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Tubulointerstitial diseases

Last updated: May 30, 2021

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Tubulointerstitial diseases are characterized by acute or chronic inflammation of the renal tubules and interstitium. Acute interstitial nephritis is commonly caused by hypersensitivity reactions to drugs, but infection or systemic disease may also precipitate the disease. Common causes of chronic nephritis include drug toxicity (especially analgesics), metabolic disease (e.g., uric acid nephropathy), and other underlying conditions (e.g., multiple myeloma). Typical symptoms in both acute and chronic nephritis are painless hematuria (without RBC casts) and pyuria. Depending on the underlying disease, nephritis may present with additional symptoms such as rash, arthralgias, and fever in the case of allergic interstitial nephritis. The most important diagnostic modalities are lab tests (increased blood urea nitrogen and creatinine) and urinalysis, although a kidney biopsy may be indicated in selected cases. Treatment usually consists of supportive measures and addressing the underlying cause (e.g., discontinuing medication). All diseases affecting the renal tubules can ultimately lead to chronic renal failure.

Acute tubulointerstitial nephritis

Allergic interstitial nephritis [3]

Crystal-induced acute kidney injury [4]

Etiology
Pathophysiology
  • Drugs with low urine solubility precipitate within the renal tubules tubular obstruction and toxicity to tubules
Clinical features
  • Patients are usually asymptomatic.
  • Renal colic
Diagnostics
  • Crystals on brightfield microscopy
Management
  • Discontinue drugs and administer IV fluids [5]
Prognosis

“Please RSVP:” Rifampin, Sulfa drugs and the V (5) Ps (Proton pump inhibitors, Pain killers (NSAIDs), “Pee pills” (diuretics), Penicillins, and Phenytoin) are the drugs that cause interstitial nephritis.

Chronic tubulointerstitial nephritis
Features

Analgesic nephropathy [7]

Myeloma cast nephropathy [8]

Etiology
Pathophysiology
  • Excessive amounts of light chains are produced and filtered into the primary urine precipitation of light chains in renal tubules → tubular obstruction and toxicity to renal tissue
Clinical features
Management
  • See “Treatment” below.
Prognosis

POSTCARDS: Pyelonephritis, Obstruction, Sickle cell disease, Tuberculosis, Cirrhosis, Analgesics (NSAIDs), Renal transplant rejection, Diabetes mellitus, and Systemic vasculitis are the causes of renal papillary necrosis.

  • Treat underlying disease
  • Monitor kidney function
  • Consider glucocorticoids
  • In selected cases, (temporary) dialysis
  1. Kodner CM, Kudrimoti A. Diagnosis and management of acute interstitial nephritis.. Am Fam Physician. 2003; 67 (12): p.2527-34.
  2. Muriithi AK, Leung N, Valeri AM, et al. Biopsy-Proven Acute Interstitial Nephritis, 1993-2011: A Case Series. American Journal of Kidney Diseases. 2014; 64 (4): p.558-566. doi: 10.1053/j.ajkd.2014.04.027 . | Open in Read by QxMD
  3. Perazella MA, Markowitz GS. Drug-induced acute interstitial nephritis. Nature Reviews Nephrology. 2010; 6 (8): p.461-470. doi: 10.1038/nrneph.2010.71 . | Open in Read by QxMD
  4. Mulay SR, Anders H-J. Crystal nephropathies: mechanisms of crystal-induced kidney injury. Nature Reviews Nephrology. 2017; 13 (4): p.226-240. doi: 10.1038/nrneph.2017.10 . | Open in Read by QxMD
  5. Nast CC. Medication-Induced Interstitial Nephritis in the 21st Century. Adv Chronic Kidney Dis. 2017; 24 (2): p.72-79. doi: 10.1053/j.ackd.2016.11.016 . | Open in Read by QxMD
  6. Joyce E, Glasner P, Ranganathan S, Swiatecka-Urban A. Tubulointerstitial nephritis: diagnosis, treatment, and monitoring.. Pediatr Nephrol. 2017; 32 (4): p.577-587. doi: 10.1007/s00467-016-3394-5 . | Open in Read by QxMD
  7. Uetrecht J. Adverse Drug Reactions. Springer Science & Business Media ; 2009
  8. Faiman BM, Mangan P, Spong J, Tariman JD. Renal Complications in Multiple Myeloma and Related Disorders. Clin J Oncol Nurs. 2011; 15 : p.66-76. doi: 10.1188/11.cjon.s1.66-76 . | Open in Read by QxMD
  9. Fored CM, Ejerblad E, Lindblad P, et al. Acetaminophen, Aspirin, and Chronic Renal Failure. N Engl J Med. 2001; 345 (25): p.1801-1808. doi: 10.1056/nejmoa010323 . | Open in Read by QxMD
  10. Jung DC, Kim SH, Jung SI, Hwang SI, Kim SH. Renal Papillary Necrosis: Review and Comparison of Findings at Multi–Detector Row CT and Intravenous Urography. RadioGraphics. 2006; 26 (6): p.1827-1836. doi: 10.1148/rg.266065039 . | Open in Read by QxMD