Two or More

Time for another reader question, but first, let’s pay attention to what day today is. Many people see today as the day for bar-b-ques or backyard ball games (or, at least, they did before Covid 19). When I married Bear a little more than seven years ago, he explained about Memorial Day. I knew it was to honor those who died protecting us, but it was so much more meaningful when explained by a veteran… someone who didn’t die protecting us and lived on to meet me and marry me. So give some quiet thoughts to these men and woman today, will you?

Now, the question. This reader has both lupus like immune mediated glomerular nephritis and Wegeners vasculitis with kidney involvement. Her question is how does she handle both?  And, here I thought I had it bad with pancreatic cancer (now gone), Chronic Kidney Disease, diabetes, and a whole host of what I consider lesser diseases!

Starting slowly is a must here since I am like a fish out of water with these two diseases. According to the MayoClinic at https://www.mayoclinic.org/diseases-conditions/granulomatosis-with-polyangiitis/symptoms-causes/syc-20351088,

”Granulomatosis with polyangiitis is an uncommon disorder that causes inflammation of the blood vessels in your nose, sinuses, throat, lungs and kidneys.

Formerly called Wegener’s granulomatosis, this condition is one of a group of blood vessel disorders called vasculitis. It slows blood flow to some of your organs. The affected tissues can develop areas of inflammation called granulomas, which can affect how these organs work.

Early diagnosis and treatment of granulomatosis with polyangiitis might lead to a full recovery. Without treatment, the condition can be fatal.”

Whoa! Not good. Let’s see how it’s treated. The Cleveland Clinic at https://my.clevelandclinic.org/health/diseases/4757-granulomatosis-with-polyangiitis-gpa-formerly-called-wegeners/management-and-treatment tells us,

“People with GPA who have critical organ system involvement are generally treated with corticosteroids [Gail here: commonly just called steroids] combined with another immunosuppressive medication such as cyclophosphamide (Cytoxan ®) or rituximab (Rituxan®). In patients who have less severe GPA, corticosteroids and methotrexate can be used initially. The goal of treatment is to stop all injury that is occurring as a result of GPA. If disease activity can be completely ‘turned off,’ this is called ‘remission.’ Once it is apparent that the disease is improving, doctors slowly reduce the corticosteroid dose and eventually hope to discontinue it completely. When cyclophosphamide is used, it is only given until the time of remission (usually around 3 to 6 months), after which time it is switched to another immunosuppressive agent, such as methotrexate, azathioprine (Imuran®), or mycophenolate mofetil (Cellcept®) to maintain remission. The treatment duration of the maintenance immunosuppressive medication may vary between individuals. In most instances, it is given for a minimum of 2 years before consideration is given to slowly reduce the dose toward discontinuation.”

Okay, got it. Now let’s take a look at lupus like immune mediated glomerular nephritis. MedicineNet at https://www.medicinenet.com/script/main/art.asp?articlekey=8064 reminds us about lupus:

Lupus: A chronic inflammatory disease that is caused by autoimmunity. Patients with lupus have in their blood unusual antibodies that are targeted against their own body tissues. Lupus can cause disease of the skin, heartlungs, kidneys, joints, and nervous system. The first symptom is a red (or dark), scaly rash on the nose and cheeks, often called a butterfly rash because of its distinctive shape. As inflammation continues, scar tissue may form, including keloid scarring in patients prone to keloid formation. The cause of lupus is unknown, although heredity, viruses, ultraviolet light, and drugs may all play a role. Lupus is more common in women than in men, and although it occurs in all ethnic groups, it is most common in people of African descent. Diagnosis is made through observation of symptoms, and through testing of the blood for signs of autoimmune activity. Early treatment is essential to prevent progression of the disease. A rheumatologist can provide treatment for lupus, and this treatment has two objectives: treating the difficult symptoms of the disease and treating the underlying autoimmune activity. It may include use of steroids [Gail here: Remember they’re used in treating this reader’s other disease, too.] and other anti-inflammatory agents, antidepressants and/or mood stabilizers, intravenous immunoglobulin, and, in cases in which lupus involves the internal organs, chemotherapy.

But our reader has lupus LIKE immune mediated glomerular nephritis, so she may need to deal with the symptoms, but not the treatment. Wikipedia at https://en.wikipedia.org/wiki/Immune-mediated_inflammatory_diseases informs us,

“An immune-mediated inflammatory disease (IMID) is any of a group of conditions or diseases that lack a definitive etiology, but which are characterized by common inflammatory pathways leading to inflammation, and which may result from, or be triggered by, a dysregulation of the normal immune response. All IMIDs can cause end organ damage, and are associated with increased morbidity and/or mortality.”

That’s as close as I could get to the definition of immune mediated.  We know that glomerular means of or about the glomerulus. Dictionary.com at https://www.dictionary.com/browse/glomerular helped me out here:

“Also called Malpighian tuft. a tuft of convoluted capillaries in the nephron of a kidney, functioning to remove certain substances from the blood before it flows into the convoluted tubule.”

And nephritis? After a decade of writing this blog, we probably all know that’s an inflammation of the nephrons.

Let’s combine the pieces to see what we get.  The nephron’s glomeruli are inflamed in the same way lupus inflames the organs. Remember that GPA also causes inflammation. (By the way, this is the perfect point in the blog to remind you I am not a doctor and have never claimed to be one.)

But how is it treated? Here’s where I admit defeat. There is quite a bit of information available on Lupus, Lupus Nephritis, and the like. But I could not find anything that includes ‘Lupus like.’

The commonality between the two diseases seems to be inflammation. But isn’t that at the root of all Chronic Kidney Disease? I admit to being surprised twice while writing this particular blog:

  • GPA was called by its older name by the doctor.
  • The dearth of treatment information for lupus like immune mediated glomerular nephritis.

Until next week,

Keep living your life!

Nephritis without the Lupus


Recently, I wrote about Lupus Nephritis. As one reader pointed out, it is possible to have Nephritis without Lupus. Let’s take a look at how that works.

According to MedicalNewsToday at https://www.medicalnewstoday.com/articles/312579.php,

“Nephritis is a condition in which the nephrons, the functional units of the kidneys, become inflamed. This inflammation, which is also known as glomerulonephritis, can adversely affect kidney function.

The kidneys are bean-shaped organs that filter the blood circulating the body to remove excess water and waste products from it.

There are many types of nephritis with a range of causes. While some types occur suddenly, others develop as part of a chronic condition and require ongoing management.”

Of course! ‘Itis’ means inflammation, while ‘neph’ means kidney. It’s amazing what you can remember learning in college over 50 years ago when you’re 72.

Hmmm, what do they mean by “many types of nephritis”? DoctorsHealthPress at doctorshealthpress.com/vital-organs/kidneys/types-nephritis-causes-symptoms-prevention/lists them for us:

1. Interstitial Nephritis                    

Interstitial nephritis is characterized by swelling between the tubules and kidneys. The kidney tubules reabsorb water and important substances from kidney filtration, and substances are secreted through urination.

Interstitial nephritis can be acute or chronic in nature. Acute interstitial nephritis is typically the result of an allergic reaction. Over 100 different medications cause interstitial nephritis, such as antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors.

Non-allergic interstitial nephritis causes include high calcium levels, low potassium levels, and autoimmune disorders.

  1. Pyelonephritis

Acute pyelonephritis is a severe and sudden kidney infection. Consequently, the kidneys will swell, which may lead to permanent damage. Frequent occurrences are known as chronic pyelonephritis.

The infection will begin in the lower urinary tract in the form of a urinary tract infection (UTI). Bacteria enter the body through the urethra and spread to the bladder. At that point, bacteria will travel from the ureters to the kidneys.

  1. Glomerulonephritis

Glomerulonephritis refers to a range of kidney conditions that cause inflammation in the very small blood vessels in the kidneys, which are called glomeruli.

It is also called glomerular disease or glomerular nephritis. When the glomeruli become damaged, the kidney can no longer efficiently remove excess fluids and waste.

  1. Lupus Nephritis [Gail here: This is they type I recently wrote about.]

Lupus nephritis is inflammation of kidneys caused by the autoimmune disease known as systemic lupus erythematous (SLE)—also called lupus. This is where the body’s immune system targets its own tissues.

As many as 60% of lupus patients will later get lupus nephritis. The most common symptoms include dark urine, weight gain, high blood pressurefoamy urine, and the need for nighttime urination.

  1. IgA Nephropathy (Berger’s Disease)

IgA (immunoglobulin A) nephropathy is also called Berger’s disease. The kidney disease occurs when the antibody IgA lodges within the kidneys.

Over time, this leads to local inflammation, which interferes in the kidneys’ ability to filter waste from the blood. It is a progressive disease that may lead to end-stage kidney failure.

  1. Alport Syndrome

Alport syndrome is an inherited disease caused by genetic mutations to the protein collagen. It can lead to kidney failure, hearing problems, and vision issues.

It will often run in families, and the severity is greater in men. Common symptoms include high blood pressure, protein in the urineblood in the urine, and swelling in the ankle, legs, feet, and around the eyes.

The genetic types of Alport syndrome include X-linked Alport syndrome (XLAS), autosomal recessive Alport syndrome (ARAS), and autosomal dominant Alport syndrome (ADAS).”

I usually move on to symptoms next but – as you can see – DoctorsHealthPress already took care of that for us. Thank you to DoctorsHealthPress.

Healthline (Yep, that’s the same Healthline that awarded SlowItDownCKD a place among the top six kidney disease blogs in both 2016 & 2017.) at https://www.healthline.com/health/acute-nephritic-syndrome#types offered more detail about the cause of several acute nephritis diseases:

Interstitial nephritis

In interstitial nephritis, the spaces between the kidney tubules become inflamed. This inflammation causes the kidneys to swell.

Pyelonephritis

Pyelonephritis is an inflammation of the kidney, usually due to a bacterial infection. In the majority of cases, the infection starts within the bladder and then migrates up the ureters and into the kidneys. Ureters are two tubes that transport urine from each kidney to the bladder.

Glomerulonephritis

This type of acute nephritis produces inflammation in the glomeruli. There are millions of capillaries within each kidney. Glomeruli are the tiny clusters of capillaries that transport blood and behave as filtering units. Damaged and inflamed glomeruli may not filter the blood properly. Learn more about glomerulonephritis.

What causes acute nephritis?

Each type of acute nephritis has its own causes.

Interstitial nephritis

This type often results from an allergic reaction to a medication or antibiotic. An allergic reaction is the body’s immediate response to a foreign substance. Your doctor may have prescribed the medicine to help you, but the body views it as a harmful substance. This makes the body attack itself, resulting in inflammation.

Low potassium in your blood is another cause of interstitial nephritis. Potassium helps regulate many functions in the body, including heartbeat and metabolism.

Taking medications for long periods of time may damage the tissues of the kidneys and lead to interstitial nephritis.

Pyelonephritis

The majority of pyelonephritis cases results fromE.coli bacterial infections. This type of bacterium is primarily found in the large intestine and is excreted in your stool. The bacteria can travel up from the urethra to the bladder and kidneys, resulting in pyelonephritis.

Although bacterial infection is the leading cause of pyelonephritis, other possible causes include:

  • urinary examinations that use a cystoscope, an instrument that looks inside the bladder
  • surgery of the bladder, kidneys, or ureters
  • the formation of kidney stones, rocklike formations consisting of minerals and other waste material

Glomerulonephritis

The main cause of this type of kidney infection is unknown. However, some conditions may encourage an infection, including:

  • problems in the immune system
  • a history of cancer
  • an abscess that breaks and travels to your kidneys through your blood

It certainly looks like there’s a lot more to nephritis than we’d thought.

Until next week,

Keep living your life!

Another Kind of Kidney Disease

While I’m still recuperating, I’ve had plenty of time to read Twitter articles, among other things. One topic I’ve been reading about is lupus nephritis. I think we’ve all heard of lupus, but just in case, here’s a definition from MedicineNet at https://www.medicinenet.com/script/main/art.asp?articlekey=8064.

“A chronic inflammatory disease that is caused by autoimmunity. Patients with lupus have in their blood unusual antibodies that are targeted against their own body tissues. Lupus can cause disease of the skin, heart, lungs, kidneys, joints, and nervous system.”

Did you catch the mention of kidneys in the above definition? That’s where the nephritis part of the condition comes in. By now, we’re all probably tired of being reminded that ‘neph’ means relating to the kidneys (although in non-medical terms, it means relating to the clouds) and ‘itis’ means inflammation. Nuts! I just reminded you again. Let’s ignore that. So, lupus nephritis actually means

“… a kidney disorder [which] is a complication of systemic lupus erythematosus.”

Thank you to MedlinePlus at https://medlineplus.gov/ency/article/000481.htm for the definition. Oh, “systemic lupus erythematosus” refers back to autoimmune disease. Still, the word “erythematosus” puzzled me. I finally figured it out after realizing I probably wasn’t going to get a definition since almost all the entries were for lupus erythematosus. Remember, I studied Greek & Latin roots way, way back in college. It means red and is from the Greek. I get it. Sometimes, lupus patients have a red rash in butterfly form across their face.

So, how do you develop this particular kidney disease? What better place to find out than Lupus.org at https://www.lupus.org/resources/how-lupus-affects-the-renal-kidney-system#.

“Inflammation of the nephrons, the structures within the kidneys that filter the blood, is called glomerulonephritis, or nephritis. Lupus nephritis is the term used when lupus causes inflammation in your kidneys, making them unable to properly remove waste from your blood or control the amount of fluids in your body.”

Hmmm, no lupus equals no lupus nephritis. However, if you do have lupus, you may develop lupus nephritis.

Let’s say hypothetically that you or a loved one (or even your neighbor down the block) has lupus and is concerned about developing lupus nephritis. How would they know if they were developing it? I had to look no further than the National Kidney Foundation at https://www.kidney.org/atoz/content/lupus.

“Lupus nephritis can cause many signs and symptoms and may be different for everyone. Signs of lupus nephritis include:

  • Blood in the urine (hematuria): Glomerular disease can cause your glomeruli to leak blood into your urine. Your urine may look pink or light brown from blood.
  • Protein in the urine (proteinuria): Glomerular disease can cause your glomeruli to leak protein into your urine. Your urine may be foamy because of the protein.
  • Edema: Having extra fluid that your kidneys cannot remove that causes swelling in body parts like your legs, ankles, or around your eyes.
  • Weight gain: due to the fluid your body is not able to get rid of.
  • High blood pressure

I know these may also be the symptoms of Chronic Kidney Disease, but if you have lupus, then they may be symptoms of lupus nephritis. To make things even more complicated, there are five different kinds of lupus nephritis depending upon which part of the kidney is affected.

I was wondering about tests to diagnose lupus nephritis, like we have blood and urine tests to diagnose CKD. Healthline (Now do you see why I was so thrilled to receive their Best Kidney Blogs Award two years in a row?) at https://www.healthline.com/health/lupus-nephritis#diagnosis cleared that up.

Blood tests

Your doctor will look for elevated levels of waste products, such as creatinine and urea. Normally, the kidneys filter out these products.

24-hour urine collection

This test measures the kidney’s ability selectively to filter wastes. It determines how much protein appears in urine over 24 hours.

Urine tests

Urine tests measure kidney function. They identify levels of:

  • protein
  • red blood cells
  • white blood cells

Iothalamate clearance testing

This test uses a contrast dye to see if your kidneys are filtering properly.

Radioactive iothalamate is injected into your blood. Your doctor will then test how quickly it’s excreted in your urine. They may also directly test how quickly it leaves your blood. This is considered to be the most accurate test of kidney filtration speed.

Kidney biopsy

Biopsies are the most accurate and also most invasive way to diagnose kidney disease. Your doctor will insert a long needle through your abdomen and into your kidney. They’ll take a sample of kidney tissue to be analyzed for signs of damage.

Ultrasound

Ultrasounds use sound waves to create a detailed image of your kidney. Your doctor will look for anything abnormal in the size and shape of your kidney.

Yes, I know these are the same tests that are used to diagnose CKD, but if you have lupus, they also can diagnose lupus nephritis.

Okay, now the biggie: How do you treat it if you do have it? The MayoClinic at  https://www.mayoclinic.org/diseases-conditions/lupus-nephritis/diagnosis-treatment/drc-20446438 had some sobering news for us:

“There’s no cure for lupus nephritis. Treatment aims to:

  • Reduce symptoms or make symptoms disappear (remission)
  • Keep the disease from getting worse
  • Maintain remission
  • Avoid the need for dialysis or a kidney transplant

Conservative treatments

In general, doctors may recommend these treatments for people with kidney disease:

  • Diet changes. Limiting the amount of protein and salt in your diet can improve kidney function.
  • Blood pressure medications. Drugs called angiotensin-converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) can help control blood pressure. These drugs also prevent protein from leaking from the kidneys into the urine. Drugs called diuretics can help you get rid of excess fluid.

However, conservative treatment alone isn’t effective for lupus nephritis.

Immune suppressants

For severe lupus nephritis, you might take drugs that slow or stop the immune system from attacking healthy cells, such as:

  • Steroids, such as prednisone
  • Cyclosporine
  • Tacrolimus
  • Cyclophosphamide
  • Azathioprine (Imuran)
  • Mycophenolate (CellCept)
  • Rituximab (Rituxan)

When immunosuppressive therapies don’t lead to remission, clinical trials may be available for new therapies.

Treatment options for kidney failure

For people who progress to kidney failure, treatment options include:

  • Dialysis. Dialysis helps remove fluid and waste from the body, maintain the right balance of minerals in the blood, and manage blood pressure by filtering your blood through a machine.
  • Kidney transplant. You may need a new kidney from a donor if your kidneys can no longer function.”

Help! Running out of room (but we’re done anyway),

Until next week,

Keep living your life!