Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 834 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 


 
Table of Contents   
CASE REPORT  
Year : 2019  |  Volume : 30  |  Issue : 1  |  Page : 258-260
Widening spectrum of renal involvement in psoriasis: First reported case of C3 glomerulonephritis in a psoriatic patient


1 Department of Nephrology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Medicine, Northern Railway Central Hospital, New Delhi, India

Click here for correspondence address and email

Date of Submission13-Jan-2018
Date of Decision20-Feb-2018
Date of Acceptance21-Feb-2018
Date of Web Publication26-Feb-2019
 

   Abstract 


Renal involvement in psoriasis is usually seen as mesangioproliferative glomerulonephritis (GN), IgA nephropathy, and focal segmental glomerulosclerosis. Microscopic hematuria is not uncommon in a patient of psoriasis with above-mentioned disorders. We found C3 GN as a cause when evaluated for macroscopic and persistent microscopic hematuria in a patient of psoriasis.

How to cite this article:
Balwani MR, Pasari A, Tolani P. Widening spectrum of renal involvement in psoriasis: First reported case of C3 glomerulonephritis in a psoriatic patient. Saudi J Kidney Dis Transpl 2019;30:258-60

How to cite this URL:
Balwani MR, Pasari A, Tolani P. Widening spectrum of renal involvement in psoriasis: First reported case of C3 glomerulonephritis in a psoriatic patient. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Mar 23];30:258-60. Available from: http://www.sjkdt.org/text.asp?2019/30/1/258/252922



   Introduction Top


Psoriasis is a chronic immune-mediated inflammatory skin disorder. Renal involvement in association with psoriasis is being increasingly reported nowadays. C3 glomerulopathy refers to aberrant alternative pathway activation leading to predominant C3 accumulation within the glomerulus. We came across a case of C3 glomerulopathy in a psoriatic patient when evaluated for hematuria.


   Case Report Top


A 28-year-old male came to consult for persistent microscopic hematuria for the past four months. The patient was a diagnosed case of psoriasis since five years which was controlled with methotrexate 15 mg once weekly. The patient gave a history of gross hematuria around three months back, for which he was treated at nearby hospital with intravenous antibiotics suspecting cystitis. At that time, the patient gave no history of the passage of clots, burning urination, hesitancy or precipitancy of urination. Afterwards, the patient was examined regularly by nearby physician and every time doctor found that patient had persistent microscopic hematuria, for which he came to consult us. There was no history of oliguria, pedal edema, facial puffiness, rash, joint pain, fever, sore throat, or recent vaccination. On examination, the patient was conscious, oriented, and normotensive. His blood pressure was 110/80 mm Hg. He had widespread skin lesions distributed over both upper and lower extremities as well as on the trunk. Skin lesions were typically scaly dry. Examination of all other systems revealed no abnormality. His peripheral blood picture revealed Hb 14.7 g%, total lymphocyte count 7200/mm3 with neutrophil 68%, lymphocyte 28%, monocyte 1%, eosinophil 3%, and erythrocyte sedimentation rate 18 mm at the end of 1 h. Blood urea and serum creatinine levels were 12 mg% and 0.95 mg%, respectively. Serum protein was 6.8 g%, albumin 3.8 g%, and globulin 3.0 g%. Serum cholesterol level was 152 mg%. Urine examination revealed pH 6.4, albumin trace, red blood cells (RBC) +++, pus cells 2-3/HPF, sugar-nil, granular casts-absent. 24 h urinary protein excretion was 273 mg. antistreptolysin O titer was not raised (152 U/mL). Urine for dysmorphic RBC was positive (48%). Ultra-sonography showed normal size kidneys with maintained cortical medullary differentiation. Serum antinuclear antibody by intrinsic factor came to be negative. Coagulation profile was normal. In view of persistent microscopic hematuria and probable glomerular etiology, the patient was advised for renal biopsy. Our provisional diagnosis was IgA nephropathy. However, kidney biopsy revealed mesangial and focal endocapillary proliferative glomerulopathy with fibrocellular crescents in three of 40 sampled glomeruli. The immunofluroscent study revealed dominant mesangial and capillary wall staining for C3 with no staining for IgG, IgM, IgA, C1q, Kappa, and lambda light chains. Electron microscopy revealed glomerular basement thickness varying from 263.1- to 519.8-nm thickness ruling out thin basement membrane disease. It also showed subendothelial, intra-membranous and mesangial electron dense deposits [Figure 1]. Thus, confirming a diagnosis of C3 glomerulonephritis (GN). After-ward, serum complement levels were sent and the level of both C3 and C4 came to be normal. The patient was started on mycophenolate mofetil 500 mg thrice a day. After starting therapy, in the past six months, there has been no episode of gross hematuria and patient has been doing well.
Figure 1: Electron microscope picture showing Intramembranous electron dense deposit (Arrow).

Click here to view



   Discussion Top


Renal involvement in psoriasis has been increasingly reported in the last few years. IgA nephropathy has been the most common finding in renal biopsy specimens (as a mesangioproliferative type) in psoriatic patients. AA amyloidosis, membranous nephropathy, and focal proliferative glomerulopathy are also reported to occur in psoriatic patients.[1],[2],[3] Drug-related kidney dysfunction should always be kept in mind while evaluating kidney dysfunction in such patients as there is frequent use of nonsteroidal anti-inflammatory drugs for joint pain control. Clinical presentation of C3 glomerulopathy is variable, but the majority of patients have slowly progressive course with renal survival of approximately 50% over 10 years.[4]

Our patient had mesangial and focal endocapillary proliferative GN with electron dense C3 deposits in the mesangium, intramem-branous and subendothelium. This is probably the first reported case of biopsy-proven C3 GN in a psoriatic patient which might unlink the possible association of a common dysregulated immune pathway. Probably, the uncontrolled inflammatory process of psoriatic arthritis would have lead to dysregulated alternative pathway activation. Our patient responded well to mycophenolate mofetil 500 mg thrice a day. Patients skin lesions also improved with the addition of mycophenolate therapy. More frequent biopsies in such different patients might reveal further details in the future. Authors strongly recommend the use of electron microscopic evaluation whenever a biopsy is performed in a psoriatic patient to evaluate microscopic hematuria.


   Conclusion Top


Renal involvement in psoriatic patients is being commonly seen nowadays. Routine urinalysis and kidney function assessment might help in early detection of renal involvement in such patients. Wider use of renal biopsy with frequent use of electron microscopic examination might help in early diagnosis of sub-clinical or overt nephropathy. This is probably the first reported case of C3 GN in a psoriatic patient where skin lesions, as well as renal manifestations, were controlled with mycophenolate therapy. This case report may be a mere coexistence or may be pointing toward some common immunological etiology which needs to be further evaluated.

Conflict of interest:

None declared.



 
   References Top

1.
Varshavskiĭ VA, Panasiuk NN, Antonov MV, Fal'kovskaia OG. The morphological characteristics of psoriatic nephropathy. Arkh Patol 1990;52:32-6.  Back to cited text no. 1
    
2.
Singh NP, Prakash A, Kubba S, et al. Psoriatic nephropathy – Does an entity exist? Ren Fail 2005;27:123-7.  Back to cited text no. 2
    
3.
Zadrazil J, Tichý T, Horák P, et al. IgA nephropathy associated with psoriasis vulgaris: A contribution to the entity of ‘psoriatic nephropathy'. J Nephrol 2006;19:382-6.  Back to cited text no. 3
    
4.
Servais A, Noël LH, Roumenina LT, et al. Acquired and genetic complement abnormalities play a critical role in dense deposit disease and other C3 glomerulopathies. Kidney Int 2012;82:454-64.  Back to cited text no. 4
    

Top
Correspondence Address:
Manish R Balwani
Department of Nephrology, Jawaharlal Nehru Medical College, Sawangi, Wardha - 440 001, Maharashtra
India
Login to access the Email id


PMID: 30804292

Rights and Permissions


    Figures

  [Figure 1]



 

Top
   
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
   Introduction
   Case Report
   Discussion
   Conclusion
    References
    Article Figures
 

 Article Access Statistics
    Viewed50    
    Printed0    
    Emailed0    
    PDF Downloaded12    
    Comments [Add]    

Recommend this journal