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Updated: Mar 10 2020

Acute Interstitial Nephritis


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  • Snapshot
    • A 60-year-old man presents to the emergency room with a 1-day history of fever and a new skin rash. He is taking methicillin for a soft tissue infection. On physical exam, he has costovetebral tenderness, and a diffuse maculopapular rash over his trunk. His serum creatinine is elevated at 3 mg/dL. Urinalysis reveals white blood cells. Further testing with Wright stain is positive for eosinophils in the urine.
  • Introduction
    • Clinical definition
      • acute interstitial nephritis (AIN), also known as tubulointerstitial nephritis, is an acute immune-mediated interstitial inflammation of the kidneys
    • Epidemiology
      • demographics
        • middle-aged adults
    • Etiology
      • drug-induced hypersensitivity (majority of cases)
        • typically developed between 1 week to 9 months
        • 5 Ps
          • Pee (diuretics, especially sulfa ones)
          • Pain-free (NSAIDs)
          • Penicillins and cephalosporins
          • Proton pump inhibitors
          • rifamPin
      • systemic infections
      • autoimmune diseases
        • systemic lupus erythematosus
        • sarcoidosis
    • Pathogenesis
      • type IV hypersensitivity reaction
      • T-cell-mediated attack on tubular cells
    • Prognosis
      • typically resolves after withdrawal of inciting agent
  • Presentation
    • Symptoms
      • primary symptoms
        • fever
        • hematuria
        • arthralgia
        • can be asymptomatic
    • Physical exam
      • rash
        • maculopapular
      • flank/costovertebral angle tenderness
  • Studies
    • Labs
      • serum eosinophilia
      • elevated serum creatinine
    • Urinalysis with microscopy and sediment analysis
      • white blood cell casts
      • hematuria
      • eosinophiluria
        • seen with Hansel or Wright stain
    • Renal biopsy
      • not usually indicated
    • Histology
      • severe tubular damage
      • interstitial edema
      • T-cell and eosinophilic infiltration
    • Diagnostic criteria
      • elevated creatinine
      • urinalysis with white cell casts and eosinophiluria
  • Differential
    • Acute tubular necrosis from NSAIDs
      • no rash or eosinophils
    • Renal atheroemboli
      • also presents with eosinophiluria, eosinophilia, and skin rash
      • rash is typically livedo reticularis with digital infarcts and not maculopapular
  • Treatment
    • Conservative
      • discontinue inciting drug
        • indications
          • for all drug-induced hypersensitivity cases
    • Medical
      • glucocorticoids
        • indications
          • if creatinine continues to rise after stopping drugs
  • Complications
    • Renal failure requiring dialysis
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