Focal segmental necrotizing glomerulonephritis in rheumatoid arthritis

Abstract

We report ten patients with rheumatoid arthritis (RA) who developed a focal segmental necrotizing glomerulonephritis (FSNGN) and extracapillary proliferation typical of vasculitic glomerulonephritis. Five patients also had extrarenal vasculitis. Renal presentation was with renal impairment (n = 9) (median creatinine 726 mumol/l, range 230-1592 mumol/l), microscopic haematuria (n = 8) and proteinuria (n = 10). Nine patients were seropositive for rheumatoid factor and nine had bone erosions. Serum from four of five patients tested by indirect immunofluorescence was positive for antineutrophil cytoplasmic antibody (ANCA) with perinuclear staining. Only three patients had penicillamine or gold therapy. Treatment was with prednisolone and cyclophosphamide (six patients, two of whom were also plasma-exchanged), prednisolone and azathioprine (two patients) and prednisolone alone (two patients). There was a marked improvement in renal function in eight patients. Two patients with dialysis-dependent renal failure recovered renal function, although in one patient this was transient and she required further dialysis 4 months later. Two other patients progressed to dialysis at 3 months and 1 year respectively. Four patients died, one remains dialysis-dependent, and four continue to have good renal function at 5 year follow-up (median creatinine 148.5 mumol/l, range 120-193 mumol/l). One patient was lost to follow-up at 5 years. FSNGN should be considered in all patients with RA and renal impairment, proteinuria and/or microscopic haematuria. This diagnosis appears to be more likely in patients with clinical extrarenal vasculitis, bone erosions or who are seropositive. In these cases, an urgent renal biopsy is indicated.

Antineutrophil cytoplasmic antibody‐negative pauci‐immune crescentic glomerulonephritis associated with rheumatoid arthritis: An unusual case report

“…in 1983 had positive immunofluorescence for immunoglobulins and C3, but ANCA was not tested for. There were five patients with focal segmental necrotizing GN in RA, as reported by Harper et al 10 . in 1997; four patients were positive for p‐ANCA.…”

ANCA associated glomerulonephritis in a patient with mixed connective tissue disease

“…6 7 Recently, three dimensional (3D) PDUS has been described as a method which allows the spatial demonstration of synovial blood vessels in the peri-and intra-articular region of inflamed joints in patients with rheumatoid arthritis. 8 We used 3D imaging to assess changes in synovial vascularity after intra-articular steroid injection (triamcinolone 20-40 mg). Six patients with rheumatoid arthritis (four female and two male, mean age 54 years; four with wrist arthritis, one with knee arthritis, and one with elbow arthritis) and two patients with psoriatic arthritis (one female and one male, mean age 55 years; one with elbow and one with acromioclavicular arthritis), who underwent injection during routine treatment, were studied.…”

“…7 Further, this entity has also been reported in about 10% of 112 renal biopsies from patients with rheumatoid arthritis (RA) and renal disease. 8 In this setting, is noteworthy the relationship between SSc and RA with NGN because findings similar to both conditions (SSc and RA) form part of the clinical manifestations grouped under the term MCTD.…”

Rituximab-induced remission in a woman with coexisting rheumatoid arthritis and nephrotic syndrome

“…Moreover, rituximab has been introduced as an emerging therapeutic agent to treat immune-mediated glomerular diseases including idiopathic membranous nephropathy [13]. Several reports reviewing single case reports and case series of rituximab use in idiopathic and secondary membranous nephropathy concluded that the efficacy seems promising particularly in light of the absence of side effects so commonly encountered with the use of alkylating agents [2,3,5,7,14].…”