Treatment of Severe Tubulointerstitial Nephritis with Confusion

Initial Assessment and Management

The American College of Physicians recommends ruling out other causes of acute kidney injury, including hypovolemia, medications, obstruction, and IV contrast, before confirming diagnosis of tubulointerstitial nephritis with confusion 1, 2
Renal biopsy should be considered to confirm diagnosis, especially in severe cases with confusion, which may indicate advanced disease 3, 4
The European Renal Association recommends immediately discontinuing any potential nephrotoxic medications, particularly proton pump inhibitors 1 and NSAIDs 1
The American Society of Nephrology suggests discontinuing antibiotics that may cause acute interstitial nephritis 5 and immune checkpoint inhibitors if applicable 2

For severe tubulointerstitial nephritis with confusion, the American College of Physicians recommends admitting the patient for monitoring and fluid balance, and initiating IV methylprednisolone 1-2 mg/kg daily 6, 3
The National Kidney Foundation suggests monitoring creatinine every 24 hours 6
After initial stabilization, the European Renal Association recommends transitioning to oral prednisone 1 mg/kg/day (maximum 80 mg/day) if improvement occurs, and tapering steroids gradually over 4 weeks for severe cases 1, 5, 6

Confusion in tubulointerstitial nephritis may indicate severe uremia requiring urgent intervention, or electrolyte disturbances, according to the American Society of Nephrology 5
The American College of Physicians recommends monitoring and correcting electrolyte abnormalities, acid-base disturbances, and uremic toxins 5, 6

The National Kidney Foundation suggests checking creatinine, electrolytes, and mental status daily during the acute phase 6, 1
The American Society of Nephrology recommends monitoring for steroid-related complications, including providing calcium/vitamin D supplementation, monitoring blood glucose, and considering gastric protection 6
The European Renal Association suggests considering PJP prophylaxis if steroids are continued for more than 4 weeks 6

Failing to identify and remove the offending agent can worsen outcomes, according to the American Society of Nephrology 5
The American College of Physicians recommends permanently discontinuing the immune checkpoint inhibitor in severe cases of immune checkpoint inhibitor-related nephritis, and considering more aggressive immunosuppression 1, 2, 3