What Rheumatologists Learn from Nephrologists
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This is a a summary of different issues related to kidney affection in patients with Rheumatic Diseases
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What Rheumatologists Learn from Nephrologists
- 1. What Rheumatologists can learn from nephrologists? Samar Tharwat Radwan Lecturer of Internal Medicine (Rheumatology & Immunology) Mansoura University
- 2. Kidney : 407
- 3. Renal syndromes in patients with rheumatic diseases Asymptomatic urinary abnormalities Nephrotic syndrome Acute nephritic syndrome Rapidly progressive GN Persistent “subacute” GN Renal vasculitis Tubulointerstitial nephritis Chronic renal failure (mild to moderate) Chronic renal failure (severe)
- 4. The functional unit of the kidney is the nephron The nephron consists of glomerulus followed by a long network of tubules The glomerulus has a highly vascular network Various diseases that affect the vascular system can affect the kidneys such as • Systemic lupus erythematosus (SLE) • Henoch-Schönlein purpura • Churg-Strauss syndrome • Microscopic polyangiitis • ANCA associated granulomatous vasculitis • Cryoglobulinemic vasculitis
- 5. Approach To Patients With Rheumatologic Disease And Suspected Renal Involvement • Careful Evaluation • Thorough physical examination (worsening HTN , edema) • Directed laboratory assessment
- 6. Renal disease, unlike rheumatologic diseases, has signs and symptoms that are not obvious until late in the course of disease So, Routine screening for renal manifestations is essential for preservation of renal function
- 8. AKI Evaluation Recent treatment (NSAIDs) Rapid: Increase in serum creatinine Decrease in urine output
- 9. EVALUATION OF RENAL DISEASE Kidney function testing Proteinuria Hematuria Other urinary microscopic findings Renal tubular dysfunction Hypocomplementemia Renal imaging Kidney biopsy
- 10. KIDNEY FUNCTIO N TESTING • GFR • A normal GFR 130 mL/ min in men 120 mL/min in women • It also depends on age, sex, and body size
- 11. KIDNEY FUNCTION TESTING Plasma creatinine measurement • Simple • Inexpensive • Correlate with GFR
- 12. In the lower range, small increases in SCr reflect major reductions in GFR Half of renal function can be lost before SCr exceeds the upper limits of normal
- 13. SCr is affected by other states with low muscle mass Anorexia nervosa Amputations Chronic illnesses
- 14. EVALUATION OF RENAL DISEASE Kidney function testing Proteinuria Hematuria Other urinary microscopic findings Renal tubular dysfunction Hypocomplementemia Renal imaging Kidney biopsy
- 15. Proteinuria • Normal :< 150 mg of protein/day • 20 mg :albumin • Microalbuminuria:30 to 300 mg/day • Macroalbuminuria >300 mg/day • Nephrotic-range proteinuria >3.5 gm/day
- 16. Proteinuria identifies • Patients with renal damage • Those at risk for worsening renal disease • Increased cardiovascular morbidity
- 17. An individual with proteinuria in the setting of a normal GFR is at high risk of progressive loss of renal function
- 18. Proteinuria Overflow proteinuria •Multiple myeloma Tubular proteinuria •< 2 g/day. •Acute interstitial nephritis immunosuppressive agents, analgesics ,cryoglobulinemia, and Sjögren syndrome Glomerular proteinuria •More severe •SLE and rheumatoid arthritis (RA)
- 19. Measurement of proteinuria • Dipstick testing: inexpensive screening not quantify proteinuria not detect nonalbumin (light chain) • A spot urine albumin-to- creatinine ratio: < 30 mg/g of albumin The best sample is the first urine of the day
- 20. 500 mg/g consider : a spot protein-to-creatinine ratio OR a 24-hour urine collection for proteinuria
- 21. The albumin-to-creatinine ratio is more sensitive than the protein-to-creatinine ratio but only detects albumin
- 22. A renal biopsy is indicated : Unexplained proteinuria Nephrotic-range proteinuria
- 23. False high levels of proteinuria Urinary tract infection Intercourse Exercise Fevers
- 24. EVALUATION OF RENAL DISEASE Kidney function testing Proteinuria Hematuria Other urinary microscopic findings Renal tubular dysfunction Hypocomplementemia Renal imaging Kidney biopsy
- 25. Hematuria • 2% to 31% of patients • Microscopic hematuria > 3 RBCs/HPF • Gross hematuria is visibly present with discoloration of urine
- 27. If the definition of hematuria is met, then the provider must first rule out reasons for false-positive results, including vigorous exercise or menstruation.
- 28. HEMATURIA Hematuria +worsening renal function/proteinuria should be referred for further workup with a nephrology consultation.
- 29. EVALUATION OF RENAL DISEASE Kidney function testing Proteinuria Hematuria Other urinary microscopic findings Renal tubular dysfunction Hypocomplementemia Renal imaging Kidney biopsy
- 30. Other urinary microscopic findings Pyuria ≥ 10 WBCs/mm³ in a urine specimen Causes UTIs Sterile pyuria tubulointerstitial disease: drug/Sjögren syndrome / SLE Eosinophils in the urine Acute Interstitial Nephritis Sterile pyuria: a practical management guide. Br J Gen Pract. 2016
- 31. EVALUATION OF RENAL DISEASE Kidney function testing Proteinuria Hematuria Other urinary microscopic findings Renal tubular dysfunction Hypocomplementemia Renal imaging Kidney biopsy
- 32. Renal tubular dysfunction • Renal tubular acidosis (RTA) and either hypokalemia or hyperkalemia. • Analgesics and nonsteroidal antiinflammatory drugs (NSAIDs).
- 33. Renal tubular acidosis (RTA)/hypokalemia/hyperkalemia RTA is manifested by hyperchloremic, non–anion gap acidosis
- 34. 10% of patients with SLE Subclinical defects (60% o patients)in the handling of: • Potassium • Sodium • Hydrogen ions
- 35. EVALUATION OF RENAL DISEASE Kidney function testing Proteinuria Hematuria Other urinary microscopic findings Renal tubular dysfunction Hypocomplementemia Renal imaging Kidney biopsy
- 36. Glomerulonephritis associated with hypocomplementemia • Lupus nephritis • Membranoproliferative GN • Mixed cryoglobulinemia • Postinfectious GN • Membranous nephropathy secondary hepatitis B infection
- 37. Normal complement ANCA-associated vasculitis Microscopic polyangiitis Goodpasture syndrome Henoch-Schönlein purpura
- 38. EVALUATION OF RENAL DISEASE Kidney function testing Proteinuria Hematuria Other urinary microscopic findings Renal tubular dysfunction Hypocomplementemia Renal imaging Kidney biopsy
- 39. RENAL IMAGING Ultrasonography • Noninvasive • Kidney size • Degree of echogenicity • Anatomic abnormalities • Obstruction Assessment of the renal vasculature • Doppler US • Magnetic resonance /CT angiography • Risk/benefit (contrast nephropathy) Multiple microaneurysms within the upper pole of the kidney
- 40. EVALUATION OF RENAL DISEASE Kidney function testing Proteinuria Hematuria Other urinary microscopic findings Renal tubular dysfunction Hypocomplementemia Renal imaging Kidney biopsy
- 41. • Rapidly progressive GN (RPGN) (rapid decline in kidney function/active urinary sediment).. ANCA-related vasculitis, and Henoch-Schönlein purpura • Unexplained AKI • Acute nephritic syndrome • Persistent proteinuria • Persistent hematuria • Nephrotic syndrome Indications
- 42. PATTERNS SEEN ON IMMUNOFLUORESCENCE MICROSCOPY Linear Anti-GBM disease Goodpasture syndrome Granular, “lumpy-bumpy SLE,postinfectious GN Pauci-immune ANCA associated granulomatous vasculitis Wągrowska-Danilewicz et al. "Immunofluorescent evaluation of renal biopsy: current point of view." Polish Journal of Pathology (2010).
- 44. SYSTEMIC LUPUS ERYTHEMATOSUS • The true incidence of LN probably exceeds 90% • Some kidney involvement may be silent
- 45. Regular screening: creatinine, proteinuria
- 46. • 1827 SLE patients with followed from 1999 to 2012 • 10-year cumulative incidence of end-stage renal disease (ESRD) and death among the patients with LN at 10.1% and 5.9%, respectively
- 47. Poor prognostic factors of LN • Younger age • Male gender • Race • Significant histologic changes • Hypocomplementemia • The presence of anticardiolipin
- 48. Renal biopsy is the gold standard for diagnosis. Rebiopsy
- 49. Renal pathologies in SLE
- 50. Treatment and prognosis are different for each type of nephritis
- 51. On multivariate analysis, serum creatinine (SCr) at presentation was the most significant predictor of renal recovery.
- 52. Proteinuria, urinary sediment, and renal function should be monitored on a regular basis even in patients without known renal disease
- 53. MIXED CONNECTIVE TISSUE DISEASE • Kidney involvement: 25% of cases • Anti–U1-RNP antibody confers some renal protective effect • Individuals with more systemic manifestations from MCTD appear to be at higher risk for kidney involvement • AKI/accelerated HTN/scleroderma kidney • TTT: steroids ,ACEIs
- 54. RHEUMATOID ARTHRITIS High prevalence of renal disease • Antirheumatic drugs :NSAIDs, cyclosporine, • D-penicillamine, methotrexate: Proteinuria • Amyloidosis • RA: RPGN/vasculitis :hematuria
- 55. SJÖGREN SYNDROME • Interstitial nephritis= ↓GFR, distal RTA, or hypokalemia or as mild nephrogenic diabetes insipidus • Interstitial nephritis + eye findings=tubulointerstitial nephritis– associated with uveitis (TINU)
- 57. POLYARTERITIS NODOSA • Renal involvement :2/3 of cases • The vessel wall: inflammatory segmental lesions ,aneurysms , rupture. • HTN • Ischemic renal lesions such as patchy cortical infarctions • 50% of PAN cases : associated with hepatitis B
- 58. ANCA- ASSOCIATED VASCULITIDES Renal manifestations include hematuria, proteinuria, and rapidly progressive renal failure. • Positive ANCA • The glomerular pathology is indistinguishable • Pulmonary lesions may develop later • Systemic manifestations may develop later
- 59. ESSENTIAL MIXED CRYOGLOBULINEMIA • Kidney involvement :60% • Asymptomatic hematuria , proteinuria, nephrotic- range proteinuria , deterioration of kidney function. • Unique features:hyaline thrombi and organized tubular deposits • Fingerprint
- 60. HENOCH- SCHÖNLEIN PURPURA • Mild proteinuria and hematuria to nephrotic syndrome or RPGN • Mesangial proliferative GN • Deposits of IGA in the mesangium • Crescentic GN: less common • Important cause of ESRD in children
- 61. PROGRESSIVE SYSTEMIC SCLEROSIS (SCLERODERMA) • Progressive mucoid thickening of the walls and narrowing of the vascular lumen of arteries • Severe HTN and ischemic Kidney disease • Scleroderma renal crisis 2% • RAAS inhibition is the first line for treatment of HTN in scleroderma • Onion skin • In normotensive scleroderma patients :AAV or interstitial nephritis is considered
- 62. AMYLOIDOSIS • Deposition of amyloid A (AA) • Inflammatory rheumatologic conditions :RA,JIA,AS,PsA,FMF • C/P: nephrotic syndrome and progressive renal failure • Kidneys: larger • TTT: anti-TNF agents The most common of AA amyloidosis in the Western world and second most common worldwide is RA Amyloid can also infiltrate the tubulointerstitial compartment and lead to renal tubular defects
- 63. If the underlying inflammatory disease is not controlled, secondary AA can recur in a renal transplant
- 64. GOUT Hyperuricemia : cyclosporine, diuretics, low-dose salicylates kidney Chronic urate nephropathy Uric acid nephrolithiasis
- 65. Gouty attack CKD • Avoid NSAIDS and colchicine • Use a tapering dose of prednisone
- 66. ANTIPHOSPHOLIPID SYNDROME • Renal involvement: 9% - 25% • Thrombosis of renal vessels : AKI, proteinuria, hematuria, and HTN • Thrombotic microangiopathy (TMA), MCD, MGN, and FSGS • Treatment is primarily anticoagulation
- 67. RENAL LESIONS WITH OTHER RHEUMATIC DISEASES • Poststreptococcal GN: rarely develops in individuals who contract acute rheumatic fever because the nephritogenic and rheumatogenic strains of β- hemolytic streptococci are different • Psoriatic arthritis :amyloidosis • Sarcoidosis: hypercalcemia , nephrolithiasis, interstitial nephritis with granuloma formation
- 68. Sarcoidosis may be manifested as obstructive uropathy secondary to retroperitoneal lymph node involvement
- 69. PHARMACOLOGIC NEPHROTOXICITY ASSOCIATED WITH DRUGS COMMONLY USED IN RHEUMATOLOGY • Nonsteroidal antiinflammatory drugs • Calcineurin inhibitors: acute kidney injury/ hypertension/ chronic kidney disease/ hemolytic-uremic syndrome
- 70. RHEUMATOLOGIC COMPLICATIONS OF KIDNEY DISEASE • β2-Microglobulin amyloidosis • Renal osteodystrophy • Hydroxyapatite arthropathy • Gout • Pseudogout • Osteomalacia • Tendinitis • Tendon rupture • Oxalate arthropathy
Editor's Notes
- Here is a list of the renal syndromes that occur in persons with rheumatic diseases.
- Rheumatologic diseases can lead to glomerular injury and AKI directly, but recent treatment including nonsteroidal antiinflammatory drugs can also be nephrotoxic and cause AKI
- Another concern about the use of PCR
- Proteinuria not only identifies
- It is important to note when proteinuria is present and when it is reduced; this protects the patient against further loss of renal function
- Overflow proteinuria occurs when an increased production of low-molecular Proteins Tubulointerstitial diseases affect renal tubules and the interstitium, leading to decreased proximal reabsorption of proteins Glomerular proteinuria occurs when there is damage to the filtration barrier itself
- Measurements of C3 and C4 are often used to narrow the differential diagnosis of kidney diseases
- Percutaneous kidney biopsy is an essential tool for determining the diagnosis, prognosis, and treatment options for patients with kidney disease.