Abstract: PUB174
Vancomycin-Associated Acute Interstitial Nephritis (AIN) with Concurrent IgAN and Minimal Change Disease (MCD)
Session Information
Category: Glomerular Diseases
- 1402 Glomerular Diseases: Clinical, Outcomes, and Therapeutics
Authors
- David, Alexcis, West Virginia University, Morgantown, West Virginia, United States
- Kaushal, Amit, West Virginia University, Morgantown, West Virginia, United States
- Shahzad, Sheikh Raza, West Virginia University, Morgantown, West Virginia, United States
Introduction
AIN is a recognized cause of vancomycin nephrotoxicity, but concurrent glomerular disease is rarely reported. We present a biopsy-proven case of vancomycin associated AIN with concurrent MCD and mild IgAN.
Case Description
A 60-year-old man with newly diagnosed diabetes (HbA1c 12%) presented with MRSA toe infection treated with vancomycin with normal renal function (Cr 0.7 mg/dL). He developed supratherapeutic vancomycin trough (44 ug/ml) and AKI that peaked at 9.7 mg/dL. Urinalysis showed pyuria without hematuria, nephrotic range proteinuria (NRP) - UPCR 10 g/g, UACR 4.8 g/g. Serologies for glomerulonephritis were negative. Renal Biopsy revealed AIN, IgAN (M0E0S0T0C0), diabetic changes, and severe foot process effacement consistent with MCD. Vancomycin was discontinued and prednisone (1 mg/kg/day) started. The patient never required dialysis and renal function returned to baseline within 6 weeks.
Discussion
Vancomycin nephrotoxicity is mostly associated with acute tubular injury; AIN is less frequent. NRP is atypical and should prompt consideration of superimposed glomerular process. The degree of proteinuria and diffuse foot process effacement was disproportionate to early diabetic nephropathy, favoring superimposed podocytopathy. Drug induced MCD is rarely reported with vancomycin exposure. The co-existence of AIN and MCD may reflect shared T-cell-mediated hypersensitivity response to vancomycin. Mild IgAN may represent incidental finding, infection (MRSA) related, or less likely due to immune dysregulation. This case highlights diagnostic value of kidney biopsy in patients with severe AKI and NRP, when findings are not explained by diabetic kidney disease or hemodynamic injury alone. Recognizing combined tubulointerstitial and glomerular disease may influence management decisions, including drug withdrawal, and timing and duration of steroids therapy. As highlighted by Herlitz et al. (CJASN 2014), IgAN with nephrotic syndrome may represent either (1) mild mesangial disease with superimposed podocytopathy (MCD), where proteinuria correlates with foot process effacement and generally favorable prognosis, although may be associated with relapsing course and need for prolonged therapy directed at MCD or (2) severely proliferative IgAN where endocapillary proliferation and inflammation drive proteinuria. Distinguishing these patterns with biopsy is critical for prognosis and management.