Focal Segmental Glomerulosclerosis and the Nephro6c Syndrome Dr. A. Gangji Dr. P. Marge>s. Part 1: Clinical

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1 Focal Segmental Glomerulosclerosis and the Nephro6c Syndrome Dr. A. Gangji Dr. P. Marge>s Part 1: Clinical

2 Pa#ent DM 18 year old McMaster student Back pain, severe fa#gue Oct 2006 Leg swelling to ER Nov 2006 Exam 150/90, 3+ edema to abdomen. Bloodwork: crea#nine 82 umol/l Serum albumin 13 g/l Urine 3+ protein, 1+ blood 24 hour urine 22 g/day protein T Chol 19.95, Tri 4.05, LDL 16.47, HDL 1.62

3 Pa#ent DM: Nephro#c Syndrome Diagnosed with nephro#c syndrome Ini#ated therapy with: Ramipril 10 mg daily, Furosemide 80 mg daily, Prednisone 60 mg daily, Atorvasta#n 20 mg daily Urine protein excre#on unchanged Renal biopsy

4 24 hour urine (mg/day) 0 Normal 150 Dipstick 2+ Albumin:creatinine (mg/mmol) trace Nephrotic Range

5 Nephro#c syndrome Proteinuria (>3.5 g/day) Edema Hypoalbuminemia (<25 g/l) Hypercholesterolemia Hypercoagulable state Hypoalbuminemia Nephro#c range proteinuria

6 Mechanism of Nephro#c Syndrome

7 Identification of Nephrotic Syndrome: - edema, hypoalbuminemia, urine protein > 3.5 g daily Non-specific therapies Diagnosis Primary (Idiopathic) Nephrotic Syndrome Secondary Nephrotic Syndrome Focal Segmental Glomerulosclerosis, Membranous Glomerulonephritis, Minimal Change Disease Systemic disease, drugs, infection, malignancy Disease specific therapy

8 The Nephron and Glomerulus

9 Primary Nephro#c Syndrome Primary: Membranous MCD FSGS MPGN I, II Other Glomerulopathies (IgA, Fibrillary GN, Immunotactoid GN) Topic III 100 Answer

10 Nephro#c syndrome: Diagnosis categorized by glomerular lesion Membranous GN (30-35%) Idiopathic (75%) Immune deposits in the GBM Systemic Lupus Erythematosis Drugs d- penicillamine, gold, captopril, NSAID Hepa##s B Malignancy (solid tumor, CLL) Focal Segmental Glomerulosclerosis (30-35%) Idiopathic Gene#c (MHC9?) HIV Drugs (heroin, pamidronate) Obesity

11 Categorized by glomerular lesion Minimal Change Disease Idiopathic (majority) NSAID, an#bio#cs, Lithium Hodgkin s Lymphoma

12 Categorized by glomerular lesion Associated with other glomerulonephri#dis MPGN, IgA, PIGN Idiopathic Hepa##s C Streptococcal infec#on

13 Nephro#c Syndrome: Electron Microscopy Podocyte foot process fusion and epithelial cells are effaced along GBM

14 Nephro#c syndrome: secondary causes Systemic Disease Diabetes Amyloidosis Systemic Lupus Erythematosis Infec#on HIV Hepa##s B or C Drugs NSAID Gold, d- penicillamine Pamidronate Captopril Lithium Malignancy Myeloma Lymphoma Solid tumor Clinical Clues: abrupt onset, severe symptoms, younger age = primary

15 Work up History Symptoms to suggest systemic illness, malignancy Risk factors for HIV, viral hepa##s Recent changes in drug regimen Blood work: Fas#ng glucose, crea#nine, electrolytes, liver enzymes, cholesterol 24 hour urine, serum and urine protein electrophoresis ANA, an#- dsdna, C3, C4 Hepa##s B, C, and HIV Chest xray Refer to nephrologist for considera#on of renal biopsy

16 Complica#ons of nephro#c syndrome Acute renal failure Secondary to volume contrac#on, ATN (avoid NSAID) Therapy (cyclosporin) Renal vein thrombosis Thromboembolism 8 fold increase risk Deep leg vein or renal vein Infec#on Pneumococcus, encapsulated organisms Hypercholesterolemia Osteoporosis Vit D deficiency, steroids Malnutri#on

17 Treatment Issues non- specific issues Edema (Volume) control Na restric#on ACEi / ARB Loop diure#cs Thromboembolism Warfarin for albumin < 20 g/l Infec#on Vaccina#on Hypercholesterolemia Sta#n therapy Osteoporosis Vit D replacement, bisphosphonate when on steroids Malnutri#on Normal protein diet

18 Pa#ent DM: Nephro#c Syndrome Nephro#c syndrome: Ramipril 10 mg daily, Furosemide 80 mg daily, Prednisone 60 mg daily, Atorvasta#n 20 mg daily Renal biopsy shows FSGS Progressive weight gain, anasarca Started cyclosporine Plasmapheresis, mycophenolate Ini#ated dialysis 6 months aler symptom onset First renal transplant 1 year later failed Remains on hemodialysis with plans for second renal transplant

19 Focal Segmental Glomerulosclerosis FSGS accounts for 20% of nephro#c syndrome in children and 40% in adults Most common primary glomerular disease causing end stage renal disease 4% of dialysis pts in US have FSGS Group of diseases with common pathology involving the glomerular podocytes 80% of FSGS is primary or idiopathic Associated with minimal change disease D Agati, NEJM 2011

20 Focal Segmental Glomerulosclerosis D Agati, NEJM 2011

21 FSGS Circula#ng Factor As of yet uniden#fied circula#ng permeability factor explains idiopathic FSGS FSGS can recur within hours aler renal transplanta#on Disease can be modulated by immunoabsorp#on or plasmapheresis Serum from pa#ents with idiopathic FSGS can induce podocyte injury in rats. Poten#al candidates: cardiotropin- like cytokine 1, soluble urokinase receptor

22 Prognosis Remuzzi et al, JCI 2006

23 D Agati, NEJM 2011

24 D Agati, NEJM 2011

25 Treatment for FSGS: Cyclosporine Cattran et al KI 1999

26 Treatment of FSGS: Rituximab Remuzzi et al, JCI 2006 Ahmed et al, NDT 2008

27 Recurrent FSGS Post Renal Transplant Risk of recurrence varies between 20 to 50% given heterogenous group of condi#ons Familial and slow progressing forms are at lower risk of recurrence An aggressive ini#al course in associa#on with heavy proteinuria leading to kidney failure with mesangial prolifera#on on biopsy have a high risk of recurrence Recurrence can be immediate Therapeu#c op#ons: Plasmapheresis, steroids, Cyclosporine or Tacrolimus, Rituximab

28 Summary - FSGS Common cause of nephro#c syndrome Represents a group of diseases with similar histology Idiopathic (circula#ng permeability factor) Gene#c Secondary Infec#on, drug, adap#ve Renal prognosis is poor in idiopathic FSGS Treatment involves non- specific therapies, high dose steroids, calcineurin inhibitor