Tubulointerstitial nephritis and uveitis (TINU syndrome)
- Geoffrey Lee, MD
Geoffrey Lee, MD
- Attending Physician
- Kingston General Hospital
- Akhtar Ashfaq, MD
Akhtar Ashfaq, MD
- Assistant Professor of Medicine
- Albert Einstein College of Medicine
A unique subset of patients with interstitial nephritis has the TINU syndrome (tubulointerstitial nephritis and uveitis). First described in 1975 , more than 250 cases have now been reported [2,3]. The majority of cases have been documented in the ophthalmology and pediatric nephrology literature via case reports and small descriptive series.
The underlying mechanisms for TINU are not well understood. Limited data suggest that modified C-reactive protein (mCRP), an autoantigen common to both the uvea and renal tubular cells, may be involved in the pathogenesis . In a study of 97 patients with various renal disorders and 40 healthy controls, the prevalence of immunoglobulin G (IgG) antibodies directed against mCRP was significantly higher among nine patients with TINU syndrome (100 percent) than among those with Sjögren’s associated interstitial nephritis (29 percent), drug-induced interstitial nephritis (36 percent), glomerulonephritis (5 percent), and healthy controls (0 percent) . Another study by the same group confirmed that the mCRP is higher among patients with TINU syndrome and late-onset uveitis compared with those with drug-induced interstitial nephritis .
The inflammation in TINU syndrome is thought to be T-lymphocyte driven, based upon the histologic findings. In contrast, immune cells in patients with TINU syndrome have a paradoxical suppression of cytokine production and a decrease in peripheral immune response, as demonstrated by anergy to skin testing. This paradox is not unique to TINU, as the presence of increased tissue inflammation with concomitant suppression of peripheral immunity is also seen in patients with sarcoidosis [5,6].
RISK FACTORS AND ASSOCIATIONS
No identifiable risk factors have been found in at least 50 percent of cases. In some instances, prior infection or the use of specific drugs (antibiotics to treat upper respiratory infections and nonsteroidal anti-inflammatory drugs [NSAIDs]) has been implicated [3,7]. The Chinese herb, "goreisan," has been associated in a case report . Although causality is unclear, concurrent Chlamydia and Epstein-Barr virus infections have been described [9,10]. TINU syndrome has also been reported in patients with autoimmune diseases like hypoparathyroidism , thyroid disease [3,12], immunoglobulin G4 (IgG4)-related autoimmune disease , and rheumatoid arthritis [11,14].
Most patients with TINU are adolescents and young women, with a median age of 15 years . It has also been reported in adults and older adults [16,17]. All series report a female-to-male predominance [3,7], with no particular racial affinity.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:
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- Simon AH, Alves-Filho G, Ribeiro-Alves MA. Acute tubulointerstitial nephritis and uveitis with antineutrophil cytoplasmic antibody. Am J Kidney Dis 1996; 28:124.
- Wakaki H, Sakamoto H, Awazu M. Tubulointerstitial nephritis and uveitis syndrome with autoantibody directed to renal tubular cells. Pediatrics 2001; 107:1443.
- Conz PA, Milan M, Bragantini L, et al. TINU syndrome associated with reduced complement levels. Nephron 2001; 89:340.
- Kase S, Kitaichi N, Namba K, et al. Elevation of serum Krebs von den Lunge-6 levels in patients with tubulointerstitial nephritis and uveitis syndrome. Am J Kidney Dis 2006; 48:935.
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- Neilson EG, Farris AB. Case records of the Massachusetts General Hospital. Case 21-2009. A 61-year-old woman with abdominal pain, weight loss, and renal failure. N Engl J Med 2009; 361:179.
- Preddie DC, Markowitz GS, Radhakrishnan J, et al. Mycophenolate mofetil for the treatment of interstitial nephritis. Clin J Am Soc Nephrol 2006; 1:718.
- van Leusen R, Assmann KJ. Acute tubulo-interstitial nephritis with uveitis and favourable outcome after five months of continuous ambulatory peritoneal dialysis (CAPD). Neth J Med 1988; 33:133.
- RISK FACTORS AND ASSOCIATIONS
- CLINICAL AND LABORATORY MANIFESTATIONS
- Renal manifestations
- Laboratory findings
- DIAGNOSIS AND HISTOLOGIC FINDINGS
- DIFFERENTIAL DIAGNOSIS
- MANAGEMENT AND PROGNOSIS
- Renal disease
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS