Content area
Full Text
Background
Acute interstitial nephritis is a less frequently reported adverse effect of flucloxacillin compared with other well known associations such as hepatotoxicity.
Objective
This article describes the conservative management of a case of flucloxacillin induced acute renal failure, and reviews the available evidence on the treatment of drug induced acute interstitial nephritis, including the use of corticosteroids.
Discussion
Drug induced acute interstitial nephritis can be managed conservatively by cessation of the suspected offending drug in many cases. Referral should be made to a nephrologist, with consideration given to renal biopsy, followed by trial of corticosteroids, if renal function does not improve within 7 days of drug cessation.
The temporal relationship between the onset of acute renal failure and the initiation of flucloxacillin, and subsequently, the cessation of flucloxacillin and the normalisation of renal function, suggests a causative role of flucloxacillin in acute renal failure in this case. Flucloxacillin is significantly excreted renally.1 Given mr a's weight was 80.10 kg, with normal eGFr and serum creatinine on presentation, he received appropriate dosage of flucloxacillin.
In Mr A's case, a pre-renal cause of acute renal failure is unlikely. He remained euvolaemic during admission without any sign to suggest hypovolaemia, such as postural hypotension. A postrenal cause is excluded by an unremarkable renal tract ultrasound, without prostatomegaly or hydronephrosis. Another possibility is sepsis. However, Mr A was systemically well. His joint aspirate, blood and urine cultures were negative. Given the time course association with the use of flucloxacillin, the most likely mechanism of action is flucloxacillin induced acute interstitial nephritis. Flucloxacillin has several other well known adverse effects, including hepatitis, gastrointestinal upset and hypersensitivity reactions.1 These were not relevant in Mr A's case.
Acute interstitial nephritis
Acute interstitial nephritis (AIN) is an important cause of acute renal failure.2,3 Histological features are interstitial oedema and an interstitial infiltrate consisting of T lymphocytes and monocytes.2 Drug induced AIN is the most common form of AIN. Acute interstitial nephritis may also be secondary to infection and autoimmune disorders.
Drugs commonly implicated in AIN include:
* penicillins
* cephalosporins, and
* nonsteroidal anti-inflammatory drugs (NSAIDs).
In drug induced AIN, acute renal impairment is temporally related to the inciting drug. Renal impairment occurs within 3 weeks of starting the drug in 80%...