Renal manifestations can occur in patients with rheumatoid arthritis due to the underlying disease, drugs used to treat it, or concurrent kidney diseases. The most common renal disorders associated with rheumatoid arthritis are membranous nephropathy, secondary amyloidosis, focal glomerulonephritis, rheumatoid vasculitis, and analgesic nephropathy. Rheumatoid vasculitis is a rare complication characterized by inflammation of small and medium blood vessels, commonly causing skin ulcers, nerve damage, and organ involvement. Diagnosis involves medical history, urine and blood tests, and sometimes kidney biopsies. Treatment depends on disease severity but may include high-dose steroids and immunosuppressive drugs.

1. Renal manifestations of
Rheumatoid Arthritis
Dr. Sandeep G Huilgol
MBBS, DNB (Internal Medicine), MMedSci(Nephrology)

2. A variety of renal disorders can occur in
patients with rheumatoid arthritis (RA), due
to the
• Underlying disease
• Drugs used
• Concurrent renal disease.

3. • The most common disorders associated with
RA are
– Membranous nephropathy,
– Secondary amyloidosis,
– Focal, mesangial proliferative glomerulonephritis
– Rheumatoid vasculitis,
– Analgesic nephropathy
• Other disorders, such as IgA nephropathy
and minimal change disease have also been
reported in patients with RA.

4. DIAGNOSIS
• History
• Urinalysis
– Membranous nephropathy and secondary amyloidosis are
noninflammatory conditions that are typically associated with
moderate to heavy proteinuria, a bland urine sediment, and a
relatively normal plasma creatinine concentration.
– Focal proliferative glomerulonephritis and rheumatoid vasculitis
generally cause an active urine
– Analgesic nephropathy is associated with a bland urine
sediment, possible episodes of flank pain due to passage of
sloughed papillae.
• Renal Biopsy

5. 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 between
diagnosis 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 polyarteritis
nodosa
 Correlated to high RF levels and low complement at onset of RV
development; indicating uncontrolled RA disease as a risk factor
 Anecdotal evidence that viral infections and drug reactions can
precipitate RV occurrence in RA patients

6. 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 medium
vessels
 Nail fold infarcts
 Nerve Infarction (involves vasa vasorum) causing mononeuritis
multiplex foot and wrist drop
 Associated w/ neuropathy characterized by numbness, burning, pain that
precedes muscle weakness, paralysis, and wasting
 Ocular Scleritis
 Non specific signs: Fever, Weight Loss

7. INVOLVEMENT OF LARGE ARTERIES
 Classically, disease often limited to small and
medium arteries; case reports of large artery
involvement exist
 Bowel
 Renal
 Brain (CVA’s)
 Coronary Vasculitis (rare)

8. DIAGNOSIS OF RV
– H&P: Suspect RV in any RA patient w/ fevers,
weight loss, skin ulcerations, necrotic digits, or sx of
sensory or motor nerve dysfxn
– Labwork: specifically elevated RF, low complement,
elevated ESR, elevated Anti-CCP (citrullinated
peptides) high odds ratio for possible RV in a
person w/ h/o RA
Keep in Mind: No definitive Lab dx of RV
– Imaging: Angiogram rarely useful as majority of
vessels involved are medium; findings(segmental
narrowing) are non-specific to RV
– Full Thickness Skin Biopsy: As above, would show
evidence of fibrinoid necrosis of vessels

9. DIFFERENTIAL DIAGNOSTIC
CONSIDERATIONS
 Cryoglobulinemia (Rx w/ Plex as opposed to
immunosuppression Rx of RV)
Presents w/ palpable purpura, cutaneous ulcers, myalgias
Usually RF positive
Small vessel vasculitis of skin(purpura, pustules) usually not
seen in RV as in Cryoglobulinemia
 Polyartertis Nodosa (nearly indistinguishable from RV); key
is clinical features, i.e. pt w/ strong hx of RA more likely
has RV rather than PN
 ANCA Vasculitides: Also RF positive
Wegener’s, Churg Strauss, Microscopic Polyangiitis
 Vasculitis-like Syndromes
Thrombo-embolic phenomenon (cholesterol emboli)
Infectious Endocarditis (fever, skin lesions, active urine
sediment)

10. TREATMENT OF RHEUMATOID
VASCULITIS
 Team with a Rheumatologist.
 Differs based on extent of involvement:
Cutaneous vs. Systemic
Systemic RV
High Dose Glucocorticoids (1-3 days of Solumedrol
1gram/day) transition to PO Prednisone
Cytotoxic agent (e.g. Cyclophosphamide); Achieves
disease remission; Alt: MTX, Azathoprione, TNF
inhibitors