Chronic tubulointerstitial nephritis - Symptoms

Chronic drug-induced tubulointerstitial nephritis

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Analgesic nephropathy

Extrarenal symptoms of chronic tubulointerstitial nephritis (analgesic nephropathy), including the drug allergic triad, are not characteristic of NSAIDs.

Targeted detection of dependence on NSAIDs and non-narcotic analgesics allows early recognition of analgesic nephropathy or even prevention of it. Elderly patients are a particularly high-risk group. All clinical landmarks that allow suspecting chronic analgesic tubulointerstitial nephritis are united by the term "major analgesic syndrome".

Thirst and polyuria are considered to be relatively early clinical signs of analgesic nephropathy. Patients often have disturbances in urine acidification, some of them develop renal tubular acidosis, which manifests itself as muscle weakness, episodes of convulsions, as well as nephrolithiasis, calcification of the renal papillae, and osteodystrophy.

Major analgesic syndrome

Organ system	Signs
Gastrointestinal tract	Gastric ulcer and duodenal ulcer (especially with repeated gastrointestinal bleeding)
Blood system	Iron deficiency and macrocytic anemia Leukopenia
Cardiovascular system	Arterial hypertension Widespread atherosclerosis
CNS	Migraines Sleep disorders (insomnia) Abuse of alcohol, sleeping pills, drugs
Reproductive system	Libido disorder Infertility
"General" signs	Premature aging Malicious smoking Personality traits (hypochondriac type)

Patients with chronic analgesic tubulointerstitial nephritis are susceptible to urinary tract infections, which often occur with an erased clinical picture.

A typical symptom of analgesic nephropathy is arterial hypertension, sometimes difficult to control. Secondary metabolic disorders develop: the most typical is hyperuricemia, which also contributes to an increase in arterial pressure.

Criteria for the diagnosis of analgesic nephropathy:

• "Big ones."
  • Daily use of analgesics for more than 1 year.
  • A decrease in the volume of the kidneys, unevenness of their contours, calcifications in the medulla on ultrasound or CT.
• "Small".
  • The presence of any chronic pain syndrome.
  • History of gastric ulcer and duodenal ulcer.
  • Personality traits: depression, tendency to hypochondria.
  • Clinical features of chronic tubulointerstitial nephritis.
  • "Sterile" leukocyturia.

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Chronic tubulointerstitial nephritis

Chronic tubulointerstitial nephritis is one of the variants of nephrotoxic action of cyclosporine and tacrolimus. Arterial hypertension and slowly progressive renal failure are characteristic. The risk of damage to the renal tubulointerstitium when prescribing tacrolimus is less than cyclosporine.

Chronic tubulointerstitial nephritis is observed in patients taking Chinese herbs, in particular, herbal mixtures intended for the treatment of obesity, and also used as immunomodulators. In some patients, rapid development of terminal renal failure was noted. Renal dysfunction of varying severity was observed in all patients. In diagnostics, great importance is attached to a detailed acquaintance with the anamnesis. Chronic tubulointerstitial nephritis associated with the use of Chinese herbs containing aristolochic acid is a relatively new form of tubulointerstitial nephropathy, characterized by certain clinical features:

• the first symptom is often renal failure, including severe renal failure;
• characterized by significant tubular dysfunction;
• proteinuria is usually small;
• blood pressure often remains normal;
• Aristolochic acid has a carcinogenic effect on the urinary tract.

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Chronic tubulointerstitial nephritis due to environmental factors

Chronic tubulointerstitial nephritis is observed in 3-20% of patients taking lithium preparations for a long time. At least 20% of them develop nephrogenic diabetes insipidus with characteristic polydipsia and polyuria.

When taking lithium preparations, nephrotic syndrome may develop, which in most cases regresses when they are discontinued. Acute renal failure is observed in cases of severe lithium intoxication. The course of the disease is relatively benign: the development of terminal renal failure has not been described.

Variants of kidney damage caused by lithium intoxication:

• chronic tubulointerstitial nephritis;
• renal diabetes insipidus;
• renal tubular acidosis;
• nephrotic syndrome;
• acute renal failure.

There are two types of renal tubulointerstitial lesions caused by lead intoxication. Fanconi syndrome, associated with hyperuricemia and eosinophilic protein complexes in the urine containing lead, is more often observed in children who have received large doses of lead over a short period of time. Signs of kidney damage are usually reversible upon elimination of contact with lead.

Long-term intoxication with small doses of lead is accompanied by the development of chronic tubulointerstitial nephritis. Progression of renal failure is slow, tubulointerstitial fibrosis is usually insignificant.

Typical signs of chronic lead tubulointerstitial nephritis are arterial hypertension and uric acid metabolism disorders. Hyperuricemia is often very pronounced and is accompanied by attacks of typical gouty arthritis ("lead" gout). The incidence of kidney cancer is increased in workers who have had long-term contact with lead.

Cadmium kidney damage is characterized by signs of severe tubular dysfunction and polyuria. Some patients have arterial hypertension. Renal dysfunction is usually minimal, but cases of terminal renal failure are known.

There are several types of radiation nephropathy. The characteristic clinical features are the possibility of signs of kidney damage occurring long after exposure to ionizing radiation (sometimes years) and progression even after contact with it has been eliminated. A typical symptom of radiation nephropathy is arterial hypertension, which is usually difficult to control and often has a malignant course.

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Chronic tubulointerstitial nephritis in systemic diseases

Chronic sarcoid tubulointerstitial nephritis is found in patients with chronic sarcoidosis with other extrapulmonary symptoms of this disease. The signs are nonspecific, arterial hypertension is not an obligatory symptom. Renal failure in chronic sarcoid tubulointerstitial nephritis is usually moderate or often absent, cases of irreversible deterioration of renal function are extremely rare. Isolated observations of relapse of the disease in a renal transplant have been described. In most patients, calcium metabolism disorders are asymptomatic, but at least 5% develop nephrolithiasis and nephrocalcinosis.

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