A 33-year-old male smoker presented with abdominal pain, fatigue, nausea and dark urine. Laboratory tests showed acute kidney injury with a creatinine of 12.2 mg/dl. Abdominal ultrasound found enlarged kidneys with increased echogenicity. He was treated conservatively but his kidney function declined further. A renal biopsy was planned but his condition dramatically improved with corticosteroid treatment, suggesting acute interstitial nephritis.

1. By DR. Ibrahim Elnagar
Resident of Nephrology

2. Personal History
 Male patient named Muhammed Ahmed Taha
 33 ys
 from elmanzala
 driver
 married , 3 offspring
 smoker 1 pack per day and no other special
habits

3. Present History
 2 days before admission
 colicky epigastric abdominal pain
o not radiated
o associated with fatigue ,nausea and dysuria with dark
yellow concentrated urine
o not associated with vomiting , diarrhea ,constipation
,or fever

4. Patient seeked medical advice and received the
following treatment:
 Cefotaxime
 NSAIDs in the form of spasmofen and voltaren amp.
 Pantoprazole
the condition didn’t improve→ Lab investigations
were ordered
Serum Creatinine 10 mg /dl

5. Past history
 No history of DM or HTN
 No history of renal disease or liver disease
 No history of immune disease
 No history of radio contrast
 No history of traveling abroad
 No history of previous surgery or blood transfusion

6. Examination
 Fully conscious
 BP 130/80
 Pulse 84/min sinus
 Respiratory rate 22/min
 No fever, rash, arthiritis
 Chest clear
 Abdomen lax ,no epigastric tenderness nor loin tenderness
 No edema LL neck vein not congested
 mild dehydrated

7. Investigation 1
 HB: 11.7 gm/DL TLC: 6.4 c/mcl PLT: 209c/mcl
 S. creatinine:12.2mg /dl S.Urea: 223mg/dl
 S.Na : 134mmol/L S.k: 5.4mmol/L
 PH: 7.35 H2co3 : 15 Pco2 : 26
 Ca: 9.5mg/dl Ph: 6.5mg/dl
 S.Albumen: 4gm/dl
 Liver enzymes : NAD
 UA Pus 30-35 RBCs 8-12 Alb +++

8. Abdominal US
 Both kidneys mildly enlarged and swollen with
increased cortical echogenicity denoting bilateral
acute nephropathy (RT: 12.9 x 5.5 LT: 12.5x5.2)
 Average parenchymal thickness
 No stones , backpressure ,or mass are seen
 Otherwise , abdominal US completely normal

9. Investigation 2
 ANA : -ve
 C3: normal
 C4: normal
 Virology: -ve
 Alb/creat :44mg/mmol (normal up to 30mg/mmol)

10. Management
 conservative :
o good hydration
o Symptomatic treatment for uremic symptoms and
oral bicarbonate Na supplementation
 Monitoring :
 dialysis : only on urgent indication

11. However,
 Patient clinically didn’t improve despite satisfactory UOP.
 Lab deteriorate :
o S.creat12.4 mg/dl
o PH: 7.3
o H2CO3:14
o PCO2: 23
o K: 7.3mmol/L
Patient started hemodialysis and was
prepared for renal biopsy

12. Corticosteroids?

13. active sediment in
urine
drug history ,
no improvement on
conservative
treatment
Acute interstitial
nephritis ???
CRP: 24 , but no fever
nor leukocytosis.
Diagnosis not
confirmed by renal
biopsy yet

15. Response
 Dramatic improvement occurs On the clinical side and
laboratory profile
7/76/75/74/73/72/7Lab
1.62.84.15.477.9S.creatinine
mg/dl
4.545.25.86.25.9S.K
mmol/l
250030004100490027001800UOP
ml/l