2. What do the lungs and kidneys have in
common?
Detailed and extensive amount of micro-vasculature
across a large surface area
Basement membrane (which has special antigens)
Exchange of materials across a thin barrier.
Both clean the body of waste material and manage the
delicate balance of other materials.
3. Facts to keep in mind
Pulmonary Renal syndromes can be FATAL.
If bleeding is occurring from both the lungs and
kidneys then these patients need to be in the ICU
and get treatment FAST otherwise they will die.
In difficult cases with vague symptoms, sometimes
an early renal biopsy can make all the difference
4. The basic pathology
LUNGS: Diffuse alveolar hemorrhage (DAH)
- Acute onset of symptoms
- 2/3 have at least mild Hemoptysis if not more gross
bleeding
- X-ray and CT scans are usually abnormal: Alveolar and
interstitial opacities, or even fibrosis type appearance
may be seen
- If severe – many of them need intubation
KIDNEYS: Rapidly Progressive Glomerlo-Nephritis
- Acute Renal Failure
- Oliguria <400ml/day
- RBC casts and RBC on UA
5. Causes of Pulmonary Renal Syndromes
ANCA associated Vasculitis: ~ 60%
Wegeners
Microscopic Polyangitis
Churg Strauss Syndrome
Goodpasture‟s syndrome ~ 20%
OTHERS:
SLE
Uremic Lung
Pneumonia with Infectious GN
6. ANCA associated Vasculitis
THREE diseases causing Pulmonary Renal Syndromes are ANCA + and
pauci-immune – meaning very few immune complexes involved in the
glomeruli. Mostly T cell mediated injury.
These three together make up 60% of all Pulmonary-Renal Syndromes
1- Wegener‟s Granulomatosis: C-ANCA or Anti-PR3
2- Microscopic Polyangitis: P-ANCA or Anti MPO
3- Churg Straus: P-ANCA or Anti-MPO
Any combination or mix of antibodies is possible but above is basic
underlying pattern.
They have similar treatment – but prognosis is worse if Anti-PR3 is present
9. Wegener’s Granulomatosis
LUNG, UPPER AIRWAY (sinus, nasopharynx) , and
RENAL involvement.
Necrotizing Vasculitis of SMALL VESSELS (arterioles AND veins)
.
Renal Biopsy shows SEGMENTAL NECRTIZING
Glomerulonephritis and Rapidly Progressive GN in later stages
Non-Caseating Granuloma formation – rarely in the kidney,
mostly in lung/sinuses.
If no renal involvement it is called LMITED Wegeners – but
kidneys usually get involved later.
Chest X-Ray may show: Nodules, persistent infiltrates, cavities
Cause unknown – has been associated with Silica exposure.
10. Wegener‟s Granulomatosis
Signs and Symptoms: Fever, Rhinorrhea, Sinus pain, Sinus ulcers,
Hemoptysis, SOB, Hematuria, Proteinuria, Cutaneous purpura.
Lung biopsy has highest yield.
More common in people with apha-1 antitrypsin deficiency
which inhibits PR3
Rx: STEROIDS + CYCLOPHOSPHAMIDE .
Plasmapharesis is not established - may or may not be used initially
depending on severity
25% will relapse REPEAT ABOVE TREATMENT and give
Methotrexate OR Azathioprine to maintain remission.
11. Microscopi polyangitis
Necrotizing vasculitis, glomerulonephritis, and pulmonary capilaritis.
Very similar to Wegener‟s Granulomatosis – Except that there are NO
GRANULOMAS on biopsy.
Lungs are involved only 50% of the time and upper airway is rarely
involved – and these involvements are rarely severe
Used to be included in P.A.N – no longer – involves the lungs – and PAN
does Not. Also not associated with HBV, but PAN is.
Can also cause GI vasculitis , cutaneous vasculitis and Mononeurtis
complex.
Rx: similar to Wegener‟s – STEROIDS + IMMUNOSUPPRESSANT.
Plasmapharesis is not established – may or may not be used depending on
severity.
Relapse also occurs – 35% of the time – treated the same – repeat and give
maintenance therapy with MTX or Azathioprine
12. Churg Strauss Syndrome
Small vessel vasculitis with focal segmental necrotizing
glomerulonephritis.
Rare “allergic state” with systemic inflammation associated with Asthma,
Hypergammaglobulinemia, RF+, raised IgE levels, and EOSINOPHILS
Rare: about 1 in 3 million
Has been associated with Asthma treated with Leukotriene antagonists.
Symptoms: Lung involvement dominates and may preceded others by
years: Cough, infiltrates, severe asthma, 1/3 have pleural effusions – high
in eosinophils.
GN (45%), Rhinitis, mononeuritis, Skin involvement (50%) , GI vasculitis
and Cardiovascular inflammation resulting in MI (most frequent cause of
death in Churg Strauss)
13. Churg Strauss….
Kidney biopsy usually does not show granuloma or eosinophils
(granulomas and eosinophils are present in lung and elsewhere) .
Do blood tests for Ige, Eosinophils.
Rx: similar: STEROIDS + IMMUNOSUPRESSANTS
May be difficult to wean off steroids and may become dependant
on them.
14. Goodpasture‟s syndrome
Autoimmune disease with Abs against the “alpha 3
NC1 domain of TYPE IV COLLAGEN” on the
basement membrane.
This epitope becomes „exposed‟ by infections,
smoking, solvents, and oxidants
10-15% also have ANCA abs against Myeloperoxidase
(MPO) – a vasculitis variant which has good prognosis.
Bimodal Age distribution:
Men in late 20s
Men and women 60-70s
15. Goodpastures syndrome…
Young Men in 20s:
Explosive, sudden onset.
Sudden anemia
More lung involvement than in older age group
Hemoptysis - specially if smokers
Dyspnea,
Hematuria
Better prognosis than older age group
16. Goodpasture‟s syndrome…
Older Age Group: 60-70s , M and F
Prolonged asymptomatic renal injury
May present with oliguria – Poor prognosis
Lung disease may range from mild dyspnea to
outright pulmonary hemorrhage
Urgent kidney biopsy if we suspect this disease and
there are mild or no lung signs
17. Goodpasture‟s syndrome…
DIAGNOSIS:
Renal Biopsy:
– Focal (<50% glomeruli affected)
- or segmental (glomeruli tuft involved in segments)
Linear Immunoflorescence staining
Anti GBM Abs against ALPHA3 -NC1-Collagen IV t
19. Goodpasture‟s syndrome
TREATMENT AND PROGNOSIS:
Plasmapharesis + Steroids + Immunosuppressants
(and supportive care if needed: ventilator , dialysis)
Signs of Poor Prognosis:
- Biopsy shows >50% crescent and advanced fibrosis,
(specially seen in long standing asymptomatic disease in
older folks)
- Cr 5-6 mg/dl
- Oliguria
- If needs urgent dialysis at presntation may not even
respond to plasmapheresis or steroids
20. Goodpasture‟s … treatment and
prognosis
Even if kidney disease does not respond to
plasmapharesis – lung disease does and it can be
lifesaving.
8-10 treatments of plasmapharesis is needed
At the same time Prednisone or IV
methylprednisolone, PLUS Cyclophosphamide
should be started together cyclophosphamide for
at least first 2 weeks
Kidney transplant can be considered – but wait 6
months for antibodies to clear out.
21. Goodpasture‟s : treatment and prognosis
If No treatment received 80% risk of ESRD in 1
year
If needed urgent Dialysis may not ever recover
renal function, need dialysis for life
Treatment started Early (Cr <5) One year
survival is 90%
25. Uremic Lung / Uremic Pulmonary Edema
Occurs in severe renal failure, ESRD , specially when HTN also
present.
Due to the actual Uremia itself – usually when Cr Clearance
<10ml/min. Fluid, electrolyte, metabolic changes – No single toxin
has been identified as the cause yet.
There is increase in pulmonary capillary permeability due to uremia
effects – causing protein rich fluid to enter the lungs from the
capillaries – causes Uremic Pulmonary Edema.
CXR shows perihilar edema, though peripheries are clear.
Correction or uremia with or without Dialysis can correct the flow
dynamics of the pulmonary vasculature and improve
27. Infectious GN
Very rarely – If Strep pharyngitis and Strep
pneumonia occur – pulmonary symptoms may still
be present by the time Renal RPGN starts …
