Biopsy-proven paediatric tubulointerstitial nephritis.

BACKGROUND: Tubulointerstitial nephritis (TIN) is an uncommon condition in which the aetiology, treatment and outcome is not well defined. We describe a large series of children with biopsy-proven TIN. METHODS: All children with biopsy-proven TIN presenting to our institution during a 23-year period were retrospectively reviewed for aetiology, symptoms, treatment, and long-term outcome. RESULTS: A total of 27 children (16 girls) were described. Median age was 12 years (range 8 months to 15 years). A potentially adverse drug reaction was found in 12 (44 %) and infection in 8 (30 %). In 13 (48 %) no initiating factor was identified. All but 1 patient were treated with corticosteroids owing to worsening kidney function and 4 patients with other immunosuppressive agents. Fifteen children (56 %) had an estimated glomerular filtration rate (eGFR) of less than 80 ml/min/1.73 m(2) at last follow-up. Fifteen of the 23 children investigated (65 %) had coexistent uveitis. CONCLUSION: This series represents a subset of paediatric TIN patients in whom there was a clinical indication for a renal biopsy, hence presenting with more severe disease than previously reported. This group were more likely to have no identifiable underlying cause and an increased requirement for corticosteroid treatment. Furthermore, more than half of the cases developed chronic kidney disease (CKD) with impaired kidney function.

Nefritis intersticial aguda por ciprofloxacino: revisión de un caso clínico / Acute interstitial nefritis by ciprofloxacino: revision of a clinical case

The acute interstitial nephritis is an important cause of acute renal failure and even the cause could be idiopathic, the most important cause is asociaded to the use of drugs, immunological disorders, neoplasic disease or infections. Clinical features are essentially those of acute renal failure form 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 finding of fever, rash, and arthralgias may be absent in up to two thirds patients. The AIN associated to drugs could present symptoms days ore even months after the intake. Renal biopsy is the only definitive method of establishing the diagnosis of AIN; this step usually is undertaken when the diagnosis is unclear and there are no contraindications for the procedure, or when the patient does not improve clinically following discontinuation of the medication suspected as the cause of AIN and renal. Others laboratory features are used to provide suggestive evidence of AIN, to guide conservative management, or to permit empiric treatment with steroid. Unfortunately, none o these test have sufficient predictive value to be diagnostically reliable. The most important treatment in drugs induced AIN is the removal of an offending agent or medication. 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.

La Nefritis Intersticial Aguda (NIA) es una importante causa de insuficiencia renal aguda y, aunque puede ser idiopática, las causas más asociadas son el uso de drogas, desórdenes inmunológicos o neoplasias e infecciones. La presentación clínica es principalmente la sintomatología de la insuficiencia renal y aguda de cualquier causa, y aparte de la historia de una nueva enfermedad o la ingesta de drogas, no existen datos específicos en la anamnesis o al examen físico o exámenes de laboratorio que permitan distinguir entre NIA y otras causas de insuficiencia renal aguda. La presentación clásica de fiebre, rash y artralgia puede estar ausente en más de 2/3 de los pacientes. La NIA asociada a medicamentos puede presentar síntomas días o meses luego de la ingesta. La biopsia renal es el único método definitivo para realizar el diagnóstico de NIA, la cual se realiza habitualmente cuando la causa del cuadro clínico no es clara y no existen contraindicaciones para el procedimiento o cuando la evolución no es la esperada a pesar de suspender el agente causal. Otros hallazgos de laboratorio son usados para sospechar una NIA y permitir un tratamiento conservador y el tratamiento empírico con corticoides. Lamentablemente ninguno de estos exámenes tiene un valor predictivo que permitan un diagnóstico confiable. El principal tratamiento de la NIA inducida por medicamentos es la suspensión de la droga que se sospecha como probable causa. Aparentemente los corticoides producirían una mejoría el cuadro clínico y mejorarían la función renal, pero no existen ensayos clínicos controlados que apoyen esto.

[Renal disease in diabetics. Immunological bases of tubule-interstitial fibrosis and glomeruloesclerosis. Current therapeutic approach]. / Enfermedad renal en el diabético. Bases inmunológicas de la fibrosis tubulointersticial y la glomeruloesclerosis. Enfoque terapéutico actual.

Susceptibility of kidney to become target of the immunological aggression is easily recognizable when we consider the high number of diseases that, with a pathogenesis explained by autoimmunity mechanisms, have the kidney as a target organ. In diabetes mellitus, hyperglycemic state stimulates different molecular factors conditioning tubule-interstitial fibrosis and glomerulosclerosis, among them the most important are: formation of products of advanced glycation; activation of protein kinase C, activation of the angiotensin II and the activation of the nuclear factor kappaB. These factors are closely related to the production of inflammatory cytokines and to the progression of renal damage. This paper reviews the role of these factors in the renal damage of diabetic patients and the effect of some drugs on the progression of the immunological damage.

Comparing peritonitis in continuous ambulatory peritoneal dialysis patients versus automated peritoneal dialysis patients.

The purpose of our study was to compare the incidence of peritonitis between continuous ambulatory peritoneal dialysis (CAPD) treatment (Group I) and automated peritoneal dialysis (APD) treatment (Group II) taking into account the same population. We compared 20 patients with a follow-up of 215 patient-months on CAPD and 252 patient-months on APD. Demographic data, diagnosis, peritoneal equilibration test (PET) results, adequacy, and peritonitis rate were analyzed. Diagnoses included glomerulopathy 35%, autosomal dominant polycystic kidney disease (ADPKD) 20%, Type II diabetes 10%, systemic lupus erythematosus 5%, interstitial nephritis 5%, nephrolitiasis 5%, and unknown 20%. PET results showed that the group consisted of 30% high transporters, 45% high-average transporters, and 25% low-average transporters. Kt/V for Group I was 1.3 +/- 0.3, and for Group II, 1.83 +/- 0.48. Creatinine clearance for Group I was 43.64 +/- 7.31 L/week/1.73 m2, and for Group II, 52.42 +/- 13.47 L/week/1.73 m2. Group I presented a peritonitis rate of 8.3 episodes/patient-month, and Group II presented a rate of 18.9 episodes/patient-month. Gram-positive organisms were responsible for 49.8% of episodes of peritonitis in Group I (S. aureus 26.6%, S. epidermidis 16.6%, others 10%) and 83% of peritonitis episodes in Group II (S. epidermidis 46.6%, S. aureus 20%). Gram-negative organisms were responsible for 16.5% of episodes of peritonitis in Group I. No gram-negative peritonitis was seen in Group II. APD patients developed two cases of candida peritonitis. Our preliminary results show that Group II exhibited a decrease in peritonitis rate while achieving better adequacy. In CAPD and APD peritonitis, gram-positive organisms predominated. In APD, we observed an increase in S. epidermidis incidence. No gram-negative organisms were observed in APD. It seems that APD is a safer treatment owing to the lower peritonitis incidence.

Fisiopatología dela insuficiencia renal aguda / Physiology of the acute renal insufficiency

La insuficiencia renal aguda (IRA), es un síndrome clínico generalmente reversible, secundario a múltiples causas, que acompaña a un gran número de entidades en pacientes críticos. La característica fundamenrtal de este síndrome es la disminución en la tasa de filtración glomerular (TFG). La IRA representa un aumento de la morbi-mortalidad entre un 30-50 por ciento en los pacientes con sepsis. La presente revisión tiene como finalidad conocer los mecanismos fisiopatológicos involucrados en la disminución de la TFG en la IRA, así como los nuevos avances terapeúticos en el manejo de esta entidad con alta mortalidad

Nefrite intersticial induzida por drogas / Interstitial nephritis induced by drugs

Sao relatados quatro casos sugestivos de nefrite intersticial aguda relacionados ao uso de antibióticos, em pacientes internados na enfermaria de Clínica Médica do Hospital Universitário Lauro Wanderley, no período de abril de 1992 a janeiro de 1993. Os pacientes foram admitidos com quadro infeccioso grave, receberam antibióticos beta-lactâmicos, desenvolvendo, no curso do tratamento, síndrome de hipersensibilidade caracterizada por febre, exantema, eosinofilia e alteraçoes urinárias. Concomitantemente, foi realizada revisao da literatura a cerca do assunto, discutindo-se sua etiopatogenia e tratamento.

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.

Síndrome nefritis intersticial aguda y uveítis / Interstitial nephritis syndrome and uveitis

Un niño de 9 años ingresó al hospital por anemia severa (hematocrito 18%) y enrojecimiento del ojo derecho, comprobándose en oftalmología que sufría uveítis. La velocidad de sedimentación de los eritrocitos (VHS) era 101 mm * h, ureico 91 mg/dl, depuración plasmática de creatinina 9 ml/min * 1,73 m*, concentraciones séricas de IgG e IgM 2.368 mg/dl y 263 mg/dl respectivamente, sobre los márgenes normales para su edad, con IgA apenas detectable y reducción de las poblaciones de células T. Los ensayos de factor reumatoide, anticuerpos antinucleares y antimúsculo liso dieron resultados negativos. Las actividades de las fracciones C3 y C4 del complemento sérico y el sedimento de orina eran normales. La muestra de la biopsia renal incluía 25 glomérulos, uno totalmente esclerótico, dos con fibrosis periglomerular y los restantes sólo con leve aumento de la matriz mesangial. Había, además, intensa infiltración inflamatoria del intersticio, con estructuras granulomatosas que incluían células gigantes, semejantes observables en reacciones por cuerpos extraños, y cristales PAS positivos en el interior de los lúmenes tubulares. A pesar del empleo de tratamiento esteroidal, el que se complicó al final con un granuloma inflamatorio intracerebral que curó en coincidencia con el uso de antibióticos por vía parenteral, el paciente evolucionó hacia la insuficiencia renal crónica y actualmente está siendo sometido a hemodiálisis, con perspectivas de transplante renal. La uveítis fue tratada con colirios de atropina y esteroides, curando con secuelas mínimas

[Interstitial nephritis syndrome and uveitis]. / Síndrome nefritis intersticial aguda y uveítis.

A nine year old male patient was admitted to a metropolitan general hospital at Santiago, Chile, because of unexplained severe anemia (hematocrit 18%) and redness of the right eye. Uveitis was confirmed by ophthalmological examination. Laboratory work up showed an erythrocyte sedimentation rate of 101 mm.h, marked nitrogen retention (BUN 91 mg/dl), creatinine clearance was 9 ml/min.1,73 sq m, serum IgG and IgM immune globulin concentrations were 2,368 mg/dl and 263 mg/dl respectively, over the normal range for age, with almost absent serum IgA and reduced T cell populations. Negative rheumatoid factor, antinuclear antibodies and anti smooth muscle antibodies reactions were obtained, together with normal levels of C3 and C4 fractions of complement and normal urine sediment. Renal biopsy specimen included 25 glomerular, one of them was wholly sclerotic, another two had periglomerular fibrosis and the remainder showed only slightly increased mesangial matrix. Heavy mononuclear inflammatory interstitial infiltration, with granulomatous structures including giant multinuclear cells as those seen in foreign body reactions (fig 1) and PAS positive intraluminal tubular crystals were also observed. In spite of steroidal treatment, which was complicated by an inflammatory brain granuloma that healed in coincidence with parenteral antibiotic therapy, the patient evolved toward chronic renal failure. We think that the available evidence strongly suggests an immunological disorder as a very likely explanation for this case.