TNF alpha inhibitors and the Kidney

Recently I came across a patient with Crohn's disease on Certolizumab with renal issues now. Certolizumab is a TNF-alpha inhibitor. So I did some literature search on adverse effects of TNF--alpha inhibitors esp. on kindey. There are many TNF-alpha inhibitors in market at present - Infliximab(Remicade), Etanercept(Enbrel), Adalimumab(Humira), Certolizumab(Cimzia) and Golimumab(Simponi). These agents are now more frequently prescribed for patients with Crohn's disease, Rheumatoid arthritis, Psoriatic arthritis, Ankylsoing spondylitis. There is increasing evidence that a minority of patients treated with TNF-alpha inhibitors develop new autoimmune diseases like vasculitis, lupus, interstitial lung disease, uveitis etc (Ramos-Casals et al, Medicine(Baltimore) 2007). Most of these conditions resolved with discontinuation of the TNF-alpha inhibitor. There is also a published series of 5 Glomerulonephritis cases reported with these agents (Stokes et al, NDT 2005). 2 out of these 5 cases were lupus nephritis, 2 were pauci-immune GN and 1 membranous GN with immune complex renal vasculitis. Mean duration of TNF-alpha inhibitor exposure in these patients was 6 months and there was clinical/laboratory improvement in most cases with drug withdrawal.