22 kim acute interstitial nephritis
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This document summarizes a clinical case conference on acute interstitial nephritis (AIN). It discusses the history, causes, diagnosis, prognosis and treatment of AIN. Experimental evidence suggests drug-induced AIN results from an immune reaction against renal antigens triggered by certain drugs. Retrospective studies indicate corticosteroid therapy may improve outcomes in AIN, though prospective trials are still needed.
22 kim acute interstitial nephritis
- 1. Tuesday Clinical Case conference 10/2007 Zae Kim, MD
- 4. Acute Interstitial nephritis Term first used by Councilman in 1898 Noted the histopathologic changes in autopsy specimens of patients with diptheria and scarlet fever Immune-mediated cause of acute renal failure Characterized by presence of an inflammatory cell infiltrate in the renal interstitium and tubules there is a paucity of data in the literature regarding optimal management of the condition
- 5. Incidence Significant cause of acute renal failure series of 109 patients from a large center biopsied for unexplained renal impairment with normal sized kidneys AIN accounted for 29 of 109 (27%) cases Farrington K, Levison DA, Greenwood RN, Cattell WR, Baker LR. Renal biopsy in patients with unexplained renal impairment and normal kidney size. Q J Med 1989; 70: 221–233
- 6. Causes
- 7. The changing profile of acute tubulointerstitial nephritis Backer RJ; Pusey CD, Nephrol Dial Transplant 2004 Jan;19(1):8-11 A review of three series that totaled 128 pts (71%) Drugs, with antibiotics responsible for 1/3 (15%) Infection-related (8%) Idiopathic (5%) Tubulointerstitial nephritis and uveitis (TINU) syndrome (1%) Sarcoidosis
- 8. Approximated frequency with which clinical manifestations occur during… (A) methicillin-induced AIN (B) AIN induced by drugs other than methicillin (C) AIN induced by NSAIDs and associated with a nephrotic syndrome http://www.nature.com/ki/journal/v60/n2/full/4492487a.html#fig2
- 9. Epidemiology The overall picture that emerges is of a syndrome that is becoming both increasingly non-specific in clinical features diverse in etiology
- 10. Noninvasive diagnostic procedure: eosinophiluria Corwin, HL, Korbet, SM, Schwartz, MM: Clinical correlates of eosinophiluria. Arch Intern Med 1985 145:1097–1099 Nolan, CR, Anger, MS, Kelleher, SP: Eosinophiluria: A new detection and definition of the clinical spectrum. N Engl J Med 1986 315:1516–1519 Corwin, HL, Bray, RA, Haber, MH: The detection and interpretation of urinary eosinophils. Arch Pathol Lab Med 1989 113:1256–1258 Ruffing, KA, Hoppes, P, Blend, D, et al : Eosinophils in urine revisited. Clin Nephrol 1994 41:163–166 http://www.nature.com/ki/journal/v60/n2/fig_tab/4492487t2.html#figure-title Number of patients 65 92 183 199 539 Patients with AIN Eosinophiluria 8 10 5 6 29 (63%) No eosinophiluria 1 1 3 9 14 Patients without AIN Eosinophiluria 27 12 15 10 64 No eosinophiluria 29 69 160 174 432 (87%)
- 11. Noninvasive diagnostic procedure: Gallium scan – highly sensitive? Gallium67 scintigraphy in the diagnosis of acute renal disease. Linton et al, Clin Nephrol. 1985 Aug;24(2):84-7 . N = 44 patients with various biopsy proven renal disease AIN = 11 patients Two blinded observers Result All 11 AIN (100%) 5/33 (15%) of other renal disease had (+) uptake Glomerulonephritis, pyelonephritis
- 12. Noninvasive diagnostic procedure: Gallium scan – not highly sensitive? N = 16 with AIN (+) gallium scan in 11/16 (68%) Koselj, M, Kveder, R, Bren, AF, Rott, T: Acute renal failure in patients with drug-induced acute interstitial nephritis. Ren Fail 1993 15:69–72 N = 12 with AIN (+) gallium scan in 7/12 (58%) Graham, GD, Lundy, MM, Moreno, JJ: Failure of 67 gallium scintigraphy to identify reliably non-infectious interstitial nephritis. J Nucl Med 1983 24:568–570
- 13. Lab: biopsy Inflammation of renal interstitium Microscopically Multifocal cellular infiltration and edema Mononulcear cells (lymphocytes and macrophages) usually are the predominant types Drug reaction Mononuclear cells, typically T cells (CD4>CD8) Glomerular and vascular sparing
- 14. Course Based on the course of methicillin-induced AIN drug-induced AIN has long been considered a relatively benign nephropathy complete recovery of renal function was supposed to be the rule if the inciting agent was removed
- 15. Analysis of published cases of AIN by drugs other than methicillin course of renal function recovery At the end of follow up Only 68% had sCr <1.7 Only 40% had sCr <1.2 68% w crt < 1.7 49% w crt < 1.2 Rossert, KI, 2001
- 16. Prognostic factor? could we identify patients with drug-induced AIN who are at high risk of incomplete recovery? Severity of renal failure? Histology Diffuse vs patchy infiltrate Degree of fibrosis Duration of renal failure
- 17. Severity of renal function as prognostic marker? Patients were arbitrarily divided into three groups depending on serum creatinine levels at the end of follow-up Maximum serum creatinine levels did not differ among these three groups Crt <1.2 Crt 1.2 – 2.2 Crt > 2.2 Rossert, KI, 2001
- 18. Prognostic factor – histology? Diffuse vs patch interstitial infiltrates n = 30, less favorable renal prognosis with diffuse vs patch sCr ~2 in 10/18 with diffuse (55%) sCr ~1.1 in 9/12 w patch (75%) Laberke, HG & Bohle, A: Acute interstitial nephritis: Correlation between clinical and morphological findings. Clin Nephrol 1980 14:263–273 Two other studies (n = 27 and 14) no correlation Kida, H, Abe, T, Tomosugi, N, et al : Prediction of the long-term outcome in acute interstitial nephritis. Clin Nephrol 1984 22:55–60 Buysen, JGM, Houtlhoff, HJ, Krediet, RT, Arisz, L: Acute interstitial nephritis: A clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990 5:94–99 Conflicting result
- 19. Prognostic factor Duration of acute renal failure N = 30 Mean sCr ~1.4 with ARF < 2 wks Mean sCr ~3.4 with ARF > 3 wks Laberke, Acute interstitial nephritis, Clin Nephrol 14:263, 1980
- 20. Pathophysiology
- 21. Pathophysiology – drug induced AIN Drug-induced AIN is secondary to immune reaction AIN occurs only in a small percentage of individuals taking the drug AIN is not dose-dependent Association with extrarenal manifestations of hypersensitivity Recurrencence after re-exposure to the drug Experimental models Suggest that drugs responsible for AIN induce an immune reaction directed against endogenous renal antigens
- 22. Based on Experimental AIN http://www.nature.com/ki/journal/v60/n2/fig_tab/4492487f1.html#figure-title
- 23. Involvement of Drug-Specific T cells in Acute Drug-Induced Interstitial Nephritis Spanou et al, JASN, 17: 2919, 2006 Role of drug-specific responses in patients with a histologic diagnosis of DIN (Drug-Induced Nephritis) Identified drug-specific T cells Characterized them phenotypically in vitro
- 24. Involvement of Drug-Specific T cells in Acute Drug-Induced Interstitial Nephritis Spanou et al, JASN, 17: 2919, 2006 Pt 1. Tx’d w abx for endocarditis, developed ARF 3 weeks after starting abx Pt 2 Tx for endocarditis, arf after 8 days Pt 3 ARF after 3 weeks
- 25. Lymphocyte Transformation Test (LTT) used to analyze drug-specific proliferation of patients PBMC Relies on observation that T cells divide and expand after encountering the antigen Measures H-thymidine uptake of dividing cells Involvement of Drug-Specific T cells in Acute Drug-Induced Interstitial Nephritis Spanou et al, JASN, 17: 2919, 2006
- 26. Lymphocyte Transformation Test… Drug-specific proliferation of patients PBMC Pt 1. Positive proliferative response of PBMC to flucloxacillin Pt 2 PBMC proliferative response to penicillin G Pt 3 PBMC proliferative response to disulfiram Involvement of Drug-Specific T cells in Acute Drug-Induced Interstitial Nephritis Spanou et al, JASN, 17: 2919, 2006 #Even though there were multi drug exposure, each patient elicited proliferative response to only one drug
- 27. T cell receptor Vb expression in a drug-specific T cell line by flow cytometry PBMC of pt 1 was incubated with flucloxacillin and IL-2 CD3+ T cells bearing Vb9 and Vb21.3 were enriched Suggesting an oligoclonal T cell expansion
- 28. TCR-Vb staining in kidney biopsy specimens - to determine whether the drug-specific T cells from PBMC might be present in the kidney Total CD4 317/mmsq TCR-Vb* 27 mm/sw Both show extensive T cell infiltrate Both stained for TCR-Vb* specific to flucloxacillin (normally found on 4-7% of circulating T cell only) Total CD4 272/mmsq TCR-Vb* 120/mmsq
- 29. Involvement of Drug-Specific T cells in Acute Drug-Induced Interstitial Nephritis Spanou et al, JASN, 17: 2919, 2006 Implications… In vitro proliferation assays might be helpful to identify the drug that is responsible for the hypersensitivity reaction Particularly in patients with more than one medication exposure It’s likley that the T cell infiltration into the kidney is due to drug-specific T cells, which then might coordinate the local inflammatory reaction
- 30. Treatment Therapy aimed at modulating the immune response has been the main treatment for AIN Several small retrospective studies have suggested that corticosteroid therapy improves clinical outcome; however, no prospective studies exist Pusey CD, Saltissi D, Bloodworth L, Rainford DJ, Christie JL. Drug associated acute interstitial nephritis: clinical and pathological features and the response to high dose steroid therapy. Q J Med 1983; 52: 194–211 Buysen JG, Houthoff HJ, Krediet RT, Arisz L. Acute interstitial nephritis: a clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990; 5: 94–99 Enriquez R, Gonzalez C, Cabezuelo JB et al . Relapsing steroid-responsive idiopathic acute interstitial nephritis. Nephron 1993; 63: 462–465
- 31. Retrospective study Drug associated acute interstitial nephritis: clinical and pathological features and the response to high dose steroid therapy. Pusey et al, Q J Med 1983
- 32. Acute interstitial nephritis: a clinical and morphological study in 27 patients Buysen et al, Nephrol Dial Transplant. 1990;5(2):94-9 N = 27 biopsy-proven AIN 17 patients renal function improved after withdrawal of the drug 10 patients Further decline in renal function in the two weeks following admission prednisone therapy was instituted All with improvement of renal function with six returning to normal
- 33. Acute interstitial nephritis: clinical features and response to corticosteroid therapy Clarkson et al, Nephrology Dialysis Transplantation 2004 19(11):2778-2783 a retrospective study of all cases (n=60) of AIN found by reviewing 2598 native renal biopsies over a 12 year period Of those patients in whom complete follow-up data were available ( n = 42) 60% received corticosteroid therapy while the remainder received supportive care only
- 34. Effect of corticosteroid therapy in AIN compared with conservative management. Values for serum creatinine (µmol/l) are given as median±interquartile range.
- 35. Why no benefit? Patients treated with steroids had more severe disease Significant proportion of the patients had NSAID-associated AIN, which is less likely to respond to steroid tx
- 36. The end
Editor's Notes
- #3: Diffuse interstitial inflammatory infiltrate – -composed of lymphocytes, monocytes, and plasma cells -extensive loss of parenchyma
- #4: Silver staining Tubular atrophy
- #9: Approximated frequency with which clinical manifestations occur during the course of methicillin-induced AIN ( A ), AIN induced by drugs other than methicillin ( B ), or AIN induced by NSAIDs and associated with a nephrotic syndrome ( C ). Methicillin-induced AIN has long been considered prototypical of drug-induced AIN. About 100 cases of methicillin-induced AIN have been described in the English literature, and analysis of these case reports shows that the corresponding clinical picture was quite monomorphic Renal symptoms typically developed about two weeks after the patients started taking methicillin. Hematuria was present in 90% of cases. It was macroscopic in about 80% of cases and was never associated with red blood cell casts. Pyuria was almost always present and often was associated with leukocyte casts. Renal failure, which occurred in only 50% of adults and 15% of children, was oliguric in 20% of the cases. Approximately 33% of the patients with abnormal renal function required dialysis. The most common extrarenal symptom was fever, which was present in about 80% of patients, could be as high as 40°C, and usually lasted 7 to 10 days after discontinuation of methicillin. A generalized cutaneous rash was observed in only 25% of patients, and arthralgias were uncommon. Eosinophilia was present in about 80% of patients, ranging from 500 to 5000/mm 3 . After the methicillin was discontinued, hematuria and pyuria usually resolved within a few days, but renal failure, when present, could last much longer and its mean duration was 1.5 months. Nevertheless, complete recovery of renal function was the rule, and serum creatinine returned to normal levels in about 90% of reported patients. Besides methicillin, many other drugs can induce AIN Table 1 , but the clinical presentation of AIN induced by these drugs is often incomplete and less suggestive of the diagnosis. To try to get a global view of this entity, we reviewed more than 150 case reports, as well as our own unpublished cases Figure 2 . This analysis showed that renal manifestations develop within three weeks after starting the inciting drug in about 80% of patients, with an average delay of about ten days. The clinical presentation most suggestive of the diagnosis is that of a sudden impairment of renal function associated with mild proteinuria and abnormal urinalysis in a patient with flank pain, normal blood pressure, and no edema. Nevertheless, such a clinical picture is observed in less than one-fourth of cases. Analysis of the different manifestations showed that renal failure is almost constant, and that dialysis is required in about one-half of patients. The presentation is usually that of parenchymal renal failure, but patients with a low fractional excretion of sodium occasionally have been reported. Hematuria and pyuria are each present in only about 50% of patients. Flank pain, reflecting distension of the renal capsule, is also observed in about the same percentage of cases, and it can be the main complaint on admission. Ultrasonography usually discloses an increased cortical echogenicity (comparable to or higher than that of the liver), but as far as we know, the diagnostic value of this finding has not been assessed 39 . Extrarenal symptoms and signs reflecting a hypersensitivity reaction typically include low-grade fever, maculopapular rash, mild arthralgias, and eosinophilia, but each of these manifestations is present in fewer than 50% of patients, and all of them are present together in fewer than 5% of patients. With some drugs, such as rifampicin or allopurinol, other manifestations of hypersensitivity such as hemolysis or hepatitis can be present. Nevertheless, it should be emphasized that signs of hypersensitivity are not specific to AIN and they also can be observed in patients with acute renal failure not related to AIN. In a study of 81 patients with acute renal failure who had a renal biopsy, signs of hypersensitivity were found in 14% of patients with drug-induced acute tubular necrosis 40 .The clinical and biologic manifestations of AIN might have some specificity, depending on the drug involved, and I would like to emphasize the particularities of AIN induced by nonsteroidal anti-inflammatory drugs (NSAIDs) and by rifampicin. Analysis of more than 80 case reports showed that NSAID-induced AIN is associated with a nephrotic syndrome in more than 70% of patients and that it usually is diagnosed in patients who have taken the drug for a few months (mean delay, 6 months). Furthermore, AIN induced by NSAID and associated with a nephrotic syndrome usually occurs in patients over 50, possibly because NSAIDs are consumed more often by elderly people. Besides these particularities, the presentation is quite similar to that of other types of drug-induced AIN Figure 2 . The main differences are that hematuria is almost never macroscopic and extrarenal symptoms are present in only about 10% of these patients.
- #11: Four large series…heterogeneity…lack biopsy proven diagnosis…difficult to draw conclusion. Low sensitivity, 29/43 pts with AIN (63%) had eosinophiluria Higher specificity, of 496 pts without AIN, 432 (87%) had no eosinophiluria.
- #14: The hallmark of AIN is the presence of inflammatory infiltrates within the interstitium. These infiltrative lesions can be diffuse, but often they are patchy, predominating in the deep cortex and in the outer medulla. They are composed mostly of T-cells and of monocytes/macrophages; plasma cells, eosinophils, and a few neutrophilic granulocytes also can be present. Among T-cells present within the interstitium, the relative number of CD4+ T-cells and CD8+ T-cells appears to be quite variable from one patient to another 59 , 60 , 61 , 62 , 63 . The relative representation of T-cells is probably influenced by the noxious drug, but also by other factors such as the genetic background of the patient. Infiltrating cells sometimes form granulomas, which are usually sparse, non-necrotic, with a few giant cells, and associated with non-granulomatous interstitial infiltrates. In some cases, T-lymphocytes infiltrate across the TBM and between tubular cells, causing what is known as tubulitis.Interstitial infiltrates are always associated with an interstitial edema separating the tubules. They also can occur with focal tubular lesions, which range from mild cellular alterations to extensive necrosis of epithelial cells, and which sometimes disrupt the TBM. These tubular lesions usually predominate where the inflammatory infiltrates are most extensive. Vessels and glomeruli appear normal, and even in AIN associated with a nephrotic syndrome, the structure of the glomeruli is preserved on light microscopy, and only on electron microscopy can fusion of foot processes be seen. In the vast majority of cases, renal biopsies from patients with AIN do not show immune deposits. Nevertheless, linear staining of the TBM for IgG occasionally can be seen, mostly in patients taking methicillin, an NSAID, phenylhydantoin, or allopurinol. Immune deposits indicate the presence of antibodies directed against membrane antigens or against drug metabolites bound to the TBM. (from Rossert)
- #23: Mechanisms whereby a drug (or one of its metabolites) can induce acute interstitial nephritis (AIN). ( A ) The drug can bind to a normal component of the tubular basement membrane (TBM) and act as a hapten. ( B ) The drug can mimic an antigen normally present within the TBM or the interstitium and induce an immune response that will also be directed against this antigen. ( C ) The drug can bind to the TBM or deposit within the interstitium and act as a planted (&quot;trapped&quot;) antigen. ( D ) The drug can elicit the production of antibodies and become deposited in the interstitium as circulating immune complexes.
- #25: Pt 1. Tx’d w abx for endocarditis, developed ARF 3 weeks after starting abx Pt 2 Tx for endocarditis, arf after 8 days Pt 3 ARF after 3 weeks
- #27: Even though there were multi drug exposure, each patient elicited proliferative response to only one drug
- #32: N = 9 Seven received treatment with high dose methyl prednisolone Spontaneous fall in serum creatinine within 72 hrs, and recovery of near normal renal function Two did not receive treatment One improved, but slowly One developed chronic renal impairement
- #35: No difference in outcome was observed between the two groups with respect to the median serum creatinine at time points of 1, 6 and 12 months following diagnosis We were unable to show a beneficial effect of corticosteroid therapy in terms of either the rate or extent of renal recovery.