Granulomatous Interstitial Nephritis: A Clinicopathologic Study of 46 Cases from a Single Institution

Abstract

Acute interstitial nephritis is commonly seen in kidney biopsies of patients with acute renal failure; however, granulomatous interstitial nephritis (GIN) is rare. We identified 46 cases of GIN in a 17-year period in this institution and we investigated their most probable etiologies. Complete clinical information was available in 38 patients. Seventeen of 38 patients (44.7%) were classified as drug-induced. Renal sarcoidosis was responsible for 28.9% of cases, and the remaining 15.9% of cases included Wegeners granulomatosis, foreign body giant cell reaction, GIN secondary to intravesical bacillus Calmette-Guérin therapy for bladder cancer, and xanthogranulomatous pyelonephritis. Clinical investigation failed to reveal possible etiology in 4 patients (10.5%), classified as idiopathic. We concluded that three quarters of our cases were either drug-induced or due to sarcoidosis; only a small proportion of our cases occurred secondary to any other cause or to unknown factors.

Granulomatous Interstitial Nephritis as a Manifestation of Crohn Disease

“…Although the presence of granulomas is an infrequent finding in renal biopsies, it may help to narrow the differential diagnosis. 17 Bijol et al 18 reported that drug-induced interstitial nephritides tend to have a diffuse distribution, with many eosinophils and neutrophils, as well as ill-formed granulomas, but the granulomas in our patient were well formed and have a focal distribution, with a few eosinophils and neutrophils. Granulomatous interstitial nephritis (GIN) is reported in between 0.5% and 0.9% of native renal biopsies, 19 in 0.6% of renal transplant biopsies, 20 and in chronic lymphocytic leukemia, and it also is seen in an idiopathic form.…”

“…21 The rise in creatinine level preceded the introduction of ciprofloxacin, and the level continued to rise after metronidazole was discontinued. 18 Nonetheless, we cannot exclude 5-ASA as the cause, because the patient has not resumed taking that drug and remains stable.…”

“…Mycobacteria and fungi (eg, Candida, Cryptococcus, Histoplasma capsulatum, and Rhodococcus) are the main infective causes and are the main etiologic factor in cases involving renal transplants. In the study by Bijol et al 18 on patients with GIN, 17 of 38 patients (44.7%) were classified as drug induced. Renal sarcoidosis was responsible for 28.9% of cases, and the remaining 15.9% of cases included Wegener granulomatosis, foreign body giant cell reaction, GIN secondary to intravesical Bacillus CalmetteGuérin therapy for bladder cancer, and xanthogranulomatous pyelonephritis.…”

“…Renal sarcoidosis was responsible for 28.9% of cases, and the remaining 15.9% of cases included Wegener granulomatosis, foreign body giant cell reaction, GIN secondary to intravesical Bacillus CalmetteGuérin therapy for bladder cancer, and xanthogranulomatous pyelonephritis. 18 In our center, a database of renal biopsies with 10 383 samples listed 34 cases of GIN, representing only 0.3% of all biopsies. The cause at the time was considered to be drug allergy (n ¼ 7), CD (n ¼ 3), sarcoidosis (n ¼ 3), autoimmune disorder (n ¼ 2, rheumatoid arthritis, lupus erythematosus), anti-neutrophil cytoplasmic antibody-related vasculitis with granulomas (n ¼ 2), infection (tuberculosis, adenovirus), other glomerular disease (n ¼ 2), transplant rejection (n ¼ 2), obstruction (n ¼ 1), and renal cell carcinoma (n ¼ 1).…”

Renal granuloma and immunoglobulin M-complex glomerulonephritis: a case of common variable immunodeficiency?

“…Bijol et al reported an incidence of granulomatous interstitial nephritis in approximately 0.5% of their medical renal biopsy specimens [8]. In retrospective case series of renal granulomas, most granulomas were categorized as drug-induced [8][9][10], and sarcoidosis was responsible for 9% to 29% of cases. A significant proportion of granulomas, 8% to 25%, were categorized as idiopathic.…”