Tubulointerstitial Nephritis

Renal injury in NSAIDs: a real-world analysis based on the FAERS database

OBJECTIVE

This study aims to evaluate the reporting risk of renal injury associated with non-steroidal anti-inflammatory drugs (NSAIDs), with a particular focus on the reporting risk levels and onset times of different NSAIDs.

METHODS

A pharmacovigilance study was conducted using data from the FAERS database from January 2004 to December 2023. Reports of renal injury were identified, and signal detection was performed using reporting odds ratio (ROR) and Bayesian confidence propagation neural network (BCPNN) methods. The study compared the incidence, mortality rates, and onset times of renal injury across five NSAIDs.

RESULTS

Among the 7436 cases of NSAID-associated renal injury analyzed, elderly patients are at an increased risk of renal injury associated with NSAID usage. Ibuprofen had the highest number of reports (3475 cases, 46.7%), while celecoxib had the lowest (542 cases, 7.3%). Ibuprofen showed the highest signal with renal injury (ROR 3.3, IC025 1.7), whereas celecoxib exhibited the lowest (ROR 1.4, IC025 0.4). Aspirin had the highest mortality rate associated with renal injury (18.7%), while ibuprofen had the lowest (3.8%). The median onset time for renal injury was 6 days, with 79.3% of adverse events occurring within the first 30 days of use.

CONCLUSION

The study indicates that ibuprofen presents the highest signal of renal injury, while celecoxib shows the lowest signal. The likelihood of NSAID-associated renal injury is heightened in elderly patients, and all five studied NSAIDs are linked to an increased likelihood of acute renal injury. NSAID-related renal damage tends to occur early in the treatment process, potentially leading to serious consequences. Due to the inherent limitations of pharmacovigilance studies, certain findings require additional validation like cohort studies. Nonetheless, the potential for an increased risk of renal injury must be taken into account in patient care.

Acute tubulointerstitial nephritis (ATIN) including drug-induced, tubulointerstitial nephritis and uveitis (TINU), ANCA-associated vasculitis (AAV), kidney- limited sarcoidosis, and hemolysis: a case series from Syria

BACKGROUND

This study aimed to detail acute tubulointerstitial nephritis (ATIN) patients, from relevant clinical manifestations to outcomes.

METHODS

We reviewed ATIN patients between 2018 and 2022. All demographic data, labs, biopsy findings, treatment protocols, and outcomes were reported.

RESULTS

ATIN was diagnosed in nine patients, eight by kidney biopsy and one clinically. Drug-induced ATIN (DI-ATIN) was reported in five patients, including rifampin (RIF), allopurinol, mesalamine, and two with cephalosporins. Severe ATIN resulted after the first dose of RIF aligned with liver injury, hemolysis, and thrombocytopenia. Also, mesalamine and allopurinol induced gradual kidney failure a few months after the drug initiation. A patient with Tubulointerstitial nephritis and uveitis (TINU) syndrome showed refractory uveitis presenting during glucocorticoids (GCs) tapering, which resolved quickly with azathioprine (AZA) when not responding to GCs reescalation. Among the rarest cases, ATIN induced by a kidney-limited sarcoidosis, G6PD patient with hemolysis induced ATIN, and isolated ATIN induced by ANCA-associated vasculitis (AAV) with positive C-ANCA, which the latter representing the first case in our country and the fourth case worldwide. Labs showed anemia (88.8%), ESR elevation (85.7%), microscopic hematuria (in all patients), pyuria (44.4%), and proteinuria (77.7%). Biopsies showed interstitial infiltrations mainly with lymphocytes and monocytes. Eosinophils were found in one biopsy and neutrophils showed in 4 biopsies (50%).

CONCLUSION

ATIN is a disease with a diagnostic challenge, thus clinicians should maintain a high suspicion for diagnosis. The combination of AKI with positive tests (especially abnormal urine sediment, ESR elevation, and anemia) may suggest ATIN diagnosis and further support the treatment initiation, particularly when kidney biopsy is unable to be performed or when the inciting agent is predictable.

Apical periodontitis and its effects on renal tissue in rats

BACKGROUND

Motivation for the study. Apical periodontitis (AP) can trigger immune responses that affect other organs. Main findings. This animal study examined the effects of AP on renal tissue, finding significant changes in parameters such as renal corpuscle area and Bowman's space, which may have implications for chronic kidney disease. Implications. Future research will provide insight into how dental conditions may affect renal health. If confirmed, regular dental checkups would not only be critical to improve the overall health of patients with kidney disease, but could also serve as a preventive measure.

OBJECTIVES.

To evaluate the effect of apical periodontitis (AP) induced in Wistar rats on histologically examined renal tissue.

MATERIALS AND METHODS.

Fourteen 12-week-old male Wistar rats weighing an average of 250 grams were used. AP was induced with pulp exposure of the upper and lower first molars using a #1011 HL spherical bur in high rotation. The lesions were left exposed to the oral environment for a period of 7 weeks. Blood pressure was measured by the tail-cuff plethysmography method from the fourth week. The kidney was dissected for histological analysis (H&E). Mann-Whitney and Student's t-test were used for non-parametric and parametric data, respectively, with a significance level of 5%.

RESULTS.

A statistically significant increase in both Bowman's space area and renal corpuscle area was found in the AP group (p<0.05). The AP group had a higher percentage of renal tissue with inflammatory infiltrate, but without significant difference. Blood pressure did change during the experimental period and no difference was identified between the groups.

CONCLUSIONS.

Induction of AP in Wistar rats resulted in significant changes of certain renal histological parameters, suggesting a possible interaction between AP and renal tissue that requires further research.

Glucocorticoid does not improve the renal prognosis of patients with diabetic nephropathy combined with acute tubulointerstitial nephritis: a retrospective analysis

BACKGROUND AND OBJECTIVES

In clinical practice, some patients are diagnosed with diabetic nephropathy (DN) combined with acute tubulointerstitial nephritis (ATIN) through renal biopsy. There is relatively little research on the treatment and prognosis of such patients, and no consensus exists on the use of glucocorticoid for treatment. Therefore, our study explores the progression of DN combined with ATIN and the renal outcomes after treatment with glucocorticoid.

METHODS

This study retrospectively analyzed patients diagnosed with DN combined with ATIN through renal biopsy at our center from January 1, 2015, to December 31, 2021. We collected general patient information, laboratory indicators, renal pathology indicators, and the glucocorticoid usage after kidney biopsy. Follow-up data were collected from medical records. Statistical analysis methods included t-tests, non-parametric tests, and chi-square tests. Univariate and multivariate Cox regression analyses were used to evaluate the risk factors for renal endpoint events in patients. Statistical significance was defined as p-values < 0.05.

RESULTS

In this study, a total of 67 patients were included. The subjects were divided into two groups based on whether they received glucocorticoid treatment: 33 patients in the steroid group and 34 in the non-steroid group. In the steroid group, 19 patients reached the renal endpoint event, which was significantly higher than in the non-steroid group (57.58% vs. 29.41%, p = 0.038). Univariate Cox regression analysis showed that serum creatinine (HR = 1.008, p < 0.001), albumin (HR = 0.919, p < 0.001), 24-h urinary protein (HR = 1.093, p = 0.002), hemoglobin (HR = 0.964, p = 0.001), triglycerides (HR = 1.12, p = 0.04), and the use of glucocorticoid (HR = 2.507, p = 0.019) were influencing factors for renal endpoint events in patients with DN combined with ATIN. Multivariate Cox regression analysis showed that albumin (HR = 0.863, p = 0.003) was an independent risk factor for renal endpoint events in patients with DN combined with ATIN.

CONCLUSIONS

The use of glucocorticoid in treatment does not improve renal prognosis in patients with DN combined with ATIN. Lower levels of albumin are associated with a worse renal prognosis.

Favorable course of leptospirosis and hantavirus-induced acute tubulointerstitial nephritis under corticosteroid treatment

BACKGROUND

We present two children with acute tubulointerstitial nephritis (ATIN) caused by leptospirosis in a 12-year-old boy and hantavirus in a 10-year-old girl. The role of glucocorticoids in the management of ATIN triggered by infectious agents is unclear.

CASE-DIAGNOSIS/TREATMENT

Both children were hospitalized with jaundice, elevated serum creatinine, and thrombocytopenia. There was no oliguria or hypertension. Urine analysis revealed tubular proteinuria. Kidney biopsy was performed on one patient and showed tubulointerstitial inflammation with mild mesangial proliferation. Both patients were treated with glucocorticoids in view of deteriorating kidney function with respective serum creatinine values of 5.2 and 4.1 mg/dl. Both children exhibited an excellent clinical and biochemical response to treatment. Neither of the patients required dialysis. Positive serology test results indicated a recent leptospirosis and hantavirus infection.

CONCLUSIONS

Leptospirosis and hantavirus associated ATIN share common clinical and biochemical features. Due to the low incidence in Europe these infectious causes of kidney dysfunction may be overlooked. Glucocorticoids may be considered in the management of ATIN.

Epidemiology of Somatic Diseases and Risk Factors in the Population Living in the Zone of Influence of Uranium Mining Enterprises of Kazakhstan: A Pilot Study

The increase in uranium mining in Kazakhstan has brought with it a number of problems. Reducing the negative impact of radiation-toxic factors on the health of workers and the population in uranium mining regions is one of them. This article presents a pilot population health study in which we developed approaches to support residents living near an operating uranium mining enterprise. The purpose of the current study was to assess the impact of technogenic factors on the health of those living near the Syrdarya uranium ore province. Data collected from 5605 residents from the village of Bidaykol (the main group)—which is located 4 km from the uranium mining enterprise—and the village of Sunakata (the control group), which is located in the Kyzylorda region, were analyzed. A bidirectional cohort study was conducted. The prevalence of acute and chronic diseases among the residents of Bidaykol was 1.3 times higher than that in the control group. The structure of morbidity was dominated by pathologies of the genitourinary system (27%), the circulatory system (14.4%), and the respiratory system (11.9%). Relative risks (RR > 1) were identified for most classes of diseases, the highest being for diseases of the blood (RR = 2.6), skin (RR = 2.3), and genitourinary system (RR = 1.9). In the main group, renal pathologies were the most frequent class in the age group of 30–40 years, occurring mainly in women. In addition, they had a direct dependence on the duration of residence in the territory of the uranium ore province. Further studies into the interaction between the technogenic factors associated with uranium mining enterprises and the development of diseases of the urinary system are needed. This will make it possible to determine ways to prevent these pathologies in the population.

Renal Side Effects of COVID-19 Vaccination

Background: The COVID-19 pandemic has imposed a challenge on global healthcare and has tremendously impacted everyone's lives. Vaccination is one of the most effective and vital strategies to halt the pandemic. However, new-onset and relapsed kidney diseases have been reported after COVID-19 vaccination. This narrative review was conducted to collect published data and generalize some hypotheses for the pathogenesis of renal side effects of COVID-19 vaccines. Methods: A systematic literature search of articles reporting renal adverse reactions, including in adults and children, in the PubMed and Web of Science databases until August 2022 was performed. Results: A total of 130 cases reporting a renal adverse reaction following COVID-19 vaccination from 90 articles were included in this review, of which 90 (69%) were new-onset kidney diseases, while 40 (31%) were relapsed kidney diseases. The most frequent renal side effects of COVID-19 vaccination were minimal change disease (52 cases), IgA nephropathy (48 cases), antineutrophil cytoplasmic autoantibody vasculitis (16 cases), and acute interstitial nephritis (12 cases). Other renal side effects occurred at a much lower frequency. Follow-up data were available for 105 patients, and 100 patients (95%) responded to the treatments. Conclusions: The number of reported cases is far less than the hundreds of millions of vaccinations, and the benefit of COVID-19 vaccination far outweighs its risks. This review will assist healthcare professionals, particularly nephrologists, who should be aware of these side effects and recognize them early and treat them efficiently.

Case Report: SARS-CoV-2 Associated Acute Interstitial Nephritis in an Adolescent

Acute interstitial nephritis (AIN) has been recently recognized as one of the infrequent kidney involvement phenotypes among adult patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Although SARS-CoV-2 associated intrinsic kidney disease has been scarcely reported in children, only one case of AIN temporally associated with the infection has been described in the pediatric population so far. We presented a case of a 12-year old boy who presented with fatigue, anorexia, and polydipsia following an RT-PCR that confirmed SARS-CoV-2 infection seven weeks prior to admission. Initial workup revealed increased serum creatinine (235 μmol/L), glucosuria, low-molecular-weight proteinuria, mild leukocyturia, and microhematuria with hyaline and granular casts on microscopy. Antibodies against the SARS-CoV-2 S protein receptor-binding domain confirmed prior infection with high titers. Kidney biopsy showed diffuse active interstitial nephritis with negative immunofluorescence and positive immunohistochemistry for SARS-CoV-2 in the inflammatory cells within the interstitium. Electron microscopy revealed several SARS-CoV-2-like particles. Kidney function continued to deteriorate despite several days of supportive therapy only (peak serum creatinine 272 μmol/L); thus, treatment with methylprednisolone pulse-dose therapy was initiated and was followed by oral prednisolone with gradual tapering. Kidney function completely recovered after 3 weeks post-discharge and remained normal after 11 weeks of follow-up (last estimated glomerular filtration rate 106 ml/min/1.73 m²) with only residual microhematuria. Our case adds to the emerging evidence of SARS-CoV-2 as a potential etiological agent of AIN in children and also suggests that interstitial kidney injury may result from secondary inflammatory damage. Epidemiological history, serologic testing, and SARS-CoV-2 detection in biopsy should be considered in the work-up of children with AIN of unknown etiology.

Kidney involvement and histological findings in two pediatric COVID-19 patients

BACKGROUND

Histological findings of kidney involvement have been rarely reported in pediatric patients with SARS-CoV-2 infection. Here, we describe clinical, laboratory, and histological findings of two pediatric cases with almost exclusive kidney involvement by SARS-CoV-2.

RESULTS

A 10-year-old girl with IgA vasculitis nephritis underwent kidney biopsy, showing diffuse and segmental mesangial-proliferative glomerulonephritis, and steroid therapy was initiated. After the worsening of the clinical picture, including an atypical skin rash, she was diagnosed with SARS-CoV-2. The re-evaluation of initial biopsy showed cytoplasmatic blebs and virus-like particles in tubular cells at electron microscopy. Despite SARS-CoV-2 clearance and the intensification of immunosuppression, no improvement was observed. A second kidney biopsy showed a crescentic glomerulonephritis with sclerosis, while virus-like particles were no longer evident. The second patient was a 12-year-old girl with a 3-week history of weakness and weight loss. Rhinitis was reported the month before. No medications were being taken. Blood and urine analysis revealed elevated serum creatinine, hypouricemia, low molecular weight proteinuria, and glycosuria. A high SARS-CoV-2-IgG titre was detected. Kidney biopsy showed acute tubular-interstitial nephritis. Steroid therapy was started with a complete resolution of kidney involvement.

CONCLUSION

We can speculate that in both cases SARS-CoV-2 played a major role as inflammatory trigger of the kidney damage. Therefore, we suggest investigating the potential kidney damage by SARS-CoV-2 in children. Moreover, SARS-CoV-2 can be included among infectious agents responsible for pediatric acute tubular interstitial nephritis.

Acute kidney injury in interstitial nephritis

PURPOSE OF REVIEW

The purpose of this review is to describe the most common causes of acute interstitial nephritis (AIN), the diagnostic work-up and the therapeutic management.

RECENT FINDINGS

Several case series and registries have found an increasing incidence of AIN, especially among older patients. Drug-induced AIN still represents the most common cause. Early withdrawal of the culprit drug together with corticosteroid therapy remain the mainstay of treatment, although recent studies have shown that prolonged treatment beyond 8 weeks does not further improve kidney function recovery.

SUMMARY

AIN is a common cause of acute kidney injury, and therefore, physicians should suspect this entity especially in patients exposed to multiple medications. While immune-allergic reaction to numerous drugs is the most common cause of AIN, other underlying systemic diseases may also be involved, and therefore, every patient should undergo a complete diagnostic evaluation. Kidney biopsy provides the definitive diagnosis of AIN, and certain histologic features may help to identify the underlying condition. In drug-induced AIN, an early discontinuation of the culprit drug is the mainstay of therapy, and unless a rapid recovery of kidney function is observed, a course of glucocorticoid therapy should be initiated.