Rheumatoid arthritis: extra-articular manifestations.

The Kidney in Rheumatoid Arthritis

“…Nevertheless, the fact that all our patients had moderately severe to very severe rheumatoid arthritis has to be taken into consideration. Paren thetically, we wish to mention that while TEiLUMand L in d a h l , and A rapakis and T ribe (quoted by H art) [14] affirm that renal amyloidosis can exist in the absence of proteinuria, our own experience (based on hundreds of bi opsies) runs counter to this assertion.…”

“…Unfortunately, the authors did not publish photos of these mor phologic abnormalities. H a rt [14] takes the completely opposite view.…”

“…Practically all of them received gold therapy after the biopsy and only in six was chrysothcrapy applied prior to the biopsy, and only for a few weeks. This precaution was necessary in view of the fact that several authors consider antirheumatic medication the real culprit in the problem of rheumatoid renal disease [13,14]. In fact, the long continued and heavy con sumption of analgesic mixtures containing phenacetin with salicylates or other antiinflammatory agents, i.e., Butazolidine, penicillamine [15], gold and other drugs, has been implicated as a cause of manifold renal diseases.…”

Gold Nephropathy

“…There is now good evidence that some patients with RA develop a mesangial GN with demonstrable ICs in the mesangial regions on immunofluorescence and elec tron microscopy in many cases [25][26][27][28][29][30], This lesion pre sents usually with microscopic haematuria and occurs in patients who have never had gold (or penicillamine) treatment as well as in those receiving chrysotherapy [23][24][25][26][27][28][29][30]. Although haematuria due to mesangial GN may occur in up to 1% of otherwise healthy people, in some populations [86,87] its association with RA is unlikely to be fortuitous or due to NSAID treatment as it does not appear to have been reported in patients with osteoarthri tis receiving NSAID treatment [29], Furthermore in goldtreated patients with RA and biopsy-proven mesangial GN the haematuria has been observed to begin and continue duringgold treatment and to resolve when treat ment is stopped [29][30][31][32], Mesangial GN is probably caused by the deposition in the mesangial regions of circulating ICs of a larger size than those which reach the glomerular subepithelial space and lead to membranous GN [88].…”

“…However, when gold treated patients underwent renal biopsy for microscopic haematuria with or without pro teinuria (a less common presentation of gold nephropa thy), mesangial GN was observed in some 60% [30], Thus is gold-treated patients with RA when urinary infection, urothelial carcinoma and analgesic nephropathy have been excluded, the presence of microscopic haematuria is suggestive of mesangial rather than membranous GN. It is, however, not diagnostic as mesangial GN can pres ent with proteinuria alone [13,30] and microscopic hae maturia can occasionally be due to gold-induced mem branous GN [51] or renal tubulointerstitial disease (TID) [14,[23][24][25][26][27][28][29][30].…”