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Immunosuppression for Drug-Induced Interstitial Nephritis

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Current total funding for this study: $141,900

Author:

Gearhoid McMahon
Nephrologist

Study Acronym:

IDIN

Acute interstitial nephritis causes acute kidney injury. Treatment varies from nephrologist to nephrologist because one group reads the literature and decides that steroids are best. Others read the same literature and say there is no conclusive evidence for steroids. Others read the literature and throw their hands in the air in frustration.

This study is for all three of those groups. All patients with AKI due to suspected AIN will undergo a renal biopsy in the absence of specific contraindications. Given the fact that the clinical criteria for AIN are not well defined currently, this would mean that many patients who did not have AIN could potentially have biopsies. This can be justified because currently, the definition of AIN is generally clinical and it would provide valuable information about the accuracy of clinical AIN diagnosis while simultaneously providing clinical correlates of AIN for better diagnosis in the future.

Patients with biopsy-proven AIN would be randomized 1:1 to steroid (1mg/kg prednisone to a maximum of 60mg daily) for 2 weeks followed by a taper over 2 months or placebo.

The primary outcome of this study would be dialysis dependence at 3 months.

Comments (1)

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In my experience, AIN tends to be an outpatient diagnosis. "SCr was 1, now 2, please eval". Or said another way, when inpatient, it's often confounded and treated like ATN. Thankfully nobody leaves the hospital still on Vanc/Zosyn ;)

So, in...

In my experience, AIN tends to be an outpatient diagnosis. "SCr was 1, now 2, please eval". Or said another way, when inpatient, it's often confounded and treated like ATN. Thankfully nobody leaves the hospital still on Vanc/Zosyn ;)

So, in the outpatient cases I've seen, this is a highly relevant question. But the outcome is wrong. The AINs I see may leave the patient with significant scar if left untreated - normal renal fx becomes permanent CKD3/4. Regain of lost fx (GFR change) would be better outcome.

Reasonable practice is to hold offending drug for 7 days. Treat if AKI persists. Randomization at that pre-determined observation date would at least clear out the spontaneous resolvers and better isolate the impact of steroids.

One of my patients is a relapser/remitter. He's now on Cellcept for > year, doing well, aiming for 2, after 2 relapses following slow steroid tapers. You only have to treat one of these patients to acknowledge that there is a role for steroids in these patients.

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