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Meyrier A, Niaudet P. Acute kidney injury complicating nephrotic syndrome of minimal change disease. Kidney Int 2018; 94:861-869. [PMID: 29980292 DOI: 10.1016/j.kint.2018.04.024] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/12/2018] [Accepted: 04/19/2018] [Indexed: 10/28/2022]
Abstract
Minimal change disease accounts for 70% to 90% of cases of nephrotic syndrome in children. It also causes nephrotic syndrome in adults, including patients older than age 60. Renal function is altered moderately in approximately 20% to 30% of patients because foot-process fusion impairs filtration of water and solutes. The glomerular filtration rate is reduced by approximately 20% to 30% and returns to baseline with remission of proteinuria. Over the past 50 years, a number of publications have reported cases of acute kidney injury occurring in approximately one-fifth to one-third of adult cases in the absence of prior or concomitant renal disease. Clinical attributes point to a male predominance, age >50, massive proteinuria, severe hypoalbuminemia, a background of hypertension and vascular lesions on kidney biopsy, along with ischemic tubular necrosis. Acute kidney injury may require dialysis for weeks or months until remission of proteinuria allows resolution of oliguria. In some cases, renal function does not recover. An effect of endothelin-1-induced vasoconstriction at the onset of proteinuria has been proposed to explain tubular cell ischemic necrosis. The main factors causing acute kidney injury in patients with minimal change disease are diuretic-induced hypovolemia and nephrotoxic agents. Acute kidney injury is uncommon in children in the absence of intercurrent complications. Infection, nephrotoxic medication, and steroid resistance represent the main risk factors. In all patients, the goal of supportive therapy is essentially to buy time until glucocorticoids obtain remission of proteinuria, which allows resolution of renal failure.
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Affiliation(s)
- Alain Meyrier
- Service de Néphrologie, Hôpital Georges Pompidou, Université Paris-Descartes, Paris, France.
| | - Patrick Niaudet
- Service de Néphrologie Pédiatrique, Hôpital Necker-Enfants Malades, Université Paris-Descartes, Paris, France
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Ashikaga E, Uda S, Kamata K, Shikida Y, Inoue T, Kuno Y, Yao A, Nakamura M, Kai K. Single low-dose rituximab for the treatment of steroid-resistant nephrotic syndrome with acute kidney injury. CEN Case Rep 2017; 5:56-60. [PMID: 28509183 DOI: 10.1007/s13730-015-0199-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 07/30/2015] [Indexed: 11/29/2022] Open
Abstract
The efficacy of rituximab for kidney disease, such as frequent relapsing nephrotic syndrome, has been reported recently. Herein, we report a case of a patient with acute kidney injury that was steroid-resistant nephrotic syndrome who responded to a single administration of low-dose rituximab. An 86-year-old Japanese woman with hypertension presented with severe peripheral edema within several days after onset. Due to the patient's age, renal biopsy was not performed, nephrotic syndrome was diagnosed and prednisolone was administered at 40 mg/day on the day after admission. However, anuria developed and hemodialysis was inevitably initiated on the 5th hospital day. The renal function did not recover, and the general condition gradually became aggravated. On the 50th hospital day, 100 mg rituximab was administered, which led to immediate depletion of CD20-positive cells. The urine volume gradually increased from 2-3 weeks after the rituximab administration, and the renal function recovered slightly. After 5 weeks, it became possible to wean the patient from dialysis, which had been applied for 3 months. Rituximab might be an option for the treatment of acute kidney injury due to steroid-resistant nephrotic syndrome.
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Affiliation(s)
- Eijin Ashikaga
- Division of Nephrology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, 211-8510, Japan
| | - Susumu Uda
- Division of Nephrology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, 211-8510, Japan.
| | - Kazuhisa Kamata
- Division of Nephrology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, 211-8510, Japan.,Tanaka Medical Clinic, Kawasaki, Japan
| | - Yasuto Shikida
- Division of Nephrology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, 211-8510, Japan
| | - Takashi Inoue
- Division of Nephrology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, 211-8510, Japan
| | - Yoshihiro Kuno
- Division of Nephrology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, 211-8510, Japan
| | - Atsushi Yao
- Division of Nephrology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, 211-8510, Japan
| | - Mari Nakamura
- Division of Nephrology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, 211-8510, Japan
| | - Keiko Kai
- Division of Nephrology, Kanto Rosai Hospital, 1-1 Kizukisumiyoshi-cho, Nakahara-ku, Kawasaki, 211-8510, Japan
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Maas RJ, Deegens JK, Beukhof JR, Reichert LJ, Ten Dam MA, Beutler JJ, van den Wall Bake AWL, Rensma PL, Konings CJ, Geerse DA, Feith GW, Van Kuijk WH, Wetzels JF. The Clinical Course of Minimal Change Nephrotic Syndrome With Onset in Adulthood or Late Adolescence: A Case Series. Am J Kidney Dis 2017; 69:637-646. [PMID: 28089478 DOI: 10.1053/j.ajkd.2016.10.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 10/24/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Few studies have examined the treatment and outcome of adult-onset minimal change nephrotic syndrome (MCNS). We retrospectively studied 125 patients who had MCNS with onset in either adulthood or late adolescence. Presenting characteristics, duration of initial treatment and response to treatment, relapse patterns, complications, and long-term outcome were studied. STUDY DESIGN Case series. SETTING & PARTICIPANTS Patients with new-onset nephrotic syndrome 16 years or older and a histologic diagnosis of MCNS in 1985 to 2011 were identified from pathology records of 10 participating centers. OUTCOMES Partial and complete remission, treatment resistance, relapse, complications, renal survival. RESULTS Corticosteroids were given as initial treatment in 105 (84%) patients. After 16 weeks of corticosteroid treatment, 92 (88%) of these patients had reached remission. Median time to remission was 4 (IQR, 2-7) weeks. 7 (6%) patients initially received cyclophosphamide with or without corticosteroids, and all attained remission after a median of 4 (IQR, 3-11) weeks. 13 (10%) patients reached remission without immunosuppressive treatment. One or more relapses were observed in 57 (54%) patients who received initial corticosteroid treatment. Second-line cyclophosphamide resulted in stable remission in 57% of patients with relapsing MCNS. Acute kidney injury was observed in 50 (40%) patients. Recovery of kidney function occurred almost without exception. Arterial or venous thrombosis occurred in 11 (9%) patients. At the last follow-up, 113 (90%) patients were in remission and had preserved kidney function. 3 patients with steroid-resistant MCNS progressed to end-stage renal disease, which was associated with focal segmental glomerulosclerosis lesions on repeat biopsy. LIMITATIONS Retrospective design, variable treatment protocols. CONCLUSIONS The large majority of patients who had MCNS with onset in adulthood or late adolescence were treated with corticosteroids and reached remission, but many had relapses. Cyclophosphamide resulted in stable remission in many patients with relapses. Significant morbidity was observed due to acute kidney injury and other complications. Progression to end-stage renal disease occurred in a few patients and was explained by focal segmental glomerulosclerosis.
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Affiliation(s)
- Rutger J Maas
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Jeroen K Deegens
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Johan R Beukhof
- Department of Nephrology, Isala Klinieken, Zwolle, the Netherlands
| | | | - Marc A Ten Dam
- Department of Nephrology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Jaap J Beutler
- Department of Nephrology, Jeroen Bosch Ziekenhuis, 's Hertogenbosch, the Netherlands
| | | | - Pieter L Rensma
- Department of Nephrology, St. Elisabeth Ziekenhuis, Tilburg, the Netherlands
| | | | - Daniel A Geerse
- Department of Nephrology, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Geert W Feith
- Department of Nephrology, Gelderse Vallei, Ede, the Netherlands
| | - Willi H Van Kuijk
- Department of Nephrology, Viecuri Medisch Centrum, Venlo, the Netherlands
| | - Jack F Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
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Thajudeen B, Rubin MF. Hemodynamic acute kidney injury in immunoglobulin A nephropathy: nephrosarca theory revisited. Am J Med 2013; 126:e13-4. [PMID: 24140146 DOI: 10.1016/j.amjmed.2013.07.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 07/17/2013] [Accepted: 07/17/2013] [Indexed: 11/16/2022]
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Iwazu Y, Akimoto T, Izawa S, Inoue M, Muto S, Ando Y, Iwazu K, Fukushima N, Yumura W, Kusano E. Accelerated recovery from nephrotic syndrome with acute renal failure by double filtration plasmapheresis in a patient with lupus podocytopathy. Clin Exp Nephrol 2012; 16:485-9. [PMID: 22350466 DOI: 10.1007/s10157-012-0606-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 01/29/2012] [Indexed: 10/28/2022]
Abstract
We describe a case of an adult female who presented with nephrotic syndrome. She was diagnosed with systemic lupus erythematosus with serum antinuclear antibodies, leucopenia with lymphopenia, butterfly erythema, and nephrotic syndrome. Renal biopsy revealed normal glomeruli with diffuse effacement of the foot processes, consistent with lupus podocytopathy. Although human albumin replacement was performed initially, acute renal failure developed rapidly. Therefore, she was treated with double filtration plasmapheresis (DFPP) in addition to oral steroid. After steroid therapy combined with DFPP, the renal function and proteinuria improved rapidly. Although the impact of DFPP on the treatment of lupus nephritis remains to be delineated, our observations suggest that DFPP in lupus podocytopathy played a pivotal role in facilitating the early recovery from renal injuries. Because of the rapid improvement of renal function without any change in body weight by DFPP, acute renal failure in the setting of lupus podocytopathy might contribute to an alternative pathophysiological factor for the diminished glomerular filtration rate, similar to that observed in the setting of idiopathic minimal change glomerulopathy.
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Affiliation(s)
- Yoshitaka Iwazu
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan.
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Abstract
OBJECTIVE This study aims to investigate the epidemiology, clinical and histological features, and prognosis of acute kidney injury (AKI) according to RIFLE classification in adult patients with idiopathic nephrotic syndrome. METHODS In this retrospective study, 277 patients with idiopathic nephrotic syndrome were reviewed from June 2005 to June 2009. RESULTS Fifty-one (18%) patients entered RIFLE class Risk (AKI-R); 24 (9%) patients entered RIFLE class Injury (AKI-I); and 20 (7%) patients entered RIFLE class Failure (AKI-F). Logistic regression analysis showed that severe hypoalbuminemia, increase in age, and being male were risk factors of AKI. Cumulative recovery rates in 3 months for groups AKI-R, AKI-I, and AKI-F were 95%, 100%, and 94%, respectively (p = 0.21). The mean time to recovery for groups AKI-R, AKI-I, and AKI-F was 20 ± 3, 25 ± 4, and 30 ± 5 days, respectively. Cumulative complete remission rates in 3 months for groups AKI-R, AKI-I, and AKI-F were 92%, 86%, and 65%, respectively (p = 0.002). The mean time to remission for groups AKI-R, AKI-I, and AKI-F was 28 ± 3, 39 ± 6, and 62 ± 8 days, respectively. CONCLUSION AKI is not uncommon in adult idiopathic nephrotic syndrome. More severe AKI was associated with longer time of nephrotic syndrome complete remission. Renal function can recover completely in most of the patients.
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Affiliation(s)
- Tianxin Chen
- Department of Nephrology, The First Affiliated Hospital of Wenzhou Medical College, Wenzhou, Zhejiang 325000, PR China.
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Mohmand H, Goldfarb S. Renal dysfunction associated with intra-abdominal hypertension and the abdominal compartment syndrome. J Am Soc Nephrol 2011; 22:615-21. [PMID: 21310818 DOI: 10.1681/asn.2010121222] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Once considered mostly a postsurgical condition, intra-abdominal hypertension (IAH) and the abdominal compartment syndrome (ACS) are now thought to increase morbidity and mortality in many patients receiving medical or surgical intensive care. Animal data and human observational studies indicate that oliguria and acute kidney injury are early and frequent consequences of IAH/ACS and can be present at relatively low levels of intra-abdominal pressure (IAP). Among medical patients at particular risk are those with septic shock and severe acute pancreatitis, but the adverse effects of IAH may also be seen in cardiorenal and hepatorenal syndromes. Factors predisposing to IAH/ACS include sepsis, large volume fluid resuscitation, polytransfusion, mechanical ventilation with high intrathoracic pressure, and acidosis, among others. Transduction of bladder pressure is the gold standard for measuring intra-abdominal pressure, and several nonsurgical methods can help reduce IAP. The role of renal replacement therapy for volume management is not well defined but may be beneficial in some cases. IAH/ACS is an important possible cause of acute renal failure in critically ill patients and screening may benefit those at increased risk.
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Affiliation(s)
- Hashim Mohmand
- Renal-Electrolyte and Hypertension Division, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA
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Qian Y, Mehandru SK, Gornish N, Frank E. The first description of severe anemia associated with acute kidney injury and adult minimal change disease: a case report. J Med Case Rep 2009; 3:20. [PMID: 19166584 PMCID: PMC2636832 DOI: 10.1186/1752-1947-3-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Accepted: 01/23/2009] [Indexed: 11/10/2022] Open
Abstract
Introduction Acute kidney injury in the setting of adult minimal change disease is associated with proteinuria, hypertension and hyperlipidemia but anemia is usually absent. Renal biopsies exhibit foot process effacement as well as tubular interstitial inflammation, acute tubular necrosis or intratubular obstruction. We recently managed a patient with unique clinical and pathological features of minimal change disease, who presented with severe anemia and acute kidney injury, an association not previously reported in the literature. Case presentation A 60-year-old Indian-American woman with a history of hypertension and diabetes mellitus for 10 years presented with progressive oliguria over 2 days. Laboratory data revealed severe hyperkalemia, azotemia, heavy proteinuria and progressively worsening anemia. Urine eosinophils were not seen. Emergent hemodialysis, erythropoietin and blood transfusion were initiated. Serologic tests for hepatitis B, hepatitis C, anti-nuclear antibodies, anti-glomerular basement membrane antibodies and anti-neutrophil cytoplasmic antibodies were negative. Complement levels (C3, C4 and CH50) were normal. Renal biopsy unexpectedly displayed 100% foot process effacement. A 24-hour urine collection detected 6.38 g of protein. Proteinuria and anemia resolved during six weeks of steroid therapy. Renal function recovered completely. No signs of relapse were observed at 8-month follow-up. Conclusion Adult minimal change disease should be considered when a patient presents with proteinuria and severe acute kidney injury even when accompanied by severe anemia. This report adds to a growing body of literature suggesting that in addition to steroid therapy, prompt initiation of erythropoietin therapy may facilitate full recovery of renal function in acute kidney injury.
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Chen CL, Fang HC, Chou KJ, Lee JC, Lee PT, Chung HM, Wang JS. Increased endothelin 1 expression in adult-onset minimal change nephropathy with acute renal failure. Am J Kidney Dis 2005; 45:818-25. [PMID: 15861346 DOI: 10.1053/j.ajkd.2005.02.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Acute renal failure (ARF) occurs in some adult patients with minimal change nephropathy (MCN). To investigate clinical and pathological factors associated with developing ARF, we compared clinical features and kidney pathological characteristics of endothelin 1 (ET-1) expression in patients with adult-onset MCN with and without ARF. METHODS The patient population consisted of 53 patients consecutively diagnosed with adult-onset MCN during a 10-year period. Based on creatinine clearance, 25 patients were assigned to the ARF group and 28 patients were assigned to the non-ARF group. RESULTS Clinical data show that the ARF group had a higher blood pressure, higher serum cholesterol level, and lower serum albumin level than the non-ARF group. Pathological data showed more severe foot-process effacement, interstitial edema, and flattened tubular epithelium in the same group. Greater ET-1 expression was detected in vessels, tubules, and glomeruli of the ARF compared with non-ARF group. The ARF group experienced a lower steroid response rate. However, there was no significant difference in stability of remission to steroid treatment in patients who achieved a remission. CONCLUSION ARF associated with enhanced kidney ET-1 expression is a reversible complication of MCN that occurs frequently in patients with apparently expanded extracellular fluid. Presumptively, ARF may develop as an amplification of the underlying pathogenesis of MCN involved in enhanced ET-1 expression, which may be superimposed by a transient episode of circulatory insufficiency during diuretic treatment.
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Affiliation(s)
- Chien-Liang Chen
- Division of Nephrology and Department of Pathology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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