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Viruses and the kidney


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A case based primer on Viruses and the Kidney, from HIV to others

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Viruses and the kidney

  1. 1. Kenar Jhaveri Hofstra North Shore LIJ School of Medicine March 2011 A case based approach
  2. 3. Goals <ul><li>Present case/clues with pictures, YOU GUESS THE VIRUS </li></ul><ul><li>Then we discuss how it effects the kidney </li></ul>
  3. 4. Case 1: 40 year old male, past IV Drug abuse Image Courtesy:
  4. 5. Labs show Crt up from 0.7 to 4.0mg/dl and protein/crt ratio 15gm Image source:
  5. 6. Patient has night sweats, weight loss and temporal wasting. Normo-tensive on exam and no edema on exam.
  6. 7. Diagnosis <ul><li>HIV associated Collapsing FSGS or HIVAN </li></ul>HIV is a RNA retrovirus
  7. 9. Case 2: Same patient, only difference:- He plays cricket for the West Indies Team nationally.
  8. 10. Diagnosis <ul><li>HTLV-1 Associated Collapsing FSGS </li></ul><ul><li>Think HIV like disease but virus is HTLV-1 </li></ul><ul><li>Other findings: </li></ul><ul><li>T cell Leukemia </li></ul><ul><li>Hypercalcemia </li></ul><ul><li>HTLV-1 is also a RNA retrovirus </li></ul>
  9. 11. Case 3: 54 y old male with 5 years post DDRTx( thymo, steroids +, triple drug regimen)
  10. 12. P/Crt ratio 7gm, crt slowly rising, anemia, thrombocytopenia, night sweats He does mention that the other day, his son “slapped” his cheeks. Courtesy: 2011
  11. 13. What if I changed the patient to either a child with this picture or a Sickle Cell Patient with proteinuria?
  12. 14. Diagnosis <ul><li>ParvoVirus B19 associated Collapsing FSGS </li></ul><ul><ul><li>Renal disease </li></ul></ul><ul><ul><ul><li>Collapsing Gloemrulopathy </li></ul></ul></ul><ul><ul><ul><li>Cystitis </li></ul></ul></ul>PB19 is a single stranded DNA virus
  13. 15. Case 4: 32 y old male with subnephrotic proteinuria, crt 1.3mg/dl now to 1.6 History of HIV on HAART. History of IV Drug abuse Image Courtesy:
  14. 16. UA showed 1-2+ RBC's/hpf. Serum albumin was 3.7 g/dL and serum cholesterol 209 mg/dL.  All serologies were negative or normal, But C3 and C4 are low.
  15. 17. RF is 400( elevated), IF shows strong C3 and IgM and Moderate IgG and negative IgA Image Source: 60nm
  16. 19. Diagnosis <ul><li>Hepatitis C associated Cryoglobulenemic Nephritis( MPGN) </li></ul>Hep C virus is single stranded RNA virus
  17. 20. Hepatitis C and the kidney <ul><li>Serum antihepatitis C virus antibody </li></ul><ul><li>Serum hepatitis C virus RNA by polymerase chain reaction </li></ul><ul><li>Elevated serum aminotransferases </li></ul><ul><li>Cryoglobulinemia (mixed type II with monoclonal immunoglobulin M kappa) </li></ul><ul><li>Cryocrit (2%–70%) </li></ul><ul><li>Low C4, C1q, CH50 </li></ul><ul><li>Normal or only slightly low C3 </li></ul>
  18. 22. Case 5: 76 y old male with ALL with Allogenic Stem Cell transplant develops hematuria On Day +60 Image source:
  19. 23. Leukopenia along with a sudden rise in crt noted from 1- 3mg/dl Image Source:
  20. 24. Developed blurry vision as well- Ophthamology made the diagnosis Before you! Image Source:
  21. 25. Diagnosis <ul><li>CMV Nephritis, along with Retinitis </li></ul><ul><li>Renal disease </li></ul><ul><ul><li>Tubular interstitial Disease </li></ul></ul><ul><ul><li>FSGS, proliferative GN </li></ul></ul><ul><ul><li>TMA </li></ul></ul><ul><ul><li>Ureteritis </li></ul></ul><ul><ul><li>Hemorrhagic cystitis </li></ul></ul>CMV is part of the Herpes Viruses (DNA virus)
  22. 26. Case 6: 67 y old LRRTx and recent admission for rejection now comes With hematuria and AKI Image Source: NKF 2001 and
  23. 27.
  24. 28. You look in the urine and find these!
  25. 29. Diagnosis <ul><li>BK Nephropathy </li></ul>DNA virus
  26. 31. Case 7: 56 y old male presents with proteinuria of 2.5gm and slowly rising crt Over 2-3 weeks. He has also noticed that he has worsening neuropathy and edema Over past months
  27. 32. On exam, he has an enlarged spleen, liver and inguinal lymph nodes and You confirm peripheral neuropathy and 2+ edema. BP is elevated at 145/90
  28. 34. Patient has monoclonal gammopathy on labs noted on serum free light chains, Over 2 weeks, patients develops hyperpigmented skin as well. SH: patient is from sub Sahara in Africa
  29. 35. Diagnosis <ul><li>HHV-8 associated Thrombotic Microangiopathy </li></ul><ul><li>Kaposi Sarcoma </li></ul><ul><li>Likely POEMS Syndrome </li></ul>HHV8 is part of the Herpes DNA viruses
  30. 37. Case 8: 17 y old male has a cough and soar throat. His girlfriend was sick Recently as well
  31. 38. You do a detailed HEENT exam and find this? Ig A
  32. 39. If this was a post kidney transplant patient, this virus can also cause Lymphoma!
  33. 40. Diagnosis <ul><li>EBV associated Ig A Nephropathy </li></ul><ul><li>EBV- Ig A Nephropathy, Proliferative GN </li></ul><ul><li>EBV – Burkitt’s Lymphoma </li></ul><ul><li>EBV- PTLD </li></ul>EBV is part of the herpes DNA viruses
  34. 41. Case 8: A 56 y old female has 13gm of proteinuria. She is a physician She had a femoral stick exposure few years prior
  35. 42. Complements are normal. On IF, shows IgG1,2 or 3
  36. 43. Her antibodies to the human phospholipase A2 receptor (PLA2R) are negative Also, her LFTs are elevated
  37. 44. Diagnosis <ul><li>Hep B associated Membranous GN </li></ul>Hep B is a double Stranded DNA virus
  38. 46. Case 9: 14 y old boy presents with fever and a rash. The illness resolves But few days later, there is acute rise in crt and hematuria.
  39. 47. The electron microscopy showed this finding:- In idiopathic variant of this disease, it can be treated with anti complement agents
  40. 48. Diagnosis <ul><li>Measles associated Dense Deposit Disease </li></ul><ul><li>Usually associated with a form of immune complex disease, proliferative GN or dense deposit disease </li></ul>Paramyxovirus causes Measles is a single stranded RNA virus
  41. 49. Case 10. What if the boy had similar findings, but had pancreatitis as well On exam you noticed parotid swelling Ig A
  42. 50. Diagnosis <ul><li>Mumps Associated Ig A Nephropathy </li></ul><ul><li>Mumps – immune complex GN and Ig A Nephropathy </li></ul>Mumps caused by paramyxovirus – RNA virus
  43. 51. Case 11. A 45 y old male with myeloma gets an allogenic stem cell transplant 15 days following, has gross hematuria and rise in crt Virus in the bone
  44. 52. This virus can also cause gastroenteritis and croup
  45. 53. Diagnosis <ul><li>Adenovirus Nephritis </li></ul><ul><li>Renal disease: </li></ul><ul><ul><li>Tubular Interstitial Disease( usually necrotizing) </li></ul></ul><ul><ul><li>Hemorrhagic Cystitis </li></ul></ul>Adenovirus is a DNA virus
  46. 54. Case 12: A 23 y old male in the CCU admitted for viral myocarditis has acute Rise in crt, and hematuria
  47. 55. Patient also develops aseptic meningitis, urine has blood, no RBCS
  48. 56. Diagnosis <ul><li>Coxsackie B associated Renal disease- here secondary to Rhabdomyolysis </li></ul><ul><li>Rhabdomyolysis </li></ul><ul><li>Ig A nephropathy </li></ul>Cox B is a Rna virus
  49. 57. What other common virus can lead to Rhabdo associated renal disease? <ul><li>Influenza A </li></ul>
  50. 58. Trends <ul><li>Interstitial Diseases:- CMV, Adenovirus, HIV, BKV </li></ul><ul><li>TMA: CMV, HHV8 and HIV </li></ul><ul><li>Rest all- Glomerular Diseases </li></ul>
  51. 60. Future Directions NIH has embarked on a program to identify viral causes of unexplained renal Diseases- focus on collapsing FSGS, and Thrombotic microangiopathy Use of a customized array of 655 viruses from 135 genera to be used. Waldman M, Kopp J. Virues and Kidney disease: Beyond HIV. Semin Nephrol 2008:28:6:595-607.