[Tubulo-interstitial nephritis in inflammatory bowel disease: extra-intestinal manifestation or drug toxicity?]

Chronic inflammatory bowel disease (IBD) is seldom complicated by renal function disorder, but when this occurs the consequences are serious. In addition to the known effects of 5-aminosalicylates, there is also evidence that tubulo-interstitial nephritis (TIN) occurs as an extra-intestinal manifestation of IBD. A 27-year-old woman with colitis ulcerosa, developed end-stage renal insufficiency due to a mesalazine-induced TIN. She was treated by haemodialysis for two years before she underwent renal transplantation. Another patient, a 36-year-old man with Crohn's disease, developed extensive granulomatous nephritis with stable moderate renal function. After excluding other possible causes, we diagnosed an extra-intestinal manifestation of his Crohn's disease. There are no official guidelines on renal function monitoring in IBD patients, nor is there consensus in literature. We advise renal monitoring after three months of treatment with 5-aminosalicylates, followed by monitoring every year. Patients not receiving treatment should be monitored every year.

Laparoscopic ileocolic resection versus infliximab treatment of distal ileitis in Crohn's disease: a randomized multicenter trial (LIR!C-trial)

Background

With the availability of infliximab, nowadays recurrent Crohn's disease, defined as disease refractory to immunomodulatory agents that has been treated with steroids, is generally treated with infliximab. Infliximab is an effective but expensive treatment and once started it is unclear when therapy can be discontinued. Surgical resection has been the golden standard in recurrent Crohn's disease. Laparoscopic ileocolic resection proved to be safe and is characterized by a quick symptom reduction.

The objective of this study is to compare infliximab treatment with laparoscopic ileocolic resection in patients with recurrent Crohn's disease of the distal ileum with respect to quality of life and costs.

Methods/design

The study is designed as a multicenter randomized clinical trial including patients with Crohn's disease located in the terminal ileum that require infliximab treatment following recent consensus statements on inflammatory bowel disease treatment: moderate to severe disease activity in patients that fail to respond to steroid therapy or immunomodulatory therapy. Patients will be randomized to receive either infliximab or undergo a laparoscopic ileocolic resection. Primary outcomes are quality of life and costs. Secondary outcomes are hospital stay, early and late morbidity, sick leave and surgical recurrence. In order to detect an effect size of 0.5 on the Inflammatory Bowel Disease Questionnaire at a 5% two sided significance level with a power of 80%, a sample size of 65 patients per treatment group can be calculated. An economic evaluation will be performed by assessing the marginal direct medical, non-medical and time costs and the costs per Quality Adjusted Life Year (QALY) will be calculated. For both treatment strategies a cost-utility ratio will be calculated. Patients will be included from December 2007.

Discussion

The LIR!C-trial is a randomized multicenter trial that will provide evidence whether infliximab treatment or surgery is the best treatment for recurrent distal ileitis in Crohn's disease.

Trial registration

Nederlands Trial Register NTR1150