Duration of Treatment with Corticosteroids and Recovery of Kidney Function in Acute Interstitial Nephritis

Abstract

Background and objectives: Drug-induced acute interstitial nephritis represents an emerging cause of acute kidney disease, especially among polymedicated elderly patients. Although corticosteroids are frequently used, controversy exists about the timing of initiation, efficacy, safety, and duration of treatment.

Design, setting, participants, & measurements: We performed a retrospective study of 182 patients with biopsy-proven drug-induced acute interstitial nephritis from 13 Spanish centers. Exposure was defined as the length of corticosteroid treatment. The main outcome was the level of serum creatinine at month 6, with respect to baseline values.

Results: The most common offending agents were nonsteroidal anti-inflammatory drugs (27%). In 30% of patients, the offending drug could not be identified. The median time to suspected drug withdrawal was 11 days (interquartile range, 5-22). All patients presented with acute kidney disease and were treated with corticosteroids. The mean initial dose of prednisone was 0.8±0.2 mg/kg per day. High-dose corticosteroid treatment was maintained for 2 weeks (interquartile range, 1-4). After 6 months, the mean recovered GFR was 34±26 ml/min per 1.73 m² and ten patients required maintenance dialysis. Use of high-dose corticosteroids for 3 weeks or treatment duration >8 weeks were not associated with better recovery of kidney function. In the multivariable analysis, delayed onset of steroid treatment (odds ratio, 1.02; 95% confidence interval, 1.0 to 1.04) and the presence of interstitial fibrosis of >50% on the kidney biopsy specimen (odds ratio, 8.7; 95% confidence interval, 2.7 to 27.4) were both associated with serum creatinine level at month 6 of >75%, with respect to baseline values.

Conclusions: High-dose corticosteroid treatment for 3 weeks or prolonged treatment for >8 weeks were not associated with greater kidney function recovery in drug-induced acute interstitial nephritis. A delay in the initiation of corticosteroids resulted in worse recovery of kidney function.

Keywords: Adrenal Cortex Hormones; Biopsy; Corticosteroids; Kidney Function Tests; Nephritis, Interstitial; Prednisone; Recovery of Function; Retrospective Studies; Urinary Tract Physiological Phenomena; acute kidney disease; creatinine; drug induced acute interstitial nephritis; kidney; renal dialysis; treatment.

Graphical abstract

Figure 1.

Significant correlation between delay in the onset of corticosteroid treatment and serum creatinine at 6 months.

Figure 2.

Changes in serum creatinine according to grade of kidney recovery. Kidney function recovery occurred nearly exclusively during the first month of evolution. *P<0.001, non-recovery group versus partial-complete recovery groups; **P<0.001 partial versus complete recovery. M, month.