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RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS
Dr Santosh K MInternal Medicine
Narayana Health-MSH
History The term rapidly progressive glomerulonephritis was first used to
describe a group of patients who had an unusually fulminant poststreptococcal glomerulonephritis and a poor clinical outcome.
Several years later, the antiglomerular basement membrane (anti-GBM) antibody was discovered to produce a crescentic glomerulonephritis in sheep, and, following this discovery, the role of anti-GBM antibody in Goodpasture syndrome was elucidated.
Soon afterward, the role of the anti-GBM antibody in rapidly progressive glomerulonephritis associated with Goodpasture disease was established.
In the mid 1970s, a group of patients was described who fit the clinical criteria for rapidly progressive glomerulonephritis but in whom no cause could be established.
Many of these cases were associated with systemic signs of vascular inflammation (systemic vasculitis), but some cases were characterized only by renal disease.
A distinct feature of these cases was the virtual absence of antibody deposition after immunofluorescence staining of the biopsy specimens, which led to the label pauci-immune rapidly progressive glomerulonephritis.
Rapidly progressive glomerulonephritis (RPGN)
Clinically - rapid loss of renal function (usually >/= 50% decline in the glomerular filtration rate [GFR] within 3 months)
Histopathology-Glomerular disease characterized by extensive crescents (usually >50%) as the principal finding
Classification based on Immunologic,pathology and presence or absence of ANCAs.
anti-GBM antibody disease (3% of cases), immune complex disease (45% of cases), pauci-immune disease (50% of cases).
RPGN can develop in any of the following clinical settings
Complication of acute or subacute infectious process Renal complication of multisystem disease: Secondary forms
comprise more than 40% of cases. In association with use of certain drugs: A review of
published data on an association between hydrocarbon exposure and anti-GBM antibody-mediated disease suggests the possibility of a casual relationship.
Primary glomerular disease in which the kidney is the sole organ involved and in which extrarenal manifestations are caused by renal function disturbances
Epidemiology RPGN type III is more common than RPGN types I or II. More than 50% of patients with crescentic
glomerulonephritis present with acute nephritic syndrome and rapidly deteriorating renal function.
Death or dialysis occurs in 73% of patients who are treated with conventional therapy and in 88% of patients if they are oligo-anuric at time of presentation.
Sex-For RPGN types I and III, a predilection for males exists.
Epidemiology from India 46 cases of CrGN[1]
71.7% of cases were pauci-immune (PI) 28.3% were immune complex-mediated(IC)
Gender PI 1.5:1 IC 2:11 Circulating ANCA positive in 80% of PI
Anti GBM-prevalence of 3.8%[2]
1. Gupta R, Singh L, Sharma A, Bagga A, Agarwal SK, Dinda AK. Crescentic glomerulonephritis: a clinical and histomorphological analysis of 46 cases. Indian J Pathol Microbiol. 2011 Jul-Sep. 54(3):497-500.
2. M Ahmad,et al Anti glomerular basement disease - An Indian scenarioIndian J Nephrol 2004;14: 182-186
causesINFECTIOUS DISEASES
MULTISYSTEM DISEASES
Poststreptococcal glomerulonephritis (PSGN)
Infective endocarditis Occult visceral sepsis Hepatitis B infection (with
vasculitis and/or cryoglobulinemia)
SLE Henoch-Schönlein purpura Systemic necrotizing vasculitis
(including Wegener granulomatosis) Microscopic polyarteritis Goodpasture syndrome Essential mixed (IgG and
immunoglobulin M [IgM]) cryoglobulinemia
Malignancy Relapsing polychondritis Rheumatoid vasculitis
Causes contd…..DRUGS Penicillamine Hydralazine (rare case reports) Allopurinol (with vasculitis) Rifampin (rare case reports) Propylthiouracil, thiamazole, carbimazole, benzylthiouracil Aminoguanidine
Type 1 Lung and kidney –Goodpasture’s
Syndrome. • 60%-70%
Kidney only
Symtomatology 15% -asymptomatic. anemia hematuria fluid retention oliguria, or uremia Flu like symptoms cough Hemoptysis Respiratory failure
Blood pressure may be normal or slightly elevated.
Peripheral edema may be present in 10% of patients.
Pallor is common. Skin rash: A lesion suggesting
leukocytoclastic vasculitis may be present.
investigations CBC count may show leukocytosis and anemia. Erythrocyte sedimentation rate (ESR) is usually elevated. Blood urea nitrogen (BUN) and serum creatinine levels are usually
elevated. Electrolytes, especially the serum potassium level, are consistent
with the degree of renal failure. Urinalysis shows modest proteinuria (1-4 g/d), microscopic
hematuria, RBCs, and RBC and WBC casts. Proteinuria could be quantified by timed (24-h collection) or spot
urine protein/creatinine ratio.Rarely, urine findings may be minimal. An absence of active urine sediment does not exclude a diagnosis of
RPGN.
imaging Abdominal ultrasound is used to assess renal size and
echogenicity and to exclude obstruction. Chest x-ray films are indicated for patients with suspected
Goodpasture’s Syndrome and vasculitides and to help manage pulmonary renal syndromes.
Sinus x-ray films and/or CT scans may show evidence of sinusitis in patients with GPA (Wegener granulomatosis).
Chest CT scans may show reticulonodular infiltrate, even when chest radiographic findings are normal and often mimics a neoplastic process.
Complement levels (C3 and C4) are within reference ranges in patients with RPGN types I and III and may be decreased in patients with RPGN type II.
Circulating anti-GBM antibodies are detected in plasma of patients with RPGN type I, but this finding is neither 100% sensitive nor 100% specific for type I.
ANCAs: Typically, myeloperoxidase (MPO)–ANCA (previously known as perinuclear ANCA [p-ANCA]) is observed in 80-90% of patients with RPGN type III pauci-immune, but neither MPO-ANCA nor PR3-ANCA is 100% specific for type III.
Antinuclear antibody findings are usually negative (unless lupus related)
Serum cryoglobulin levels may be elevated in cryoglobulinemias and may be falsely negative.
Renal biopsyINDICATIONS1. Unexplained renal failure2. Acute nephritic syndrome3. Nephrotic syndrome4. Isolated non-nephrotic proteinuria5. Isolated glomerular hematuria6. Renal masses (primary or secondary)7. Renal transplant rejection8. Connective-tissue diseases (eg, systemic lupus erythematosus)
Absolute contraindications to renal biopsy Uncorrectable bleeding diathesis Uncontrollable severe hypertension Active renal or perirenal infection Skin infection at biopsy siteRelative contraindications Uncooperative patient Anatomic abnormalities of the kidney which may increase risk Small kidneys Solitary kidneyComplicationsBleeding –1. collecting system2. Perinephric fat3. SubcapsularPain Fibrosis(18%)
Gross specimen of RPGN
Renal Biopsy and IF demonstrating the linear deposits along the basement membrane of the glomerulus
Anti GBM disease S Creat <5.7 100%patient survival and 95% renal survival @
1st year 84% and 76% at he end of 3 years
S Creat >5.7 but no dialysis 63% and 82% @1st year 69% and 62% at 3yrs
Requiring dialysis 65% and 8% 56% and 5% 2 3yrs
I.Levy JB, Turner AN, Rees AJ, Pusey CD. Long-term outcome of antiglomerular basement membrane antibody disease treated with plasma exchange and immunosuppression. Ann Intern Med 2001;134:1033-42.
Treatment of Goodpasture’s Syndrome
40 to 45 percent of patients will benefit by not progressing to end-stage renal disease or death, when treated with plasmapheresis in combination with immunosuppression
Bolton WK. Goodpasture's syndrome. Kidney Int 1996; 50:1753. Madore F, Lazarus JM, Brady HR. Therapeutic plasma exchange in renal diseases. J Am Soc Nephrol
1996; 7:367. Couser WG. Rapidly progressive glomerulonephritis: classification, pathogenetic
mechanisms, and therapy. Am J Kidney Dis 1988; 11:449.
Treatment of GP initial plasmapheresis therapy for two to three weeks, with
serial assessment of anti-GBM titers and clinical status. If the patient still has hemoptysis or positive anti-GBM titers at the end of the two- to three-week regimen, we suggest continuation of plasmapheresis until hemoptysis resolves and anti-GBM titers are markedly suppressed or negative (grade 2B)
Monitoring anti-GBM antibody levels every week during plasmapheresis, then approximately every two weeks, until they are negative on two occasions.
Treatment of GP To minimize antibody formation, and recurrence of disease
manifestations, we recommend an initial two- to three-month course of immunosuppressive therapy ( Grade 1B )
Oral prednisone (1 mg/kg per day to a maximum of 60 to 80 mg/day),
A three day pulse of intravenous methylprednisolone (15 to 30 mg/kg, maximum dose of 1000 mg) on each of the three days.
The dose of prednisone is tapered after remission is induced (usually by three weeks) to 20 mg/day.
This dose is maintained until six weeks, then slowly tapered until discontinuation at approximately six months.
Cyclophosphamide Oral cyclophosphamide (2 mg/kg per day) for two to three
months.
Hepatic impariment: Give 75% of normal dose if transaminase levels are >3 times upper limit of normal or bilirubin is 3.1-5 mg/dL
Renal impairment: CrCl <10 mL/min, give 75% of normal dose; CrCl >10 mL/min, give full dose
contraindications Severe myelosuppression Hypersensitivity
Cautions Use with caution in patients with hepatic or renal impairment,
leukopenia, thrombocytopenia, recent radiation therapy or chemotherapy
Pelvic irradiation potentiates hemorrhagic cystitis Potential for radiation recall when used in conjunction with radiation
therapy Risk of potentially fatal and irreversible interstitial pulmonary fibrosis if
given over prolonged periods May cause infertility in male patients who received high doses as
children Monitor for secondary malignancies
Cyclops trial Pulse VS daily oral cyclophosamide for
induction of remission in ANCA-associated vasculitis
Hypothesis
Primary Outcomes Median time to remission pulse cyc 3 months (range 0.5-8) vs. oral cyc 3 months (range 1-
7.5)Hazard ratio 1.098 (95% CI 0.78-1.55; P=0.59)
Secondary Outcomes -pulse VS oral
Proportion in remission at 9 months 88.1% vs. 87.7% Relapses 78.9% of patients who achieved remission by 9
months. 13 vs. 6 patients (HR 2.01; 95% CI 0.77-5.30)
Adverse events 77% vs. 77% Severe or life-threatening: 19 vs. 31 patients All-cause mortality 6.5% vs. 12.3% (P=0.79) Changes in renal function (improvement in eGFR)
5 ml/min/1.73 m2 vs. 8 ml/min/1.73 m2 (P=0.36)
Secondary Outcomes contd…..
Leukopenia 26% vs. 45% (P=0.016)
Infection 20 vs. 21 patients
Cumulative dose of cyclophosphamide 8.2 grams vs. 15.9 grams (P<0.001)
Cumulative dose of prednisolone 7587 mg vs. 7586 mg
Role of azathioprine Effective substitute for cyclophosphamide 1-3mg/kg/day Oral suspension 50mg/ml Iv as an infusion in NS or 5D over 1hr
?????
Henoch-Schönlein purpura (HSP) An acute immunoglobulin A (IgA)–mediated disorder
characterized by a generalized vasculitis involving the small vessels of the skin, the gastrointestinal (GI) tract, the kidneys, the joints, and, rarely, the lungs and the central nervous system (CNS)
Rash (95-100% of cases), especially involving the legs; this is the hallmark of the disease
Abdominal pain and vomiting (35-85%) Joint pain (60-84%), especially involving the knees and
ankles Subcutaneous edema (20-50%) Scrotal edema (2-35%) Bloody stools
Skin findings (usually the first sign of HSP) - Erythematous macular or urticarial lesions, progressing to blanching papules and later to palpable
Renal findings - Acute glomerular lesions, including mesangial hypercellularity, endocapillary proliferation, necrosis, cellular crescents, and leukocyte infiltration
investigations Antinuclear antibody (ANA)
and rheumatoid factor (RF) Factors VIII and XIII Urinalysis Complete blood count (CBC) Platelet count Erythrocyte sedimentation
rate (ESR) Stool guaiac test Blood urea nitrogen (BUN)
and creatinine Amylase and lipase Electrolytes Renal biopsy
Plasma D-dimer Plasma thrombin-
antithrombin (TAT) complex, prothrombin fragment (PF)-1, and PF-2
Prothrombin time (PT) and activated partial thromboplastin time (aPTT)
Serum IgA Antistreptolysin O (ASO) CH50 C3 and C4 Immunocomplexes of IgG
and IgA Endoscopy
Management Supportive measures may include the
following:• Ensuring adequate hydration• Monitoring for abdominal and renal complications• Treating minor symptoms of arthritis, edema, fever, or
malaise• Eating a bland diet• Discontinuance of any drugs suspected of playing a
causative role• NSAIDS for joint inflammation
CORTICOSTERIODS
Persistent nephrotic syndrome
Crescents in more than 50% of glomeruli
Severe abdominal pain Substantial GI hemorrhage Severe soft tissue edema Severe scrotal edema Neurologic system
involvement Intrapulmonary
hemorrhage
Azathioprine Cyclophosphamide Cyclosporine Dipyridamole High-dose IV
immunoglobulin G (IVIg)
Plasmapheresis may be effective in delaying the progression of kidney disease.
Cryoglobulinemia Cryoglobulins are single or mixed immunoglobulins that
undergo reversible precipitation at low temperatures Cryoglobulinemia is characterized by the presence of
cryoglobulins in the serum Kidneys and skin
Brouetclassification
f;:m 3:1Mean age 42-52yrs
type I cryoglobulinemia clinical manifestations are related to hyperviscosity and
thrombosis Acrocyanosis Retinal hemorrhage Severe Raynaud phenomenon with digital ulceration Livedo reticularis Purpura Arterial thrombosis
Type II and III purpura, arthralgia, and weakness (25-30%) Joint involvement (usually, arthralgias in the proximal
interphalangeal [PIP] joints, metacarpophalangeal [MCP] joints, knees, and ankles)
Fatigue Myalgias Renal immune-complex disease Cutaneous vasculitis Peripheral neuropathy erythematous macules and purpuric papules
(90-95%), as well as ulcerations (10-25%)
Meltzer M, Franklin EC, Elias K, McCluskey RT, Cooper N. Cryoglobulinemia--a clinical and laboratory study. II. Cryoglobulins with rheumatoid factor activity. Am J Med. 1966 Jun. 40(6):837-56
RENAL disease
Survival rates reported among patients with renal involvement vary from >60% at 5 years of follow-up to 30% at 7 years
The risk of renal failure appears to be greater in those with HCV-associated disease
secondary to thrombosis (type I cryoglobulinemia) or immune complex deposition (types II and III). The incidence of renal disease varies from 5-60%.
Clinically-nephritic/nephrotic/acute renal failure Histology- MPGN
thickening of the capillary walls in the glomeruli and an increased number of cells.
Type I cryoglobulinemia
36 patients .skin or vasomotor symptoms were present in 75%; nephropathy in 30%; and neuropathy in 47%.
The underlying B cell disease was a nonmalignant monoclonal gammopathy in 36%and hematologic malignancy in 64%.
Treatments included fludarabine and rituximab-based regimens.
Five-year survival was 82%
Néel A, Perrin F, Decaux O, Dejoie T, Tessoulin B, Halliez M, et al. Long-term outcome of monoclonal (type 1) cryoglobulinemia. Am J Hematol. 2014 Feb. 89(2):156-61. [Medline].
To evaluate for serum cryoglobulins
The blood specimen must be collected in warm tubes (37°C) in the absence of anticoagulants.
Allow the blood sample to clot before removal of serum with centrifugation (at 37°C).
The period required for the serum sample to incubate (at 4° C) depends on the type of cryoglobulin present, as follows:
Type I tends to precipitate within the first 24 hours (at concentrations >5 mg/mL) Type III cryoglobulins may require 7 days to precipitate a small sample (< 1
mg/mL)
Repeat centrifugation is performed to determine cryocrit (volume of precipitate as a percentage of original serum volume). Cryoglobulin concentration may be determined via spectrophotometric analysis
treatment
Treat the underlying cause Nonsteroidal anti-inflammatory drugs (NSAIDs) may be used
in patients with arthralgia and fatigue. Immunosuppressive medications are indicated upon
evidence of organ involvement Plasmapheresis is indicated for severe or life-threatening
complications
NIH for lupus nephritis National Institute of Health (NIH) protocol which consists of
intravenous cyclophosphamide [0.5-1 gm/m2, adjusted to white blood cell (WBC)], given monthly for the first six months then quarterly for at least 12 months
summary
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