinical features and response to corticosteroid therapy. Nephrol Dial Transplant 2004; 19:2778.
- Corwin HL, Korbet SM, Schwartz MM. Clinical correlates of eosinophiluria. Arch Intern Med 1985; 145:1097.
- Nolan CR 3rd, Anger MS, Kelleher SP. Eosinophiluria--a new method of detection and definition of the clinical spectrum. N Engl J Med 1986; 315:1516.
- Abraham PA, Keane WF. Glomerular and interstitial disease induced by nonsteroidal anti-inflammatory drugs. Am J Nephrol 1984; 4:1.
- Clive DM, Stoff JS. Renal syndromes associated with nonsteroidal antiinflammatory drugs. N Engl J Med 1984; 310:563.
- Galpin JE, Shinaberger JH, Stanley TM, et al. Acute interstitial nephritis due to methicillin. Am J Med 1978; 65:756.
- Schwarz A, Krause PH, Kunzendorf U, et al. The outcome of acute interstitial nephritis: risk factors for the transition from acute to chronic interstitial nephritis. Clin Nephrol 2000; 54:179.
- Laberke HG, Bohle A. Acute interstitial nephritis: correlations between clinical and morphological findings. Clin Nephrol 1980; 14:263.
- Kida H, Abe T, Tomosugi N, et al. Prediction of the long-term outcome in acute interstitial nephritis. Clin Nephrol 1984; 22:55.
- Handa SP. Drug-induced acute interstitial nephritis: report of 10 cases. CMAJ 1986; 135:1278.
- Bhaumik SK, Kher V, Arora P, et al. Evaluation of clinical and histological prognostic markers in drug-induced acute interstitial nephritis. Ren Fail 1996; 18:97.
- Koselj M, Kveder R, Bren AF, Rott T. Acute renal failure in patients with drug-induced acute interstitial nephritis. Ren Fail 1993; 15:69.
- Liangos O, Tighiouart H, Perianayagam MC, et al. Comparative analysis of urinary biomarkers for early detection of acute kidney injury following cardiopulmonary bypass. Biomarkers 2009; 14:423.
- Kuwabara T, Mori K, Mukoyama M, et al. Urinary neutrophil gelatinase-associated lipocalin levels reflect damage to glomeruli, proximal tubules, and distal nephrons. Kidney Int 2009; 75:285.
- Ooi BS, Jao W, First MR, et al. Acute interstitial nephritis. A clinical and pathologic study based on renal biopsies. Am J Med 1975; 59:614.
- Joh K, Aizawa S, Yamaguchi Y, et al. Drug-induced hypersensitivity nephritis: lymphocyte stimulation testing and renal biopsy in 10 cases. Am J Nephrol 1990; 10:222.
- Shibasaki T, Ishimoto F, Sakai O, et al. Clinical characterization of drug-induced allergic nephritis. Am J Nephrol 1991; 11:174.
- Spanou Z, Keller M, Britschgi M, et al. Involvement of drug-specific T cells in acute drug-induced interstitial nephritis. J Am Soc Nephrol 2006; 17:2919.
- Buysen JG, Houthoff HJ, Krediet RT, Arisz L. Acute interstitial nephritis: a clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990; 5:94.
- González E, Gutiérrez E, Galeano C, et al. Early steroid treatment improves the recovery of renal function in patients with drug-induced acute interstitial nephritis. Kidney Int 2008; 73:940.
- Appel GB. The treatment of acute interstitial nephritis: More data at last. Kidney Int 2008; 73:905.
- Muriithi AK, Leung N, Valeri AM, et al. Biopsy-proven acute interstitial nephritis, 1993-2011: a case series. Am J Kidney Dis 2014; 64:558.
- Preddie DC, Markowitz GS, Radhakrishnan J, et al. Mycophenolate mofetil for the treatment of interstitial nephritis. Clin J Am Soc Nephrol 2006; 1:718.
- Zuliani E, Zwahlen H, Gilliet F, Marone C. Vancomycin-induced hypersensitivity reaction with acute renal failure: resolution following cyclosporine treatment. Clin Nephrol 2005; 64:155.