NP30 Nephrology

Systemic Disease with Renal Manifestation/Hypertension

Essential Med Notes 2015

Scleroderma
50% of scleroderma patients have renal involvement (mild proteinuria, high Cr, HTN)
histology: media thickened, onion skin hypertrophy of small renal arteries, fibrinoid necrosis
of afferent arterioles and glomeruli
10-15% scleroderma patients have a scleroderma renal crisis (occurs in first few years of disease):
malignant HTN, ARF, microangiopathy, volume overload, visual changes, HTN encephalopathy
renal involvement usually occurs early in the course of illness
treatment: BP control with ACEI slows progression of renal disease

Multiple Myeloma
see Hematology, H49
malignant proliferation of plasma cells in the bone marrow with the production of
immunoglobulins
patients may present with severe bone disease and renal failure
light chains are filtered at the glomerulus and appear as Bence-Jones proteins in the urine
(monoclonal light chains)
kidney damage can occur by several mechanisms
hypercalcemia
light chain cast nephropathy (LCCN, see below) or myeloma kidney
hyperuricemia
infection
secondary amyloidosis
monoclonal Ig deposition disease (MIDD)
diffuse tubular obstruction
LCCN
large tubular casts in urine sediment (light chains + Tamm-Horsfall protein)
proteinuria and renal insufficiency, can progress rapidly to kidney failure
MIDD
deposits of monoclonal Ig in kidney, liver, heart, and other organs
mostly light chains (85-90%)
causes nodular glomerulosclerosis (similar to diabetic nephropathy)
lab features: increased BUN, increased Cr, urine protein immunoelectrophoresis positive for
Bence-Jones protein (not detected on urine dipstick)
poor candidates for kidney transplantation

Effects of Losartan on Renal and Cardiovascular

Outcomes in Patients with Type 2 DM and
Nephropathy
NEJM 2001;345:861-869
Study: Randomized, double-blind, placebocontrolled trial with mean follow-up of 3.4 yr.
Patients: 1,513 patients (mean age 60, 63% male,
multi-ethnicity) with NIDDM and nephropathy
(urinary albumin:Cr 300 and serum Cr 115-265
mol/L) on conventional antihypertensives (CCB,
diuretics, -blockers, centrally acting agents).
Intervention: Losartan 50 mg PO OD (could be
doubled after 4 wk) vs. placebo.
Outcomes: Primary endpoints included doubling
of serum Cr, ESRD, or death. Secondary endpoints
included morbidity and mortality from CVD causes.
Results: Losartan reduced incidence of doubling
of serum Cr (RR 25%) and ESRD (RR 28%), but had
no effect on risk of death. Benefit exceeded that
attributable to BP changes alone. Secondary end
points were similar, although rate of hospitalization
for heart failure was significantly lower with
losartan (RR 32%).
Conclusion: Losartan conferred significant
renal benefits in patients with type 2 DM and
nephropathy, and was generally well tolerated.

Protein Restriction for Diabetic Renal Disease

Cochrane DB Syst Rev 2007;4:CD002181
Purpose: To review the effects of dietary
protein restriction on the progression of diabetic
nephropathy.
Study Selection: Randomized controlled trials
(RCTs) and before and after studies of the effects of
restricted protein diet on renal function in subjects
with DM. 12 studies were reviewed.
Results: The risk of end-stage renal disease or
death was lower in patients on low-protein diet.
In patients with type 1 DM no effect on GFR was
noted in the low-protein diet group.

Malignancy
cancer can have many different renal manifestations
kidney transplantation cannot be performed unless malignancy is cured
solid tumors: mild proteinuria or membranous GN
lymphoma: minimal change GN (Hodgkins) or membranous GN (non-Hodgkins)
renal cell carcinoma
tumor lysis syndrome: hyperuricemia, diffuse tubular obstruction
chemotherapy (especially cisplatin): ATN or chronic TIN
pelvic tumors/mets: postrenal failure secondary to obstruction
2 amyloidosis
radiotherapy (radiation nephritis)

Hypertension
HTN occurs in about 20% of population
etiology classified as primary (essential; makes up 90% of cases) or secondary
primary HTN can cause kidney disease (hypertensive nephrosclerosis), which may in turn
exacerbate the HTN
secondary HTN can be caused by renal parenchymal or renal vascular disease

Long-Term Outcomes of Scleroderma Renal

Crisis
Ann Intern Med 2000;133:600-603
Study: Prospective observational cohort study with
follow up of 5-10 yr.
Patients: 145 patients with scleroderma renal
crisis who received ACEI and 662 patients with
scleroderma who did not have renal crisis.
Primary Outcome: The need for dialysis and early
death among patients with renal crisis.
Results: Sixty-one percent of patients with renal
crisis had good outcomes (55 had no dialysis
and 34 received temporary dialysis); only 4 of
these patients progressed to chronic renal failure
and permanent dialysis. Greater than 50% of the
patients who initially required dialysis discontinued
it 3-18 mo later. Permanent dialysis or early death
occurred in 39% of the patients.
Conclusion: Renal crisis can be managed when
HTN is aggressively controlled with ACEI.

Features of Multiple Myeloma

CARLI
Calcium (elevated)
Anemia
Renal Failure
Lytic Bone Lesions
Infections