• RPGN - Rapidly Progressive Acute Renal Failure (over weeks)
  Two ways to approach Differential
  Demographics
  • Young
    • lupus
  • Older
    • ANCA
    • Anti GBM
  Complement
  • Low complement
    • Peri- infectious; strep and staph (endocarditis)
    • lupus
    • Cryo
    • MPGN
  • Normal complements
    • IGA (immune complex but slow/chronic so liver could produce complements to compensate) 
      • Can cause vasculitis with abdominal pain and rash (Henoch-Schonlen Purpura)
    • ANCA
    • Anti-GBM
      
      
  Drugs like PPI unlikely to cause such a rapid change in Cr with interstitial nephritis 
  
  

  Posted 04/06/17 09:18:58 AM by Ying Liu

• Clinical Pearls
  • Would expect hypertension with RPGN
  • Another way to rule out alvelolar hemmorhage is PFTs and look for DLCO that is not normal 
  • If on HD for more than 3 months, renal recovery is unlikely and want to reduce immunosuppression given HD 
  • Cr above 7 (woman) and 10 (man) renal recovery is unlikely, especially if anuric 
  
  

  Posted 04/06/17 09:19:55 AM by Ying Liu

• Rituxumab vs cyclophosphamide for ANCA and Anti-GBM Disease
  • 2 trials
    • Jones et al. studied more severe disease and both groups (rituxumab and Cyclophosphamide) got at least 2 doses of cyclophosphamide. No differences between groups
    • Stone et al. studied a group with less severe disease and rituxumab group was non-inferior to cyclophosphamide group
  • In women of reproductive age, cyclophosphamide affects feritility  (dependent on age, not an issue until 20-21 and then is dose dependent)
  • Data for rituxumab for anti GBM is very scarce and cyclophosphamide is first line (cyclophosphamide kils Tregs faster than rituxumab can deplete B cells). Often will use oral cyclophosphamide for faster load 
  • Plasmapharesis to get rid of the antibodies is the best way to treat anti GBM 
  
  

  Posted 04/06/17 09:51:28 AM by Ying Liu

• For further reading...

  Jones et al. 
  
  

  Posted 04/06/17 09:51:48 AM by Ying Liu

• For further reading...

  Stone et al. 
  
  

  Posted 04/06/17 09:52:03 AM by Ying Liu

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