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Acute tubulointerstitial nephritis — ESENeph MCQ

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HardGlomerulonephritisAcute tubulointerstitial nephritisESENeph

A 67-year-old woman develops fever, rash and eosinophilia 4 weeks after starting omeprazole. Creatinine has risen from 78 to 244 micromol/L; urine dipstick shows protein 1+ and blood 1+. Urine microscopy shows white cell casts and sterile pyuria. Renal ultrasound is normal. What is the most likely diagnosis?

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Correct answer: C — Drug-induced acute tubulointerstitial nephritis

The triad of rash, eosinophilia and AKI with sterile pyuria after a new drug exposure strongly suggests acute tubulointerstitial nephritis, and proton-pump inhibitors are recognised triggers. Acute tubular necrosis is usually linked to ischaemia or toxins and does not usually cause sterile pyuria with systemic hypersensitivity features. Minimal change disease would present with heavy proteinuria and hypoalbuminaemia. The pearl is that withdrawal of the culprit drug is the key first step; biopsy and corticosteroids are considered when recovery is incomplete or diagnosis is uncertain.

Reference: NICE NG148; BNF; Renal Medicine 2022 Curriculum