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Nephrology
R4 이홍주 / prof. 임천규
J Clin Pathol 2009;62:505–515
Ann Acad Med Singapore 2009:38:240~50
Ann Acad Med Singapore 2009:38:240~50
• ATIN ???
• AIN ???
• ATN ???
• ATIN
Acute Tubulointerstitial nephritis
=
• AIN
Acute interstitial nephritis
• ATN
Acute tubular necrosis
• Acute interstitial nephritis(AIN)
– inflammatory infiltrates in interstitium
– Interstitial edema
– usually associated with an acute deterioration in renal function.
Renal biopsy
ARF
15-27%
1-3%
others
AIN
Clin Nephrol 1984; 22: 217–222
Q J Med 1998; 66: 97–115
others
AIN
Am J Kidney Dis 2000; 35: 433–447
Q J Med 1989;70: 221–233
Kidney International (2010) 77, 956–961
• immunological basis
Kidney International (2001)
LM
•
Interstitium
 Inflammatory cell infiltration
- diffuse or patchy
- lymphocytes(CD4+ T cells),
macrophages, eosinophils, plasma cells
 edema
- typical finding
 granulomas
•
Glomeruli & vessels
 distinctly normal
IF
negative in most of patients
EM
nonspecific lesions
... NSAIDs-induced AIN : diffuse effacement of podocyte’s foot processes
• Fibrotic changes
 advanced interstitial fibrosis accompanied by tubular atrophy
 within 7-10 days of initiation of the inflammatory process
 unless rapid withdrawal of offending drug or onset of steroid treatment
Features
Acute renal failure
100%
Acute renal failure requiring dialysis
40%
Arthralgias
45%
Fever
36%
Skin rash
22%
Eosinophilia (4500 eosinophils per mm3)
35%
Microhematuria
67%
Gross hematuria
5%
Leukocyturia
82%
Non-nephrotic proteinuria
93%
Nephrotic-range proteinuria
2.5%
Complete nephrotic syndrome
0.8%
Kidney Int 2008; 73: 940–946
Drug-induced AIN
• acute worsening of renal function : all the patients
 starting of the offending drug ~ appearance of renal manifestations =10 days
(1 day ~ several months)
• specific clinical findings in drug-induced AIN : allergic-type reaction




low-grade fever
maculopapular skin rash
Eosinophilia
urinary eosinophils - ‘No’ diagnostic usefulness.
AIN secondary to infectious diseases / idiopathic AIN
• extrarenal manifestations
• maculopapular rash, arthralgias, eosinophilia – uncommon
• TINU syndrome = AIN + bilateral anterior uveitis
 follow renal dysfunction
• AIN coincidental with autoimmune pancreatitis
: a dense infiltration of IgG4-positive mononuclear cells in renal interstitium
• rapid improvement of renal function after the removal of the inducing agent
• longer follow-up
‘Not’ fully recovered their baseline renal function in significant proportion (30-70%)
<1.7mg/dL
• duration
of treatment
(68%)
– offending drug or duration and severity of renal failure
– not a correlation with the levels of SCr at the end of follow-up
• predictive role of
 diffuse interstitial infiltrates ?
 extent of interstitial fibrosis - ↑ risk of chronic renal impairment
<1.2mg/dL
(49%)
• role of steroids in the treatment of drug-induced AIN : controversial
retrospective study
•
•
•
•
60 patients with biopsy-proven AIN  F/U data in 42 patients.
60% - steroid vs 40% - supportive care.
‘no’ difference in sCr levels after 1, 6, and 12 months following AIN
chronic renal impairments in significant proportion
 considerable delay between the onset of AIN Sx and renal biopsy (3 weeks)
 considerable delay to start steroids after renal biopsy
Nephrol Dial Transplant 2004; 19: 2778–2783
• whether the timing of treatment initiation ?
early vs late
retrospective multicenter study
• 61 patients with biopsy-proven, drug induced AIN.
• 85% - steroids vs 15% of - conservative
• need of chronic dialysis : 3.8 vs 44%
 steroid treatment is indicated in drug-induced AIN
 start soon or immediately after the diagnosis to diminish the risk of chronic
renal impairment.
Kidney Int 2008; 73: 940–946
• steroids
mainstay of treatment
in idiopathic AIN
TINU
AIN associated with systemic diseases
AIN with autoimmune pancreatitis.
• plasmapheresis and cytotoxics (cyclophosphamide, cyclosporine / MMF)
in idiopathic AIN resistant to steroids
retrospectively
• cases of biopsy-proven IgA nephropathy
• from July 2000 to June 2009 at a medical center in Taiwan
non IgAN
ATN, 8
IgAN, 9
Non-IgAN,
11
AIN, 3