Eosinophilic tubulointerstitial nephritis on treatment with isotretinoin

Systemic isotretinoin has an impact on hemoglobin, ferritin, urea, ceruloplasmin, albumin, uric acid levels, and neutrophil to lymphocyte ratio in acne patients

BACKGROUND

Patients suffering from moderate-to-severe acne are commonly treated with systemin isotretinoin; however, a great controverse about its safety had been raised. The aim of the present study is to evaluate the effects of isotretinoin on hepatic, renal, and hematologic functions and to evaluate the potential oxidative stress in relation to isotretinoin therapy.

METHODS

Fifty-three female patients, treated from moderate-severe acne with isotretinoin (0.5 mg/kg/day), were included. Blood samples were taken for measuring low density lipoprotein (LDL), triglycerides, hemoglobin, erythrocyte sedimentation rate (ESR), bilirubin, total protein, albumin, globulin, blood urea nitrogen, ferritin, uric acid, creatinine, C-reactive protein (CRP), ceruloplasmin, alanine transaminase (ALT), aspartate transaminase (AST) levels, and red blood cells (RBC), white blood cells (WBCs), and platelet counts before starting isotretinoin treatment and 6 months later.

RESULTS

Isotretinoin was associated with increased levels of triglycerides, LDL, ESR, CRP, uric acid, and ferritin after 6 months of therapy (p < 0.0001), blood urea levels were significantly elevated from 3.681 ± 0.91 to 3.838 ± 0.877 (p = 0.014), ALT, AST, hemoglobin, globulin, and total proteins were significantly elevated after 6 months. Platelets, WBCs, albumin, albumin/globulin ratio, copper, ceruloplasmin, and neutrophil/lymphocyte ratio were significantly decreased after 6 months.

CONCLUSION

Isotretinoin therapy could be associated with oxidative stress and hepatic, lipid, and blood abnormalities in patients with acne. Serum ferritin was elevated while serum ceruloplasmin was decreased. Isotretinoin could also affect immune regulation (decreasing neutrophil to lymphocyte ratio), isotretinoin was associated with a possible positive nitrogen balance (increasing proteins) and with elevations of blood urea nitrogen and uric acid levels.

Isotretinoin Associated Rhabdomyolysis: Monitoring Creatine Kinase and Educating Patients

Monitoring specific values at baseline and throughout treatment is standard of care for isotretinoin therapy; however, creatine kinase (CK) blood monitoring is often excluded. Herein, we describe the importance of CK monitoring during isotretinoin therapy to assess the risk of rhabdomyolysis and potential renal damage, regardless of muscle-related symptom presentation. We present 2 patients with hyperCKemia: a 16-year-old male on isotretinoin whose CK levels were elevated (7,325 U/L) when rhabdomyolysis symptoms were present, and an asymptomatic 18-year-old male with elevated CK levels (35,000 U/L) before starting isotretinoin. Based on our experience, we strongly recommend obtaining CK levels to monitor for and potentially prevent rhabdomyolysis and its associated complications.

Isotretinoin and the Kidney: Opportunities and Threats

Retinoids are one of the most effective drugs in inducing complete or prolonged remission of severe acne vulgaris, but the adverse reactions associated with the use of them are raising a concern about the potential effect of these drugs on internal organs function such as the kidney. The aim of this review is to comprehensively gather data about isotretinoin, both potential adverse and beneficial effects on the kidney based on the current experimental and clinical findings. Very few studies, including five case reports, described that systemic oral isotretinoin within usual doses (40 mg/day or 0.5 mg/kg⁄day) within 1 to 4 months of treatment might be associated with different types of renal dysfunctions. These include acute interstitial nephritis, nephrotic syndrome, and hematuria with dysuria. The adverse reactions of systemic isotretinoin on the kidney and urinary system are unlikely and rare. In contrast, six experimental studies demonstrated the beneficial effects of either oral or parenteral low- (2 or 5 mg/kg/day) or high- (10, 20, 25, 40 mg/kg/day) dose isotretinoin on the kidney in the rat models of glomerulonephritis, obstructive nephropathy or allograft nephropathy. The nephroprotective functions of isotretinoin in these studies were attributed to its anti-proliferative, anti-fibrotic, and anti-inflammatory actions. However, clinical studies are warranted to elucidate the possible beneficial effects of isotretinoin in preventing or attenuating kidney injury in different settings.