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Key Features

  • Interstitial inflammatory response with edema and possible tubular cell damage, responsible for ~10–15% of cases of intrinsic renal failure

  • Causes of acute interstitial nephritis

    • Drugs (> 70% of cases), including

      • Penicillins

      • Cephalosporins

      • Sulfonamides

      • Nonsteroidal anti-inflammatory drugs

      • Proton pump inhibitors

      • Rifampin

      • Phenytoin

      • Allopurinol

    • Infectious diseases, including

      • Streptococcal infections

      • Leptospirosis

      • Cytomegalovirus

      • Histoplasmosis

      • Rocky Mountain spotted fever

    • Immunologic disorders, including

      • Systemic lupus erythematosus

      • Sjögren syndrome

      • Sarcoidosis

      • Cryoglobulinemia

    • Idiopathic

  • Causes of chronic interstitial nephritis

    • Obstructive uropathy

    • Vesicoureteral reflux (reflux nephropathy)

    • Analgesic nephropathy

    • Heavy metals (lead, cadmium, mercury, bismuth)

    • Multiple myeloma

    • Gout

Clinical Findings

  • Fever (> 80%)

  • Transient maculopapular rash (25–50%)

  • Arthralgias

  • Peripheral blood eosinophilia (80%)

  • The classic triad of fever, rash, and arthralgias is present in only 10–15% of cases

Diagnosis

  • Peripheral blood eosinophilia (80%)

  • Acute or chronic kidney disease

  • White cells (95%), red cells, and white cell casts in urine

  • Proteinuria usually modest (< 2 g/24 h)

  • Renal biopsy is diagnostic

  • Differential diagnosis

    • Acute tubular necrosis

    • Acute glomerulonephritis

    • Prerenal azotemia

    • Chronic glomerulopathy (eg, diabetes)

    • Hypertensive nephrosclerosis

    • Obstructive uropathy

Treatment

  • Supportive measures

  • Removal of inciting agent

  • In more severe cases of drug-induced interstitial nephritis,

    • Short-term, high-dose methylprednisolone (0.5–1 g/day intravenously for 1–4 days) or

    • Prednisone (60 mg/day orally for 1–2 weeks) followed by a taper can be used

  • Prognosis good; recovery occurs over weeks to months

  • Dialysis may be necessary in up to 33%

  • Patients rarely progress to end-stage renal disease

  • Prognosis worse in those with prolonged courses of oliguric failure and advanced age

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