Saudi Journal of Kidney Diseases and Transplantation

ORIGINAL ARTICLE
Year
: 2008  |  Volume : 19  |  Issue : 1  |  Page : 67--71

Interstitial and Glomerular Renal Involvement in Sarcoidosis


Hayet Kaaroud1, Lilia Ben Fatma1, Soumaya Beji1, Ahmed Jeribi1, H Ben Maiz2, Fatma Ben Moussa1, Rym Goucha1, Sami Turki1, Adel Kheder1,  
1 Department of Internal Medicine and Nephrology, Charles Nicolle Hospital, Tunis, Tunisia
2 Laboratoire Sante 02, Charles Nicolle Hospital, Tunis, Tunisia

Correspondence Address:
Hayet Kaaroud
Department of Internal Medicine, Boulevard 9 Avril 1938, 1006 BS Tunis
Tunisia

Abstract

Sarcoidosis is a systemic disease characterized by chronic granulomatous inflammation. Chronic kidney disease (CKD) was reported in less than 1% of patients of sarcoidosis. The prevalence of tubulo-interstitial nephritis (TIN) in sarcoidosis varies from 7 to 27%. In this retrospective study, we present 15 patients with interstitial or glomerular renal involvement secondary to sarcoidosis diagnosed in our center from 1975 to 2006. Patients were 13 (96.6%) females and two males with a mean age of 56.5 years. CKD was present in 14(93.3%) patients, proteinuria in 13(96.6%), and nephrotic syndrome in one. Pulmonary involvement was present in 10 (66.6%) patients. Renal biopsy performed in 12 (80%) patients revealed TIN lesions in 10 (66.6%) patients, extracapillary proliferative glomerulonephritis (GN) in one, and membranous GN type 2 in another. Corticosteroid therapy using prednisolone 0.5 to 1 mg/kg per day was used in 12(80%) patients. Ten (66.6%) patients were followed up for a mean period of 25 months (ranged from 2 to 48 months). The outcome was favorable with 7 (46.6%) patients improved their renal function, 6 (40%) remained with a moderate CKD, one normalized his renal function, and one died suddenly after 2 months of initiating the treatment corticosteroids. We conclude that corticosteroid treatment is efficient in TIN and variably efficient in GN. Patients with sarcoidosis may cause advanced renal failure, which renders it a serious nephrological condition.



How to cite this article:
Kaaroud H, Fatma LB, Beji S, Jeribi A, Maiz H B, Moussa FB, Goucha R, Turki S, Kheder A. Interstitial and Glomerular Renal Involvement in Sarcoidosis.Saudi J Kidney Dis Transpl 2008;19:67-71


How to cite this URL:
Kaaroud H, Fatma LB, Beji S, Jeribi A, Maiz H B, Moussa FB, Goucha R, Turki S, Kheder A. Interstitial and Glomerular Renal Involvement in Sarcoidosis. Saudi J Kidney Dis Transpl [serial online] 2008 [cited 2019 Dec 12 ];19:67-71
Available from: http://www.sjkdt.org/text.asp?2008/19/1/67/37436


Full Text

 Introduction



Sarcoidosis is a systemic disease charac­terized by chronic granulomatous inflamma­tion. [1],[2] The most common clinical features are pulmonary, and skin lesions. [1] Renal disease in sarcoidosis is rare due to nephrocalcinosis and or nephrolithiasis related to hypercalciuria. [3],[4]

In this study, we present 15 patients with sarcoidosis and renal interstitial, or glomerular involvement.

 Materials and Methods



Using a computerized database, we reviewed retrospectively from 1975 to 2006 patients diagnosed as sarcoidosis with renal involve­ment that included interstitial or glomerular injury. We excluded from the analysis all patients with nephrocalcinosis or nephro­lithiasis. We analysed clinical features (pul­monary, ophthalmic, skin involvement), phy­sical examination, laboratory tests (renal function, liver function tests, corrected cal­cium, serum globulins, and urinary 24 hours protein excretion), studies for mycobacterium tuberculosis (TB) including tuberculin tests, TB sputum culture, radiological tests (chest X-ray, abdominal ultrasound and compute­rized tomography scan), bronchoscopy, bron­chus biopsy, bronchoalveolar lavage, salivary glands biopsy, and renal biopsy.

 Results



We studied the records of 15 patients diag­nosed as sarcoidosis with non nephrocalci­nosis non-nephrolithiasis renal involvement. Thirteen patients (96.6%) were females and two patients were males with a mean age of 56.5 years (range from 19 to 83 years). Cli­nical, biologic, histological features, treat­ment and follow-up periods are shown in [Table 1].

Clinical manifestations were proteinuria in 13 (96.6%) patients, hematuria in 6 (40%) patients and high blood pressure in six (40%) patients. Pulmonary involvement was present in 10 (66.6%) patients with pulmonary inters­titial syndrome in 8 (53%) patients, and mediastinal lymph node in 4 (27%) patients. Broncho-alveolar lavage showed in 6 (40%) patients a high index of lymphocysts. Peri­pheral lymph nodes were present in 2 patients, axillary and jugular in one patient and mesen­teric in another.

Chronic kidney disease (CKD) was revealed in 14 (93.3%) patients with a mean serum creatinine of 460 µmol/L (ranged from 138 to 1215 µmol/L), While one patient had normal renal function. Elevated serum calcium was noted in 3 (21%) patients with a mean level of 3.12 mmol/L. Elevated erythrocytes sedimentation rates were revealed in 12 (80%) patients with a mean of 107 mm the first hour, and gamma globulin levels with a mean of 16.3 g/L. Liver cholestase was present in one patient with liver granulomas. Serum angiotensin-converting enzyme (ACE) level was checked in 2 patients, but was elevated in one to a level of 205 units. Urinary 24 hours protein excretion was measured in 13 (96.6%) patients with a mean level of 1.23g/24 hours (ranged from 0.2 to 3.6 g/24 hours). Nephrotic syndrome was present in one patients with urinary 24 hours proteinuria of 3.6 g/24 hours.

Tuberculosis screening was performed in most patients including the tuberculin test, which was negative in 12 (80%) patients. Urine and sputum culture for TB was nega­tive in all patients. Chest-X-ray showed pulmonary interstitial syndrome in 8 (53%) patients, and mediastinal lymph nodes in 4 (27%) patients.

Renal biopsies performed in 12 (80%) pa­tients revealed tubulo-interstitial lesions in 10 (66.6%) patients, extra-capillary proli­ferative glomerulonephritis(GN) in one, and membranous GN type 2 in another. Salivary gland biopsy performed in 5 (33.3%) patients revealed lymphoplasmocyts infiltrate in 2 patients. A liver biopsy showed sarcoidosic granuloma in one patient.

Corticosteroid therapy with prednisolone 0.5 to 1 mg/kg per day was administered in 12 (80%) patients. In one patient, cyclophos­phamide was added to prednisolone because of retinal vasculitis. One patient with end­stage renal disease necessitated chronic hemodialysis. Ten (66.6%) patients were fo­llowed up for a mean period of 25 months (range from 2 to 48 months).

The outcome was favorable with 7 (46.6%) patients improved their renal function, 6 (40%) remained with a moderate CKD, one normalized his renal function, and one died suddenly after 2 months of initiating the treatment corticosteroids.

 Discussion



Sarcoidosis typically affects young adults with the same rate in males and females. Renal failure in sarcoidosis may occur as a consequence of hypocalcemia or hypercal­ciuria, glomerular disease or granulomatous interstitial nephritis. [5] Chronic kidney disease (CKD) was reported in less than 1% of patients in sarcoidosis, and it seems to be more frequent in older patients.

As reported in a few patients in the litera­ture, the impairment renal function resulted in the diagnosis of sarcoidosis in our patients. [6],[7],[8],[9],[10],[11],[12] In sarcoidosis, hypercalciuria may be present in half of the patients, whereas only 10 to 20% have hypercalcemia. [3],[5] Hyper­calcemia is due to increased intestinal absorp­tion of calcium related to increased levels of calcitriol. Patients with sarcoidosis commonly have elevated levels of angiotensin conver­ting enzyme (ACE). [13] As calcitriol, ACE is a product of epitheloid cells within the granuloma. Serum ACE was elevated in one patient in our study.

Granulomatous interstitial nephritis is common in sarcoidosis, and was first documented in 1933. [14],[15],[16] The prevalence has been estimated from post-mortem series, and reports vary from 7 to 27%. [16],[17] In our study, 80% of the patients had TIN, and 47% with granuloma. As in almost patients cited in the literature, most of our patients pre­sented with advanced CKD, which may be severe enough to require dialysis at least transiently. [3] Glomerular involvement in sarcoidosis may manifest as focal segmental sclerosis, membranous GN, mesangiopro­liferative GN, mesangiocapillary GN, and IgA GN, although their mechanisms are not known. [18] Crescentic GN associated with sarcoidosis is very rare, [17],[18],[19] as was revealed in our seventh patient.

Corticosteroid treatment is efficient in TIN. [3] In our study, this treatment was used in 57% TIN patients with normalization of renal function in 6% and improvement of renal function in 33.3% patients.

Corticosteroid treatment is variably efficient in GN depending on its pathological type. As observed in idiopathic form, the membranous GN associated with sarcoidosis has high rate of resistance to corticosteroid treatment. That was the result in our two patients with membranous GN treated by corticosteroid.

The relapse in patients who respond to treatment can be retreated and respond again to another course of corticosteroid. [3] In our patients, no relapse was noted.

We conclude that sarcoidosis is a multi­system granulomatous disorder of unknown cause. Granulomatous interstitial nephritis is more common than glomerular involvement. Most patients may develop advanced renal failure. Sarcoidosis cannot necessary be con­sidered a benign nephrological disease.

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