warfarin and Nephritis--Interstitial

Acute kidney injury in the context of nephrotic syndrome is a serious and alarming clinical problem. Largely, acute kidney injury is a relatively frequent complication among patients with comorbidities while it has been independently associated with an increased risk of adverse outcomes, including death and chronic kidney disease. Nephrotic syndrome, without hematuria or with minimal hematuria, includes a list of certain glomerulopathies; minimal change disease, focal segmental glomerulosclerosis and membranous nephropathy. In the light of primary nephrotic syndrome, pathophysiology of acute kidney injury is differentiated by the nature of the primary disease and the severity of the nephrotic state. This review aims to explore the clinical circumstances and pathogenetic mechanisms of acute kidney injury in patients with nephrotic syndrome due to primary glomerulopathies, focusing on newer perceptions regarding the pathogenesis and management of this complicated condition, for the prompt recognition and timely initiation of appropriate treatment in order to restore renal function to its baseline level. Prompt recognition of the precise cause of acute kidney injury is crucial for renal recovery. Clinical characteristics, laboratory and serological findings along with histopathological findings, if required, will reveal the implicated pathway leading to individualized approach and management.

Topics: Acute Kidney Injury; Anticoagulants; Biopsy; Calcineurin Inhibitors; Glomerulosclerosis, Focal Segmental; Humans; Kidney; Nephritis, Interstitial; Nephrotic Syndrome; Renal Veins; Thrombosis; Warfarin

A 73-year-old man presented for evaluation of weakness and black tarry stools that occurred 1 day prior to admission. His medical history is significant for diabetes mellitus, stage 3 chronic kidney disease and deep vein thrombosis on warfarin. He was admitted to the hospital and was found to have acute kidney injury and gastrointestinal bleeding due to a supratherapeutic International Normalized Ratio. His hospital course was complicated by persistent decline in his renal function. He was given intravenous fluid resuscitation, fresh frozen plasma and packed red blood cells for his acute blood loss anaemia. Urinalysis was consistent with acute tubular necrosis. Given the persistent rise in creatinine, a kidney biopsy was obtained, and was significant for mild inflammatory changes, without evidence of vasculitis or allergic interstitial nephritis. Histopathological examination with tissue fixation revealed cholesterol embolisation. Given that he had no recent endovascular procedure or instrumentation, this atheroembolic event was attributed to his warfarin use.

Topics: Aged; Anticoagulants; Diagnosis, Differential; Embolism, Cholesterol; Gastrointestinal Hemorrhage; Humans; Male; Muscle Weakness; Nephritis, Interstitial; Venous Thrombosis; Warfarin

Warfarin sodium has been associated with leucocytoclastic vasculitis and has once been associated with allergic interstitial nephritis. Hypersensitivity to warfarin sodium simultaneously resulting in allergic interstitial nephritis and leucocytoclastic vasculitis has not yet been previously reported. We present a 48-year-old man who was on warfarin sodium for 2 months and presented with acute renal failure and reddish purplish macules on his hypogastric regions and lower extremities bilaterally. Kidney biopsy showed allergic interstitial nephritis and punch skin biopsy showed leucocytoclastic vasculitis. Both biopsies also showed high eosinophil count, highly suggestive of a drug-induced reaction. After a negative comprehensive work-up and the absence of other recent medication changes, our patient was determined to have allergic interstitial nephritis and leucocytoclastic vasculitis secondary to warfarin sodium.

Topics: Anticoagulants; Drug Hypersensitivity; Humans; Male; Middle Aged; Nephritis, Interstitial; Vasculitis, Leukocytoclastic, Cutaneous; Warfarin

A 57-year-old woman with pulmonary sarcoidosis was admitted to the hospital because of an elevation of serum creatinine and blood urea nitrogen. On admission, the laboratory data suggested interstitial nephritis without proteinuria and hematuria, whereas a renal biopsy showed granulomatous interstitial nephritis and mild mesangial proliferative glomerulonephritis. Immunoglobulin and C1q deposits were negative, but mannose-binding lectin, C3, C4d, and C5b-9 deposits were marked in the glomerular mesangial areas. The lectin pathway of complement activation may have contributed to the development of glomerular injury in this patient. DNA of Propionibacterium acnes , which is now strongly suspected as the pathogen of sarcoidosis, was detected in the patient's glomerular mesangial cells; tubular epithelial cells, which were involved in granulomatous inflammation; and mononuclear cells in epithelioid granulomas by in situ hybridization. These findings may add new insights to the pathogenesis of renal sarcoidosis, including its relation to infection, because mannose-binding lectin plays a crucial role in the host defense against various pathogens. From this case of renal sarcoidosis, it is hypothesized that P acnes may be involved in pathogenesis of granulomatous interstitial nephritis and that it plays a role in glomerular complement activation via the lectin pathway.

Topics: Anti-Inflammatory Agents; Anticoagulants; Complement Activation; Complement C3; Complement C4b; Complement Membrane Attack Complex; DNA, Bacterial; Drug Therapy, Combination; Female; Glomerular Mesangium; Glomerulonephritis, Membranoproliferative; Gram-Positive Bacterial Infections; Heparin; Histiocytosis, Langerhans-Cell; Humans; Lung; Lung Diseases, Interstitial; Mannose-Binding Lectin; Methylprednisolone; Middle Aged; Nephritis, Interstitial; Peptide Fragments; Prednisone; Propionibacterium acnes; Sarcoidosis; Warfarin

Topics: Anemia, Hemolytic; Animals; Blood Proteins; Blood Sedimentation; Dehydration; Diabetes Mellitus; Dog Diseases; Dogs; Epilepsy, Temporal Lobe; Hematocrit; Nephritis, Interstitial; Pancreatic Diseases; Pancreatic Neoplasms; Warfarin