Korean J Gastroenterol.  2014 May;63(5):308-312. 10.4166/kjg.2014.63.5.308.

A Case of Late Onset-Acute Tubulointerstitial Nephritis with Infliximab and Mesalazine Treatment in a Patient with Crohn's Disease

• Yoo YJ
• Chung SY
• Gu DH
• Ko GJ
• Pyo HJ
• Kwon YJ
• Bak YT
• Won NH

• KMID: 2155329
• DOI: http://doi.org/10.4166/kjg.2014.63.5.308

Abstract

Infliximab is a chimeric anti-tumor necrosis factor-alpha monoclonal antibody. Infusion related reactions and infection are well known side effects of infliximab; however, renal complications have not been well recognized. We report on a patient with late onset-acute tubulointerstitial nephritis (ATIN) after treatment with infliximab and mesalazine for Crohn's disease. A 25-year-old woman was admitted with a purpuric rash on both lower extremities and arthralgia. She had been diagnosed with Crohn's disease 5.6 years previously and had been treated with mesalazine and infliximab. Serum creatinine level, last measured one year ago, was elevated from 0.6 mg/dL to 1.9 mg/dL. Results of urinalysis, ultrasound, and serologic examinations were normal. With a tentative diagnosis of Henoch-Schonlein purpura, oral prednisolone was given, and serum creatinine decreased to 1.46 mg/dL, but was elevated to 2.6 mg/dL again at two months after discontinuation of prednisolone. Renal biopsy indicated that ATIN was probably induced by drug, considering significant infiltration of eosinophils. Concomitant use of infliximab with mesalazine was supposed to trigger ATIN. Oral prednisolone was administered, and serum creatinine level showed partial recovery. Thus, ATIN should be suspected as a cause of renal impairment in Crohn's disease even after a long period of maintenance treatment with infliximab and mesalazine.

Keyword

Acute tubulointerstitial nephritis; Acute kidney injury; Crohn disease; Infliximab

MeSH Terms

Adalimumab/therapeutic use
Anti-Inflammatory Agents/therapeutic use
Creatine/blood
Crohn Disease/*drug therapy
Drug Therapy, Combination
Eosinophils/immunology
Female
Humans
Infliximab/*adverse effects/*therapeutic use
Kidney/pathology
Mesalamine/*adverse effects/*therapeutic use
Nephritis, Interstitial/*diagnosis/drug therapy/*etiology
Prednisolone/therapeutic use
Adalimumab
Anti-Inflammatory Agents
Creatine
Mesalamine
Prednisolone
Infliximab

Figure

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  Fig. 1. Changes of serum creatinine levels. Creatinine level showed a slight decrease after initial administration of oral prednisolone. However, it increased again when the steroid was discontinued according to infliximab treatment. Oral prednisolone (0.5 mg/kg) was reintroduced, and the serum creatinine level remained nearly stable after adalimumab treatment.

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  Fig. 2. Histologic examination with light microscopy of kidney. (A) There was diffuse tubular damage and infiltration of interstitial inflammation into the tubular epithelial cells (H&E, ×100). (B) Inflammatory cell infiltration was superimposed on chronic tubulointerstitial nephritis, which manifested as tubular atrophy with attendant interstitial fibrosis. Infiltration of various inflammatory cells, including lymphocytes, plasma cells, eosinophils, and a few neutrophils, was observed, and a higher proportion of eosinophil infiltration (arrows) was noted (H&E, ×400).

Reference

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