GLOMERULONEPHRITIS QUIZ

A 12-year-old boy consults his family physician because of the recent onset of edema. He has no other relevant history and the physical examination is remarkable only for significant pitting edema in the lower extremities. His blood pressure is 135/80. BUN 15 mg/dL, Creatinine 0.9 mg/dL, Albumin 1.7 g/dL (normal = 3.5 to 5 g/dL), Glucose 92 mg/dL, Urinalysis 4+ protein (by dipstick); no cells or casts, albumin creatinine ratio 10.8.

The most appropriate treatment is:

A.Prednisone and cyclosporine

B.Prednisone and Rituximab

C.Prednisone

D.Prednisone and Cyclophosphamide

E.Prednsione and Cellcept

________________________

The correct answer to GN Quiz of 10/8/11 is C: No changes

67 year old man presents with a 1-week history of anorexia, nausea, lassitude, and pedal edema. Past medical history reveals Longstanding hypertension, osteoarthritis. Medications: hydrochlorothiazide, amlodipine. ibuprofen. PE: BP 142/68mmHg, heart rate 72 bpm, Temp of 97.8^OF. JVP 8 cm; normal cardiac and pulmonary examinations; and 2+ pitting edema.  Urinalysis: SG 1.017, protein 4+, no blood, neg glucose. Urine sediment was bland. BUN 18 mg/dL; Cr 0.8 mg/dL; Sodium 137 mEq/L, Potassium4.4 mEq/L, Chloride 95 mEq/L, C02 21 mEq/L, Ca 9.2 mg/dL, Phos 3.6 mg/dL, UA 4.6 mg/dL; Alb 2.9 g/dL; HCT 38%. anti-dsDNA antibody level 0. Albumin to creatinie ratio 7.7. Renal ultrasound showed normal sized kidneys bilaterally without obstruction.

The glomeruli, on light microscopy, will most probably show:

A). Thickened loops with evidence of double contours

B). Swollen endothelial cells -- glomerular endotheliosis

C.) No changes

D.) Focal segmental sclerosis

E.) Mesangial proliferation

Explanation NSAIDs can be associated with minimal change or membranous nephropathy. The key study that characterized this syndrome is from Warren et al in AJKD in 1989 (1). They reported that of 55 patients with adult onset minimal change glomerulopathy (MCG) studied at their center between 1971 and 1986, five (9%) had an association with the use of nonsteroidal anti-inflammatory drugs (NSAIDs). All of the patients were female, and their mean age at the time of diagnosis was 57.4 +/- 11 (SD) (range 47 to 71) years. They had received NSAIDs for an average of 6.9 +/- 6.4 (range, 3 to 18) months before developing proteinuria. The patients with NSAID MCD can present with or without interstitial nephritis. Fogo has a nice case in AJKD also (3).

Other renal syndromes that may be observed following NSAID exposure are shown below (see Ref. 2)

• Prerenal azotemia
• Ischemic acute tubular necrosis
• Allergic interstitial nephritis (AIN)
• Minimal change disease
• AKI plus bilateral flank pain
• Sodium and water retention
• Hyperkalemia
• CKD and papillary necrosis

The paper by Huerta and colleagues in AJKD in 2005 reports the 3 fold higher risk of AKI with exposure to NSAIDs.

References

1. Warren, GV, Korbet, SM, Schwartz, MM, Lewis, EJ. Minimal change glomerulopathy associated with nonsteroidal antiinflammatory drugs. Am J Kidney Dis 1989; 13:127.

2. Whelton A, Hamilton CW. Nonsteroidal anti-inflammatory drugs: effects on kidney function. J Clin Pharmacol. 1991 Jul;31(7):588-98.

3. Fogo AB. Quiz page. Acute interstitial nephritis and minimal change disease lesion, caused by NSAID injury. Am J Kidney Dis. 2003 Aug;42(2):A41, E1. PubMed PMID: 12900841.