Renal disease due to allergic vasculitis (Part 3)

The article was written by Doctor of Emergency Department - Vinmec Phu Quoc International General Hospital

Allergic vasculitis is an acute secondary disease, mainly caused by allergies. Studies have shown that, due to an immune reaction between antigens and antibodies that take place in the endothelium (mainly capillaries)

5.2.1. Clinical manifestations. Renal disease usually manifests several days after the onset of clinical symptoms of allergic vasculitis. Typically microcytic erythrocytosis and moderate proteinuria without clinical symptoms during active disease. Some patients may experience edema, increased blood pressure, and slightly increased blood creatinine levels. A small number of patients have nephrotic syndrome. Some patients present with rapidly progressive glomerulonephritis with histopathologically crescent-shaped extracapillary glomerulus.
Diagnosis of allergic vasculitis is based on the classic clinical presentation as presented, usually does not require renal biopsy. When the diagnosis is uncertain, biopsies of both lesional and non-lesional skin may reveal IgA deposition in the vascular wall, detectable by immunofluorescence staining, and possibly renal biopsy.
Clinical manifestations of the disease usually resolve spontaneously, although re-occurrence is possible. There was no relationship between the severity of the present disease and the prognosis or between the severity of glomerulonephritis and the severity of extrarenal symptoms. Renal damage is of importance in the long-term prognosis, and patients with nephrotic syndrome and renal failure are at high risk for progression to end-stage renal failure. In most patients with allergic vasculitis, both children and adults, renal function recovers completely. Urinary abnormalities persist in 5-15% of patients for several years following disease activity. 2.8% of patients were children and 3.9% of patients were adults, progressing to end-stage renal failure.
Meadow et al. 1972 classified the clinical severity of kidney injury in patients with allergic vasculitis as follows:
Normal: clinically normal, no urine abnormalities, normal renal function.
Mild urine abnormalities: clinically normal, with erythrocytosis (microscopic or macroscopically intermittent) and/or proteinuria less than 1g/24 hours, normal renal function.
A. Active kidney disease: Proteinuria greater than 1g/24 hours, with or without hypertension, normal renal function.
B. Renal failure: glomerular filtration rate less than 60 ml/min/1 73m2 body area. Will die or need dialysis or a kidney transplant.
5.2.2. Relation between renal histopathology and clinical lesions Studies have shown that, in patients with clinical grade D progressive neurological damage, 70.8% of renal histopathological lesions are in Grade V; 23.8% are grade IV. Patients with grade VI renal histopathology (intercapillary glomerulonephritis) also have a poor prognosis.
Research on the relationship between glomerular deposition and clinical progress shows that patients have subepithelial deposition, and especially deposition in all three locations in the glomerulus (in the interstitium). vascular, subendothelial, and subepithelial) have a worse prognosis than patients with mesangial deposition alone, or mesangial and subepithelial deposits, but not deposition under endothelial cells.

There is no specific treatment for allergic vasculitis, nor for kidney damage due to allergic vasculitis. If disease onset is associated with an infection, appropriate antibiotics may be given. Attention should be paid to fluid and electrolyte balance, especially in children presenting with renal and intestinal disease. If edema is associated with hypoalbuminemia, which may be due to renal disease, gastrointestinal disease, or interstitial infiltration of albumin by increased vascular permeability or nephrotic syndrome, intravenous infusion may be considered. albumin or plasma vessels. During intravenous infusion of albumin or plasma, attention should be paid to monitoring of circulating volume by measuring central venous pressure, signs of peripheral hypoperfusion (increased central and peripheral temperature difference, sodium concentration) urine is less than 10 mmol/l). It should be noted that many patients with edema, including some with hypoalbuminemia, presenting with renal failure have normal or increased circulating volumes.
6.1. Treatment of extra-renal symptoms The patient has arthralgia and requires pain medication. Blood transfusion may be necessary for patients with gastrointestinal bleeding. Abdominal ultrasonography is of great value in patients with acute abdominal syndrome for appropriate treatment. If the patient has abdominal pain, exclude cases requiring surgical management.

6.2. Treatment of kidney disease Most patients with allergic vasculitis have no clinical symptoms of renal disease, or only transient urinary abnormalities, even those with clinical manifestations of mild renal disease. No treatment is needed,
Patients with clinical manifestations of more severe kidney disease such as nephrotic syndrome or acute glomerulonephritis syndrome should be treated. But among these patients, less than 50% of patients have a poor long-term prognosis, with chronic renal failure only seen in patients whose renal biopsy shows histopathological grade IV to grade VI.
Patients with allergic vasculitis who have other associated chronic kidney disease should be treated. Blood pressure should be well controlled, particularly during the active phase of the disease (presence of urinary abnormalities and/or decreased glomerular filtration rate). Blood pressure should be carefully monitored before, during, and after the active disease phase.
Trials of oral corticosteroid therapy at doses of 1-2 mg/kg/day, or 30-60 mg/m2 of body surface area/day in patients with allergic vasculitis have shown a poorer prognosis than the patient population. untreated individuals. Therefore, corticosteroids are not recommended unless the patient has nephrotic syndrome.
Patients with allergic vasculitis who have a rapidly progressive glomerulonephritis syndrome (extracapillary sickle glomerulonephritis), in combination with corticosteroids with other immunosuppressants (usually azathioprine or other alkylating agents) ) showed a better prognosis in 55% of patients, compared with 11% of patients not treated with these agents.
In recent years, two treatments have been introduced for patients with allergic vasculitis with rapidly progressive glomerulonephritis: high-dose methylprednisolone (pulse therapy with 500 mg/day IV infusion). pulse every other day, 3 times infusion, then oral prednisolone 0.5mg/kg/day), and plasma exchange. Both methods appear to be equally effective, with renal function improving in about 75% of patients.
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