Case 36-2003: A Woman with Impaired Renal Function
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《新英格兰医药杂志》
To the Editor: In Case 36-2003 (Nov. 20 issue),1 Singh and Bazari suggest that for patients with presumptive drug-induced acute interstitial nephritis, initiation of corticosteroid therapy should be "straightforward" and that the response of renal function to high-dose corticosteroids should be considered in the decision whether or not to perform a kidney biopsy. However, the rationale for treating drug-induced acute interstitial nephritis with corticosteroids remains unsubstantiated. The results of seven selected studies failed to provide evidence of a beneficial effect of corticosteroid therapy in terms of preventing chronic renal insufficiency in patients with this problem.2
Furthermore, other findings indicate that using only clinical features to diagnose acute interstitial nephritis is often hazardous. In an analysis of data from 25 patients with suspected acute interstitial nephritis who subsequently underwent renal biopsy, Buysen et al. reported that the clinicians' diagnosis had been confirmed in only 11 patients (44 percent).3 We would like to emphasize both the difficulty of diagnosing drug-induced acute interstitial nephritis on the basis of clinical findings alone and the fundamental diagnostic role of renal histologic evaluation.
Luis Teixeira, M.D.
Alfred Mahr, M.D.
H?pital Cochin
Paris 75679, France
luisteixeira@wanadoo.fr
Sonia Barry, M.D.
H?pital Lagny Marne-la-Vallée
Lagny sur Marne 77400, France
References
Case Records of the Massachusetts General Hospital (Case 36-2003). N Engl J Med 2003;349:2055-2063
Rossert J. Drug-induced acute interstitial nephritis. Kidney Int 2001;60:804-817.
Buysen JG, Houthoff HJ, Krediet RT, Arisz L. Acute interstitial nephritis: a clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990;5:94-99.
The discussants reply: Teixeira and colleagues suggest that "the rationale for treating drug-induced acute interstitial nephritis with corticosteroids remains unsubstantiated." However, for patients with severe renal dysfunction — particularly those in whom dialysis is initiated — both years of personal experience and published data support the use of corticosteroids. Indeed, Buysen et al.1 report that recovery from renal failure is faster in patients who are treated with corticosteroids than in those who are not. Although we agree that there has been no prospective controlled study of the efficacy of corticosteroids in acute interstitial nephritis, it is important not to overinterpret the conclusions of the seven studies cited by Teixeira et al. that do not support a role for corticosteroid treatment.2 These studies had major limitations in that they were small, nonrandomized, and retrospective. Indeed, patients treated with corticosteroids generally had worse base-line renal function than those not receiving corticosteroids. Our own practice in treating patients with severe renal dysfunction is to discontinue the drug and use high-dose corticosteroids. The rationale for using corticosteroids is to accelerate the recovery of renal function and to reduce the risk of interstitial scarring. We agree that there is an important role for a percutaneous renal biopsy in the management of acute interstitial nephritis. However, the diagnosis can often be made on clinical grounds, particularly when there is a strong temporal relation with the offending agent and clinical evidence of hypersensitivity. In Case 36-2003, a renal biopsy was performed because of uncertainty about the diagnosis, the patient's advanced renal failure, and the lack of recovery after ibuprofen had been discontinued.
Ajay K. Singh, M.B., M.R.C.P.
Hasan Bazari, M.D.
Robert Colvin, M.D.
Harvard Medical School
Boston, MA 02115
asingh@partners.org
References
Buysen JG, Houthoff HJ, Krediet RT, Arisz L. Acute interstitial nephritis: a clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990;5:94-99.
Rossert J. Drug-induced acute interstitial nephritis. Kidney Int 2001;60:804-817.
Furthermore, other findings indicate that using only clinical features to diagnose acute interstitial nephritis is often hazardous. In an analysis of data from 25 patients with suspected acute interstitial nephritis who subsequently underwent renal biopsy, Buysen et al. reported that the clinicians' diagnosis had been confirmed in only 11 patients (44 percent).3 We would like to emphasize both the difficulty of diagnosing drug-induced acute interstitial nephritis on the basis of clinical findings alone and the fundamental diagnostic role of renal histologic evaluation.
Luis Teixeira, M.D.
Alfred Mahr, M.D.
H?pital Cochin
Paris 75679, France
luisteixeira@wanadoo.fr
Sonia Barry, M.D.
H?pital Lagny Marne-la-Vallée
Lagny sur Marne 77400, France
References
Case Records of the Massachusetts General Hospital (Case 36-2003). N Engl J Med 2003;349:2055-2063
Rossert J. Drug-induced acute interstitial nephritis. Kidney Int 2001;60:804-817.
Buysen JG, Houthoff HJ, Krediet RT, Arisz L. Acute interstitial nephritis: a clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990;5:94-99.
The discussants reply: Teixeira and colleagues suggest that "the rationale for treating drug-induced acute interstitial nephritis with corticosteroids remains unsubstantiated." However, for patients with severe renal dysfunction — particularly those in whom dialysis is initiated — both years of personal experience and published data support the use of corticosteroids. Indeed, Buysen et al.1 report that recovery from renal failure is faster in patients who are treated with corticosteroids than in those who are not. Although we agree that there has been no prospective controlled study of the efficacy of corticosteroids in acute interstitial nephritis, it is important not to overinterpret the conclusions of the seven studies cited by Teixeira et al. that do not support a role for corticosteroid treatment.2 These studies had major limitations in that they were small, nonrandomized, and retrospective. Indeed, patients treated with corticosteroids generally had worse base-line renal function than those not receiving corticosteroids. Our own practice in treating patients with severe renal dysfunction is to discontinue the drug and use high-dose corticosteroids. The rationale for using corticosteroids is to accelerate the recovery of renal function and to reduce the risk of interstitial scarring. We agree that there is an important role for a percutaneous renal biopsy in the management of acute interstitial nephritis. However, the diagnosis can often be made on clinical grounds, particularly when there is a strong temporal relation with the offending agent and clinical evidence of hypersensitivity. In Case 36-2003, a renal biopsy was performed because of uncertainty about the diagnosis, the patient's advanced renal failure, and the lack of recovery after ibuprofen had been discontinued.
Ajay K. Singh, M.B., M.R.C.P.
Hasan Bazari, M.D.
Robert Colvin, M.D.
Harvard Medical School
Boston, MA 02115
asingh@partners.org
References
Buysen JG, Houthoff HJ, Krediet RT, Arisz L. Acute interstitial nephritis: a clinical and morphological study in 27 patients. Nephrol Dial Transplant 1990;5:94-99.
Rossert J. Drug-induced acute interstitial nephritis. Kidney Int 2001;60:804-817.