A variety of renal disorders can occur inpatients with rheumatoid arthritis (RA), dueto the• Underlying disease• Drugs used• Concurrent renal disease.
• The most common disorders associated withRA are– Membranous nephropathy,– Secondary amyloidosis,– Focal, mesangial proliferative glomerulonephritis– Rheumatoid vasculitis,– Analgesic nephropathy• Other disorders, such as IgA nephropathyand minimal change disease have also beenreported in patients with RA.
DIAGNOSIS• History• Urinalysis– Membranous nephropathy and secondary amyloidosis arenoninflammatory conditions that are typically associated withmoderate to heavy proteinuria, a bland urine sediment, and arelatively normal plasma creatinine concentration.– Focal proliferative glomerulonephritis and rheumatoid vasculitisgenerally cause an active urine– Analgesic nephropathy is associated with a bland urinesediment, possible episodes of flank pain due to passage ofsloughed papillae.• Renal Biopsy
Rheumatoid Vasculitis Rheumatoid Vasculitis (RV) is a rare complication of longstanding,severe Rheumatoid Arthritis (RA) Estimated incidence in 2-5% of RA patients Associated with chronic RA: Mean lag time 13.6 years betweendiagnosis of RA and onset of RV Males are 2-4x more likely to develop RV than females Characterized by Extra-Articular involvement of disease Specifically the small and medium vessel arteries similar to polyarteritisnodosa Correlated to high RF levels and low complement at onset of RVdevelopment; indicating uncontrolled RA disease as a risk factor Anecdotal evidence that viral infections and drug reactions canprecipitate RV occurrence in RA patients
DISEASE MANIFESTATIONS Cutaneous Manifestations secondary to vascular compromise (90%of RV patients evidence this) Digital ischemia to fingers and toes Cutaneous ulcers resulting from obstruction of superficial and mediumvessels Nail fold infarcts Nerve Infarction (involves vasa vasorum) causing mononeuritismultiplex foot and wrist drop Associated w/ neuropathy characterized by numbness, burning, pain thatprecedes muscle weakness, paralysis, and wasting Ocular Scleritis Non specific signs: Fever, Weight Loss
INVOLVEMENT OF LARGE ARTERIES Classically, disease often limited to small andmedium arteries; case reports of large arteryinvolvement exist Bowel Renal Brain (CVA’s) Coronary Vasculitis (rare)
DIAGNOSIS OF RV– H&P: Suspect RV in any RA patient w/ fevers,weight loss, skin ulcerations, necrotic digits, or sx ofsensory or motor nerve dysfxn– Labwork: specifically elevated RF, low complement,elevated ESR, elevated Anti-CCP (citrullinatedpeptides) high odds ratio for possible RV in aperson w/ h/o RAKeep in Mind: No definitive Lab dx of RV– Imaging: Angiogram rarely useful as majority ofvessels involved are medium; findings(segmentalnarrowing) are non-specific to RV– Full Thickness Skin Biopsy: As above, would showevidence of fibrinoid necrosis of vessels
DIFFERENTIAL DIAGNOSTICCONSIDERATIONS Cryoglobulinemia (Rx w/ Plex as opposed toimmunosuppression Rx of RV)Presents w/ palpable purpura, cutaneous ulcers, myalgiasUsually RF positiveSmall vessel vasculitis of skin(purpura, pustules) usually notseen in RV as in Cryoglobulinemia Polyartertis Nodosa (nearly indistinguishable from RV); keyis clinical features, i.e. pt w/ strong hx of RA more likelyhas RV rather than PN ANCA Vasculitides: Also RF positiveWegener’s, Churg Strauss, Microscopic Polyangiitis Vasculitis-like SyndromesThrombo-embolic phenomenon (cholesterol emboli)Infectious Endocarditis (fever, skin lesions, active urinesediment)
TREATMENT OF RHEUMATOIDVASCULITIS Team with a Rheumatologist. Differs based on extent of involvement:Cutaneous vs. SystemicSystemic RVHigh Dose Glucocorticoids (1-3 days of Solumedrol1gram/day) transition to PO PrednisoneCytotoxic agent (e.g. Cyclophosphamide); Achievesdisease remission; Alt: MTX, Azathoprione, TNFinhibitors