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12 nefritis intersticial

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Clase: Nefritis Tubulointersticial. Dr Herrera

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12 nefritis intersticial

  1. 1. • Injuria renal asociado generalmente a deterioro de la función renal .• Asociado a infiltrado de cell inflamatorias en túbulos e intersticio.• 15% - 30% de Bx en AKI se deben a NIA.• Datos subestimados : no todos los AKI biopsia, ni todos los NIA hacen AKI relevante
  2. 2. The changing profile of acute tubulointerstitial nephritis Backer RJ; Pusey CD, Nephrol Dial Transplant 2004 Jan;19(1):8-11• Una revision de 3 series:128 pacientes – (71%) Drugs, with antibiotics responsible for 1/3 – (15%) Infection-related – (8%) Idiopathic – (5%) Tubulointerstitial nephritis and uveitis (TINU) syndrome – (1%) Sarcoidosis
  3. 3. • Lesión renal : mecanismo de hipersensibilidad al fármaco estimula una respuesta inmunitaria• Una reacción mediada por cell y provoca una infiltración intersticial : linfocitos T, monocitos, células plasmáticas y eosinófilos.• A nivel sistémico: rash cutáneo, fiebre, artralgias, eosinofilia y, en ocasiones elevación de las enzimas hepáticas
  4. 4. SINTOMAS SIGNOS■ Asymptomatic ■ Normal examination■ Constitutional (e.g. fever, ■ Fever chills, malaise, anorexia) ■ Skin rash (e.g. morbilliform,■ Arthralgia, arthritis maculopapular, diffuse■ Myalgia, myositis erythroderma, toxic■ Flank pain epidermal necrolysis) ■ Enlarged lymph nodes ■ Flank tenderness or presence of a palpable mass
  5. 5. (A) methicillin-induced AIN(B) AIN induced by drugs other than methicillin(C) AIN induced by NSAIDs and associated with a nephrotic syndromehttp://www.nature.com/ki/journal/v60/n2/full/4492487a.html#fig2
  6. 6. • Cada factor etiológico tiene su propio mecanismo de acción.• AKI puede ser por polifarmacia
  7. 7. • B LACTAMICOS. - Metilcilina es el ejemplo clasico - En dias o pocas semanas - Fiebre, Rash y eosinofiluria > 75%• NO B LACTAMICOS - Ciprofloxacino es el ejemplo clasico.• AINES - Es rara la presencia de la triada clasica - El tiempo de exposicion: 6- 8 meses - Pueden presentar proteinuria
  8. 8. • Identificar en la medida de lo posible el o los fármacos causantes.• En la mayoría de los casos esto es suficiente por el buen pronostico de la NIA.• Quedan por resolver otras cuestiones de las que disponemos de muy escasa información contrastada: - ¿Qué ocurrecon el infiltrado intersticial característico de las NIAF? - ¿Cuánto tiempo tarda en resolverse? - ¿Se resuelve restaurándose la primitiva integridad del parénquima o se trasforma en zonas de fibrosis?
  9. 9. • Hidratación: Siempre.• Corticoides: La mayoría de los estudios, corto seguimiento, sin biopsias .• González E, Gutiérrez E, Galeano C, et al. Early steroid treatment improves the recovery of renal function in patients with drug-induced acute interstitial nephritis. Kidney Int 2008;73:940-6.
  10. 10. • Es una enfermedad larvada que representa el escenario final de una exposición crónica a varios agentes.• Es casi siempre diagnosticada incidentalmente.• Los síntomas dependen de las funciones tubulares comprometidas (nicturia, poliuria, orina clara, etc., acidosis)
  11. 11. • En el 50% la uremia es el primer síntoma• El 50% con HTA• Síndrome de Fanconi (glucosuria, aminoaciduria, hipouricemia e hipomagnesemia)• Proteinuria < 1 gr/24h• La anemia suele ser deproporcionada
  12. 12. • Fibrosis tubulointersticial• Atrofia tubular• Esclerosis arteriolar• La bx no discierne etiología
  13. 13. • Es la mas común• Combinacion: AINES + Acetminofen, Penacetin Acetaminofen (3 – 4 kg/año), etc.• Mas comun en mujeres de > 60ª• Dx TAC: calcificaciones papilares• Tto de soporte.• Aumento de incidencia de Canceres uroepiteliales
  14. 14. • 50%: Disfunción tubular Distal: Diabetes Insípida nefrogenica Vasopresina resistente.• la NITC es menos frecuente sobre todo en los que han tenido episodios de intoxicación por Litio.• Dilataciones micro quísticas en el túbulo distal, con vocalización y presencia de filamentos.• Tratamiento: Evitar dosis toxicas de Litio
  15. 15. • Frecuente en población negra y en poblaciones mineras.• HTA, gota recurrente y ERC.• Niños: Encefalopatía, Fanconi e IRA.• Hiperuricemia es desproporcionada.• Dx es difícil si no hay clínica de saturnismo.• Dx Deposito en huesos de CaNa2 EDTA. Tratamiento: EDTA

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