Acute interstitial nephritis associated with moxifloxacin use

BACKGROUND: Moxifloxacin is a fluoroquinolone antimicrobial agent with proven efficacy against community-acquired respiratory pathogens. Common adverse effects associated with its use include gastro-intestinal symptoms, but nephrotoxicity has not yet been reported to the manufacturer or in the literature (based on a MEDLINE search [key words: fluoroquinolone, moxifloxacin, kidney, interstitial, and nephritis; years: 1970-2005]). OBJECTIVE: The purpose of this article was to describe a case of nephrotoxicity associated with moxifloxacin use. METHODS: A 68-year-old woman weighing 65 kg was referred to our nephrology clinic by her general practitioner because of an acute increase in serum creatinine concentration (SCC). In this patient, biopsyproven acute tubulointerstitial nephritis (ATIN) developed approximately 10 days after the end of moxifloxacin therapy for a nonspecific bronchial infection. The patient initially presented with nonspecific clinical symptoms, foaming of her urine, elevated erythrocyte sedimentation rate, and the acute increase in SCC. Urinalysis revealed signs of tubulointerstitial damage, including leukocyturia and proteinuria with a high concentration of alpha(1)-microglobulin. Oral corticosteroid therapy with prednisolone was started approximately 14 days after symptom development, beginning at 1 mg/kg body weight QD. RESULTS: After the initiation of therapy, renal function was gradually restored over 6 months, but mild proteinuria persisted. Although the exact pathogenesis of drug-induced ATIN remains unclear, an immune-mediated hypersensitivity reaction is the assumed mechanism. CONCLUSIONS: Fluoroquinolones might have a nephrotoxic effect. In this patient, ATIN was likely associated with moxifloxacin use. Because the course of ATIN is unpredictable and might lead to long-term dialysis, considering ATIN as a possible diagnosis in the scenario of systemic symptoms after moxifloxacin treatment is essential.     

Cloxacillin-induced acute tubulo interstitial nephritis.

OBJECTIVE: To report a case of possible cloxacillin-induced acute tubulo interstitial nephritis (AIN). CASE SUMMARY: A 15-year-old male patient presented with hypertension, edema, lumbar pain, sterile pyuria, eosinophiluria (ten percent), and severe renal dysfunction three months after the ingestion of cloxacillin. A renal biopsy revealed diffuse edema and inflammatory infiltrate of the interstitium (five percent eosinophils). He received four sessions of peritoneal dialysis with dramatic improvement in urinary output and renal function. His biochemical parameters returned to normal values 21 days after admission, without the use of glucocorticosteroids. DISCUSSION: Published case reports on AIN induced by penicillin and related drugs are reviewed and compared. The role of interstitial edema in acute renal failure associated with drug-induced AIN is mentioned. CONCLUSIONS: AIN is a rare but significant complication of therapy with penicillin and related drugs. The clinical picture is similar for all of these drugs, but skin rash and fever are absent in AIN induced by cloxacillin and cloxacillin-related drugs. Dialysis improved the patient's urinary output and renal function. Beta-lactam antibiotics should be avoided in patients with cloxacillin-induced AIN.     

A case of tubulointerstitial nephritis and uveitis syndrome following drug‐induced acute interstitial nephritis

Distinguishing between late‐onset TINU syndrome and drug‐induced AIN remains difficult given that patients with TINU syndrome may develop uveitis long after the onset of AIN. Therefore, ophthalmic examination is required not only upon diagnosis but also continuously or when eye symptoms and relapse of urinary findings are observed.     

Diagnosis and management of acute interstitial nephritis

Acute interstitial nephritis is an important cause of acute renal failure resulting from immune-mediated tubulointerstitial injury, initiated by medications, infection, and other causes. Acute interstitial nephritis may be implicated in up to 15 percent of patients hospitalized for acute renal failure. Clinical features are essentially those of acute renal failure from any cause, and apart from a history of new illness or medication exposure, there are no specific history, physical examination, or laboratory findings that distinguish acute interstitial nephritis from other causes of acute renal failure. Classic findings of fever, rash, and arthralgias may be absent in up to two thirds of patients. Diagnostic studies such as urine eosinophils and renal gallium 67 scanning provide suggestive evidence, but they are unable to reliably confirm or exclude the diagnosis of acute interstitial nephritis. Renal biopsy remains the gold standard for diagnosis, but it may not be required in mild cases or when clinical improvement is rapid after removal of an offending agent or medication. The time until removal of such agents, and renal biopsy findings, provide the best prognostic information for return to baseline renal function. Corticosteroids appear to provide some benefit in terms of clinical improvement and return of renal function, but no controlled clinical trials have been conducted to confirm this.     

急性间质性肾炎34例临床分析

目的 分析急性间质性肾炎(AIN)的病因、临床特点、肾脏病理改变、治疗及转归.方法 回顾性分析2007年1月至2010年10月经肾活检确诊为AIN的34例患者的病因、临床特点、肾脏病理结果、治疗措施及转归.结果 34例AIN患者中,药物相关性急性间质性肾炎(DAIN)27例,占79.4%,其中抗生素导致的AIN占DAIN的70.4%,最常见的抗生素依次为β-内酰胺类、氨基糖甙类、喹诺酮类、磺胺类;主要临床表现有急性肾功能衰竭(ARF)(100%)、发热(64.7%)、蛋白尿(55.9%)、少尿或无尿(52.9%)、镜下血尿(41.2%)、白细胞尿(38.2%)、皮疹(32.4%)、糖尿(26.5%)及关节痛(14.7%);病理显示肾小管损伤轻重不等,肾小球及肾血管无明显病变;18例(52.9%)口服强的松治疗,7例(20.6%)应用甲基强的松(urbason)冲击,有7例(20.6%)行血透治疗,2例仅给予对症支持治疗;经治疗6周后,34例患者中,20例患者完全治愈,4例因故好转后出院,7例血透患者有5例摆脱透析治疗,3例未愈患者蛋白尿未完全转阴.入院时患者平均血清肌酸酐(Scr)为(531.64±236.65)μmol/L,尿素氮(BUN)为(19.89±7.28)mmol/L,尿酸(UA)(414.88±141.09)μmol/L,治疗6周后,肾功能的各项指标均有明显降低,平均Scr为(133.29±85.26)μmol/L,BUN为(7.40±2.71)mmol/L,UA(309.39±94.09)μmol/L,与治疗前相比P值均＜0.01,有显著疗效.结论 AIN的常见致病因素为药物.临床表现呈多样性,无特异性,发热为其最常见的临床表现.临床及病理改变决定治疗措施,激素及血液透析是治疗AIN的有效方法,及时把握时机,并选取恰当的治疗方法是改善预后的关键.     

药物性急性间质性肾炎10例分析

本文对根据临床和病理确诊为药物性急性间质性肾炎的10例病人进行分析:由β-内酰胺类抗生素引起者为90%,临床表现多种多样,轻重不一.肾损害可为不同类型,肾衰为50%.并对实验室指标和组织学改变进行观察,肾脏有不同程度的间质小管损害并均伴肾小球系膜增生.糖皮质激素对本病有确切疗效.     

Myoglobinopathy as a cause of acute interstitial nephritis

The course of the acute renal failure (ARF) was studied in 3 patients with rhabdomyolysis (1 with the position compression syndrome, 1 with march myoglobinuria, and 1 with chronic recurrent rhabdomyolysis). The ARF syndromes were revealed in 2 patients 5-7 days after onset of the disease; in 1 patient (chronic recurrent rhabdomyolysis), ARF recurred. This suggests that the patients developed acute interstitial nephritis (AIN) Prolonged myolytic conditions due to ill-timed initiation of treatment led to the fact that AIN was complicated by ARF in 2 patients, and 1 patient with chronic myopathy had an "immune readiness" for myoglobin to affect the kidneys, which also resulted in ARF. It was stressed that the methods of extracorporeal detoxification (hemodialysis, hemosorption) were highly effective in treating AIN and ARF.     

Nephrotic syndrome.

The nephrotic syndrome appears to be an expression of a number of complex disease processes. The supportive, as well as the definitive, management of the nephrotic syndrome patient requires considerable knowledge of disease pathophysiology, drugs, and drug interactions. Therapy of any degree cannot be undertaken lightly for fear of further compromising the nephrotic syndrome patient.     

Allergic interstitial nephritis possibly related to sunitinib use

Background: Sunitinib is an oral multitargeted inhibitor indicated for the treatment of renal cell carcinoma.Objective: This report describes a case of allergic interstitial nephritis possibly related to this agent.Case Summary: A 69-year-old female patient with a history of metastatic renal cell carcinoma after left radical nephrectomy presented to our nephrology clinic after completing 2 courses of sunitinib therapy. The patient was noted to have progressive kidney dysfunction with proteinuria, together with peripheral eosinophilia and eosinophiluria, which developed during the first of 2 cycles of sunitinib therapy. Her concomitant medications included atenolol, triamterene/hydrochlorothiazide, amlodipine, and multivitamin tablets, all of which she had been receiving at stable doses over the previous 2 years. There were no other over-the-counter medications involved and other possible causes of interstitial nephritis were excluded. The proteinuria, eosinophilia, and eosinophiluria worsened with the second course and resolved after sunitinib discontinuation, which resulted in initial stabilization followed by slight improvement in kidney function. The Naranjo Adverse Drug Reaction Probability Scale score for this event was 7, indicating a probable association of the event with the drug. With clinical improvement after discontinuation of sunitinib and the presence of a solitary remaining kidney and thrombocytopenia, renal biopsy was not performed after discussion with the patient. When challenged with a related agent, sorafenib, the patient experienced worsening of serum creatinine and increasing eosinophilia, similar to that noted with sunitinib, suggesting that this event may be a class effect.Conclusions: Nephrologists and oncologists should be aware of allergic interstitial nephritis as an adverse effect related to this agent. Although there are no current recommendations for monitoring serum creatinine with sunitinib therapy, we recommend that serum creatinine and white cell count with differential be checked within 2 weeks of initiation of therapy with sunitinib to enable earlier diagnosis of this condition and avoid renal damage.     

IgA肾病合并急性间质性肾炎2例报告

正急性间质性肾炎(AIN)是导致急性肾损伤(AKI)的重要原因之一。AIN的主要病理表现为肾间质炎细胞浸润,通常不伴肾小球病变。在慢性肾小球肾炎基础上发生的AIN的临床病理表现与单纯AIN、慢性肾小球肾炎继发间质损害有一定区别。本科室近期连续诊治2例IgA肾病合并急性间质性肾炎患者,现报告如下。     

Drug associated acute interstitial nephritis: clinical and pathological features and the response to high dose steroid therapy

Nine episodes of drug associated acute interstitial nephritis, in seven patients, were treated between 1972 and 1980. The drugs implicated were cotrimoxazole (three times), ampicillin, Magnapen (ampicillin and flucloxacillin), penicillin, gentamicin, paracetamol and bendrofluazide. The time from exposure to the onset of symptoms ranged from one to 30 days. Presentation was with acute renal failure, which was non-oliguric in five cases, accompanied by rash (four), fever (four), and loin pain (two). Renal biopsy was carried out in all cases, and showed a characteristic interstitial infiltrate comprising substantial numbers of lymphocytes and plasma cells, with a variable number of neutrophils, eosinophils and histiocytes. Immunofluorescence was negative in all four cases studied in the acute phase, and showed scattered deposits of IgG, IgM, IgA and C3 on the tubular basement membrane in one patient during recovery. Significant proteinuria and an abnormal urine deposit were present in all cases, and seven of nine had radiological evidence of enlarged kidneys. Seven episodes were treated with high doses of methyl prednisolone and in all there was a response with a diuresis or spontaneous fall in serum creatinine within 72 hrs, and recovery of virtually normal renal function. Of two cases who did not initially receive steroids, one improved more slowly and one developed chronic renal impairment.     

Hantavirus-related acute interstitial nephritis in western Europe. Expansion of a world-wide zoonosis

We report the clinical, biological and serological characteristics of 76 cases of Hantavirus-induced acute interstitial nephritis diagnosed in Belgium and France between 1977 and 1986. The disease is characterized by a fever of sudden onset promptly accompanied by pain in the loin or abdomen, nausea and vomiting, myalgias and occasionally with acute myopia and conjunctival injection. Within a week acute renal failure develops, necessitating haemo- or peritoneal dialysis in up to 10 per cent of patients. Transient proteinuria, microscopic haematuria and leukocyturia are observed simultaneously. Thrombocytopenia and mild elevations of hepatic enzymes, LDH and CPK, as well as biological signs of acute inflammatory reaction are observed, lasting for a few days. Spontaneous complete recovery is the rule. This picture is virtually identical with that of nephropathia epidemica, a Hantavirus nephropathy observed in northern Europe. This conclusion is supported by the observation of elevated antibody titres against the Puumala virus, the agent of nephropathia epidemica. This rodent-borne infection is markedly milder than that caused by other Hantaviruses such as the Hantaan or the Seoul virus in Asia. Acute interstitial disease due to Hantavirus should be included in the differential diagnosis of febrile acute renal failure.     

Nephrotic syndrome associated with metastatic melanoma: a case report

Nephrotic syndrome (NS) may occur after or concomitantly with malignancy. The use of immunosuppressive approaches in patients with cancer and NS is controversial, especially when the association between the pathologies is unclear. The aim of this study was to report the case of a patient with metastatic melanoma who developed NS and to examine the association between NS and neoplasia. A 56‐year‐old woman diagnosed with right hallux melanoma, removed by marginal resection with no sign of metastasis, developed NS after 6 months without the detection of another associated disease. The histological diagnosis was focal and segmental glomerulosclerosis (FSGS). The patient was older than most patients with FSGS and was treated with immunosuppressive agents (prednisone and cyclosporine) concomitantly with melanoma treatment. Nephrotic syndrome was the first manifestation of metastatic melanoma recurrence in this patient. Proteinuria was controlled adequately after immunosuppression and melanoma treatment. Although NS has been associated with cancer, laboratory and histological markers correlating it with melanoma are needed.     

雷公藤多甙片联合激素和ARB类药物治疗狼疮性肾炎

目的观察雷公藤多甙片联合激素和ARB类药物治疗狼疮性肾炎的近期疗效。方法狼疮性肾炎患者30例接受雷公藤多甙片、泼尼松、缬沙坦片治疗,疗程60 d,治疗结束后评定疗效,并观察24 h尿蛋白定量、血浆白蛋白及治疗中的不良反应等。结果30例中完全缓解18例(60%),部分缓解10例(33.3%),无效2例(6.7%)。患者中部分可见胃肠反应,血细胞升高,停用及对症治疗处理后,恢复正常。结论雷公藤多甙片联合激素和ARB类药物治疗狼疮性肾炎具有较好的疗效。     

Anti-KJ: a new antibody associated with the syndrome of polymyositis and interstitial lung disease.

Antibodies to aminoacyl-tRNA synthetases (anti-Jo-1, anti-PL-7, anti-PL-12) have been found in the serum of some patients with polymyositis (PM). Patients with these antibodies have an unusually high rate of interstitial lung disease (ILD) in association with their PM. Two patients (K.J. and B.T.) with severe ILD and PM were found to have antibodies to a cytoplasmic antigen, but tests to determine whether the antigen was an aminoacyl-tRNA synthetase were negative, including tests of KJ serum for inhibitory effects on the 20 synthetases. KJ immunoprecipitates did not contain tRNA, in contrast to antisynthetase sera. When IgG samples were added to a reticulocyte in vitro translation system at a concentration of 0.3 mg/ml, KJ IgG inhibited globin mRNA translation by 98%, while anti-Jo-1 IgG inhibited 62% and normal IgG had little effect. Thus, both anti-KJ and the antisynthetases are directed at antigens that are involved in translation and protein synthesis, and both are associated with the syndrome of lung disease and PM. This syndrome may be associated with antibodies to translation-related proteins in general, which may have implications for the link of PM and enteroviruses, which are mRNA viruses.     

雷公藤多甙致老年肾病综合征患者急性间质性肾炎一例(英文)

Introduction Multi-glycoside of Tripterygium wilfordii hook f ( GTW) ,extracts of the medicinal plant Tripterygium wilfordii hook f,has an established history of use in the treatment of inflammatory and autoimmune diseases including rheumatoid arthritis,systemic lupus erythematosus,nephritis and chronic idiopathic urticaria[1-3]. The major active component is triptolide,a diterpenoid triepoxide,which     

Prevalence of use and acute toxicity associated with the use of NBOMe drugs

Abstract

Introduction. The 25X-NBOMe series are N-2-methoxybenzyl analogues of the respective 2C-X substituted phenethylamine and include 25B-N(BOMe)2, 25B-NBOMe, 25C-NBOMe, 25D-NBOMe, 25E-NBOMe, 25G-NBOMe, 25H-NBOMe, 25I-NBOMe, 25N-NBOMe and 25iP-NBOMe. There are reports of their use as novel psychoactive substances and associated acute toxicity from Europe, the United States and elsewhere over the last five years. This review will discuss the epidemiology of use and pattern of acute toxicity associated with use of these compounds. Methods. A PubMed search was performed using the search terms ‘NBOMe’, ‘25B-N(BOMe)2’, ‘25B-NBOMe’, ‘25C-NBOMe’, ‘25D-NBOMe’, ‘25E-NBOMe’, ‘25G-NBOMe’, ‘25H-NBOMe’, ‘25I-NBOMe’, ‘25N-NBOMe’ and ‘25iP-NBOMe’ covering the years 1966–2014. In addition, abstracts from the 2010–2014 congresses of the European Association of Poisons Centres and Clinical Toxicologists and the 2010–2013 North American Congress of Clinical Toxicology were reviewed using these search terms. Further information was obtained from the European Information System and Database on New Drugs co-ordinated by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). Prevalence of use. There are no national or international surveys collecting data on the prevalence of use of NBOMe drugs. The only information on prevalence of use is from two sub-population surveys of individuals who frequent nightclubs. Of 22,289 respondents of the 2013 Global Drugs Survey, 582 (2.6%) had previously used an NBOMe; the most commonly used NBOMe was 25I-NBOMe (442 respondents, 2.0% of whole cohort and 75.9% of those who had used an NBOMe). In a survey of 397 clubbers in London nightclubs in 2013, 11.8% had heard of the NBOMe drugs (compared with 96.0% for mephedrone), and 4.8% had ever used an NBOMe (compared with 76.6% for mephedrone). Acute toxicity. There were 29 published cases in the literature of acute toxicity associated with the use of an NBOMe: 25I-NBOMe – 23 cases; 25B-NBOMe – 3 cases; 25C-NBOMe – 3 cases. Commonly reported features include tachycardia (96.6%), hypertension (62.0%), agitation/aggression (48.2%), seizures (37.9%) and hyperthermia (27.6%). Five patients were reported to have developed acute kidney injury. There were an additional 25 reports of acute toxicity related to the use of 25I-NBOMe reported to the EMCDDA. The pattern of toxicity in these cases is similar to that seen in the published cases. NBOMe-related deaths. 25I-NBOMe has been detected in eight fatalities; in one of these, 25C-NBOMe was also detected. The role of the NBOMe drugs in these deaths has not been determined in all cases. Conclusions. Currently, there is evidence suggesting limited use of the NBOMe class of drugs as novel psychoactive substances compared with that of classical recreational drugs and other novel psychoactive substances such as mephedrone.