tubulointerstitial nephritis uveitis syndrome
Introduction
Brief introduction of uveitis syndrome in tubulointerstitial nephritis Tubulointerstitial nephritis and uveitis syndrome (TINU) is a newly discovered syndrome involving the kidney and the eye. It occurs mostly in adolescent women and the kidney is characterized by idiopathic acute tubulointerstitial nephritis. The main manifestation of the eye is bilateral non-granulomatous anterior uveitis. basic knowledge The proportion of illness: 0.001% Susceptible people: no special people Mode of infection: non-infectious Complications: cataract glaucoma retinal detachment
Cause
Tubulointerstitial nephritis etiology of uveitis syndrome
(1) Causes of the disease
The etiology of this syndrome is unclear, although anti-toxoplasma antibodies, anti-Chlamydia antibodies and anti-EBV antibodies have been detected in the serum of patients, but no other authors have supported it. The relevant infectious factors in the pathogenesis of this syndrome The role still needs to be further determined. Although some patients have used antibiotics or non-steroidal anti-inflammatory drugs before the disease, the clinical manifestations do not support the view that the disease is caused by drugs. Recently, studies have shown that this disease has HLA-DR14 antigen. Correlation, suggesting that there may be immune genetic factors involved in the occurrence of this disease.
(two) pathogenesis
The pathogenesis is still unclear. Serological tests and renal biopsy results suggest that it is an immune disease because patients have both humoral and cellular immune abnormalities, but more evidence suggests T cell-mediated immunity. The reaction plays an important role in its occurrence:
1 The renal interstitial infiltrating cells are mainly T lymphocytes;
2 occasionally see granulomatous inflammation;
3 fluorescein-labeled antibody examination revealed no deposition of immune complexes;
4 generally have a good response to glucocorticoids, but the exact role of cellular and humoral immunity in this syndrome remains to be further studied.
Prevention
Tubulointerstitial nephritis uveitis syndrome prevention
As the inflammation is alleviated, the frequency of eyedrops is gradually reduced. Non-steroidal anti-inflammatory drug eye drops can also be used for eye treatment. However, it is necessary to pay attention to the slow withdrawal of the drug to prevent recurrence. The recurrence of the local treatment is still effective in patients with poor response to hormone therapy, or repeated recurrence of TINU syndrome, which may leave varying degrees of renal dysfunction, but only a few (< 5%) progress to end-stage renal failure.
Complication
Tubulointerstitial nephritis complication of uveitis syndrome Complications cataract glaucoma retinal detachment
The most common complications are post-iris adhesions, followed by complicated cataracts, secondary glaucoma, and complications such as rhegmatogenous retinal detachment and optic disc neovascularization.
Symptom
Tubulointerstitial nephritis uveitis syndrome symptoms common symptoms double renal diffuse lesions granuloma sclera outer inflammation retinal hemorrhage loss of appetite fatigue weak photoprotein urine
1. Systemic manifestations: The patient's symptoms are mainly fever (53%), weight loss (47%), fatigue and discomfort (44%), loss of appetite (28%), abdominal pain (28%), joint pain or muscle pain ( 17%), nausea, vomiting, headache, etc. These non-specific symptoms often appear in the first month before kidney disease, kidney damage mainly manifests as polyuria, frequent urination, proteinuria, normal blood glucose (kidney) diabetes, amino acid urine, Hematuria under the microscope, white blood cells in the urine, casts, etc., urinary 2-microglobulin is also elevated, some patients may have elevated levels of serum urea nitrogen and creatinine, usually without hypertension, such nephritis to glucocorticoids or Other immunosuppressive agents generally respond well, but this syndrome can progress to chronic inflammation and even renal failure.
2. Ocular manifestations: The ocular manifestations of this syndrome are mainly uveitis, which usually occurs after several weeks or months of kidney damage. Analysis of the patient's data found that 65% of the cases were, 21% Patients with uveitis and interstitial nephritis occur simultaneously, and 15% of patients with uveitis occur before kidney damage.
Patients had red eyes, eye pain (77%), other symptoms with blurred vision or decreased vision, photophobia, uveitis typically showed bilateral acute non-granulomatous anterior uveitis, and about 15% showed a single Side involvement, 9% of the two eyes alternate disease, ophthalmologic examination can be found ciliary congestion, mild to severe anterior chamber inflammation (anterior chamber inflammatory cells and flashing glow), occasional aqueous fibrinous exudation, iris nodules.
Uveitis can also be manifested as bilateral granulomatous anterior uveitis; in addition to total uveitis, intermediate uveitis and posterior uveitis, it has been reported that patients can initially present bilateral anterior uveitis Later, inflammation spreads backward, causing intermediate uveitis and posterior uveitis, changes in the ciliary body flat snow sloping, vitreous inflammatory cells and opacity, cystoid macular edema, focal or multifocal choroiditis, Optic disc edema and optic disc hemorrhage, retinal vascular sheath, retinal hemorrhage, chorioretinal scar formation, etc., some patients may occasionally have dry eyes, scleral outer layer inflammation.
Renal tubulointerstitial nephritis uveitis syndrome is prone to recurrence. Observation of 50 patients who were followed up for more than 2 years found that 54% of patients had recurrence of uveitis, and a small number of patients presented with chronic menstruation. Multiple acute exacerbations, younger patients (under 20 years of age) are prone to such chronic inflammation.
Examine
Tubulointerstitial nephritis, uveitis syndrome
1. Blood test Patients may have the following abnormalities:
1 mild positive cytochrome anemia;
2 ESR is accelerated;
3 plasma gamma globulin, increased levels of acute reactive protein;
4 serum creatinine and urea nitrogen levels increased; 5 eosinophils increased.
2. Urine examination Patients may have the following abnormalities:
1 proteinuria, often +~++;
2 hematuria;
3 tubular urine;
4 white blood cells appear in the urine;
5 amino acid urine;
6 urinary 2-microglobulin increased;
7 urine sugar is positive, but blood sugar levels are normal.
3. Immunological examination Patients may have the following abnormalities:
1 Increased CD4 and CD45RA T cells in peripheral blood helper T cells;
2 peripheral blood cytotoxic T cells increased;
3 renal tubular antigen lymphocyte migration inhibition test was positive;
4 serum IgG, IgM, IgA levels increased;
5 anti-neutrophil cytoplasmic antibody positive;
6 anti-nuclear antibody positive;
7 immune complex is positive.
Fluorescein fundus angiography: Matsuo analyzed the clinical manifestations and fluorescein fundus angiography changes in 15 patients with tubulointerstitial nephritis uveitis syndrome, and found that all patients had iritis or iridocyclitis. There were 8 cases of optic disc congestion, 9 cases of vitreous opacity, 10 cases of retinal changes (retinal hemorrhage, retinal vein inflammation, subretinal exudation, retinal punctate lesions, cystoid macular edema), and 13 cases showed optic disc dye osmosis. Leakage, 12 cases of mid-week retinal microvascular leakage, 2 cases of retinal pigment epithelial damage, it can be seen that fluorescein fundus angiography can find more fundus changes.
Diagnosis
Diagnosis and diagnosis of uveitis syndrome in renal tubulointerstitial nephritis
Diagnostic criteria
There is no satisfactory diagnostic criteria for tubulointerstitial nephritis uveitis syndrome. Mandeville et al. have developed a diagnostic criteria that stipulates the diagnostic criteria for acute interstitial nephritis and the characteristics of uveitis. Based on the diagnostic parameters, It is judged as deterministic tubulointerstitial nephritis uveitis syndrome, suspected tubulointerstitial nephritis uveitis syndrome and tubulointerstitial nephritis uveitis syndrome, due to this standard More cumbersome, we have listed the diagnosis points of this syndrome in Table 3 for clinical reference.
It is generally believed that a diagnosis can be made based on typical renal damage, bilateral non-granulomatous anterior uveitis, but sometimes the patient's uveitis can occur before the kidney damage, or the uvea begins several months after the kidney damage. Inflammation, which brings certain difficulties to the diagnosis, so not only the medical history should be asked in detail, but also follow-up observation should be taken to confirm the diagnosis.
Because patients have fever, fatigue, nausea, vomiting, weight loss, abdominal pain and other systemic non-specific manifestations, patients with binocular non-granulomatous anterior uveitis should be examined for blood and urine to avoid delay in diagnosis.
Differential diagnosis
Because bilateral non-granulomatous anterior uveitis of this syndrome is not characteristic, these patients should be careful to rule out other causes and other unique types that can cause anterior uveitis, the main of which are juvenile chronic joints. Inflammation associated with uveitis, sarcoma-like uveitis and Sjögren syndrome, seronegative spondyloarthropathy.
Uveitis associated with juvenile chronic arthritis occurs mostly in children and young women, and uveitis also manifests as bilateral non-granulomatous inflammation, which is associated with tubulointerstitial nephritis uveitis syndrome. The performance is similar, but the former often has a history of arthritis (mainly knee, ankle). Uveitis is typically characterized by occult morbidity and chronic menstruation, often with zonal corneal degeneration, complicated cataracts and secondary glaucoma. Symptoms, anti-nuclear antibodies are mostly positive, and patients have no abnormal laboratory tests for kidney damage, which contribute to the identification of the two diseases.
Sarcomatoid disease can cause kidney damage and uveitis, and the level of immunoglobulin is often increased, similar to that caused by tubulointerstitial nephritis uveitis syndrome, but uveitis caused by sarcoma-like disease is mostly granulomatous. Anterior uveitis or uvitis, which causes hilar lymphadenopathy and lung disease, serum angiotensin-converting enzyme, and elevated lysozyme levels, all contribute to differential diagnosis.
Sjögren syndrome is often characterized by interstitial nephritis, some patients with antinuclear antibodies, rheumatoid factor, anti-DNA antibody positive, these are similar to tubulointerstitial nephritis, but it usually occurs in 30 to 50 years old, the main performance of the eye For dry eyes, not uveitis, it is not difficult to make a differential diagnosis based on these.
