Original article
Clinical Manifestations and Outcomes of Fluoroquinolone-Related Acute Interstitial Nephritis

https://doi.org/10.1016/j.mayocp.2017.08.024Get rights and content

Abstract

Objective

To describe the clinical presentation, diagnosis, and outcomes of patients with biopsy-proven acute interstitial nephritis (AIN) related to fluoroquinolone (FQ) therapy.

Patient and Methods

We conducted a retrospective review of biopsy-proven AIN attributed to FQ use at Mayo Clinic's campus in Rochester, Minnesota, from January 1, 1993, through December 31, 2016. Cases were reviewed by a renal pathologist and attributed to FQ use by an expert nephrologist. We also reviewed and summarized all published case reports of biopsy-proven AIN that were attributed to FQ use.

Results

We identified 24 patients with FQ-related biopsy-proven AIN at our institution. The most commonly prescribed FQ was ciprofloxacin in 17 patients (71%), and the median antibiotic treatment duration was 7 days (interquartile range [IQR], 5-12 days). The median time from the initiation of FQ to the diagnosis of AIN was 8.5 days (IQR, 3.75-20.75 days). Common clinical manifestations included fever (12; 50%), skin rash (5; 21%), and flank pain (2; 8%), and 9 (38%) had peripheral eosinophilia. However, 4 (17%) of the patients were asymptomatic at the time of diagnosis and AIN was suspected on the basis of routine laboratory monitoring. Most patients (17; 71%) recovered after the discontinuation of antibiotic therapy, and renal function returned to baseline at a median of 20.5 days (IQR, 11.75-27.25 days). Six patients (25%) required temporary hemodialysis, and 14 patients (58%) received corticosteroid therapy.

Conclusion

The onset of FQ-related AIN can be delayed, and a high index of suspicion is needed by physicians evaluating these patients. Overall outcomes are favorable, with recovery to baseline renal function within 3 weeks of discontinuing the offending drug.

Section snippets

Patients and Methods

We retrospectively reviewed all cases of biopsy-proven AIN that were attributed to FQ use at Mayo Clinic's campus in Rochester, Minnesota, from January 1, 1993, through December 31, 2016. Cases were identified using the Department of Laboratory Medicine and Pathology database. Patient demographic data, comorbidities, clinical presentation, and outcome data were abstracted from electronic medical records. Specifically, we reviewed indication of antimicrobial use, the duration and type of FQ

Results

We identified 24 patients with FQ-related biopsy-proven AIN managed at Mayo Clinic's campus in Rochester, Minnesota, from January 1, 1993, through December 31, 2016. Demographic characteristics, clinical manifestations, and outcomes of these patients are summarized in the Table. (Details of individual cases are described in Supplemental Table 1, available online at http://www.mayoclinicproceedings.org.) This represented 10% of all biopsy-proven AIN cases during this time period at our

Discussion

Acute interstitial nephritis is an important cause of reversible AKI and occurs because of a hypersensitivity reaction in the renal parenchyma. Most (71%) of AIN is thought to be drug-induced,15, 16, 18, 19 followed by less common etiologies such as autoimmune diseases (20%),16, 32 infection (4%), and idiopathic (5%). The kidneys are the organs most susceptible to drug-induced hypersensitivity reactions, as they are a major site of excretion for drugs and drug metabolites.23 In a recent study,

Conclusion

Fluoroquinolone-related AIN is infrequent but must be considered by treating physicians when patients receiving FQ therapy develop AKI. Timing of AIN onset, clinical manifestations, and severity of kidney injury can be variable. Diagnosis can be challenging, as most patients do not have extrarenal manifestations of AIN and renal biopsy may be necessary to establish the diagnosis. Discontinuing the offending agent, with or without adjunctive corticosteroid therapy, leads to resolution of AKI in

Acknowledgments

We thank Patricia Erwin, MLS, Assistant Professor of Medical Education, for her help in searching online bibliographic databases of the National Library of Medicine and Ovid Embase for cases of fluoroquinolone-related acute interstitial nephritis.

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    Data Previously Presented: Presented in part at the 2017 Annual Meeting of the Infectious Diseases Society of America in San Diego, CA.

    Potential Competing Interests: Dr Leung serves as a consultant to Prothena and receives grants from Omeros Corporation. Dr Nasr receives royalties from Alnylam Pharmaceuticals, Inc.

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