A renal lesion in ankylosing spondylitis

Rare case of ankylosing spondylitis complicated by IgA vasculitis

Ankylosing spondylosis (AS) is characterised by bilateral sacroiliitis, asymmetric peripheral oligoarthritis, association with the human leucocyte antigen-B27, enthesitis and dactylitis. The association of IgA vasculitis with AS has been documented in few case reports. We present a rare case of a man in his 40s with AS, who presented with fever, bloody loose stools, abdominal pain, lower limb arthritis, palpable purpura over the lower limbs. He subsequently, also developed renal involvement in the form of proteinuria. His skin biopsy showed evidence of leucocytoclastic vasculitis, while renal biopsy showed focal proliferative, necrotising IgA glomerulonephritis. He was thus diagnosed to have Henoch Schonlein purpura with IgA nephropathy in the background of AS. He was treated with steroids and mycophenolate mofetil with resolution of his symptoms.

Coexistence of IgA nephropathy and undifferentiated spondyloarthropathy in a female patient

We report a female patient with IgA nephropathy associated with undifferentiated spondyloarthropathy. The patient manifested proteinuria and microhematuria and was diagnosed as having IgA nephropathy based on the histopathologic findings of the renal biopsy. Two years later, the bone X-ray demonstrated syndesmophytes and multiple calcifications in the ligament and tendon insertions, suggestive of long-term enthesitis, but the patient had occasionally noticed mild lumbago up to the time she visited our hospital, with spontaneous pain in the bilateral shoulders and lower back. IgA nephropathy can be concomitant with a mild form of seronegative spondyloarthropathy in women. Possible association of this disorder should be carefully checked in patients with IgA nephropathy irrespective of clinical symptoms suggesting the arthropathy, particularly in women.

Renal abnormalities in a population of patients with psoriatic arthritis

OBJECTIVE

To investigate the prevalence of and to identify predictive factors for renal abnormalities in patients with psoriatic arthritis (PsA).

METHODS

73 patients with PsA were consecutively examined by laboratory analyses and clinically for joint manifestations. Renal function was estimated by creatinine clearance and urinary albumin.

RESULTS

17 (23.3%) of the patients had renal abnormalities as defined by creatinine clearance below the lower cut off of normal distribution (mean - 2 SD) and/or urinary excretion of albumin more than 25 mg/24 h. These patients were significantly older at the time of the study, older at joint disease onset, had longer skin disease duration, increased serum levels of beta2-microglobulin, and higher incidence of increased ESR and/or CRP levels. Increased ESR/CRP levels had significantly predictive value in multivariate analysis.

CONCLUSIONS

In this study subclinical renal abnormalities was a prevalent finding. Predictive factor was inflammatory activity measured by laboratory variables. There were no predisposing effects of NSAID or DMARD therapy.

Elevation of serum IgA in spondyloarthropathies and IgA nephropathy and its pathogenic role

Ankylosing spondylitis and IgA nephropathy share some immunologic features, eg, elevated serum IgA and IgA-immune complex levels. These entities are frequently found as being associated. IgA and IgA immune complex catabolism involves asialoglycoprotein receptors and specific IgA Fc receptors (FcalphaR or CD89) on tissue and blood cells. Recent studies revealed impaired CD89 expression in both diseases. These abnormalities, which are associated with receptor saturation, might generate the increase in serum IgA and IgA immune complex levels by either altered recycling or failure of degradation. This article reviews the literature on IgA abnormalities and discusses the potential role of FcalphaR in IgA nephropathy and AS and the consequences of its similar defect in the two diseases.

Renal diseases in ankylosing spondylitis: review of the literature illustrated by case reports

Ankylosing spondylitis (AS) can be accompanied by extraarticular manifestations in the cardiovascular, pulmonary, neurologic and renal organs. Secondary renal amyloidosis is the most common cause of renal involvement in AS (62%) followed by IgA nephropathy (30%), mesangioproliferative glomerulonephritis (5%) as well as rarely membranous nephropathy (1%), focal segmental glomerulosclerosis (1%) and focal proliferative glomeruleonephritis (1%). Treatment associated nephrotoxicity may result from non-steroidal anti-inflammatory drugs or disease modifying agents. The purpose of this paper was to alert for the possibility of renal damage in AS and to analyse the frequencies of different etiologies of renal involvement. Two typical case reports of renal involvement in AS are presented to illustrate the clinical course of such patients. Renal side effects and possible pre-existing renal diseases should be taken into account while choosing the appropriate medication for patients with AS.

Renal abnormalities in ankylosing spondylitis

Renal abnormalities have been reported in Ankylosing Spondylitis (AS) patients. Possible mechanisms include the effects of nonsteroidal anti-inflammatory drugs (NSAIDs), an increased incidence of glomerulonephritis, particularly the ones associated with deposition of IgA-containing immune complexes and the renal deposition of amyloid. These observations prompted us to evaluate in detail the frequency and severity of renal dysfunction in 40 AS patients, consecutively selected attending the rheumatology disease unit outpatient clinic at Escola Paulista de Medicina, using sensitive tests of glomerular and tubular function. Fourteen of the 40 patients presented one or more signs of renal involvement: microscopic hematuria (9 patients), microalbuminuria (4 patients), decreased renal function assessed by serum creatinine (2 patients), and creatinine clearance (4 patients). None of the patients presented increased urinary excretion of retinol binding protein (RBP). The finding of renal abnormalities in 35% of our patients suggests that in this illness evidence of renal involvement should be actively investigated.

Immunosuppressive treatment of Berger's disease

BACKGROUND

The aim of our study was to determine whether immunosuppressive treatment is effective in preventing and reversing the evolution of Berger's disease toward chronic renal failure.

METHODS

We studied 20 unselected, consecutive patients with biopsy-proven Berger's disease who met the criteria for disease progression. They had proteinuria, significant histologic changes, persistent hematuria, and red cell casts. The treatment consisted of prednisone in an alternate-day regimen and cyclophosphamide, either in a daily oral administration or in a monthly intravenous pulse injection, both given for a 6-month cycle. Five patients had chronic renal failure (as disclosed by plasma creatinine of 230 +/- 71 mumol/L), hypertension, and proteinuria (2.7 +/- 0.8 gm/day), whereas the remaining 15 patients had normal renal function (plasma creatinine, 97 +/- 18 mumol/L) and less severe proteinuria (1.9 +/- 1.1 gm/day). However, even these 15 patients had a significant number of risk factors heralding progression to chronic renal failure.

RESULTS

Over an average follow-up of 8.7 +/- 3.7 years (range, 5 to 15 years), all patients but one had complete disease remission, including five patients with incipient chronic renal failure. Relapse occurred in two patients who were healed after a repeat treatment cycle. Over the entire follow-up period, no patient progressed to chronic renal failure and plasma creatinine concentration remained stable, even in subjects in whom it was high before treatment (257 +/- 79 versus 230 +/- 71 mumol/L; p > 0.05).

CONCLUSION

The immunosuppressive treatment of patients with Berger's disease with high probability of progression appears to be effective in the prevention of end-stage renal disease.

[Mesangial IgA deposits nephropathy]

Idiopathic IgA nephropathy of Berger's disease is characterized by prominent and diffuse IgA deposits in the mesangium. In many countries, it is the most common type of primary chronic glomerulonephritis. Typically, it is revealed by recurrent episodes of gross hematuria in association with ENT infection, but it can progress insidiously with microscopic hematuria and proteinuria. Serum IgA levels are increased in about 50% of cases. IgA nephropathy is not a minor condition: 20% of patients develop end-stage chronic renal failure 10 years after diagnosis and 50% after 20 years. IgA nephropathy can recur in a transplanted kidney suggesting that this disease is a systemic disorder although it has a remarkable tropism for the kidney. Even though many points remain to be elucidated, its pathogenesis appears to be linked to a genetic factor responsible for a lymphocyte dysfunction and an acquired environmental factor such as penetration of an antigen via the mucosa which may give rise to an excessive and inappropriate IgA immune response with the deposition of IgA in the mesangium and the development of progressive renal alterations. No treatment has been shown to be effective but tonsillectomy advised in case of a recurrent tonsillar focal infection is most often accompanied by a decrease in the incidence of gross hematuria. Corticosteroid therapy can be of benefit in cases involving a nephrotic syndrome associated with minimal glomerular lesions. In all cases, control of possible hypertension is of value in slowing the progression of this disease.

IgA nephropathy associated with ankylosing spondylitis: occurrence in women as well as in men

Two patients (one male, one female) with ankylosing spondylitis (AS) and IgA nephropathy are described. The female patient is the first reported case to have AS and IgA nephropathy concurrently. Contrary to previously reported cases, her renal manifestation preceded her rheumatic symptoms. It is suggested that women with IgA nephropathy and AS may be overlooked as the severity of spondylitis and joint involvement is less than in men.

Relation of microscopic haematuria in ankylosing spondylitis to circulating IgA containing immune complexes

Ankylosing spondylitis (AS) is associated with IgA nephropathy. To study the pathogenetic mechanism of this association the presence of haematuria and circulating IgA containing immune complexes (IgA ICs) in 70 patients with AS was determined. In this retrospective study haematuria was present in 15 patients and 25 patients had IgA ICs. Circulating IgA ICs were shown in 9/15 (60%) of the patients with haematuria and in 16/55 (29%) of those without haematuria. These results suggest that IgA ICs in patients with ankylosing spondylitis have a pathogenetic role in causing IgA nephropathy.

Renal affection in patients with ankylosing spondylitis and psoriatic arthritis

In a retrospective study of 148 patients with well-defined ankylosing spondylitis (AS), psoriatic arthritis (PSA) or reactive arthritis (ReA) an 11% prevalence of idiopathic hematuria, proteinuria, or cylinduria was found in the former two groups. None of the patients with ReA had unexplained pathological urinary findings. Such findings were associated with raised ESR and presence of peripheral arthritis in AS and with the duration of disease in PSA. No patient lacking sacroiliitis showed pathological urinary findings. We believe that such findings may reflect nephropathy associated with AS and PSA.

Increased incidence of recurrent hematuria in ankylosing spondylitis: a possible association with IgA nephropathy

A retrospective analysis of our patients with ankylosing spondylitis revealed a 17.8% incidence of recurrent hematuria. Two of the five patients with recurrent hematuria had previously undergone renal biopsies showing a focal proliferative glomerulonephritis. The only specimen examined by immunofluorescent staining showed the typical changes of IgA nephropathy. A control group of patients with rheumatoid arthritis did not show recurrent hematuria. Recurrent hematuria may be a frequent occurrence in ankylosing spondylitis and may signify the presence of one of the glomerulonephritides such as IgA nephropathy.