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Renal hypersensitivity caused by drug — Clinical Guidelines

Overview

Renal hypersensitivity caused by drugs refers to severe systemic reactions often involving multiple organs, including the kidneys, triggered by drug exposure. These reactions can manifest as drug-induced hypersensitivity syndrome (DIHS) or drug reaction with eosinophilia and systemic symptoms (DRESS), characterized by skin rash, fever, lymphadenopathy, and internal organ involvement 1 8 9 10.

Diagnosis

Clinical Presentation: Skin rash, fever, lymphadenopathy, organ-specific symptoms (including renal involvement) 1 8 9 10.

Laboratory Tests: Elevated liver enzymes, eosinophilia, and reactivation of herpesviruses (HHV-6, EBV, CMV) 1 3 13.

Histopathology: Skin biopsy may show characteristic changes; renal biopsy may reveal interstitial nephritis or other patterns 1 8.

Differential Diagnosis: Exclude other causes of multi-organ involvement, such as infections and autoimmune diseases 2 7.

Management

Drug Withdrawal: Immediate discontinuation of the offending drug 1 8 10.

Supportive Care: Fluid resuscitation, antipyretics, and management of organ dysfunction (e.g., renal replacement therapy if needed) 1 3 9.

Immunosuppressive Therapy: Corticosteroids are often first-line; adjunctive agents like IVIG or other immunosuppressants may be considered in severe cases 1 8 10.

Monitoring: Close monitoring of organ function, particularly renal function, and viral reactivation 3 9.

Special Populations

Pediatrics: DIHS can occur in children, often with severe presentations; early recognition and management are crucial 8.

Elderly: Increased risk of complications due to pre-existing comorbidities; careful monitoring and supportive care are essential 9.

Key Recommendations

Prompt Identification and Withdrawal of Offending Drug: Immediate cessation of the suspected drug upon suspicion of hypersensitivity reaction (Evidence: Strong 1 8).

Initiate Corticosteroid Therapy for Severe Cases: Use corticosteroids as first-line immunosuppressive therapy in patients with severe organ involvement (Evidence: Moderate 1 8).

Monitor for Viral Reactivation and Organ Dysfunction: Regular monitoring of liver, kidney function, and viral markers (e.g., HHV-6) is essential (Evidence: Moderate 3 13).

Consider Adjunctive Immunosuppressive Therapy in Refractory Cases: Use IVIG or other immunosuppressants if there is no response to corticosteroids (Evidence: Weak 10).

Enhance Documentation Practices: Ensure accurate recording of drug hypersensitivity reactions in electronic health records to improve identification and management (Evidence: Expert opinion 11).

References

1 Xavier H, Hara I, Ottesen LH, Verheijen RB, Ghiorghiu D, Morgan C. A Comprehensive Methodology to Systematically Identify Drug Hypersensitivity and Anaphylactic Reactions in Clinical Trial Databases. Pharmaceutical medicine 2020. link 2 Brockow K, Ardern-Jones MR, Mockenhaupt M, Aberer W, Barbaud A, Caubet JC et al.. EAACI position paper on how to classify cutaneous manifestations of drug hypersensitivity. Allergy 2019. link 3 Wei Y, Li N, Xing H, Guo T, Gong H, Chen D. Effectiveness of fecal microbiota transplantation for severe diarrhea after drug-induced hypersensitivity syndrome. Medicine 2019. link 4 Mendes D, Alves C, Loureiro M, Fonte A, Batel-Marques F. Drug-induced hypersensitivity: A 5-year retrospective study in a hospital electronic health records database. Journal of clinical pharmacy and therapeutics 2019. link 5 Sachs B, Fischer-Barth W, Merk HF. Reporting rates for severe hypersensitivity reactions associated with prescription-only drugs in outpatient treatment in Germany. Pharmacoepidemiology and drug safety 2015. link 6 Dodiuk-Gad RP, Laws PM, Shear NH. Epidemiology of severe drug hypersensitivity. Seminars in cutaneous medicine and surgery 2014. link 7 Burbach GJ, Zuberbier T. Diagnosis of drug-induced skin reactions: a future role for computer-aided systems?. Current opinion in allergy and clinical immunology 2011. link 8 Orbak Z, Sepetcigil O, Karakelleoğlu C, Gülses S. Penicillin V-induced drug rash with eosinophilia and systemic symptoms. The West Indian medical journal 2010. link 9 Kano Y, Ishida T, Hirahara K, Shiohara T. Visceral involvements and long-term sequelae in drug-induced hypersensitivity syndrome. The Medical clinics of North America 2010. link 10 Brown RJ, Rother KI, Artman H, Mercurio MG, Wang R, Looney RJ et al.. Minocycline-induced drug hypersensitivity syndrome followed by multiple autoimmune sequelae. Archives of dermatology 2009. link 11 Radford A, Undre S, Alkhamesi NA, Darzi SA. Recording of drug allergies: are we doing enough?. Journal of evaluation in clinical practice 2007. link 12 Tsuruta D, Someda Y, Sowa J, Kobayashi H, Ishii M. Drug hypersensitivity syndrome caused by minocycline. Journal of cutaneous medicine and surgery 2006. link 13 Kano Y, Hiraharas K, Sakuma K, Shiohara T. Several herpesviruses can reactivate in a severe drug-induced multiorgan reaction in the same sequential order as in graft-versus-host disease. The British journal of dermatology 2006. link 14 . Executive summary of disease management of drug hypersensitivity: a practice parameter. Joint Task Force on Practice Parameters, the American Academy of Allergy, Asthma and Immunology, the American Academy of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immunology. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology 1999. link 15 Wengrower D, Tzfoni EE, Drenger B, Leitersdorf E. Erythroderma and pneumonitis induced by penicillin?. Respiration; international review of thoracic diseases 1986. link 16 Rosei MA, Citro G, D'Erme M, Finazzi-Agrò A. Some immunochemical properties of pig kidney DOPA decarboxylase. Immunological communications 1984. link 17 Tomecki KJ, Catalano CJ. Dapsone hypersensitivity. The sulfone syndrome revisited. Archives of dermatology 1981. link

Renal hypersensitivity caused by drug