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22-08 - Interstitial Nephritis
22-08 - Interstitial Nephritis
OF THE PHILIPPINES
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Current Medical Diagnosis & Treatment 2022
2208: Interstitial Nephritis
Tonja C. Dirkx; Tyler B. Woodell
ESSENTIALS OF DIAGNOSIS
Fever.
Transient maculopapular rash.
Acute or chronic in nature.
Pyuria, white blood cell casts, and hematuria.
GENERAL CONSIDERATIONS
Acute interstitial nephritis accounts for 10–15% of cases of intrinsic renal failure. An interstitial inflammatory response with edema and possible
tubular cell damage is the typical pathologic finding. Cellmediated immune reactions prevail over humoral responses. T lymphocytes can cause direct
cytotoxicity or release lymphokines that recruit monocytes and inflammatory cells.
Although drugs account for over 70% of cases, acute interstitial nephritis also occurs in infectious diseases, autoimmune disorders, or as idiopathic
conditions. The most common drugs implicated are penicillins and cephalosporins, immune checkpoint inhibitors, sulfonamides and sulfonamide
containing diuretics, NSAIDs, proton pump inhibitors, rifampin, and allopurinol. Infectious causes include streptococcal infections, leptospirosis,
cytomegalovirus, histoplasmosis, and Rocky Mountain spotted fever. SLE, Sjögren syndrome, sarcoidosis, and cryoglobulinemia can also cause
interstitial nephritis, though they are more classically associated with glomerulonephritis.
CLINICAL FINDINGS
Clinical features include fever (more than 80% of cases), rash (25–50%), arthralgias, and peripheral blood eosinophilia (80%). The classic triad of fever,
rash, and arthralgias is present in only 10–15% of cases. The urine often contains white cells (95%), red cells, and white cell casts. Proteinuria is often
present, particularly in NSAIDinduced interstitial nephritis, but is usually modest (less than 2 g/24 h). Eosinophiluria is neither very sensitive nor
specific for interstitial nephritis; evaluation for eosinophiluria is not advised. Although the clinical history and laboratory data often give clues to the
diagnosis, kidney biopsy is sometimes needed.
TREATMENT & PROGNOSIS
Acute interstitial nephritis often carries a good prognosis, with recovery occurring over weeks to months. Urgent dialytic therapy may be necessary in
up to onethird of all referred patients before resolution, but patients rarely progress to ESKD. Those with prolonged oliguria and advanced age have a
worse prognosis. Treatment consists of supportive measures and removal of the inciting agent. If kidney injury persists, a short course of
corticosteroids can be considered, although the data to support their use are not substantial, and their efficacy may depend on the elapsed time
between onset of AKI and their initiation. Shortterm, highdose methylprednisolone (0.5–1 g/day intravenously for 1–4 days) or prednisone (60
mg/day orally for 1–2 weeks) followed by a prednisone taper can be used in more severe cases of druginduced interstitial nephritis.
Moledina DG et al. Treatment of druginduced acute tubulointerstitial nephritis: the search for better evidence. Clin J Am Soc Nephrol. 2018;13:1785.
[PubMed: 30397028]
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2208: Interstitial Nephritis, Tonja C. Dirkx; Tyler B. Woodell
Shingarev R et al. Kidney complications of immune checkpoint inhibitors: a review. Am J Kidney Dis. 2019;74:529.
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[PubMed: 31303350]
corticosteroids can be considered, although the data to support their use are not substantial, and their efficacy may depend on the elapsed time
LYCEUM OF THE PHILIPPINES
between onset of AKI and their initiation. Shortterm, highdose methylprednisolone (0.5–1 g/day intravenously for 1–4 days) or prednisone (60
mg/day orally for 1–2 weeks) followed by a prednisone taper can be used in more severe cases of druginduced interstitial nephritis.
Access Provided by:
Moledina DG et al. Treatment of druginduced acute tubulointerstitial nephritis: the search for better evidence. Clin J Am Soc Nephrol. 2018;13:1785.
[PubMed: 30397028]
Shingarev R et al. Kidney complications of immune checkpoint inhibitors: a review. Am J Kidney Dis. 2019;74:529.
[PubMed: 31303350]
Downloaded 2022312 3:11 A Your IP is 103.100.136.238
2208: Interstitial Nephritis, Tonja C. Dirkx; Tyler B. Woodell Page 2 / 2
©2022 McGraw Hill. All Rights Reserved. Terms of Use • Privacy Policy • Notice • Accessibility