Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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