Severe acute kidney injury due to oxalate crystal induced severe interstitial nephritis:A case report

BACKGROUND Acute kidney injury(AKI)due to interstitial nephritis is a known condition primarily attributed to various medications.While medication-induced interstitial nephritis is common,occurrences due to non-pharmacological factors are rare.This report presents a case of severe AKI triggered by intratubular oxalate crystal deposition,leading to interstitial nephritis.The aim is to outline the case and its management,emphasizing the significance of recognizing uncommon causes of interstitial nephritis.CASE SUMMARY A 71-year-old female presented with stroke-like symptoms,including weakness,speech difficulties,and cognitive impairment.Chronic hypertension had been managed with hydrochlorothiazide(HCTZ)for over two decades.Upon admis-sion,severe hypokalemia and AKI were noted,prompting discontinuation of HCTZ and initiation of prednisolone for acute interstitial nephritis.Further investigations,including kidney biopsy,confirmed severe acute interstitial nephritis with oxalate crystal deposits as the underlying cause.Despite treatment,initial renal function showed minimal improvement.However,with prednisolone therapy and supportive measures,her condition gradually improved,high-lighting the importance of comprehensive management.CONCLUSION This case underscores the importance of a thorough diagnostic approach in identifying and addressing uncommon causes of interstitial nephritis.The occurrence of interstitial nephritis due to oxalate crystal deposition,especially without typical risk factors,emphasizes the need for vigilance in clinical practice.

Acute lobar nephritis in children: Not so easy to recognize and manage

Acute lobar nephritis(ALN) is a localized non-liquefactive inflammatory renal bacterial infection, which typically involves one or more lobes. ALN is considered to be a midpoint in the spectrum of upper urinary tract infection, a spectrum ranging from uncomplicated pyelonephritis to intrarenal abscess. This condition may be difficult to recognize due to the lack of specific symptoms and laboratory findings. Therefore the disease is probably underdiagnosed. Computed tomography scanning represents the diagnostic gold standard for ALN, but magnetic resonance imagine could be considered in order to limit irradiation. The diagnosis is relevant since initial intravenous antibiotic therapy and overall length of treatment should not be shorter than 3 wk. We review the literature and analyze the ALN clinical presentation starting from four cases with the aim to give to the clinicians the elements to suspect and recognize the ALN in children.

Stabilization of estimated glomerular filtration rate in kidney transplantation from deceased donors with acute kidney injuries

AIM To evaluate and compare the outcomes of kidney transplant(KT) from deceased donors among standard criteria, acute kidney injury(AKI) and expanded criteria donors(ECDs). METHODS This retrospective study included 111 deceased donor kidney transplant recipients(DDKT). Deceased donors were classified as standard criteria donor(SCD), AKI donor and ECD. AKI was diagnosed and classified based on change of serum Cr by acute kidney injury network(AKIN) criteria. Primary outcome was one-year estimated glomerular filtration rate(eG FR) calculated from Cr by CKD-EPI. Multivariate regression analysis was done by adjusting factors such as type of DDKT, %Panel-reactive antibodies, cold ischemic time, the presence of delayed graft function and the use of induction therapy. Significantfactors that can affect the primary outcomes were then identified. RESULTS ECD group had a significantly lower eG FR at one year(33.9 ± 17.3 mL /min) when compared with AKI group(56.6 ± 23.9) and SCD group(63.6 ± 19.9)(P < 0.001). For AKI group, one-year eG FR was also indifferent among AKIN stage 1, 2 or 3. Patients with AKIN stage 3 had progressive increase of eG FR from 49.6 ± 27.2 at discharge to 61.9 ± 29.0 mL /min at one year. From Kaplan-Meier analysis, AKI donor showed better two-year graft survival than ECD(100% vs 88.5%, P = 0.006). Interestingly, AKI group had a stable eG FR at one and two year. The two-year eG FR of AKI group was not significantly different from SCD group(56.6 ± 24.5 mL /min vs 58.6 ± 23.2 mL /min, P = 0.65). CONCLUSION Kidney transplantations from deceased donors with variable stage of acute kidney injuries were associated with favorable two-year allograft function. The outcomes were comparable with KT from SCD. This information supports the option that deceased donors with AKI are an important source of organ for kidney transplantation even in the presence of stage 3 AKI.

A Case of Staphylococcus Associated Glomerulonephritis Confused with Acute Interstitial Nephritis

Staphylococcus associated glomerulonephritis (SAGN) is an uncommon infection-related glomerulonephritis. Although infection is typically ongoing when patients present with SAGN, in the case of deep-seated infections, the presence of infection may not be apparent. The aim of this study is to highlight the importance of renal biopsy when the diagnosis is not obvious. We present a case of staphylococcus associated glomerulonephritis in a patient treated with beta-lactam antibiotics for staphylococcus bacteraemia. A renal biopsy helped differentiate between interstitial nephritis and staphylococcus associated glomerulonephritis.

A Case of Acute Renal Failure Associated with IgG4-Related Disease Presenting Both Tubulointerstitial Nephritis and Retroperitoneal Fibrosis

We report a case of IgG4-related disease presenting both tubulointerstitial nephritis and retroperitoneal fibrosis causing acute renal failure in a 63-year-old male. He was admitted to our hospital because of acute renal failure requiring emergent hemodialysis. Computed tomography showed a soft-tissue density mass with an irregular border in the retroperitoneum. The mass involved bilateral ureters and had caused acute renal failure by bilateral hydronephrosis. Because of a history of uveitis and high IgG4 levels, we considered a diagnosis of retroperitoneal fibrosis, IgG4-related disease. Kidney biopsy revealed IgG4-related kidney disease with interstitial nephritis. After relief of urinary obstruction by inserting ureteral catheters into the bilateral ureters, renal function recovered.

Fabry disease combined with acute interstitial nephritis:one case and literature review

Objective:To explore the clinical and pathological features of Fabry disease complication of acute interstitial nephritis.Methods:A retrospective analysis of a patient with Fabry disease and acute interstitial nephritis diagnosed and in the Department of Nephrology,Children’s Hospital Affiliated to Capital Institute of Pediatrics in January 2017 was performed.A literature search was performed with“Fabry disease,acute interstitial nephritis”as the keywords in Wanfang database and PubMeds database.Result:The patient was 10-years-old with acute renal dysfunction.Electron microscopy showed stratified myelin-like bodies,zebra bodies and fused foot segment.The patient was finally diagnosed with the combination of Fabry disease and acute interstitial nephritis.By now,such cases have been reported.Conclusion:Whether Fabry's disease and acute interstitial nephritis shared the common pathogenic mechanism is unclear.Early renal biopsy is important for the diagnosis of this disease.

急性肾小球肾炎(Acute nephritis)的治疗

急性肾小球肾炎是固免疫介导的炎症反应引起肾小球疾病。病情表现轻重不一。治疗上无特殊方法。治疗原则多采用综合治疗。急性期充分休息,富含维生素低盐饮食,防治并发症如高血压、尿毒症等。治疗方案结合临床实践,临症选择下述方案。1.皮质激素方案适用于微小病变型肾病综合征、膜性肾炎、急性间质性肾炎,也用于狼疮性肾炎、结节性多动脉炎肾病、肾炎—肺出血综合征、紫癜性肾炎等。本案用药原则始量足、减量慢、维持长。常规方案:治疗方法通常分两步进行。

Clinicopathological spectrum of snake bite-induced acute kidney injury from India

AIM To study the clinico-pathological spectrum of snake bite-induced acute kidney injury(AKI).METHODS A retrospective study of patients admitted at Indira Gandhi Medical College Hospital,Shimla with snake bite-induced AKI from July 2003 to June 2016.Medical records were evaluated for patient's information on demographic,clinical characteristics,complications and outcome.Outcomes of duration of hospital stay,requirement for intensive care unit support,treatment with dialysis,survival and mortality were analyzed.The survival and non survival groups were compared to see the difference in the demographic factors,clinical characteristics,laboratory results,and complications.In patients subjected to kidney biopsy,the findings of histopathological examination of the kidney biopsies were also analyzed.RESULTS One hundred and twenty-one patients were diagnosed with snake bite-induced AKI.Mean age was 42.2 ± 15.1 years and majority(58%) were women.Clinical details were available in 88 patients.The mean duration of arrival at hospital was 3.4 ± 3.7 d with a range of 1 to30 d.Eighty percent had oliguria and 55% had history of having passed red or brown colored urine.Coagulation defect was seen in 89% patients.The hematological and biochemical laboratory abnormalities were:Anemia(80.7%),leukocytosis(75%),thrombocytopenia(47.7%),hyperkalemia(25%),severe metabolic acidosis(39.8%),hepatic dysfunction(40.9%),hemolysis(85.2%) and rhabdomyolysis(68.2%).Main complications were:Gastrointestinal bleed(12.5%),seizure/encephalopathy(10.2%),hypertension,pneumonia/acute respiratory distress syndrome(ARDS) and disseminated intravascular coagulation(9.1% each),hypotension and multi organ failure(MOF)(4.5% each).Eighty-two percent patients required renal replacement therapy.One hundred and ten(90.9%) patient survived and 11(9.1%) patients died.As compared to the survival group,the white blood cell count(P = 0.023) and bilirubin levels(P = 0.006) were significant higher and albumin levels were significantly lower(0.005) in patients who died.The proportion of patients with pneumonia/ARDS(P = 0.001),seizure/encephalopathy(P = 0.005),MOF(P = 0.05) and need for intensive care unit support(0.001) was significantly higher and duration of hospital stay was significantly shorter(P = 0.012) in patients who died.Kidney biopsy was done in total of 22 patients.Predominant lesion on kidney biopsy was acute tubular necrosis(ATN) in 20(91%) cases.In 11 cases had severe ATN and in other nine(41%) cases kidney biopsy showed features of ATN associated with mild to moderate acute interstitial nephritis(AIN).One patient only had moderate AIN and one had patchy renal cortical necrosis(RCN).CONCLUSION AKI due to snake bite is severe and a high proportion requires renal replacement therapy.On renal histology ATN and AIN are common,RCN is rare.

Characteristics and clinical outcome of nonsteroidal anti-inflammatory drug-induced acute hepato-nephrotoxicity among Chinese patients

AIM: To determine the clinicopathological characteristics of nonsteroidal anti-inflammatory drug (NSAID)-induced acute hepato-nephrotoxicity among Chinese patients.

Nephropathy in dietary hyperoxaluria:A potentially preventable acute or chronic kidney disease

Hyperoxaluria can cause not only nephrolithiasis and nephrocalcinosis,but also renal parenchymal disease histologically characterized by deposition of calcium oxalate crystals throughout the renal parenchyma,profound tubular damage and interstitial inflammation and fibrosis.Hyperoxaluric nephropathy presents clinically as acute or chronic renal failure that may progress to endstage renal disease(ESRD).This sequence of events,well recognized in the past in primary and enteric hyperoxalurias,has also been documented in a few cases of dietary hyperoxaluria.Estimates of oxalate intake in patients with chronic dietary hyperoxaluria who developed chronic kidney disease or ESRD were comparable to the reported average oxalate content of the diets of certain populations worldwide,thus raising the question whether dietary hyperoxaluria is a primary cause of ESRD in these regions.Studies addressing this question have the potential of improving population health and should be undertaken,alongside ongoing studies which are yielding fresh insights into the mechanisms of intestinal absorption and renal excretion of oxalate,and into the mechanisms of development of oxalate-induced renal parenchymal disease.Novel preventive and therapeutic strategies for treating all types of hyperoxaluria are expected to develop from these studies.

Relationship between High Level of Estimated Glomerular Filtration Rate and Contrast-Induced Acute Kidney Injury in Patients who Underwent an Emergency Percutaneous Coronary Intervention

Background： Mounts of studies have shown that low estimated glomerular filtration rate （eGFR） is associated with increased risk of adverse outcomes in patients with coronary artery disease. However, high level of eGFR was less reported. In the study, we aimed to explore the relationship between the baseline eGFR, especially the high level, and contrast-induced acute kidney injury （CI-AKI） in a Chinese population who underwent an emergency percutaneous coronary intervention （PCI）. Methods： Patients who underwent an emergency PCI from 2013 to 2015 were enrolled and divided into five groups as eGFR decreasing. Baseline characteristics were collected and analyzed. The rates of CI-AKI and the composite endpoint （including nonfatal myocardial infarction, revascularization, stroke, and all-cause death） at 6- and 12-month follow-up were compared. Logistic analysis for CI-AKI was performed.Results： A total of 1061 patients were included and the overall CI-AKI rate was 22.7% （241 / 1061）. The separate rates were 77.8% （7/9） in Group 1 （eGFR 〉 120 ml·min^-1 -1.73 m^-2）, 26.0% （118/454） in Group 2 （120 ml·min^-1·min^-11.73 m^-2〉 eGFR≥90 ml·min^-1 1.73^-2）, 18.3% （86/469） in Group 3 （90 ml·min^-1 1.73 m^-2〉 eGFR 〉60 ml·min^-1·min^-11.73 m^-2）, 21.8% （26/119） in Group 4 （60 ml·min^-1·1.73 m^-2〉 eGFR≥30 ml·min^-1·min^-11.73 m^-2）, and 40.0% （4/10） in Group 5 （eGFR 〈30 ml·min^-1·min^-1·min^-11.73 m^-2）, with statistical significance （χ^2 = 25.19, P 〈 0.001）. The rates of CI-AKI in five groups were 77.8%, 26.0%, 18.3%, 21.8%, and 40.0%, respectively, showing a U-typed curve as eGFR decreasing （the higher the level of eGFR, the higher the CI-AKI occurrence in case ofeGFR_〉60 ml·min^-1·1.73 m^-2）. The composite endpoint rates in five groups were 0, 0.9%, 2.1%, 6.7%, and 0 at 6-month follow-up, respectively, and 0, 3.3%, 3.4%, 16.0%, and 30.0% at 12-month follow-up, respectively, both with significant differences （χ^2 = 16.26, P = 0.009 at 6-month follow-up, and χ^2 = 49.05, P 〈 0.001 at 12-month follow-up）. The logistic analysis confirmed that eGFR was one of independent risk factors of CI-AKI in emergency PCI patients. Conclusions： High level ofeGFR might be associated with increased risk of CI-AKI in patients with emergency PCI, implying for future studies and risk stratification in clinical practice.

Clinical and renal pathologic analysis of acute interstitial nephritis in 51 children

Objective To discuss the etiology,clinical manifestations and renal pathological features of acute interstitial nephritis(AIN)in children.Methods The etiology,clinical manifestations,pathological characteristics,clinical effects and outcome of the children with AIN diagnosed by renal biopsy from January 2010 to December 2019 in Nanjing Jinling Hospital were analyzed retrospectively.

TSP-1 promotes glomerular mesangial cell proliferation and extracellular matrix secretion in Thy-1 nephritis rats

The proliferation of glomerular mesangial cells （GMC） and secretion of the extracellular matrix （ECM） in rat with Thy-1 nephritis （Thy-lN） resembling human mesangioproliferative glomerulonephritis have been explored for many years; however, the molecular mechanisms of GMC proliferation and ECM production remain unclear. Our previous studies have demonstrated that the thrombospondin-1 （TSP-1） gene was involved in mediating rat GMC proliferation and ECM synthesis induced by sublytic C5b-9 in vitro. 111 the present study, the roles of the TSP-1 gene in GMC proliferation, ECM production, and urinary protein secretion in Thy-lN rats were determined by using TSP-1 small hairpin RNA, and the results revealed that silencing of the TSP-1 gene in rat renal tissues could diminish GMC proliferation （P 〈 0.01） and ECM secretion （P 〈 0.01） as well as urinary protein secretion （P 〈 0.05） in Thy-lN rats. Together, the current findings suggested that TSP-1 gene expression was required for GMC proliferation and ECM production in Thy-lN rats.

Clinical characteristics of acute lobar nephronia in renal allograft

To the Editor:Acute lobar nephronia(ALN),also known as acute focal bacterial nephritis,is a severe form of upper urinary tract infection(UTI)that is characterized by the presence of an inflammatory mass lesion in the kidney without abscess formation.It is considered to be the midpoint between acute pyelonephritis and renal abscess.^([1])ALN was first described in 1979 as a radiologic diagnosis in ten adults and two children.^([2])

15.4.Interstitial nephritis and interstitial nephropathy

920356 Correlation of levels of IgE and IL-4in INS patients.YAO Zhi (姚智),et al.DeptImmunol,Beijing Med Univ,100083.Chin Jimmunol 1992;8(1):48-49.

Interstitial nephritis and interstitial nephropathy

950358 Detection of glucocorticoid receptor (GCR)of lymphocyte in childnephrotic syndrome (NS).TANG Jieru(汤洁如),et al.Dept Pediatr,1st AffiliHosp,Sun Yat-sen Meal Univ,Guangzhou.Chin JNephrol 1994;10(6):342-343.Assesment of steroid receptor content in humanneoplastic cells or mammary tumor cells has been pre-viously used to prearct steriod sensitivity in variouscancers.In the present study,we evaluated the rela-tionship between GCR content and the prednisone sen-

Glomerular disease

950356 Experimental studies of glomerular endothe- lial cell culture and its production of extracellular ma-trixes.CHEN Xiangmei(陈香美),et al.Dept Nephrol,Great Wall Hosp,Beijing,100853.Natl Med J China1995;75(1):25-27.We successfully cultured human fetal and bovineglomerular endothelial cells by cell cloning and main-

15.4.Interstitial nephritis and interstitial nephropathy

930331 Significance of determination of urinealbumin for early diagnosis of diabeticnephropathy.ZHOU Zhongyuan (周中源),Shanghai 4th People’s Hosp.Shanghai Med J1993;16(2):74—76.The results of urine albumin determination in208 patients with non-insulin dependent dia-betes mellitus but tested negative for urinaryprotein on routine examination and in 177 nor-mal controls were reported.The results showedthat the excretion of urine albumin in 131 pa-tients was obviously higher than that in normalcontrols (p【0.001).In the diabetic patientstested negative for urinary protein on routineexamination the excretion of urine albumin

儿童肾小管间质性肾炎-葡萄膜炎综合征临床和病理特征回顾性队列研究

背景国外研究报道肾小管间质性肾炎-葡萄膜炎(TINU)综合征在儿童急性间质性肾炎(AIN)中的占比较高,但部分患儿临床表现不典型,易漏诊,目前我国关于TINU综合征在AIN患儿中的占比及其预后尚不明确。目的分析AIN患儿中TINU综合征的临床和病理特征。设计回顾性队列研究。方法纳入2012年1月至2022年12月在北京大学第一医院经肾活检病理证实的AIN患儿,根据末次随访时的最终诊断分为TINU组和非TINU组。截取患儿的发病年龄、性别、既往史、前驱感染史、用药史,起病和复诊时临床表现、眼科会诊结果,首次就诊时的实验室检查结果,肾活检病理资料,治疗和随访情况。主要结局指标TINU综合征患儿的肾脏和眼部表现,治疗和预后。结果共21例AIN患儿纳入本研究,占同期肾活检患儿的1.6%。TINU组10例(48%),非TINU组11例(干燥综合征2例,药物相关和结节病各1例,病因不详7例)。TINU患儿中5例在肾活检前或同时、5例在肾活检后1~12个月诊断葡萄膜炎,均为双眼受累,前葡萄膜炎4例,全葡萄膜炎6例;非TINU组中的1例结节病患儿在病初诊断为葡萄膜炎。10例TINU患儿中,男、女各5例,起病年龄8~15岁,3例有前驱感染史,4例有药物治疗史,就诊时均有纳差\体重下降,发热4例,关节痛2例,眼部结膜充血、疼痛、流泪2例;有泡沫尿4例,尿量增多/新发夜尿6例,血压升高2例。经过全身和眼部应用糖皮质激素后,10例TINU组患儿肾脏表现均改善或消失,6例葡萄膜炎好转,未好转的1例予糖皮质激素点眼、3例联合其他免疫抑制剂治疗。随访时间为11(4,21)个月,2例在泼尼松停用或减量时出现AIN症状反复,予糖皮质激素和免疫抑制剂治疗后好转;2例出现眼部并发症(1例双眼继发性青光眼伴双侧视野缺损、1例白内障),3例仍有葡萄膜炎。TINU与非TINU所致的AIN患儿比较,人口学资料、发病年龄、前驱感染史、用药史、首诊时有眼部症状的患儿比例、其他临床症状、实验室检查指标、肾脏病理表现、肾脏复发比例等差异均无统计学意义。结论除眼部病变外,TINU综合征与其他病因所致AIN在临床表现、实验室检查和病理改变均类似;葡萄膜炎的临床表现隐匿,可晚于肾脏症状出现,对AIN患儿应重视眼科病史收集、眼科检查和随诊,以免漏诊TINU综合征。

H型高血压急性缺血性脑卒中患者亚甲基四氢叶酸还原酶C677T基因多态性及其与肾功能的相关性

目的观察H型高血压急性缺血性脑卒中患者亚甲基四氢叶酸还原酶(MTHFR)C677T的基因多态性,分析其与H型高血压急性缺血性脑卒中患者肾功能的相关性。方法选择153例H型高血压急性缺血性脑卒中患者为观察组,同期158例非H型高血压急性缺血性脑卒中患者为对照组。两组均采集外周静脉血,采用PCR扩增和微阵列技术检测MTHFR C677T基因型,测算全身免疫炎症指数(SII),采用日立7600型全自动生化分析仪检测两组血清肌酐,据此测算肾小球滤过率(eGFR)。采用多元线性回归分析法分析MTHFR C677T基因型与H型高血压急性缺血性脑卒中患者同型半胱氨酸(Hcy)、eGFR的相关性,采用Spearman相关分析法分析SII与H型高血压急性缺血性脑卒中患者eGFR、Hcy的相关性。结果与对照组相比,观察组患者TT基因型分布频率最高,T等位基因频率最高(χ^(2)分别为19.188、5.138,P均<0.05)。观察组、对照组患者SII分别为583.54(384.97,903.73)、425.03(310.26,583.16),二者相比,P<0.05。与CC、CT基因型比较,TT基因型的H型高血压急性缺血性脑卒中患者血清Hcy水平高,eGFR水平低(F分别为28.544、3.749,P均<0.05)。MTHFR C677T TT基因型与H型高血压急性缺血性脑卒中患者血清Hcy呈正相关(β=4.173,P<0.05),与eGFR呈负相关(β=-6.559,P<0.05)。SII与H型高血压急性缺血性脑卒中血清Hcy水平呈正相关(r=0.226,P<0.05),与eGFR呈负相关(r=-0.129,P<0.05)。结论H型高血压急性缺血性脑卒中患者MTHFR C677T基因型主要为TT型。MTHFR C677T TT基因型的H型高血压急性缺血性脑卒中患者可能更易引起肾功能下降。