肾小球肾炎合并急性间质性肾炎的临床病理分析

目的 探讨肾小球肾炎合并急性间质性肾炎(AIN)患者的临床和病理特点。 方法 回顾性分析21例经肾活检证实的肾小球肾炎合并AIN患者的资料，以同期无肾小球疾病的AIN患者 35例作为对照。 结果 肾小球肾炎合并AIN占同期AIN的37.5%。β内酰胺类抗生素、中药是引起AIN的主要病因。76.2%的患者就诊原因为发现血肌酐升高。肾组织学检查同时存在肾小球肾炎和AIN的病理改变，肾间质与肾小球病变程度不平行，前者普遍重于肾小球损害，肾间质中嗜酸性粒细胞对诊断有提示价值。随访中，64.7%的患者肾功能最终恢复正常或基线水平，中位恢复时间为150 d（单纯AIN组为60 d），两组患者在2年内肾功能恢复情况方面无明显差异。 结论 肾小球肾炎合并AIN的患者临床表现不典型，AIN的症状易被肾小球肾炎掩盖。肾活检对诊断和鉴别有重要价值。早期诊治的患者预后较好。     

Proton pump inhibitors and acute interstitial nephritis: report and analysis of 15 cases

AIM: Although proton pump inhibitors (PPI) are usually safe and effective therapeutic agents, serious adverse effects can occur. The aim of the present study was to report and analyse the clinical features of 15 patients with acute interstitial nephritis (AIN) and acute renal failure from PPI that were referred to renal services in Auckland over a period of 3 years. METHODS: The clinical presentation, therapeutic drugs, demographic details and renal outcome of the patients were considered. The population at risk and total PPI exposure were able to be defined. The diagnosis of AIN was made by renal biopsy in 12 cases. In all patients, the time-course of drug exposure and improvement of renal function on withdrawal suggested PPI were causal. RESULTS: The median patient age was 78 years. The mean baseline serum creatinine level was 83 micromol/L, peak level 392 micromol/L, and recovery level 139 micromol/L. The erythrocyte sedimentation rate (ESR) and C-reactive protein were elevated at the time of diagnosis in the 11 and 12 patients, respectively, where this information was collected (ESR mean 85 mm/h, and C-reactive protein mean 81 mg/L). AIN occurred at 8 per 100 000 patient years (95% confidence level 2.6-18.7 per 100 000 patient years). Although four patients presented with an acute systemic allergic reaction, 11 were asymptomatic with an insidious development of renal failure. CONCLUSION: PPI are now the most commonly identified cause of AIN in the Auckland area. Recovery occurs after withdrawal of the drug but is often incomplete. Early diagnosis may be facilitated by clinician awareness of the insidious onset of renal failure, and an elevated erythrocyte sedimentation rate and C-reactive protein.     

Acute plasmacytic interstitial nephritis in a child with Down syndrome

 A 7.5-year-old boy with Down syndrome presented in acute renal failure (ARF) needing dialysis. When 1.5 years old he had a neuroblastoma, was treated for 1 year with chemotherapy and radiotherapy, and off chemotherapy had since been in remission. Renal biopsy revealed an interstitial inflammation, principally of plasma cells with some lymphocytes and eosinophils. Immunofluorescence showed no deposition of immunoglobulins or complement (C3). The plasma cells were a mixture of kappa and lambda light chain-producing cells. The patient spontaneously improved a week after admission. Initial ultrasonography showed enlarged kidneys with loss of corticomedullary differentiation. We are unaware of a report of ARF in a child, resulting primarily from a polyclonal plasmacytic interstitial nephritis. The etiology remains unclear. Received: 31 March 1988 / Revised: 19 August 1998 / Accepted: 30 September 1998     

Association of Kawasaki disease and interstitial nephritis

Renal insufficiency is a rare manifestation of Kawasaki disease. We report a 2·5-year-old boy with Kawasaki disease who developed acute renal failure during the acute phase of his illness. A percutaneous renal biopsy revealed acute interstitial nephritis. No etiological agent could be identified and renal recovery occurred with supportive care alone.     

Drug-induced granulomatous interstitial nephritis in a pediatric patient

Acute interstitial nephritis (AIN) is a known cause of acute renal failure in children. In most instances, drug therapy is the offending agent. Although granuloma formation has been observed in drug-induced interstitial nephritis, it is not a commonly associated manifestation. This is a case of a 15-year-old white female with Tetralogy of Fallot and pulmonary atresia who developed acute renal failure secondary to drug-induced interstitial nephritis and renal granulomas. In addition to interstitial edema with eosinophils and lymphocytes, her renal biopsy showed interstitial granulomas, immune complexes within tubular basement membranes, and the unusual feature of multinucleated giant cells engulfing tubules. Her acute renal failure resolved after the withdrawal of antibiotics and the initiation of intravenous steroid therapy.     

Mumps interstitial nephritis: a case report

Mumps is still a common childhood disease in rural areas where mumps vaccination is not widespread. A 14-year-old girl with fatal interstitial nephritis as a complication of mumps is reported. The patient had not been vaccinated with mumps vaccine and had contracted mumps during a village epidemic. The illness began with parotitis, and renal insufficiency developed within a week. The patient’s renal function rapidly deteriorated and the outcome was fatal. The postmortem renal necropsy sample demonstrated interstitial mononuclear cell infiltration, edema, and focal tubular epithelial cell damage, confirming the clinical diagnosis. In developing countries routine mumps vaccination may help to prevent possible fatal complications of mumps. Furthermore, patients with mumps, especially complicated cases, should be followed closely. Received: 19 August 1998 / Revised: 7 December 1998 / Accepted: 8 December 1998     

药物性急性间质性肾炎的临床及病理研究

目的 了解药物性急性间质肾炎(D-AIN)的临床及病理特点,以求提高诊治水平。方法 分析14例D-AIN的临床表现及肾脏病理、免疫病理特征,并用药物淋巴细胞转化试验辅助诊断致病药物。结果 D-AIN临床表现多样,缺乏特征性;肾活检是确诊的主要手段。结论 药物特异性淋巴细胞转化试验有助于明确致病的过敏药物。     

Acute interstitial nephritis: clinical features and response to corticosteroid therapy.

BACKGROUND: Acute interstitial nephritis (AIN) is a recognized cause of reversible acute renal failure characterized by the presence of an interstitial inflammatory cell infiltrate. METHODS: In order to evaluate the clinical characteristics and management of this disorder, we performed a retrospective study of all cases of AIN found by reviewing 2598 native renal biopsies received at our institution over a 12 year period. Presenting clinical, laboratory and histological features were identified, as was clinical outcome with specific regard to corticosteroid therapy response. RESULTS: AIN was found in 2.6% of native biopsies, and 10.3% of all biopsies performed in the setting of acute renal failure during the period analysed (n = 60). The incidence of AIN increased progressively over the period observed from 1 to 4% per annum. AIN was drug related in 92% of cases and appeared to be idiopathic in the remainder. The presenting symptoms included oliguria (51%), arthralgia (45%), fever (30%), rash (21%) and loin pain (21%). Median serum creatinine at presentation was 670 micromol/l [interquartile range (IQR) 431-1031] and 58% of cases required acute renal replacement therapy. Corticosteroid therapy was administered in 60% of cases. Serum creatinine at baseline was similar in the corticosteroid-treated and conservatively managed groups; 700 micromol/l (IQR 449-1031) vs 545 micromol/l (IQR 339-1110) P = 0.4. In this, the largest retrospective series to date, we did not detect a statistically significant difference in outcome, as determined by serum creatinine, between those patients who received corticosteroid therapy and those who did not, at 1, 6 and 12 months following presentation. CONCLUSION: The results of this study do not support the routine administration of corticosteroid therapy in the management of AIN.     

Acute renal failure due to interstitial nephritis after intravesical instillation of BCG

Intravesical chemotherapy with bacilli Calmette-Guerin (BCG) has been an established therapy for preventing recurrence of, and for treatment of, superficial transitional cell carcinoma of the bladder, but it is not without side effects. A variety of renal complications have been reported and attributed to mycobacterial infection. Although renal complications are uncommon, several cases of interstitial nephritis (with or without granulomas) and mesangial glomerulonephritis have been reported. We report a 76-year-old male patient who developed acute renal failure due to interstitial nephritis after intravesical instillation of BCG. Corticosteroids may serve the recovery of renal function without concomitant use of anti-tubercular therapy, provided systemic signs and mycobacterial infection are absent. Serum creatinine should be checked in at-risk patients in order to detect this complication early.     

Phenazopyridine associated acute interstitial nephritis and review of literature

Phenazopyridine is a urinary analgesic; commonly seen side-effects of this drug include, orange discoloration of urine, methemoglobinemia, yellowish skin discoloration, hepatitis and acute renal failure. Various case reports with phenazopyridine associated acute renal failure secondary to acute tubular necrosis have been reported in the literature. Acute kidney injury in these patients is caused by either direct injury to renal tubular epithelial cells or secondary to pigment induced nephropathy from hemolytic anemia. Hypoxic injury from phenazopyridine-induced methemoglobinemia has been well documented. We report a case of biopsy proven acute interstitial nephritis, associated with therapeutic doses of phenazopyridine without any evidence of methemoglobinemia or other mechanism of renal injury. Clinicians should be aware of the toxicity of this commonly used drug and should look closely for signs of renal insufficiency. Identifying and stopping the offending medication stays as the first step, but recent studies indicate that early steroid administration improves renal recovery, as well as decreasing the risk of progression to chronic kidney disease with fibrosis and consequent permanent renal damage.     

Granulomatous interstitial nephritis due to isolated renal sarcoidosis

An 81-year-old woman was admitted to our hospital because of acute exacerbation of chronic renal failure. Her 24-h urine protein value was 0.37g, but neither hematuria nor leukocyturia was seen. Renal biopsy specimens showed noncaseating granulomas with giant cells in the interstitium. A clinical examination revealed no evidence of tuberculosis, fungus, or malignancy. All of the drugs she had been taking were discontinued, but her renal function continued to deteriorate. No uveitis, erythema nodosum, or common macular skin lesion was seen. A computed tomography scan of the thorax and a total-body gallium-67 scan showed no abnormalities. The serum lysozyme level was greater than four times above normal. Finally, a diagnosis was made, of granulomatous interstitial nephritis due to isolated renal sarcoidosis. Treatment was started with 60mg/day of prednisolone, and she had an excellent response. Her serum creatinine level decreased to the level shown before the acute exacerbation. It is important to consider renal sarcoidosis as a differential diagnosis in patients with severely progressive renal failure, because corticosteroid therapy is very effective.     

Acute interstitial nephritis due to mesalazine

A case of mesalazine-induced acute interstitial nephritis (AIN) in a 41-year-old patient with ulcerative colitis (UC) is reported here. Clinical symptoms such as fever and arthralgia, and laboratory findings such as eosinophilia and renal failure suggested AIN, which was confirmed by biopsy. With withdrawal of mesalazine and intravenous methylprednisolone the patient's renal function was recovered. It is observed that early discontinuation of mesalazine is associated with amelioration of interstitial nephritis in most patients, so the recommendation is that patients receiving mesalazine should undergo routine monitoring of renal function. Delayed diagnosis may lead to permanent renal function impairment.     

Acute renal failure due to uterine prolapse: a case report

Abstract

Herein, we present a successfully treated case with acute renal failure due to ureteral obstruction caused by total uterine prolapsed. A 55-year-old female patient presented to our hospital with the complaints of protrusion of the uterus for the last 3 months, pollakiuria, nocturia, decreased urine volume, and swelling of her body for the last week, and as well as impaired general status with shortness of breath for the last several days. Her physical examination revealed a blood pressure of 140/90?mmHg, pulse rate of 80 beats/min, body temperature of 37.8?°C, as well as uterine prolapse with infection and erosion on the surface of the uterus, crepitating rales in the basal segments of both lungs, and pretibial edema. Results of laboratory analyses were as follows: BUN?=?70?mg/dL, Cr?=?6.5?mg/dL, CRP?=?8.7?mg/dL, and leukocyte?=?12,000/mm³. Blood gas analysis revealed a pH of 7.35 and bicarbonate level of 14?mmol/L. Data obtained from ultrasonography, DTPA scintigraphy, and abdominal CT, which were performed assuming that the patient had post-renal renal failure due to the compression by uterus, supported this assumption. Bilateral nephrostomy catheters were inserted and appropriate fluid-electrolyte therapy for volume status and antibiotherapy were commenced. Renal functions returned to normal levels on the 4th day of therapy and her complaints disappeared. The patient underwent total abdominal hysterectomy and was monitored in terms of renal functions and diuresis. The present case was presented due to its importance for being a quite rare case who dramatically responded to accurate intervention performed in time.     

Acute interstitial nephritis and uveitis syndrome: activated immune cell infiltration in the kidney

Infiltrating cells were analysed in renal biopsy tissue obtained from a 15-year-old girl with acute interstitial nephritis and uveitis using monoclonal antibodies specific for mononuclear cell surface markers. The interstitial infiltrates consisted mainly of T cells and monocytes/macrophages. A considerable proportion of the infiltrating cells were identified by a monoclonal antibody against the interleukin-2 receptor, indicating that a majority of those immune cells are activated. This observation documents the participation of cell-mediated immune injury in interstitial nephritis associated with uveitis.     

Limited Value of the Fractional Excretion of Sodium Test in the Diagnosis of Acute Renal Failure

The excreted fraction of filtered sodium (FeNa) was examinedin 54 patients with acute intrinsic renal failure in whom renalbiopsy was performed to determine the morphology of the acuterenal disease. In patients with acute tubulointerstitial nephritis oliguricpatients had almost constantly elevated FeNa values, whereasin non-oliguric patients with acute tubulointerstitial nephritisthis was observed in less than half. The five patients withacute extracapillary glomerulonephritis had an FeNa greaterthan 1. FeNa values were low, especially in non-oliguric patients whohad mild impairment of renal function. The presence of a highFeNa value correlated significantly with severe morphologicaltubular changes observed on renal biopsy. We conclude that patients with acute tubulointerstitial nephritiscannot be distinguished from those with acute glomerulonephritisby FeNa, as in both types of acute nephritis the FeNa test showsboth low and elevated values.     

Rabeprazole-induced acute interstitial nephritis

Acute interstitial nephritis is an uncommon but important cause of acute renal failure. Proton pump inhibitors are now thought to be the most common class of drugs implicated in drug-induced acute interstitial nephritis. This is the first reported case of rabeprazole-induced acute interstitial nephritis.