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Diagnosis: Proliferative mesangial glomerulonephritis associated to rheumatoid arthritis

Renal involvement in rheumatoid arthritis is well recognised but is usually attributed to either the development of amyloidosis, adverse reactions to gold or penicillamine, analgesic nephropathy, or an interstitial nephritis with tubular dysfunction in patients with associated keratoconjunctivitis sicca.

Mesangial glomerulonephritis is a frequent renal biopsy finding in patients with rheumatoid arthritis (RA) presenting with haematuria and/or proteinuria.

In a study by Korpela et al (23 patients), the authors found that "the clinical renal findings of the patients were isolated hematuria (n = 10), isolated proteinuria (n = 6) and hematuria combined with proteinuria (n = 7). Hematuria persisted and renal function remained normal in all patients with isolated hematuria. A possible association between the presence of hematuria and the use of antirheumatic drugs was not established in this study. Proteinuria was clinically closely associated with the use of antirheumatic drugs in 9 out of 13 cases (7 gold salts, 2 D-penicillamine) suggesting that antirheumatic drugs are important contributors to proteinuria in these patients. Renal function, although initially reduced in some patients, remained stable in all but 1 patient who developed the nephrotic syndrome and died of uremia" (Korpela M, et al. Nephron. 1991;59:46-50. [PubMed link]).

Helin et al (Helin HJ, et al. Arthritis Rheum. 1995;38:242-7. [PubMed link]) found in 40 cases that IgM was the sole immunoglobulin (12 cases) or occurred with lesser amounts of C3 (4 cases), IgA (6 cases), C1q (1 case), IgG and C3 (1 case), or IgA and C3 (1 case). In other studies immunoglobulins or complement are detected in few cases (Hordon LD, et al Ann Rheum Dis. 1984;43:440-3. [PubMed link] [Free full text]).

In conclusion, mesangial proliferative GN associated to RA usually presents as isolated hematuria, isolated proteinuria, or both hematuria and proteinuria. Prognosis is good without renal failure. Proteinuria associated with treatment is reversible on drug withdrawal

See the chapter Lupus nephritis and renal involvement in other rheumatologic diseases of our Tutorial.

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Bibliography

• Karstila K, Korpela M, Sihvonen S, Helin H, Mustonen J. Prognosis of mesangial glomerulonephritis in patients with rheumatoid arthritis. Clin Nephrol. 2007;68:335-6 [PubMed link]
• Korpela M, Mustonen J, Teppo AM, Helin H, Pasternack A. Mesangial glomerulonephritis as an extra-articular manifestation of rheumatoid arthritis. Br J Rheumatol. 1997;36:1189-95. [PubMed link] [Free full text link]
• Helin HJ, Korpela MM, Mustonen JT, Pasternack AI. Renal biopsy findings and clinicopathologic correlations in rheumatoid arthritis. Arthritis Rheum. 1995 Feb;38(2):242-7. [PubMed link]
• Korpela M, Mustonen J, Pasternack A, Helin H. Mesangial glomerulopathy in rheumatoid arthritis patients. Clinical follow-up and relation to antirheumatic therapy. Nephron. 1991;59:46-50. [PubMed link]
• Hordon LD, Sellars L, Morley AR, Wilkinson R, Thompson M, Griffiths ID. Haematuria in rheumatoid arthritis: an association with mesangial glomerulonephritis. Ann Rheum Dis. 1984;43:440-3. [PubMed link] [Free full text]
• Sellars L, Siamopoulos K, Wilkinson R, Leohapand T, Morley AR. Renal biopsy appearances in rheumatoid disease. Clin Nephrol. 1983;20:114-20. [PubMed link]

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