Nephritis, Interstitial

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)

• Kidney 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