Drug-induced acute interstitial nephritis: Prospective randomized trial comparing oral steroids and high-dose intravenous pulse steroid therapy in guiding the treatment of this condition

Abstract

The most important aspect of treating drug-induced acute interstitial nephritis (AIN) is timely discontinuation of the offending drug. Steroids, oral as well as intravenous (IV), are used in the treatment of drug-induced AIN. The present study was undertaken to compare the efficacy of oral prednisolone versus IV suprapharmacological doses of corticosteroids in the treatment of drug-induced AIN. This prospective randomized controlled study included drug-induced AIN diagnosed on histopathology over a period of two years. Patients were randomized to oral prednisolone (Group A) 1 mg/kg for two weeks or pulse methylprednisolone (Group B) 30 mg/kg for three days (maximum 1 g) followed by oral prednisolone 1 mg/kg for two weeks, tapered over two weeks. Response was reported as complete remission (CR) [improvement in estimated glomerular filtration rate (eGFR) to ≥60 mL/min/1.73 m], partial remission (PR) (improvement but eGFR <60 mL/min/1.73 m), or nonresponders to steroids (no CR/PR). Steroid therapy was instituted to 31 biopsy-proven AIN cases (Group A - 16 and Group B - 15). Drugs implicated in the causation of AIN included pantoprazole, diclofenac, rifampicin, naproxen, aspirin, imipenem, piroxicam, cefixime, lornoxicam, Chinese herbs, etoricoxib, ciprofloxacin, and phenytoin. There was no difference in the baseline parameters between the two groups. At the end of follow-up, 58.06% achieved CR and 41.93% achieved PR. In Group A, nine (56.2%) achieved CR and seven (43.7%) achieved PR. In Group B, nine (60%) achieved CR and six (40%) achieved PR. There was no significant difference between the two groups. Pulses of high doses of corticosteroids have a significant but transient anti-inflammatory effect. Both oral and IV suprapharmacological doses of corticosteroids are equally effective in the treatment of drug-induced AIN, if used early.

Management of Drug-Associated Acute Interstitial Nephritis

“…A prospective randomized trial of 31 patients with drug-associated AIN compared the use of 1 mg/kg per day prednisone equivalent with or without an initial bolus of 30 mg/kg methylprednisolone (maximum 1 g). Patients randomized to the pulse dose arm demonstrated a slightly greater improvement in kidney function by 1 week, but by weeks 2 and 3 the degree of recovery from baseline was similar between groups (13). In a multicenter cohort of 182 cases of steroid-treated drug-associated AIN, no benefit was observed with the use of pulse-dose steroids or extended steroid courses.…”

Rivaroxaban-Induced Acute Interstitial Nephritis: A Case Report

“…The management of drug-induced AIN typically involves discontinuation of the offending agent [18]. The role of steroid treatment in drug-induced AIN remains controversial, and its efficacy has not been tested in randomized trials [19].…”

“…Chowdry et al reported no difference in outcome between the use of IV versus oral steroids, as both are equally effective when used early. More severe complications, however, such as an increase in blood pressure was more apparent in the IV steroid group [18]. There is no definitive guideline regarding the duration of steroid therapy in the treatment of drug-induced AIN.…”

Nefritis tubulointersticial aguda. Revisión bibliográfica

“…En las causas autoinmunes, la evaluación sistémica del paciente y el manejo inmunosupresor guiado es clave para el control de la enfermedad. En todos los casos la correcta reanimación hídrica del paciente es imprescindible (45) .…”