Takayasu's arteritis associated with glomerulonephritis. A case report

Renal artery involvement is associated with increased morbidity but not mortality in Takayasu arteritis: a matched cohort study of 215 patients

BACKGROUND

We analyzed differences in presentation and survival of Takayasu arteritis (TAK) with or without renal artery involvement (RAI) from a large monocentric cohort of patients with TAK.

METHODS

Clinical and angiographic features were compared between TAK with versus without RAI, with bilateral versus unilateral RAI, and with bilateral RAI versus without RAI using multivariable-adjusted logistic regression. Inter-group differences in survival were analyzed [hazard ratios (HR) with 95% confidence intervals (95%CI)] adjusted for gender, age at disease onset, diagnostic delay, baseline disease activity, and significant clinical/angiographic inter-group differences after multivariable-adjustment/propensity score matching (PSM).

RESULTS

Of 215 TAK, 117(54.42%) had RAI [66(56.41%) bilateral]. TAK with RAI or with bilateral RAI had earlier disease onset than without RAI (p < 0.001). Chronic renal failure (CRF) was exclusively seen in TAK with RAI. TAK with RAI (vs without RAI) had more frequent hypertension (p = 0.001), heart failure (p = 0.047), abdominal aorta (p = 0.001) or superior mesenteric artery involvement (p = 0.018). TAK with bilateral RAI (vs unilateral RAI) more often had hypertension (p = 0.011) and blurring of vision (p = 0.049). TAK with bilateral RAI (vs without RAI) more frequently had hypertension (p = 0.002), heart failure (p = 0.036), abdominal aorta (p < 0.001), superior mesenteric artery (p = 0.002), or left subclavian artery involvement (p = 0.041). Despite higher morbidity (hypertension, CRF), mortality risk was not increased with RAI vs without RAI (HR 2.32, 95%CI 0.61-8.78), with bilateral RAI vs unilateral RAI (HR 2.65, 95%CI 0.52-13.42) or without RAI (HR 3.16, 95%CI 0.79-12.70) even after multivariable adjustment or PSM.

CONCLUSION

RAI is associated with increased morbidity (CRF, hypertension, heart failure) but does not adversely affect survival in TAK. Key Points •Renal artery involvement in TAK is associated with chronic renal failure. •TAK with renal artery involvement more often have heart failure and hypertension. •Bilateral renal artery involvement (compared with unilateral) is more often associated with hypertension and visual symptoms. •Renal artery involvement is not associated with an increased risk of mortality in TAK.

Takayasu arteritis: association with focal segmental glomerulosclerosis

We herein report on a 29-year-old woman who presented with edema and proteinuria. In light of her blood pressure differences and, finally, with the angiographic findings, Takayasu arteritis (TA) was the diagnosis. Renal biopsy showed focal segmental glomerulosclerosis (FSGS) and other possible etiologic alternatives were excluded. This was a very rare association and we could not find any other cases reported on TA accompanied with FSGS before. A poor treatment response was observed at the end of a 1-year therapy.

Segmental ulcerative vasculitis: a cutaneous manifestation of Takayasu's arteritis

A 16-year-old girl with pyoderma gangrenosum (PG)-like skin lesions on the extremities, trunk and face developed Takayasu's arteritis (TA; pulseless disease). After 3 years under maintenance cyclosporin A therapy, the patient developed an ischaemic cerebral accident. Severe obstruction of both subclavian and left carotid arteries was found by Doppler sonography, angiography and computerised axial tomography. Evolution of this disease showed some characteristic findings: (a) PG-like lesions as the first cutaneous manifestation of pulseless disease; (b) methotrexate and cyclosporin A giving good results for the cutaneous lesions, but apparently not exerting an influence on the evolution of TA and the fatal outcome. This morphologic pattern may reflect underlying TA or Wegener's arteritis, and should be termed segmental ulcerative vasculitis.

Oculorenal manifestations in systemic autoimmune diseases

Vasculitides form a heterogeneous group of diseases characterized by blood-vessel inflammation and necrosis. They have a wide spectrum of manifestations because of the involvement of arteries and other vessels of various sizes and locations. Early diagnosis and prompt treatment may decrease the morbidity and mortality associated with these disorders. Examination of the eye and kidney should be performed routinely in those diseases. This article reviews the major types of oculorenal manifestations in systemic autoimmune diseases.

Takayasu's arteritis associated with intrarenal vessel involvement

Takayasu's arteritis (TA) is an inflammatory process frequently associated with stenosis and obliteration of the aorta and its primary branches. Renal manifestations of the disease include renal artery stenosis, hypertension, and ischemic kidney disease. To our knowledge, vasculitis involving intrarenal arteries has not been reported in association with TA. We report a case with clinical and arteriographic features of TA associated with involvement of intrarenal vessels.

Anticoagulants in Takayasu's arteritis associated with crescentic glomerulonephritis and nephrotic syndrome: a case report

The authors describe a 46-year-old Japanese woman who had Takayasu's arteritis associated with nephrotic syndrome due to mesangial proliferative glomerulonephritis with crescent. Although a few cases of focal and segmental mesangial proliferative glomerulonephritis associated with Takayasu's arteritis have been reported, nephrotic syndrome has not been reported previously in this situation.

Pyoderma gangrenosum and sterile multifocal osteomyelitis preceding the appearance of Takayasu arteritis

A 9-month-old infant had pyoderma gangrenosum (PG) and sterile osteomyelitis. Three years later the patient developed Takayasu arteritis (TA). Sterile osteomyelitis was reported in approximately 30 patients with different skin lesions, but never together with pyoderma gangrenosum. The association of PG and TA has been reported rarely, and then mainly in adults or in children over age 9 years. This rare association should alert physicians with a case of infantile PG of unknown etiology to consider the possible diagnosis of TA.

Takayasu arteritis in Korean children: Clinical report of seventy cases

Seventy cases of Takayasu arteritis in Korean children are reported. There were 57 females and 13 males (male-to-female ratio; 1:4.4). The youngest patient was a 3-year-old female. Family history was positive in one patient. The most common chief complaints on admission were dyspnea, headache, palpitation, and edema which were due to hypertension and congestive heart failure. Hypertension was seen in 65 out of 70 patients (92.8%). The abdominal aorta, thoracic aorta, and renal arteries were the most commonly involved sites in these children. Two patients had nephrotic syndrome. The frequency of positive tuberculin reaction was much higher in children with Takayasu arteritis compared with the general population, and the intensity of the reaction was also stronger. The majority of the patients required immediate medical treatment to control congestive heart failure due to hypertension at initial presentation. When ESR was elevated, corticosteroid was administered. Surgical treatment showed good results in six out of ten cases. Percutaneous intraluminal angioplasty was effective for lowering the blood pressure in six out of nine cases. In three cases, restenosis occurred and angioplasty was repeated in two cases.

Pathological studies on Takayasu arteritis

Takayasu arteritis is a primary inflammatory disease of elastic arteries such as the aorta, its larger branches and the pulmonary artery trunk. According to our recent statistical survey of autopsy cases in Japan, the frequency of the disease in all autopsy cases was approximately 0.033% and the sex ratio was 1:4.5. The most frequent ages of the onset were 20-30 years, those of the death were 40-50 years. The latter was delayed about 20 years in comparison with a previous report. In the recent cases, the vascular lesions widely expanded. Luminal dilatation and aneurysm formation also increased in frequency, their ratio being approximately 57%. In the autopsy cases, the following active lesions were observed: (1) acute exudative inflammation (including suppuration), (2) chronic non-specific productive inflammation and (3) various types of granulomatous inflammation. These findings suggest that many triggers may play a role in the morphogenesis of Takayasu arteritis. The inflammatory lesions are produced in the media and adventitia through the vasa vasorum, and terminate in a diffuse or nodular fibrosis. New active lesions are often observed near the old fibrotic ones. This suggests that Takayasu arteritis may be a progressive disease. Intimal thickening of the peripheral branches from the affected arteries is very often observed. In consequence, secondary ischemic lesions are formed in various organs, especially the heart, brain and kidneys.

Takayasu's arteritis associated with crescentic glomerulonephritis

We describe the initial course and followup of a 16-year-old white female patient who presented in 1983 with aortitis and rapidly progressive renal failure. Renal biopsy revealed crescentic glomerulonephritis. Segmental occlusions of the distal aorta and both common iliac arteries were demonstrated on aortography. Initially, her renal function and arterial occlusions markedly improved with pulse prednisolone therapy, but 34 months later, the glomerulonephritis and aortitis worsened. This case report, the first of its kind, documents both the association of Takayasu's arteritis with crescentic glomerulonephritis and a marked, though incomplete, response to pulse therapy.

Prolonged survival in a child with renovascular hypertension from abdominal-pulmonary Takayasu's arteritis

Takayasu's disease is an inflammatory condition of the large arteries which comprises circulation to the head, extremities, and, less often, the abdominal viscera or lungs. A 10-year-old girl with renovascular hypertension secondary to Takayasu's arteritis has been followed for over 5 years. Her course is unusual in that (1) her disease is not related to tuberculosis; and (2) despite a persistently active disease course, she has been allowed to experience a fairly normal life-style through continued, extensive medical and surgical management. Vascular involvement has been documented by digital subtraction angiography; less invasive techniques were not useful for monitoring disease progression.

Glomerulonephritis associated with Takayasu's arteritis: report of three cases and review of literature

Clinical features and pathologic findings of the kidney in three patients with Takayasu's arteritis and associated nephritis are described. Clinical evidence of renal disease included proteinuria, hematuria, and a reduction of glomerular filtration rate. Renal histology revealed mesangial proliferative glomerulonephritis in one patient and minor glomerular abnormalities in the other two. The clinical course of the glomerulopathy is slow, yet progressive, and the corticosteroid and immunosuppressive therapy appear to delay the progression of the glomerular damage. In one patient in whom repeated examination of the kidney after corticosteroid and immunosuppressive treatment was possible, the glomerular pathology remained unchanged. This report of three patients with Takayasu's arteritis and concomitant nephritis supports the previous speculation of the association between these two conditions. The glomerular, vasculitic, and arteriopathic involvements in these patients may suggest a common immunologic mechanism.