Department of Nephrology, Hospital Fundación de Alcorcón, Madrid, Spain.
Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.
Clin J Am Soc Nephrol. 2018 Dec 7;13(12):1851-1858. doi: 10.2215/CJN.01390118. Epub 2018 Nov 5.
Drug-induced acute interstitial nephritis represents an emerging cause of acute kidney disease, especially among polymedicated elderly patients. Although corticosteroids are frequently used, controversy exists about the timing of initiation, efficacy, safety, and duration of treatment.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We performed a retrospective study of 182 patients with biopsy-proven drug-induced acute interstitial nephritis from 13 Spanish centers. Exposure was defined as the length of corticosteroid treatment. The main outcome was the level of serum creatinine at month 6, with respect to baseline values.
The most common offending agents were nonsteroidal anti-inflammatory drugs (27%). In 30% of patients, the offending drug could not be identified. The median time to suspected drug withdrawal was 11 days (interquartile range, 5-22). All patients presented with acute kidney disease and were treated with corticosteroids. The mean initial dose of prednisone was 0.8±0.2 mg/kg per day. High-dose corticosteroid treatment was maintained for 2 weeks (interquartile range, 1-4). After 6 months, the mean recovered GFR was 34±26 ml/min per 1.73 m and ten patients required maintenance dialysis. Use of high-dose corticosteroids for 3 weeks or treatment duration >8 weeks were not associated with better recovery of kidney function. In the multivariable analysis, delayed onset of steroid treatment (odds ratio, 1.02; 95% confidence interval, 1.0 to 1.04) and the presence of interstitial fibrosis of >50% on the kidney biopsy specimen (odds ratio, 8.7; 95% confidence interval, 2.7 to 27.4) were both associated with serum creatinine level at month 6 of >75%, with respect to baseline values.
High-dose corticosteroid treatment for 3 weeks or prolonged treatment for >8 weeks were not associated with greater kidney function recovery in drug-induced acute interstitial nephritis. A delay in the initiation of corticosteroids resulted in worse recovery of kidney function.
药物性急性间质性肾炎是急性肾损伤的一个新兴病因，尤其是在多药治疗的老年患者中。虽然经常使用皮质类固醇，但在开始治疗的时机、疗效、安全性和治疗持续时间方面仍存在争议。
设计、地点、参与者和测量：我们对来自 13 个西班牙中心的 182 名经活检证实的药物性急性间质性肾炎患者进行了回顾性研究。暴露定义为皮质类固醇治疗的时间长度。主要结局是与基线相比，第 6 个月时的血清肌酐水平。
最常见的致病药物为非甾体抗炎药（27%）。在 30%的患者中，无法确定致病药物。怀疑停用可疑药物的中位时间为 11 天（四分位距 5-22）。所有患者均出现急性肾损伤，并接受皮质类固醇治疗。泼尼松的初始平均剂量为 0.8±0.2mg/kg/天。高剂量皮质类固醇治疗持续 2 周（四分位距 1-4）。6 个月后，平均恢复的肾小球滤过率为 34±26ml/min/1.73m，10 名患者需要维持性透析。3 周或 8 周以上的高剂量皮质类固醇治疗与肾功能恢复无明显相关性。多变量分析显示，类固醇治疗开始时间延迟（比值比 1.02；95%置信区间 1.0 至 1.04）和肾活检标本中间质纤维化>50%（比值比 8.7；95%置信区间 2.7 至 27.4）与与基线相比，第 6 个月时血清肌酐水平>75%有关。
在药物性急性间质性肾炎中，高剂量皮质类固醇治疗 3 周或延长治疗时间>8 周与肾功能恢复无显著相关性。皮质类固醇治疗开始时间的延迟导致肾功能恢复更差。
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