Tubulointerstitial nephritis and cancer chemotherapy: update on a neglected clinical entity
Medha Airy1, Rajeev Raghavan, Luan D Truong
1Department of Medicine, Division of Nephrology, Baylor College of Medicine, Houston, TX, USA.
Background:
Cancer patients are particularly vulnerable to drug-induced kidney injury during their chemotherapy. Whereas the direct nephrotoxic effects of these drugs are well recognized, that of tubulointerstitial nephritis (TIN) is less well known, underdiagnosed and often reported only as a functional tubular disorder. The diagnosis of acute TIN is important because of its insidious onset with tubular dysfunction, its potential reversibility if detected early and the possibility of its response to steroid treatment.
Methods:
We performed a literature review (44 cases) and reviewed our institutional biopsy register (12 cases) of patients on cancer chemotherapy with documented TIN. Biopsies were considered in three groups: acute TIN, chronic TIN and acute on chronic TIN. The outcomes that were evaluated were recovery of kidney function, development of chronic kidney disease and onset of end-stage renal disease (ESRD).
Results:
Ifosfamide, BCG, tyrosine kinase inhibitors and premetrexed were the most commonly implicated drugs. Ifosfamide and premetrexed were associated with worst outcomes. Recovery of kidney function was better in acute TIN (ATIN) (29%) with fewer progressing to ESRD (12.9%) than with chronic TIN (7.6% recovery, 15.3% ESRD). Steroid use appeared to favorably alter outcomes in ATIN (40% recovery) compared with conservative treatment (18.75% recovery). Peak serum creatinine, age, gender and type of malignancy did not influence outcomes.
Conclusions:
As a potentially reversible lesion that can respond to withdrawal of the suspected agent, and in some cases to a short course of steroid therapy, it is important to consider ATIN in the differential diagnosis of all cases of acute kidney injury in cancer patients on chemotherapy.
Insights
Chemotherapy can cause acute tubulointerstitial nephritis (ATIN) in cancer patients, often underdiagnosed. Early detection and steroid treatment improve kidney function recovery, highlighting the importance of considering ATIN in acute kidney injury.
Area of Science:
- Nephrology
- Oncology
- Pharmacology
Background:
- Cancer patients undergoing chemotherapy are susceptible to drug-induced kidney injury.
- Tubulointerstitial nephritis (TIN) is an underdiagnosed cause of kidney dysfunction in these patients, often presenting as a functional tubular disorder.
- Early diagnosis of acute TIN (ATIN) is crucial due to its potential reversibility and response to steroid treatment.
Purpose of the Study:
- To investigate the incidence, implicated drugs, and outcomes of tubulointerstitial nephritis in cancer patients receiving chemotherapy.
- To evaluate the impact of acute versus chronic TIN on kidney function recovery and progression to end-stage renal disease (ESRD).
- To assess the efficacy of steroid therapy in managing ATIN.
Main Methods:
- A literature review of 44 cases and analysis of 12 institutional biopsy cases of cancer patients with documented TIN.
- Biopsies were categorized into acute TIN, chronic TIN, and acute on chronic TIN.
- Outcomes assessed included kidney function recovery, development of chronic kidney disease, and onset of ESRD.
Main Results:
- Ifosfamide, BCG, tyrosine kinase inhibitors, and premetrexed were common culprits, with ifosfamide and premetrexed linked to poorer outcomes.
- Acute TIN showed better kidney function recovery (29%) and lower ESRD rates (12.9%) compared to chronic TIN (7.6% recovery, 15.3% ESRD).
- Steroid treatment in ATIN correlated with improved recovery (40%) versus conservative management (18.75%).
Conclusions:
- Acute tubulointerstitial nephritis (ATIN) is a critical consideration in the differential diagnosis of acute kidney injury in cancer patients on chemotherapy.
- Recognizing and treating ATIN, potentially with steroid therapy, can lead to reversible kidney injury.
- Prompt diagnosis and management are essential to improve renal outcomes in this vulnerable population.
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