Improvement in renal function after empirical steroid therapy in NSAID-induced acute kidney injury

Abstract

We report a case of an 81-year-old woman, who developed acute kidney injury (AKI) during treatment of gout with naproxen. The patient’s other comorbidities were chronic kidney disease grade G3b, chronic heart failure with permanent atrial fibrillation, arterial hypertension, osteoarthritis and osteoporosis. After excluding other causes of AKI, a presumptive diagnosis of NSAID-induced acute interstitial nephritis was established. Because of multiple comorbidities and anticoagulation, renal biopsy was not attempted. Since we observed no improvement after naproxen discontinuation, steroid-pulse therapy was initiated, with subsequent oral steroid follow-up. As a result, after several days we achieved improvement in renal function, with complete recovery after couple of months. In conclusion, we suggest that aggressive steroid therapy be considered for patients with presumptive diagnosis of NSAID-induced interstitial nephritis, especially when comorbidities and general state preclude invasive diagnostic measures.

Keywords

• Interstitial nephritis
• acute kidney injury
• NSAID toxicity

References

1. Raghavan R, Eknoyan G. Acute interstitial nephritis - a reappraisal and update. Clin Nephrol. 2014;82(3):149-62. doi: 10.5414/cn108386.
2. Joyce E, Glasner P, Ranganathan S, SwiateckaUrban A. Tubulointerstitial nephritis: Diagnosis, treatment, and monitoring. Pediatr Nephrol. 2017;32(4):577-87. doi: 10.1007/s00467-016-3394-5.
3. Heptinstall RH. Interstitial nephritis. A brief review. Am J Pathol. 1976;83(1):213-36.
4. Finnigan N, Bashir K. Allergic Interstitial Nephritis (AIN). Retrieved from: https://www. ncbi.nlm.nih.gov/books/NBK482323/
5. Kodner CM, Kudrimoti A. Diagnosis and management of acute interstitial nephritis. Am Fam Physician. 2003;67(12):2527-34.
6. Harrison T, Isselbacher K, Wilson J. Harrison’s principles of internal medicine. Acute Interstitial Nephritis. Retrieved from: https://accessmedicine.mhmedical.combook. aspx?bookID=2129#159214099
7. Schrier R, Coffman T, Falk R. Schrier’s Diseases of the Kidney. Philadelphia; Wolters Kluwer 2015. 1115-1150 p.
8. Sakarcan A, Marcille R, Stallworth J. Antibioticinduced recurring interstitial nephritis. Pediatr Nephrol. 2002;17(1):50-1. doi: 10.1007/ s004670200009.

9. Quinto LR, Sukkar L, Gallagher M. Effectiveness of corticosteroid compared with non-corticosteroid therapy for the treatment of drug-induced acute interstitial nephritis: a systematic review. Intern Med J. 2019;49(5):562-9. doi: 10.1111/imj.14081.
10. Brachemi S, Bollée G. Renal biopsy practice: What is the gold standard? World J Nephrol. 2014;3(4):287-94. doi: 10.5527/wjn.v3.i4.287.
11. Levin A, Stevens PE. Summary of KDIGO 2012 CKD Guideline: Behind the scenes, need for guidance, and a framework for moving forward. Kidney Int. 2014;85(1):49-61. doi: 10.1038/ ki.2013.444.
12. Widecka K et al. Stanowisko ekspertów dotyczące hiperurykemii i jej leczenia u pacjentów z wysokim ryzykiem sercowo-naczyniowym. Arter Hypertens. 2017;21(1):1-9. doi: 10.5603/ AH.2017.0001.
13. Hahn K, Kanbay M, Lanaspa MA, Johnson RJ, Ejaz AA. Serum uric acid and acute kidney injury: A mini review. J Adv Res. 2017;8(5):529-36. doi: 10.1016/j.jare.2016.09.006.
14. Brar S, Ye F, James MT, Hemmelgarn B, Klarenbach S, Pannu N. Association of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use with outcomes after acute kidney injury. JAMA Intern Med. 2018;178(12):1681-90. doi: 10.1001/jamainternmed.2018.4749.
15. Sambrook PN. How to prevent steroid induced osteoporosis. Ann Rheum Dis. 2005;64(2):176-8. doi: 10.1136/ard.2003.018556.
16. Perazella MA, Markowitz GS. Bisphosphonate nephrotoxicity. Kidney Int. 2008;74(11):1385-93. doi: 10.1038/ki.2008.356.
17. Fernandez-Juarez G, Perez JV, Caravaca-Fontán F, Quintana L, Shabaka A, Rodriguez E, et al. Duration of treatment with corticosteroids and recovery of kidney function in acute interstitial nephritis. Clin J Am Soc Nephrol. 2018;13(12):1851- 8. doi: 10.2215/CJN.01390118.
18. Schwarz A, Krause PH, Kunzendorf U, Keller F, Distler A. The outcome of acute interstitial nephritis: risk factors for the transition from acute to chronic interstitial nephritis. Clin Nephrol. 2000;54(3):179-90.
19. Preddie DC, Markowitz GS, Radhakrishnan J, et al. Mycophenolate mofetil for the treatment of interstitial nephritis. Clin J Am Soc Nephrol. 2006;1(4):718-722. doi: 10.2215/CJN.01711105.
20. Preddie DC, Markowitz GS, Radhakrishnan J, Nickolas TL, D’Agati VD, Schwimmer JA, et al. Acute interstitial nephritis: Clinical features and response to corticosteroid therapy. Nephrol Dial Transplant. 2004;19(11):2778-83. doi: 10.1093/ndt/ gfh485.
21. Acute interstitial nephritis - Symptoms, diagnosis and treatment. BMJ Best Practice. Bestpractice.bmj. com. 2019 Retrieved from: https://bestpractice. bmj.com/topics/en-us/938
22. Rossert J. Drug-induced acute interstitial nephritis. Kidney Int. 2001;60(2):804-17. doi: 10.1046/j.1523-1755.2001.060002804.x.
23. Waljee AK, Rogers MA, Lin P, Singal AG, Stein JD, Marks RM, et al. Short term use of oral corticosteroids and related harms among adults in the United States: Population based cohort study. BMJ. 2017;357:j1415. doi: 10.1136/bmj.j1415.
24. Hogan JJ, Mocanu M, Berns JS. The native kidney biopsy: Update and evidence for best practice. Clin J Am Soc Nephrol. 2016;11(2): 354-62. doi: 10.2215/CJN.05750515.
25. Visconti L, Cernaro V, Ricciardi CA, Lacava V, Pellicanò V, Lacquaniti A, et al. Renal biopsy: Still a landmark for the nephrologist. World J Nephrol. 2016;5(4):321-7. doi: 10.5527/wjn.v5.i4.321.
26. Coresh J. Update on the burden of CKD. J Am Soc Nephrol. 2017;28(4):1020-2. doi: 10.1681/ ASN.2016121374.
27. Trevena L. Minimally disruptive medicine for patients with complex multimorbidity. Aust J Gen Pract. 2018;47(4):175-9. doi: 10.31128/AFP-10-17- 4374.
28. Gajewski P. Interna Szczeklika 2021. Kraków; Medycyna Praktyczna 2021. 1662-7 pp.