Renal lupus syndrome

Although rare, cases of renal lupus syndrome and pemphigus blisters have also been reported as a consequence of D-penicillamine-induced immune complexes (Ntoso et al., 1986 Bigazzi, 1988), as well as with other drugs. With renal lupus syndrome, secondary glomerulonephritis may result if granular IgG antibodies are produced and deposited on the basement membranes. In patients with pemphigus blisters, autoantibodies to the intercellular substance of the skin have been recovered from the sera, and dermal biopsies have demonstrated intracellular deposits or... 

The answer is c. (Hardman, p 868. Katzung, pp 231—232) Procainamide blocks open Na+ channels. Long-term therapy can result in drug-induced lupus syndrome, identified by circulating antinuclear antibodies. Many patients may develop a facial rash and joint pains. Pericarditis can occur, but renal involvement is rare. 

Procainamide can be administered safely by intravenous and intramuscular routes and is well absorbed orally. A metabolite (/V-acetylprocainamide, NAPA) has class 3 activity. Excessive accumulation of NAPA has been implicated in torsade de pointes during procainamide therapy, especially in patients with renal failure. Some individuals rapidly acetylate procainamide and develop high levels of NAPA. The lupus syndrome appears to be less common in these patients. 

Glomerulonephritis is one of the most serious complications of systemic lupus erythematosus (SLE) and accounts for much of the morbidity and mortality of patients afflicted with the disease. The renal manifestations of lupus nephritis are variable and encompass a wide spectrum of histopathologic lesions. ° ° The underlying histopathology is associated with different prognoses and responses to therapy, which cannot be predicted solely based on clinical manifestations. A renal biopsy is therefore required to assess the severity of the disease and to predict the short-term and long-term outcomes associated with therapy. Drugs, such as hydralazine and procainamide, are known to precipitate a lupus syndrome however, they are unlikely to cause disease that affects the kidney. 

Pathophysiologically normochromic and normo-cytic anaemia, as occurs in many clinical syndromes exemplified by renal failure, a number of cancers, rheumatoid arthritis and systemic lupus erythematosus, is typical. Initially erythrocytes are of normal size and degree of haemoglobinization. However, persistent impairment of iron supply, especially from mitochondria to globin in the cytoplasm, leads to them becoming hypochromic and microcytic. 

The main clinical uses of immunosuppressive drugs are suppression of organ and tissue rejection after transplant surgery and the treatment of diseases with an autoimmune component. Thses include renal diseases, e.g. glomerulonephritis, some nephrotic syndromes, connective tissue diseases, such as systemic lupus erythematosus rheumatoid arthritis, and systemic vasculitis. 

Antithyroid drugs, especially propylthiouracil, can be associated with the development of antineutrophil cytoplasmic antibody (ANCA)-positive vasculitis, often manifesting as renal disease. Atypical presentations, with pulmonary capillaritis (58) and lupus-like syndrome (59), have been described in individual cases. Furthermore, two cases of vasculitis have been associated with carbimazole, one presenting with eosinophilic granulomatous vasculitis localized to the stomach (60) and another with p-ANCA positive vasculitis causing simultaneous acute renal insufficiency and massive pulmonary hemorrhage (61). 

Nephrotic syndrome may complicate the course of many primary and secondary glomerulopathies. Diabetic nephropathy is the most common cause of nephrotic proteinuria (not always accompanied by full-blown nephrotic syndrome). Lupus nephritis and renal amyloidosis are much rarer secondary glomerulopathies resulting in nephrotic syndrome. The prevalence of primary glomerulopathies differs between Blacks and Whites (focal segmental glomerulosclerosis is more common... 

Thrombotic thrombocytopenic purpura is a rare acute or subacute disease in adults, rather similar to the hemolytic uremic syndrome in children, in which there is systemic malaise, fever, skin purpura, renal failure, hematuria and proteinuria. Hemorrhagic infarcts caused by platelet microthrombi occur in many organs in the brain they may cause stroke-like episodes (Matijevic and Wu 2006) although more commonly there is global encephalopathy. The blood film shows thrombocytopenia, hemolytic anemia and fragmented red cells. The differential diagnosis includes infective endocarditis, idiopathic thrombocytopenia, heparin-induced thrombocytopenia with thrombosis, systemic lupus erythematosus, non-bacterial thrombotic endocarditis and disseminated intravascular coagulation. 

Ibuprofen can cause renal impairment, ranging from an insignificant reduction to an acute fall in creatinine clearance associated with a general hypersensitivity reaction, especially in patients with systemic lupus erythematosus or acute tubular necrosis (20). The nephrotic syndrome without renal insufficiency and acute interstitial nephritis without the nephrotic syndrome have been described after self-administration of over-the-counter ibuprofen (SEDA-12, 86). 

Mizoribine is mostly well tolerated when it is used to treat different renal diseases, such as vasculitis, lupus nephritis, or nephritic syndrome (1-3). However, hemorrhagic enteritis and erosive changes in the intestinal mucosa have been found in dogs, and similar adverse effects have been reported in humans (4). 

Oliguric renal insufficiency with the nephrotic syndrome and active interstitial nephritis has been described in a young woman with systemic lupus erythematosus taking intermittent long-term naproxen (SEDA-15,102). 

Suda M, Yoshikawa Y, Sirzuki T, Dohi Y, Shibata T. [A case report of rheumatoid arthritis which showed acute renal failure, nephrotic syndrome and drug-related lupus-like syndrome cairsed by D-peniciUamine.] Nippon Jinzo Gakkai Shi 1990 32(11) 1235 1. 

Hjrpersusceptibihty reactions range from relatively common mild rashes to life-threatening Stevens-Johnson syndrome and toxic epidermal necrolysis. Hepatic, cardiac, muscular, pulmonary, hematological, reticuloendothelial, and renal reactions and systemic lupus erythematosus are uncommon. 

The major limitation to the use of spironolactone is its liability to cause (sometimes lethal) hyperkalemia, particularly in the elderly, in patients with reduced renal function, and in patients who simultaneously take potassium supplements or ACE inhibitors. As with other diuretics, hyponatremia and dehydration can occur. Other less frequent adverse effects are gastrointestinal intolerance, neurological symptoms, and skin rashes. Hypersensitivity rashes and a lupus-Uke syndrome have been reported rarely. A few cases of mammary carcinoma have been reported and potential human metabolic products of spironolactone are carcinogenic in rodents. Second-generation effects have not been reported. 

A lupus-like syndrome in conjunction with generalized erythroderma and progressive renal insufficiency has been attributed to yohimbine (14,15). 

Interferon-a Recombinant IFN-a -Viral hepatitis - Non-Hodgkin lymphoma - Several other malignancies - Acute renal failure - Proteinuria - Lupus-like disease -Pauci-immuneGN -RPGN -FSGS - Minimal change nephrotic syndrome -Allograft rejection 27,31,32, 33-35, 38-40, 42-48,51,52, 54, 58,59... 

Despite a good overall safety profile, anti-TNF antibodies can induce a number of adverse effects, including autoimmunity and infections. A trial in the treatment of Crohn s disease noted infusion reactions, transient increased of anti-dsDNA antibodies, and serum sickness-like delayed hypersensitivity with retreatment. Induction of human-antichimeric-antibodies was suggested as the cause of some of the infusion reactions [90]. A prospective study in 35 patients with Crohn s disease showed induction of ANA and anti-dsDNA autoantibodies in 53% and 35% of infliximab-treated patients [91]. A single patient showed clinical features consistent with drug-induced lupus, including the presence of ANA and anti-dsDNA autoantibodies, which quickly resolved after discontinuation of infliximab. Reports on renal adverse effects of anti-TNF antibodies are very rare. Saint Marcoux described the occurrence of crescentic GN in as few as 2 patients out of a cohort of 39 patients, treated with an anti-TNF antibody for rheumatoid arthritis [92]. A case report by Chin et al. [93] described the case of a 29-year-old Australia-born Vietnamese who presented with nephrotic syndrome. A renal biopsy showed membranous nephropathy. Symptoms attenuated after discontinuation of infliximab therapy. 

Renal lesions observed after silica exposure have been associated with ANCA positivity suggesting a pathogenetic role of ANCA [64-67]. Other autoimmune manifestations have been reported in a cohort of 50 workers after occupational exposure to a scouring powder mainly containing silica [68]. Systemic symptoms were present in 32 of these subjects including Sjogren s syndrome (n=6), systemic lupus erythematosus (n=3), "overlap" syndrome (n=5) and with undifferentiated... 

Indications Rheumatoid arthritis, systemic lupus erythematosus, prevention of rejection in renal transplantation, lupus nephritis, nephrotic syndrome Category Immunosuppressant Half-life 6 hours... 

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