eMedicine Specialties > Nephrology > Tubulointerstitial Diseases of the Kidney
Nephritis, Interstitial: Treatment & Medication
Updated: Nov 11, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Treatment of acute tubulointerstitial nephritis
- In most cases, cessation of the offending agent results in quick recovery and complete resolution of the renal disorder, although some patients progress to chronic renal insufficiency.
- If no sign of improvement is observed within a few days of discontinuation of the offending agent, consider therapy with steroids. Although controlled trials are lacking, many authors suggest using prednisone at relatively high doses, eg, 1 mg/kg for 4-6 weeks, with rapid tapering of the dose. This intervention may improve the outcome, speeding renal recovery and reducing the requirement for dialysis.
- Treatment of chronic tubulointerstitial disease: Treatment depends on the etiology and generally consists of supportive measures, such as adequate blood pressure control and management of anemia.
- Treatment of lead nephropathy
- Chelation therapy is of proven value and must be implemented in acute lead poisoning. Although the oral chelating agent succimer (Chemet) has proved highly successful in treating children, it has not been widely used in adults. Nevertheless, it appears effective in reducing body lead stores.
- Chelation therapy with EDTA may slow progressive renal insufficiency in patients with mild lead intoxication. Several studies from Taiwan have shown that chelation therapy in patients with modest increases in body lead burden (ie, 80-600 µg of lead) significantly slowed and/or reversed the rate of decline in the glomerular filtration rate (GFR) compared to placebo. This was found in both diabetics and nondiabetics.6,7 Given that these studies took place in Taiwan, it is difficult to generalize these results. Further study is needed before this treatment can be recommended.
- Because no effective therapy reverses the long-term consequences of lead poisoning, the best therapy is prevention and awareness of potential environmental and occupational sources for lead exposure.
- In patients with established lead nephropathy, treatment consists of management of hypertension, gout, and chronic renal insufficiency.
- Many patients with lead nephropathy progress to end-stage kidney failure and require dialysis.
- Treatment of cyclosporine/tacrolimus induced renal failure: Treatment includes reducing cyclosporine/tacrolimus doses and target trough levels. Discontinuing these medications and/or switching to other immunosuppressives (eg, rapamycin), especially in those with more advanced renal failure, should also be considered.
Consultations
Most patients presenting with renal insufficiency, proteinuria, and/or acid-base electrolyte disorders require consultation with a nephrologist.
Diet
Hypertensive patients should be on a low-sodium diet. For all patients with early renal disease, recommend general guidelines for a healthy diet, ie, low-fat (low-cholesterol) diet rich in fresh fruits and vegetables such as the dietary approaches to stop hypertension (DASH) diet.
Medication
For acute allergic interstitial nephritis, if no spontaneous recovery in renal function is observed after cessation of the offending agent, implementing a short course of steroid therapy is generally recommended. No controlled studies exist on the effect of corticosteroids. Therefore, no well-defined dosage and duration exist. Most practitioners recommend a relatively high dose (eg, 1 mg/kg prednisone) with a rapidly tapering regimen within several weeks.
Glucocorticoids
Immunosuppressants for treatment of autoimmune disorders.
Prednisone (Sterapred)
Has anti-inflammatory properties and causes profound and varied metabolic effects. Modifies the body's immune response to diverse stimuli. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Stabilizes lysosomal membranes and suppresses lymphocytes and antibody production.
Adult
0.5-2 mg/kg/d PO, taper as condition improves; single am dose safer for long-term use, but divided doses have greater anti-inflammatory effect
Pediatric
Not established
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Chelating agents
These agents promote the excretion of lead.
Succimer (Chemet)
Metal chelator, analog of dimercaprol. Used in lead poisoning. Particularly useful in children with lead blood levels >45 mcg/dL. Approved for chelation therapy in children for lead poisoning. Its value in chronic lead nephropathy is not established.
Adult
10 mg/kg PO q8h for 5 d, followed by 10 mg/kg PO q12h for 14 d; repeat dosing may be necessary
Pediatric
Administer as in adults
Not to be administered concomitantly with edetate calcium disodium or penicillamine
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Renal or hepatic impairment; to prevent toxicity, patients should be well hydrated
Edetate calcium disodium (Calcium Disodium Versenate)
For lead chelation. Only the calcium disodium preparation should be used. In the context of this article, use of this medication is confined to testing, ie, to perform the EDTA lead mobilization test for diagnosing lead etiology of chronic tubulointerstitial nephritis. Extended therapy to reduce body lead stores may possibly be beneficial.
Adult
EDTA lead mobilization test: 2 g IV/IM; for IV, dilute with 500 mL of D5W or 0.9% NaCl and infuse over 8-12 h; if IM used, mix with 5 mL of 2% lidocaine to avoid pain at injection site
Pediatric
Administer as in adults; not to exceed 1 g/d
EDTA enhances hypoglycemic effects of insulin in diabetic patients; not to be used with other chelating agents
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Patients should be well hydrated; EDTA may worsen CNS toxicity if administered prior to BAL therapy; use only calcium disodium preparation to avoid hypocalcemia; do not confuse with the similarly named product edetate disodium (Endrate), which is indicated for hypercalcemia and ventricular arrhythmia secondary to digitalis toxicity; each of these 2 products are commonly referred to as EDTA, and, as a result, the 2 products are easily mistaken for each other when prescribing, dispensing, and administering; deaths in patients when mistakenly given edetate disodium instead of edetate calcium disodium or when edetate disodium was used for chelation therapy; for more information, see the FDA MedWatch Safety Information
More on Nephritis, Interstitial |
| Overview: Nephritis, Interstitial |
| Differential Diagnoses & Workup: Nephritis, Interstitial |
 Treatment & Medication: Nephritis, Interstitial |
| Follow-up: Nephritis, Interstitial |
| Multimedia: Nephritis, Interstitial |
| References |
| Further Reading |
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References
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Further Reading
Related eMedicine topics:
Acute Renal Failure
Alport Syndrome [Nephrology]
Alport Syndrome [Pediatrics: General Medicine]
Goodpasture Syndrome [Nephrology]
Goodpasture Syndrome [Pediatrics: General Medicine]
Hypersensitivity Nephropathy
Lead Nephropathy
Nephritis
Nephritis, Lupus
Papillary Necrosis [Radiology]
Papillary Necrosis [Urology]
Renal Failure, Acute
Clinical guidelines:
ACR Appropriateness Criteria® renal failure. American College of Radiology - Medical Specialty Society. 1995 (revised 2008). 10 pages. NGC:007019
K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. National Kidney Foundation - Disease Specific Society. 2004 May. 290 pages. NGC:003985
Clinical trials:
Abatacept and Cyclophosphamide Combination Therapy for Lupus Nephritis (ACCESS)
Etanercept for the Treatment of Lupus Nephritis
Immune System Related Kidney Disease
Study of Systemic Lupus Erythematosus
Keywords
interstitial nephritis, nephritis, kidney disease, obstructive uropathy, acute interstitial nephritis, nephritis lupus, analgesic nephropathy, end-stage renal disease, tubulointerstitial diseases, tubulointerstitial nephritis, acute tubulointerstitial nephritis, chronic tubulointerstitial nephritis, lithium nephropathy, cyclosporine-induced nephropathy, tacrolimus-induced nephropathy, lead nephropathy, atherosclerotic kidney disease, cholesterol microembolic disease, Balkan endemic nephropathy, Chinese herb nephropathy
