(See also Overview of Tubulointerstitial Diseases.)
Etiology
Tubulointerstitial nephritis can be primary, but a similar process can result from glomerular damage or renovascular disorders.
Primary tubulointerstitial nephritis may be
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Acute (see table Causes of Acute Tubulointerstitial Nephritis)
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Chronic (see table Causes of Chronic Tubulointerstitial Nephritis)
Acute tubulointerstitial nephritis
Acute tubulointerstitial nephritis (ATIN) involves an inflammatory infiltrate and edema affecting the renal interstitium that often develops over days to months. Over 95% of cases result from infection or an allergic drug reaction.
ATIN causes acute kidney injury; severe cases, delayed therapy, or continuance of an offending drug can lead to permanent injury and chronic kidney disease.
Renal-ocular syndrome, acute tubulointerstitial nephritis plus uveitis, also occurs and is idiopathic.
Chronic tubulointerstitial nephritis
Chronic tubulointerstitial nephritis (CTIN) arises when chronic tubular insults cause gradual interstitial infiltration and fibrosis, tubular atrophy and dysfunction, and a gradual deterioration of renal function, usually over years. Concurrent glomerular involvement (glomerulosclerosis) is much more common in CTIN than in ATIN.
Causes of chronic tubulointerstitial nephritis are myriad; they include immunologically mediated disorders, infections, reflux or obstructive nephropathy, drugs, and other disorders. CTIN due to toxins, metabolic derangements, hypertension, and inherited disorders results in symmetric and bilateral disease; when CTIN is due to other causes, renal scarring may be unequal and involve only one kidney. Some well-characterized forms of CTIN include
Reflux nephropathy and myeloma may cause tubulointerstitial injury but the predominant pathology in these conditions is glomerular disease.
Hereditary cystic kidney diseases are discussed elsewhere.
Causes of Acute Tubulointerstitial Nephritis
Cause |
Examples |
Drugs* |
|
|
Antibiotics |
Beta-lactam antibiotics (the most common cause) Ciprofloxacin Ethambutol Indinavir Isoniazid Macrolides Minocycline Rifampin Tetracycline Trimethoprim/sulfamethoxazole Vancomycin |
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Anticonvulsants |
Carbamazepine Phenobarbital Phenytoin Valproate |
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Diuretics |
Bumetanide Furosemide Thiazides Triamterene |
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Nonsteroidal anti-inflammatory drugs (NSAIDs) |
Diclofenac Fenoprofen Ibuprofen Indomethacin Naproxen |
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Other |
Allopurinol Aristolochic acid† Captopril Cimetidine Interferon alfa Lansoprazole Mesalamine Omeprazole Ranitidine |
Metabolic disorders |
|
|
Hyperoxalaturia |
|
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Hyperuricosuria |
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Renal parenchymal infection |
|
|
Bacterial |
Brucella species (brucellosis) Corynebacterium diphtheriae Legionella species (Legionella infections) Leptospira species (leptospirosis) Mycobacterium species Mycoplasma species Rickettsia species Salmonella species Staphylococci Streptococci Treponema pallidum (syphilis) Yersinia species |
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Fungal |
Candida species |
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Parasitic |
Toxoplasma gondii (toxoplasmosis) |
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Viral |
Polyomavirus |
Other conditions |
|
|
Idiopathic without and with uveitis |
— |
|
Immunologic |
Anti-tubular basement membrane (anti-TBM) antibody-associated interstitial nephritis Idiopathic hypocomplementemic interstitial nephritis IgG4-related tubulointerstitial nephritis‡ Renal transplant rejection |
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Neoplastic |
Myeloma |
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* Most common causative drugs are listed; > 120 drugs are implicated. |
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† Contained in some medicinal herbs used in traditional Chinese medicine. |
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‡ Yamaguchi Y, Kanetsuna Y, Honda K, et al: Characteristic tubulointerstitial nephritis in IgG4-related disease. Hum Pathol 43(4):536-549, 2012. doi: 10.1016/j.humpath.2011.06.002. |
|
Causes of Chronic Tubulointerstitial Nephritis
Cause |
Examples |
|
Balkan nephropathy |
— |
|
Cystic diseases |
Acquired cystic disease |
|
Drugs |
Analgesics* Antineoplastics (cisplatin and nitrosourea) Chinese herbs (due to aristolochic acid†) Immunosuppressants (cyclosporine* and tacrolimus) Lithium* |
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Granulomatous |
|
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Hematologic |
|
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Hereditary nephropathy associated with hyperuricemia and gout |
— |
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Idiopathic |
— |
|
Immunologic |
Renal transplant rejection IgG4-related tubulointerstitial nephritis‡ |
|
Infection |
Renal parenchymal: Systemic |
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Mechanical |
|
|
Mesoamerican nephropathy§ |
–– |
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Metabolic |
Chronic hypokalemia Cystinosis Hypercalcemia, hypercalciuria Hyperoxaluria Hyperuricemia*, hyperuricosuria |
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Radiation nephritis |
— |
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Toxins |
Aristolochic acid† Heavy metals (eg, arsenic, bismuth, cadmium, chromium, copper, gold, iron, lead, mercury, uranium) |
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Vascular |
Atheroembolism Hypertension Renal vein thrombosis |
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* Common causes. |
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† Contained in some medicinal herbs used in traditional Chinese medicine. |
|
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‡ Yamaguchi Y, Kanetsuna Y, Honda K, et al: Characteristic tubulointerstitial nephritis in IgG4-related disease. Hum Pathol 43(4):536-549, 2012. doi: 10.1016/j.humpath.2011.06.002. |
|
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§ Correa-Rotter R, Wesseling C, Johnson RJ: CKD of unknown origin in Central America: The case for Mesoamerican nephropathy. Am J Kidney Dis63(3):506-520, 2014. doi: 10.1053/j.ajkd.2013.10.062. |
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General references
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Yamaguchi Y, Kanetsuna Y, Honda K, et al: Characteristic tubulointerstitial nephritis in IgG4-related disease. Hum Pathol 43(4):536-549, 2012. doi: 10.1016/j.humpath.2011.06.002.
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Correa-Rotter R, Wesseling C, Johnson RJ: CKD of unknown origin in Central America: The case for Mesoamerican nephropathy. Am J Kidney Dis63(3):506-520, 2014. doi: 10.1053/j.ajkd.2013.10.062.
Symptoms and Signs
Acute tubulointerstitial nephritis
Symptoms and signs of acute tubulointerstitial nephritis (ATIN) may be nonspecific and are often absent unless symptoms and signs of renal failure develop. Many patients develop polyuria and nocturia (due to a defect in urinary concentration and sodium reabsorption).
ATIN symptom onset may be as long as several weeks after initial toxic exposure or as soon as 3 to 5 days after a 2nd exposure; extremes in latency range from 1 day with rifampin to 18 months with a nonsteroidal anti-inflammatory drug (NSAID). Fever and urticarial rash are characteristic early manifestations of drug-induced ATIN, but the classically described triad of fever, rash, and eosinophilia is present in < 10% of patients with drug-induced ATIN. Abdominal pain, weight loss, and bilateral renal enlargement (caused by interstitial edema) may also occur in ATIN and with fever may mistakenly suggest renal cancer or polycystic kidney disease. Peripheral edema and hypertension are uncommon unless renal failure occurs.
Chronic tubulointerstitial nephritis
Diagnosis
Few clinical and routine laboratory findings are specific for tubulointerstitial nephritis. Thus, suspicion should be high when the following are present:
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Typical symptoms or signs
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Risk factors, particularly a temporal relationship between onset and use of a potentially causative drug
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Characteristic urinalysis findings, particularly sterile pyuria
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Modest proteinuria, usually < 1 g/day (except with use of nonsteroidal anti-inflammatory drugs [NSAIDs], which may cause nephrotic-range proteinuria, 3.5 g/day)
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Evidence of tubular dysfunction (eg, renal tubular acidosis, Fanconi syndrome)
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Concentrating defect out of proportion to the degree of renal failure
Eosinophiluria cannot be relied upon to make or exclude the diagnosis. Other tests (eg, imaging) are usually necessary to differentiate ATIN or chronic tubulointerstitial nephritis (CTIN) from other disorders. A presumptive clinical diagnosis of ATIN is often made based on the specific findings mentioned above, but renal biopsy is necessary to establish a definitive diagnosis.
Acute tubulointerstitial nephritis
Urinalysis that shows signs of active kidney inflammation (active urinary sediment), including red blood cells (RBCs), white blood cells (WBCs), and WBC casts, and absence of bacteria on culture (sterile pyuria) is typical; marked hematuria and dysmorphic RBCs are uncommon. Eosinophiluria has traditionally been thought to suggest ATIN; however, the presence or absence of urinary eosinophils is not particularly useful diagnostically. Proteinuria is usually minimal but may reach nephrotic range with combined ATIN-glomerular disease induced by NSAIDs, ampicillin, rifampin, interferon alfa, or ranitidine.
Blood test findings of tubular dysfunction include hypokalemia (caused by a defect in potassium reabsorption) and a nonanion gap metabolic acidosis (caused by a defect in proximal tubular bicarbonate reabsorption or in distal tubular acid excretion).
Ultrasonography, radionuclide scanning, or both may be needed to differentiate acute tubulointerstitial nephritis from other causes of acute kidney injury when kidney biopsy is not possible. In ATIN, ultrasonography may show kidneys that are greatly enlarged and echogenic because of interstitial inflammatory cells and edema. Radionuclide scans may show kidneys avidly taking up radioactive gallium-67 or radionuclide-labeled white blood cells (WBCs). Positive scans strongly suggest ATIN (and indicate that acute tubular necrosis is less likely), but a negative scan does not exclude ATIN.
Renal biopsy is usually reserved for patients with the following:
In acute tubulointerstitial nephritis, glomeruli are usually normal. The earliest finding is interstitial edema, typically followed by interstitial infiltration with lymphocytes, plasma cells, eosinophils, and a few polymorphonuclear leukocytes. In severe cases, inflammatory cells can be seen invading the space between the cells lining the tubular basement membrane (tubulitis); in other specimens, granulomatous reactions resulting from exposure to beta-lactam antibiotics, sulfonamides, mycobacteria, or fungi may be seen. The presence of noncaseating granulomas suggests sarcoidosis. Immunofluorescence or electron microscopy seldom reveals any pathognomonic changes.
Chronic tubulointerstitial nephritis
Findings of CTIN are generally similar to those of ATIN, although urinary RBCs and WBCs are uncommon. Because CTIN is insidious in onset and interstitial fibrosis is common, imaging tests may show small kidneys with evidence of scarring and asymmetry.
In chronic tubulointerstitial nephritis, renal biopsy is not often done for diagnostic purposes but has helped characterize the nature and progression of tubulointerstitial disease. Glomeruli vary from normal to completely destroyed. Tubules may be absent or atrophied. Tubular lumina vary in diameter but may show marked dilation, with homogeneous casts. The interstitium contains varying degrees of inflammatory cells and fibrosis. Nonscarred areas appear almost normal. Grossly, the kidneys are small and atrophic.
Prognosis
Acute tubulointerstitial nephritis
In drug-induced ATIN, renal function usually recovers within 6 to 8 weeks when the causative drug is stopped, although some residual scarring is common. Recovery may be incomplete, with persistent azotemia above baseline. Prognosis is usually worse if ATIN is caused by NSAIDs than by other drugs. When other factors cause ATIN, histologic changes usually are reversible if the cause is recognized and removed; however, some severe cases progress to fibrosis and chronic kidney disease. Regardless of cause, irreversible injury is suggested by the following:
Chronic tubulointerstitial nephritis
In CTIN, prognosis depends on the cause and on the ability to recognize and stop the process before irreversible fibrosis occurs. Many genetic (eg, cystic kidney disease), metabolic (eg, cystinosis), and toxic (eg, heavy metal) causes may not be modifiable, in which case CTIN usually evolves to end-stage renal disease.
Treatment
Treatment of both ATIN and CTIN is management of the cause.
For immunologically induced ATIN and sometimes drug-induced ATIN, corticosteroids (eg, prednisone 1 mg/kg orally once/day with gradual tapering of the dose over 4 to 6 weeks) may accelerate recovery.
For drug-induced ATIN, corticosteroids are most effective when given within 2 weeks of stopping the causative drugs. NSAID-induced ATIN is less responsive to corticosteroids than other drug-induced ATIN. ATIN should be proven by biopsy before corticosteroids are started.
Treatment of chronic tubulointerstitial nephritis often requires supportive measures such as controlling blood pressure and treating anemia associated with kidney disease. In patients with CTIN and progressive renal injury, angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) may slow disease progression but should not be used together because of an additive risk of hyperkalemia and accelerating disease progression.
Key Points
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Causes of chronic tubulointerstitial nephritis (CTIN) are myriad and much more diverse than those for acute tubulointerstitial nephritis (ATIN), which is usually caused by an allergic reaction to a drug or by an infection.
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Symptoms are often absent or nonspecific, particularly in CTIN.
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Suspect the diagnosis based on risk factors and urinary sediment, exclude other causes using imaging, and sometimes confirm the diagnosis by biopsy.
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Stop causative drugs, treat any other causes, and provide supportive treatment.
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Treat biopsy-proven immune-mediated and sometimes drug-induced ATIN with corticosteroids (within 2 weeks of stopping any causative drugs).
