Hyperglobulinaemic renal tubular acidosis: a report of nine cases

Comprehensive analysis of clinical and laboratory features of 440 published cases of Sjögren's syndrome and renal tubular acidosis

AIM

To describe the clinical and laboratory features of Sjögren's syndrome (SS) with renal tubular acidosis (RTA) from published literature.

METHODS

A systematic search of indexed publications in all languages till December 2021 identified cases of SS with RTA (SS-RTA) and were included if either antibody (anti-SSA/anti-SSB) or salivary gland histopathology were positive.

RESULTS

There were 440 cases of SS-RTA (63.9% from Asia, 95.5% women). The median (range) age was 37 (6-78) years. Only 7.7% had a previous diagnosis of SS. Oral or ocular sicca symptoms were present in 63.7%. Positive ocular tests, oral tests, anti-SSA, anti-SSB and salivary gland histopathology were reported in 256/331 (77.3%), 123/128 (96%), 382/407 (93.9%), 298/379 (78.6%), and 246/268 (91.8%), respectively. Hypokalemic paralysis (HP) was the presenting feature in 63.6%; 25% had multiple episodes of HP and 8.4% had respiratory paralysis. Type 1, type 2, combined type 1 & 2, and type 4 RTA was seen in 388, 8, 38, and 3 patients, respectively. Proximal dysfunction and RTA complications were infrequently evaluated. Fanconi syndrome, nephrogenic diabetes insipidus, proteinuria, and low estimated glomerular filtration rate were found in 45, 21, 178, and 157, respectively. Nephrocalcinosis, renal stones, and osteomalacia were reported in 92, 79, and 72, respectively. Tubulointerstitial nephritis was found in 142 out of 152 renal biopsies.

CONCLUSION

SS-RTA is an early manifestation of SS characterized by younger age and subclinical sicca symptoms. Although evaluated less frequently, oral sicca signs and salivary gland biopsy have a high positive yield. HP is the most common presentation. RTA is mostly distal; proximal dysfunction and complications were infrequently assessed.

Primary presentation with acute flaccid quadriparesis in Sjogren's syndrome sans sicca

We report the case of a 40-year-old housewife, who presented with vomiting since past 5 days and weakness of all four limbs since 1 day. Clinical examination confirmed the presence of flaccid quadriparesis with preserved tendon reflexes. Routine laboratory parameters showed severe hypokalaemia. On further evaluation she was diagnosed to have type 1 renal tubular acidosis secondary to Sjogren's syndrome. Sicca symptoms were conspicuous by their absence.

Retrospective cohort study of 148 patients with polyclonal gammopathy

OBJECTIVE

To quantify clinical conditions and laboratory values associated with moderate to marked polyclonal gammopathy.

PATIENTS AND METHODS

Patient characteristics, laboratory correlates, evolving disease states, and survival of all patients seen at the Mayo Clinic, Rochester, Minn, during 1991 with a polyclonal gamma globulin level of 3.0 g/dL or higher were reviewed in this retrospective cohort study.

RESULTS

One hundred forty-eight patients were identified (median age, 58 years; 59% female). In 130 patients (88%), only 1 diagnosis was identified. Liver disease was the most common single disease association in 79 (61%) of 130 patients, followed by connective tissue diseases in 28 (22%), chronic infections in 8 (6%), hematologic disorders in 6 (5%), and nonhematologic malignancies in 4 (3%). No difference in gamma globulin levels existed between groups. With a median follow-up of 67 months, 90 (63%) of 143 patients for whom follow-up was available were alive. By multivariate analysis, age, albumin concentration, disease group, and platelet count were predictive of survival. No patient developed myeloma or a clonal plasmaproliferative disorder.

CONCLUSION

Moderate to marked polyclonal gammopathy may reflect an underlying condition: liver disease, connective tissue disease, hematologic disorder, infection, or malignancy.

Autoantibodies and primary Sjögren's syndrome in a hypocitraturic stone population

Primary Sjögren's syndrome may be complicated by distal renal tubular acidosis (dRTA) and hypocitraturia, which are risk factors for calcium stone formation. Approached from a different perspective, in patients with urolithiasis and dRTA, autoantibodies and various autoimmune diseases are not uncommon. In search for signs of autoimmune disease, we analysed antinuclear antibodies and total levels of serum IgG in 197 hypocitraturic stone formers (67 women and 130 men). Antinuclear antibodies were present in 1.5% of the men and in 18% of the women. An isolated increase in serum IgG was found in 9% of the men and in 3% of the women. Anti-SS-A antibodies were analysed in a subgroup of 46 women and were estimated to occur in 16% of all hypocitraturic stone forming women. Four of 4 examined women, but no men, fulfilled the criteria of definite or possible primary Sjögren's syndrome. We recommend the analysis of anti-SS-A antibodies in female hypocitraturic stone formers.

Etiologies of the sicca syndrome: primary systemic amyloidosis and others

BACKGROUND

The sicca syndrome has been defined as the occurrence of xerostomia and xerophthalmia. Sjögren's syndrome is the most common cause of the sicca syndrome; however, these two syndromes are not synonymous and there are many potential etiologies of the sicca syndrome. A less known cause of sicca syndrome is amyloidosis that to date has only been reported in the nondermatology literature.

OBSERVATIONS

A 79-year-old man with known amyloidosis presented with persistent xerostomia. He had the classic cutaneous findings of periorbital and "pinch" purpura. A labial biopsy showed diffuse deposition of amorphous eosinophilic material surrounding salivary acini. Apple-green birefringence was noted with Congo red staining and the diagnosis was made of amyloidosis in the minor salivary glands causing xerostomia.

CONCLUSIONS

The sicca syndrome can be caused by systemic amyloidosis. Because this fact is not in the dermatologic literature, many dermatologists are not aware of this uncommon presentation. The knowledge of the many causes of the sicca syndrome and an understanding of the differences between this and Sjögren's syndromes are important for any dermatologist.

Hashimoto thyroiditis, distal renal tubular acidosis, pernicious anaemia and encephalopathy: a rare combination of auto-immune disorders in a 12-year-old girl

A case of a 12-year-old girl with a multiple auto-immune disorder is reported. She showed Hashimoto thyroiditis which subsequently developed to hashitoxicosis and distal renal tubular acidosis at 5 years of age, pernicious anaemia at the age of 9 and severe encephalopathy at the age of 12. Laboratory studies revealed very high titres of anti-microsomal and anti-thyroglobulin antibodies and positive gastric parietal cell antibody. As to the encephalopathy, positive oligoclonal IgG bands and high values of IgG index and IgG synthesis ratio in CSF were observed with aggravation of her neurological symptoms. High-dose steroid therapy was effective toward the encephalopathy. Paediatricians should pay careful attention to patients with Hashimoto thyroiditis for association with other autoimmune disorders.

Renal tubular dysfunction in primary Sjögren's syndrome: clinical studies in 27 patients

Kidney involvement in Sjögren's syndrome (SS) including renal tubular disorders are well recognized but little is known about frequency and extent of such dysfunction in the general population of patients with primary SS, due to a lack of group studies. We studied 27 patients with primary SS and without other possible causes of tubular dysfunction. Increased urinary beta 2M excretion, due to proximal tubular dysfunction, was present in 26% of patients. Inadequate urine acidification after oral NH4 Cl, proving distal tubular dysfunction, was found in 12% of the patients studied. Concentrating ability, tested by thirst, was decreased in 44% of patients studied. Abnormal renal tubular tests correlated with presence of ANA (p = 0.05) but not with other clinical parameters. In conclusion demonstrable renal tubular dysfunctions occur in over half the patients with primary SS. Literature concerning this subject is discussed.

Non-psychogenic primary polydipsia in autoimmune chronic active hepatitis with severe hyperglobulinaemia

The association of hyperglobulinaemia with renal tubular acidosis and nephrogenic diabetes insipidus is well established. A patient with marked hyperglobulinaemia due to autoimmune chronic active hepatitis is described who presented with severe polydipsia and polyuria but had entirely normal renal tubular function indicating a primary thirst disorder.

The kidney in hypergammaglobulinemic purpura

A 25-year-old woman with long-standing hypergammaglobulinemic purpura developed distal renal tubular acidosis and a urine-concentrating defect. The acidification defect was characterized as suggestive of impaired distal proton secretion by infusion of neutral phosphate. The concentrating defect was a form of acquired nephrogenic diabetes insipidus. On renal biopsy, IgM mesangial nephropathy was found along with multiple large hyaline tubular casts. The renal findings in hypergammaglobulinemic purpura are reviewed.

Hypouricemia and renal tubular acidosis in primary biliary cirrhosis

A 51-year-old woman with primary biliary cirrhosis developed distal renal tubular acidosis and hypouricemia (1.4 mg per 100 ml) in the course of hepatic injury. Her renal clearance of uric acid reached 33.7 ml/min (mean +/- SD in five normal age-matched women: 9.2 +/- 3.1 ml/min). Pyrazinamide, an inhibitor of uric acid secretion, considerably reduced the uric acid clearance, while it was not enhanced by probenecid, a blocker of uric acid reabsorption. Thus, the hypouricemia may have been due to a defect of postsecretory reabsorption of uric acid in the renal tubules. The present case emphasizes the significance of hypouricemia and hyperuricosuria as indicators of renal tubular injury in primary biliary cirrhosis.

Renal involvement in visceral leishmaniasis

In a prospective study of 50 patients with visceral leishmaniasis, laboratory abnormalities suggestive of renal involvement were not infrequent. Proteinuria and/or microscopic hematuria or pyuria were observed in 51% of such cases. Twenty-four hour urinary protein excretion was elevated in 57% of patients in all cases below 1g/24 hours. An abnormal acid-load test was demonstrated in 12 of 18 patients studied before therapy of the parasitic infection with N-methyl-glucamine. Of interest was the demonstration of tubulo-interstitial involvement in the renal histology of all seven patients studied; also, in five of seven patients there was a proliferative glomerulonephritis, usually mild, on histologic examination. In general, there was a tendency to subsidence of abnormal laboratory findings within one month after specific therapy. Renal involvement in visceral leishmaniasis was mild and seemed to revert with the cure of the leishmanial infection.

Hypokalemic paralysis in Sjögren's syndrome secondary to renal tubular acidosis

A 62-year-old woman with Sjögren's syndrome, distal renal tubular acidosis and hypokalemic muscle paralysis is described. The sicca syndrome was nearly subclinical and went unrecognized for several years. The main and first manifestation to be expressed was that of hypokalemic muscle paralysis secondary to renal tubular acidosis. In the last decade several reports have appeared indicating that renal tubular acidosis is associated with Sjögren's syndrome. The data in this report support the view that adult onset distal renal tubular acidosis is often a disorder of an autoimmune disease, frequently that of Sjögren's syndrome. The complications to renal tubular acidosis such as hypokalemic muscle paralysis or chronic muscle weakness, nephrolithiasis, and osteomalacia can be avoided if the diagnosis of renal tubular acidosis is made and corrective alkali therapy is maintained.

A human autoantibody to renal collecting duct cells associated with thyroid and gastric autoimmunity and possibly renal tubular acidosis

A complement fixing autoantibody reacting with certain renal collecting duct cells, possibly so called dark cells, is described in 113 patients. Clinically, the antibody was strongly associated with thyroid disorders and pernicious anaemia. The patients also showed a markedly increased frequency of thyroid antibodies and antibodies to gastric parietal cells and to intrinsic factor. One of the patients had a distal renal tubular acidosis (RTA) and pernicious anaemia. The antibody was also found in all of three other patients with either latent or manifest RTA. RTA is associated with various immunological diseases, and the renal collecting duct cell antibody may turn out to be a marker of this disorder, either involved in its pathogenesis or representing a secondary phenomenon.

Renal tubular acidosis: its types and role in renal calculosis

In the light of published observations attention is called to the various forms of renal tubular acidosis (RTA), its etiology, pathologic significance, excretion of an "alkaline-persistent" urine in the presence of hyperchloremic acidosis, and to the possible consequences: nephrocalcinosis and renal calculosis. The frequency of incomplete RTA of various causes in calculosis is pointed out. The patient material of the authors and the results of phosphate therapy are presented, stressing the importance of alkalizing therapy and its prophylactic value.

Impaired urinary acidification in the hypothyroid rat

Since abnormalities in the renal handling of sodium and water in both the proximal and distal tubule have been described in primary hypothyroidism, this study was undertaken to examine renal tubular hydrogen secretion in this disorder. Metabolic acidosis was induced in hypothyroid rats (H) and their age matched controls (C) by the administration of an oral ammonium chloride load of 0.15 g/24 h/kg for three days. On day 3 animals were prepared for clearance and acid-base studies, receiving an infusion of Ringer's solution of 0.6 ml/hr/100 g during surgery and the experimental procedure. A 26% decrease in GFR (P less than 0.005) and a doubling in fractional excretion of sodium (P less than 0.02) were observed in H rats. The lowest blood pH and average bicarbonate concentration and the excretion of chloride were similar in the two groups, indicating that the acid load was reabsorbed and led to similar degrees of systemic acidification. Urine flow also was comparable in the two groups. Minimal urine pH after NH4Cl was 6.21 +/- 0.06 in H and 5.68 +/- 0.09 in C (P less than 0.001). Ammonium excretion was 28% (P less than 0.05) lower in H than in C. The defect in urine acidification in H was only partially corrected after 5 days on a low sodium diet and DOCA administration for 2 days. Fractional bicarbonate excretion at normal blood pH and bicarbonate concentration was not different in the two groups. These data indicate that hypothyroid rats have a mild defect in urine acidification and that it is localized predominantly in the distal tubule.

Multiple immunological abnormalities in a family

The family of a woman with multiple autoimmune diseases has been investigated. Clinical evidence of an autoimmune disorder was detected in two relatives, and five others had serological and immunoglobulin abnormalities. It is suggested that there is an inherited predisposition to develop immunological abnormalities, and that a number of associated autoimmune diseases may develop in families in which this occurs.

Renal tubular acidosis and autoimmune liver disease

Forty-two patients with autoimmune liver disease have been investigated. Renal tubular acidosis was detected in 60% of the patients with primary biliary cirrhosis, in 30% with active chronic hepatitis, and in one out of seven cases with cryptogenic cirrhosis. The presence of the defect of renal acidification was not related to the level of plasma potassium, copper, or total globulin, nor to the pattern of immunological abnormalities detected in the serum. It is suggested that autoimmune liver disease and renal tubular acidosis may be part of a systemic disorder in the pathogenesis of which immunological mechanisms are involved.

Fibrosing alveolitis associated with renal tubular acidosis

The discovery of a case of renal tubular acidosis and fibrosing alveolitis led to the investigation of 19 further patients. Abnormal pulmonary function tests were found in a further four patients with overt renal tubular acidosis and in four out of eight patients with "incomplete" renal tubular acidosis. The response to an ammonium chloride test in seven patients with cryptogenic fibrosing alveolitis was normal. Those patients with a defect of both renal acidification and pulmonary gas transfer had concurrent autoimmune diseases such as Sjögren's syndrome and primary biliary cirrhosis. It is suggested that the renal and pulmonary abnormalities may be part of a systemic disorder capable of affecting many organs. Moreover, hyperglobulinaemia and autoantibodies in these patients further suggests that immunological mechanisms are concerned in the pathogenesis of these abnormalities.

"Sicca complex" in liver disease

Sixty-three patients with liver disease were studied for the presence of the components of Sjögren's syndrome. The "sicca complex" (that is, patients without arthritis) was detected in 42% of patients with active chronic hepatitis, 72% with primary biliary cirrhosis, and 38% with cryptogenic cirrhosis. One patient with active chronic hepatitis and one with primary biliary cirrhosis had rheumatoid arthritis. No evidence of Sjögren's syndrome was detected in seven patients with alcoholic cirrhosis. It is suggested that the sicca complex and autoimmune liver disease may be part of a systemic disorder in which immunological mechanisms are concerned in the pathogenesis.