Long-term outcome according to renal histological lesions in 118 patients with monoclonal gammopathies.

BACKGROUND: The prognosis of monoclonal gammopathies with multiple myeloma and renal involvement is poor, and the indication for renal replacement therapy is controversial. Few studies address the value of renal histology for determining prognosis according to initial pathology findings. METHODS: We studied the course of 118 patients with multiple myeloma according to renal biopsy lesions. The monoclonal component was identified and quantified in serum and urine. Tumor cell mass was classified as stage 1, 2 or 3, according to Durie and Salmon. End-points were death, or survival on dialysis, or serum creatinine level at last examination. RESULTS: Renal biopsy showed myeloma kidney in 48 cases (41%), AL-amyloidosis in 35 (30%), light chain deposit disease in 22 (19%), chronic tubulointerstitial nephritis in 12 (10%) and cryoglobulinaemic kidney with multiple myeloma in 1. Maintenance haemodialysis was required in 46 patients (39%), earlier (P<0.0001) in myeloma kidney (mean: 3 months after diagnosis) than in AL-amyloidosis (mean: 15 months) and light chain deposit disease (mean: 18 months). Median survival was 12 months in myeloma kidney, 24 months in AL-amyloidosis and 48 months in light chain deposit disease. Dialysis increased survival in light chain deposit disease, in contrast with myeloma kidney and AL-amyloidosis patients whose survival was shorter when dialysed. The main cause of death during first year of dialysis was cardiac involvement in AL-amyloidosis, and sepsis or cardiac insufficiency in myeloma kidney. There was a trend to increased survival with multidrug chemotherapy which seemed to slow progression to end-stage renal failure. At last follow-up (median: 12 months, range 1-297), 65 (55%) patients had died. By multivariate analysis, independent predictors of survival were: age < 70, serum creatinine < or = 300 micromol/l, and serum calcium < or = 2.5 mmol/l. CONCLUSIONS: Initial renal biopsy helps predict prognosis in patients with multiple myeloma and renal involvement. Maintenance haemodialysis is a reasonable indication in light chain deposit disease and AL-amyloidosis, especially in patients aged < 70. Multidrug therapy tends to prolong survival and slow progression to end-stage renal disease.

Immunoallergic granulomatous interstitial nephritis following treatment with omeprazole.

A 69-year-old male who had a long history of ocular myasthenia was treated with omeprazole for 3 months. Progressive renal insufficiency was discovered fortuitously. There were no clinical or laboratory manifestations of immunoallergy. Renal biopsy revealed severe granulomatous interstitial nephritis, tubular injury and fibrosis. Histology of a liver nodule disclosed hepatic granulomatous involvement. Withdrawal of omeprazole and a short course of corticosteroids were followed by improvement but not normalization of renal function. This is the eighth report of omeprazole-induced interstitial nephritis. In the present case as in 2 others in the literature, the patients had been followed up for an autoimmune disease previously, which suggests that in patients with such a background, patients should be examined regularly for renal functional impairment during treatment with omeprazole.

[Acute kidney failure in glomerulonephritis and in angiitis]. / Insuffisances rénales aiguës des glomérulopathies et des angéites.

Some cases of postinfectious glomerulonephritis initially are oligoanuric. Renal biopsy is essential to distinguish the purely endocapillary and exsudative form from that with endo- and extracapillary proliferation. The former characterises spontaneously regressive poststreptococcal glomerulonephritis, which is now rare, whilst the latter is caused by various strains of gram-positive and gram-negative strains and entails a much less favourable outcome in terms of renal and patient survival. Acute renal failure is a common complication of angiitis, mainly polyarteris nodosa (PAN) and Wegener granulomatosis. A third variety of crescentic glomerulonephritis is due to anti-glomerular basement membrane (GBM) antibodies, with or without pulmonary haemorrhage. Glomerular immunofluorescence discloses a typical pattern of linear IgG deposits along the GBMs. Treatment based on plasma exchanges, corticosteroids and alkylating agents can prevent end stage renal failure when undertaken early. Other glomerulopathies may be complicated with acute renal failure, including haematuric forms of IgA nephropathy.

The current spectrum of infectious glomerulonephritis. Experience with 76 patients and review of the literature.

To identify the demographic, clinical, and pathologic features and the prognosis of renal disease in a series of patients with infectious or postinfectious proliferative glomerulonephritis (GN), data were collected from records of 76 adult patients admitted from 1976 to 1993 to 2 neighboring suburban hospital nephrology units, whose catchment population consists of patients living in a suburban borough of Paris with a below-average socioeconomic status. Thirty-four patients (45%) were alcoholics, diabetics, or intravenous illicit-drug users. Sixty-six patients presented with acute nephritic and/or nephrotic syndrome. Acute renal failure was present in 56 (76%) and required dialysis in 14. The diagnostic workup comprised at least 1 renal biopsy in each case. The patient's background, site of infection, clinical course, laboratory variables, and, when available, bacteriologic findings were analyzed in each case to interpret the evolution of the disease. Initial renal biopsy disclosed endocapillary GN in 44 patients, crescentic GN in 26, and membranoproliferative GN in 6. Ten patients had endocarditis. Staphylococci and Gram-negative strains, not streptococci, were the most common bacteria identified. The origin of sepsis was mainly the oropharynx (21), the skin (19) and the lung (14); 19 cases involved multiple sites of infection. Eight patients died (11%), and 20 (26%) recovered renal function, but GN followed a chronic course in 38 (50%), rapidly requiring maintenance dialysis in 6. Poor prognostic factors included age over 50 years, purpura, endocarditis, and glomerular extracapillary proliferation. Twenty-six patients underwent repeat renal biopsy 1 month to 11 years after the initial presentation. The main finding, irrespective of the interval since the first biopsy, was that ongoing or new iatrogenic infection acquired during hospitalization was almost invariably acquired during hospitalization was almost invariably associated with developing glomerular proliferative changes. This study shows that infectious proliferative GN remains common, but that its epidemiology has changed from what was observed until 2 decades ago. The responsible bacteria, when identified, now comprise a majority of staphylococci and Gram-negative strains, in contrast to the streptococci which predominated 3 decades ago. Infectious GN affects with increasing frequency patients with an underlying condition responsible for immunosuppression, especially alcoholism, even in the absence of cirrhosis. Destructive glomerular proliferation persists, especially but not exclusively until infection has been eradicated, and despite rescue treatment with corticosteroids and/or cytostatic drugs. Thus, the prognosis is poor, and infectious GN often ends in renal death. Infection continues in this decade to represent a frequent and probably often overlooked cause of end-stage renal failure.(ABSTRACT TRUNCATED AT 400 WORDS)

[Rapidly progressive glomerulonephritis of infectious origin]. / Glomérulonéphrites rapidement progressives d'origine infectieuse.

Among 64 patients who presented with glomerulonephritis of infectious origin, 17 cases (26%) of crescentic glomerulonephritis were studied retrospectively. Five patients had bacterial endocarditis and the identified primary infections were cutaneous or oropharyngeal. At the time of diagnosis, 15 patients had acute nephritic syndrome, 3 were anuric and only 2 had normal renal function. Despite symptomatic treatment, the prognosis in these patients was poor: 5 died of infectious disease, 3 are definitively on dialysis and 7 suffer from chronic renal failure. Initiation of immunosuppressive regimens prior to the development or irreversible renal lesions could possibly improve renal prognosis, but entail the risk of life threatening infections in such patients.

[Glomerulonephritis of infectious origin]. / Les glomérulonéphrites d'origine infectieuse.

Glomerulonephritis may complicate infections due to various microorganisms. These microorganisms are bacterial, fungal, viral or parasitic. Considerable clinical and experimental evidence has accumulated to indicate that glomerular injury is due to in situ immune complex deposition. In France, renal lesions are more often due to focal skin infection and sinus or visceral abscesses, with or without endocarditis, rather than to pharyngeal streptococcal infection. Staphylococcal infections are a frequent cause, especially in intravenous illicit drug users. Recovery requires suppression of the infective agent. However, in severe forms, after initial acute glomerular damage the evolution may be characterized by the development of chronic glomerulonephritis.