Sunday, 27 October 2013

@Interstitial nephritis (Tubulo-interstitial nephritis)

Interstitial nephritis is defined as a condition of inflammation of the spaces between renal tubules, affecting the interstitium of the kidneys and kidney function in wast removal.
A. Signs and symptoms 
In the study of Symptoms in patients with tubulo-interstitial nephritis, researchers at the School of Medicine, Juntendo University, indicated that in patients with acute TIN, marked
1. Fever,
2. Back or flank pain
3. CVA tenderness
4. Skin rash
5. Arthralgia
6. Cosinophilia and
7. Eosinouria are observed.
Clinical symptoms might be induced by glomerular, proximal tubular or distal tubular dysfunction in chronic TIN. Mild to moderate
8. Proteinuria
9. Edema
10. Hypertension
11. Azotemia
12. Glucosuria
13. Aminoaciduria
14. Polyuria and
15. Polydipsia are characteristic findings in patients with chronic TIN(1).

B. Causes and Risk factors
1. In the study of The outcome of acute interstitial nephritis: risk factors for the transition from acute to chronic interstitial nephritis, researchers at the Department of Nephrology, MHH, Hannover, Germany, in determination of risk factors for the development of chronic renal insufficiency, and thus, the transition from acute to chronic interstitial nephritis, showed that acute interstitial nephritis was found in 6.5% of all biopsies (64 patients with 68 episodes of acute interstitial nephritis); it was infection-induced in 10%, idiopathic in 4%, and drug-induced in 85% of the cases (antibiotics in 13 cases, analgesics in 17, non-steroidal anti-inflammatory drugs (NSAIDs) in 16, diuretics in 5, and various other drugs in 7). Renal insufficiency was reversible in 69% and permanent in 31% (12% partially reversible, 19% irreversible). The infection-induced and idiopathic types of acute interstitial nephritis were always reversible. Drug-related acute interstitial nephritis caused permanent renal insufficiency in 36% with a maximum of 56% in NSAID-induced cases. In drug-induced cases, intake of the suspected drug for more than a month prior to diagnosis caused permanent renal insufficiency in 88% and interstitial granuloma in 31%(2).

2. Impaired potassium and magnesium homeostasis and urinary losses are associated with the increased risk of acute tubulo-interstitial nephritis(3)

3. Hypercalcemia is a life-threatening disorder and is related primarily to neoplastic diseases and primary and secondary hyperparathyroidism and associated to the risk of Interstitial nephritis(4).

4. Allergic effect
A severe generalized multisystem allergic reaction occurred in a 16-month-old infant following the use of trimethoprim-sulfamethoxazole. Acute interstitial nephritis developed three weeks following the onset of this reaction and resolved after three months. This is the first description of this renal toxicity with TMP-SMX in a child(4a).

5. Etc.

C. Diseases associated with interstitial nephritis
1. Crohn's Disease
There is a report of s case of of granulomatous interstitial nephritis (GIN) associated with Crohn's disease (CD) was reported. GIN is a rare pathological finding in renal biopsy specimens. In a patient affected by CD, granulomas may be found in various tissues and organs such as lymph nodes, mesentery, liver, and lungs and occasionally in bones, joints, and skeletal muscle. Few cases of granuloma have been reported in the kidney, and it is not always possible to relate the presence of granuloma to CD, to other interstitial granulomatosis diseases, or to a drug-induced reaction(5).

2. Sjögren's syndrome
In the study of the tissue distribution of cellular adhesion molecules (ICAM-1, ELAM-1, VCAM-1) was studied in specimens from six normal human kidneys and in six biopsies from kidneys with tubulointerstitial nephritis associated with Sjögren's syndrome, researchers at the Toho University School of Medicine, showed that adhesion molecules were thought to play a role in the pathogenesis of tubulointerstitial nephritis and sialoadenitis associated with Sjögren's syndrome. It was thus concluded that the same inflammatory process that took place in the salivary glands to induce the characteristic tissue change of Sjögren's syndrome likely was operative in the renal tubulointerstitial tissue as well(6).

3. Uveitisa
There is a report of Clinical features and natural course of acute tubulointerstial nephritis and uveitis (TINU syndrome) in five adolescent patients (3 girls and 2 boys), according to Dr. Nikolić V, and reseach team(7)

4. Tuberculosis
Tuberculosis (TB) is a common disease worldwide, but kidney affection, i.e. tubulointerstitial nephritis (TIN) caused by Mycobacterium tuberculosis is rare. More frequent in patients with TB is drug induced TIN, i.e. the result of intensive antitubercular treatment(8). 

5. Castleman's disease
There is a report of a case of mesangial proliferative glomerulonephritis with interstitial nephritis associated with multicentric Castleman's disease (MCD) successfully treated with an anti-interleukin-6 receptor antibody (tocilizumab)(9).

6. Feline morbillivirus
Feline morbillivirus, a previously undescribed paramyxovirus associated with tubulointerstitial nephritis in domestic cats(10)

7.  Etc.   

D. Diagnosis
Dr. Nikolić V and the research team in the review of the data between 1986 and 1997 of 21 patients, aged 7-16 years (mean, 12.8), with acute tubulointerstitial nephritis, including eight with tubulointerstitial nephritis and uveitis (TINU syndrome). Laboratory studies included urinalysis, complete blood count, erytrocyte sedimentation rate (ESR), plasma creatinine, glomerular filtration rate (GFR), electrolytes, proteins, IgG, C3, C4 antinuclear-antibodies (ANA), antistreptolysin-O and antibodies to hantaviruses. Renal ultrasound was done in all patients. Renal biopsy was performed in 5 children(11).

E. Prevention
1. Avoid overdose of medication and vitamins
Overdose of certain medication indicated above and some vitamins are associated to the increased risk of the diseases.
2. Eat well to enhance the immune system to prevent bacterial and viral causes of inflammation.
3. Use herbs with caution
Overdose of herb can damage to kidney of that can lead to interstitial nephritis(11a).
4. Avoid extreme Exercise
There is a report of a A 45-year-old man presented with abdominal pain, vomiting, and oliguria after severe exercise as a result of Familial renal hypouricemia with exercise-induced acute renal failure (ARF)(12).
5. Reduce in take of animal fat to prevent waste to the kidney
6. Reduce intake of salt to reduce the risk of hypertension and kidney overload.
7. Etc.
F. Treatment 
F.1. In conventional medicine perspective
1. Acute tubulointerstitial nephritis
In the study to evaluate the controversial effects of steroids in acute tubulointerstitial nephritis (ATIN), showed that steroid treated (StG) patients had a greater degree of improvement in their renal function; however there was no correlation between the degree of improvement in eGFR and delay in starting steroids. PPIs were second commonest implicated drug category among drug induced cases(13).

2. Chronic tubulointerstitial nephritis
Chronic tubulointerstitial nephritis has no cure. Many patients may require dialysis. In younger patient,  kidney transplant may be the only choice. 

F.2. In herbal medicine perspective
1. Soy
In the study to evaluate the effects of soy protein isolate (SPI) on severe kidney damage in deoxycorticosterone acetate (DOCA) salt-treated obese Zucker rats, researchers at the Food Science Research Institute, Fuji Oil Company Ltd., Izumisano-shi, showed that that consecutive treatment of SPI protects against renal dysfunction, particularly tubulointerstitial nephritis, in DOCA salt-treated obese Zucker rats(14).

2.  Flaxseed
In the study to determine if flaxseed would also modify clinical course and renal pathology in the Han:SPRD-cy rat, showed that Flaxseed ameliorates Han:SPRD-cy rat polycystic kidney disease through moderation of the associated chronic interstitial nephritis. The diet alters renal content of polyunsaturated fatty acids in a manner that may promote the formation of less inflammatory classes of renal prostanoids(15).

3. Etc.
F.3. In traditional Chinese medicine perspective 
1. Traditional Chinese medicine with immunosuppressant
In an  experimental study combined on traditional Chinese medicine with immunosuppressant for treatment and prevention of tubular interstitial nephritism researchers at the Department of Nephrology, First Affiliated Hospital, showed that the infiltration of cells was inhibited in the "Chinese herbs combined with prednisone" group, the infiltration of cells, TGF-beta expression and interstitial fibrosis were all inhibited in the cyclophosphamide and prednisone" group. But in the prednisone group, interstitial fibrosis was not inhibited. These data suggest that the combined use of Chinese herbs, immunosuppressant and prednisone can inhibit the interstitial cell infiltration and prevent the interstitial fibrosis in diffuse proliferative glomerulonephritis(16).

2. Astragali Radix and Angelicae Sinensis Radix (AS-IV)with ferulic acid
Other researchers suggested that AS-IV synergizes with FA to alleviate renal tubulointerstitial fibrosis; this was associated with inhibition of tubular epithelial-mesenchymal transdifferentiation (EMT) and fibroblast activation, as well as an increase in NO production in the kidney(17).

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