Chapter 146: Renal Tubular Disease
Tubulointerstitial diseases constitute a diverse group of acute and chronic, hereditary and acquired disorders involving the renal tubules and supporting structures (Table 146-1). Functionally, they may result in a wide variety of physiologic phenotypes, including nephrogenic diabetes insipidus (DI) with polyuria, non-anion-gap metabolic acidosis, salt wasting, and hypo- or hyperkalemia. Azotemia is common, owing to associated glomerular fibrosis and/or ischemia. Compared with glomerulopathies, proteinuria and hematuria are less dramatic, and hypertension is less common. The functional consequences of tubular dysfunction are outlined in Table 146-2.
Toxins | |
---|---|
Exogenous toxins | Metabolic toxins |
Analgesic nephropathya | Acute uric acid nephropathy |
Lead nephropathy | Gouty nephropathya |
Chinese herb nephropathy | Hypercalcemic nephropathy |
Balkan endemic nephropathy | Hypokalemic nephropathy |
Miscellaneous nephrotoxins (e.g., antibiotics, cyclosporine, radiographic contrast media, heavy metals)a,b | Miscellaneous metabolic toxins (e.g., hyperoxaluria, cystinosis, Fabry’s disease) |
Neoplasia | |
Lymphoma | |
Leukemia | |
Multiple myeloma (cast nephropathy, AL amyloidosis) | |
Immune Disorders | |
Acute (allergic) interstitial nephritisa,b | Transplant rejection |
Sjögren’s syndrome | HIV-associated nephropathy |
Amyloidosis | |
Vascular Disorders | |
Arteriolar nephrosclerosisa | Sickle cell nephropathy |
Atheroembolic disease | Acute tubular necrosisa,b |
Hereditary Renal Diseases | |
Disorders associated with renal failure | Hereditary tubular disorders |
Autosomal dominant polycystic kidney disease | Bartter’s syndrome (hereditary hypokalemic alkalosis) |
Autosomal recessive polycystic kidney disease | Gitelman’s syndrome (hereditary hypokalemic alkalosis) |
Medullary cystic kidney disease Hereditary nephritis (Alport’s syndrome) | Pseudohypoaldosteronism type I (hypotension/salt wasting and hyperkalemia) |
Pseudohypoaldosteronism type II (hereditary hypertension and hyperkalemia) | |
Liddle’s syndrome (hypertension and hypokalemia) | |
Hereditary hypomagnesemia | |
Hereditary nephrogenic diabetes insipidus | |
X-linked (AVP receptor dysfunction) | |
Autosomal (aquaporin-2 dysfunction) | |
Infectious Injury | |
Acute pyelonephritisa,b | |
Chronic pyelonephritis | |
Miscellaneous Disorders | |
Chronic urinary tract obstructiona | |
Vesicoureteral refluxa | |
Radiation nephritis |
aCommon.
bTypically acute.
DEFECT | CAUSE(S) |
---|---|
Reduced GFRa | Obliteration of microvasculature and obstruction of tubules |
Fanconi syndrome | Damage to proximal tubular reabsorption of solutes, primarily glucose, amino acids, and phosphate; may also exhibit hypouricemia, proximal tubular acidosis, low-molecular-weight proteinuria |
Hyperchloremic acidosisa | 1. Reduced ammonia production (CKD) or excretion (hyperkalemia) |
2. Inability to acidify the collecting duct fluid (distal renal tubular acidosis) | |
3. Proximal bicarbonate wasting (proximal RTA) | |
Polyuria, isothenuriaa | Damage to medullary tubules (thick ascending limb and/or collecting duct) and vasculature |
Hypokalemic alkalosis | Damage or hereditary dysfunction of the thick ascending limb or distal convoluted tubule (Bartter’s and Gitelman’s syndromes) |
Magnesium wasting | Damage or hereditary dysfunction of the thick ascending limb or distal convoluted tubules |
Hyperkalemiaa | Potassium secretory defects including aldosterone resistance |
Salt wasting | Distal tubular damage with impaired sodium reabsorption |
aCommon.
Abbreviations: CKD, chronic kidney disease; RTA, renal tubular acidosis.
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Citation
Kasper, Dennis L., et al., editors. "Chapter 146: Renal Tubular Disease." Harrison's Manual of Medicine, 20th ed., McGraw Hill Inc., 2020. harrisons.unboundmedicine.com/harrisons/view/Harrisons-Manual-of-Medicine/623061/all/Chapter_146:_Renal_Tubular_Disease.
Chapter 146: Renal Tubular Disease. In: Kasper DLD, Fauci ASA, Hauser SLS, et al, eds. Harrison's Manual of Medicine. McGraw Hill Inc.; 2020. https://harrisons.unboundmedicine.com/harrisons/view/Harrisons-Manual-of-Medicine/623061/all/Chapter_146:_Renal_Tubular_Disease. Accessed February 1, 2025.
Chapter 146: Renal Tubular Disease. (2020). In Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L., Jameson, J. L., & Loscalzo, J. (Eds.), Harrison's Manual of Medicine (20th ed.). McGraw Hill Inc.. https://harrisons.unboundmedicine.com/harrisons/view/Harrisons-Manual-of-Medicine/623061/all/Chapter_146:_Renal_Tubular_Disease
Chapter 146: Renal Tubular Disease [Internet]. In: Kasper DLD, Fauci ASA, Hauser SLS, Longo DLD, Jameson JLJ, Loscalzo JJ, editors. Harrison's Manual of Medicine. McGraw Hill Inc.; 2020. [cited 2025 February 01]. Available from: https://harrisons.unboundmedicine.com/harrisons/view/Harrisons-Manual-of-Medicine/623061/all/Chapter_146:_Renal_Tubular_Disease.
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