Acute Kidney Injury Relevant to Tubulointerstitial Nephritis with Late-Onset Uveitis Superimposed by Thrombotic Microangiopathy: A Case Report and Review of the Literature

Abstract

Background: The syndrome of tubulointerstitial nephritis and uveitis (TINU) is an uncommon and multisystemic autoimmune disorder. This review reports a rare case of TINU being superimposed on thrombotic microangiopathy (TMA) and, by comparing with the available literature, also summarizes the clinical features, associated conditions, treatment, and outcome of patients with TINU. Summary: Herein, we report the case of a 37-year-old male patient with acute kidney injury (AKI) clinicopathologically identified as malignant hypertension-induced TMA superimposed by acute tubulointerstitial nephritis, which was suspected to be related to drug hypersensitivity. After treatment with oral prednisone combined with a renin-angiotensin system inhibitor, the patient achieved partial renal recovery and was withdrawn from hemodialysis. Recurrent AKI concomitant with new-onset asymptomatic uveitis was detected during routine clinical follow-up after cessation of prednisone. TINU was then diagnosed, and prednisone followed by cyclophosphamide was prescribed. The patient achieved better renal recovery than in the first round of treatment and maintained stable renal function afterward. By reviewing the literature, 36 cases were reported as TINU superimposed on other conditions, including thyroiditis, osteoarthropathy, and sarcoid-like noncaseating granulomas. Key messages: TINU could be complicated by many other conditions, among which TMA is very rare. When presented as AKI, kidney biopsy is important for differential diagnosis. The case also shows that recurrent AKI with concomitant uveitis after prednisone withdrawal strongly suggested the need for long-term follow-up and elongated prednisone therapy for TINU syndrome.

A Young Man With Acute Kidney Injury and Uveitis: An Unusual Presentation and Case Report

“…Ophthalmic findings were present in all cases. Two of which were unilateral uveitis [4,8]. Similarly, our case had left anterior uveitis.…”

“…Three out of four patients were female [4,6,7]. The clinical presentation varied among the cases ranging from reduced visual acuity and/or burning sensation in the eyes with a blurred vision to lumbar pain, transitory dark urine, anorexia, weight loss, significant hypertension, progressive renal dysfunction, and periorbital and leg edema [4,[6][7][8]. Our patient presented with left eye congestion with no pain or discharge and weight loss.…”

“…Certain precipitating factors for TINU are reported in three of the cases [6][7][8]: firstly, upper respiratory tract infection associated with mild conjunctivitis and found prior to the diagnosis of TINU [6]; secondly, the use of herbal medications in the preceding two weeks prior to a finding of elevated serum creatinine level and the diagnosis of TINU [8]; and thirdly, the presence of multiple chronic diseases including hypertension, dyslipidemia, obesity, and insulin resistance with a sedentary lifestyle [7]. Ophthalmic findings were present in all cases.…”

“…Similarly, our case had left anterior uveitis. The other two were bilateral anterior uveitis [6,8]. In one of the aforementioned case reports, new-onset bilateral uveitis occurred in a patient after prednisone was tapered to discontinuation at four months [8].…”

“…The other two were bilateral anterior uveitis [6,8]. In one of the aforementioned case reports, new-onset bilateral uveitis occurred in a patient after prednisone was tapered to discontinuation at four months [8]. Treatments used to treat uveitis included topical ophthalmic prednisone, topical cycloplegic, and topical ocular therapy, such as scopolamine, nepafenac, and dexamethasone.…”