Kidney damage in rheumatoid arthritis
Introduction
Introduction to kidney damage in rheumatoid arthritis Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease that is generally thought to be caused by genetic, infection, and other factors that induce the body's autoimmune response. Mainly manifested as bilateral symmetry of finger joint swelling and pain with morning stiffness, long-term can cause joint deformity and dysfunction, the main causes of death are infection, cardiovascular disease and kidney damage. basic knowledge The proportion of illness: 0.12% Susceptible people: no specific population Mode of infection: non-infectious Complications: cerebral infarction Hemiplegia Pancreatitis Disseminated intravascular coagulation
Cause
Causes of renal damage in rheumatoid arthritis
(1) Causes of the disease
The etiology of this disease is not clear, and may be related to infectious agents (such as Epstein-Barr virus, Mycoplasma, etc.) and genetic susceptibility. The incidence of human leukocyte antigen (HLA)-DR4 positive patients is 3-4 times higher than that of normal people. HLA-DR4 partial amino acids It has a similar gene fragment to the pathogen (EB virus), so HLA can act as a receptor for pathogens or a receptor for autoantibodies, which is immune to damage, stimulates B lymphocytes to produce rheumatoid factor (antibody of IgG Fc segment), IgG rheumatoid The factor binds to the autoantigen to form an in situ or circulating immune complex, activates cellular immunity, and releases a large number of cytokines (such as IL-1, IL-6, tumor necrosis factor TNF-, etc.), causing synovitis of the joint, gradually destroying the joint Cartilage, osteoporosis, bone destruction, ligament sclerosis, eventually joint deformity, disuse, rheumatoid arthritis and vasculitis, human leukocyte cytoplasmic autoantibodies (ANCA) can be found in the blood, mainly for the perinuclear Type P-ANCA, speculated that the incidence of RV is related to immune complexes and P-ANCA, the latter caused cellular immune damage, Voskoy analysis of 69 patients with RV and 138 patients with simple rheumatoid arthritis, suggesting that the risk factors for RV are:
1. Male.
2. Serum rheumatoid factor positive.
3. Joint destruction.
4. Subcutaneous nodules.
Most of them have extra-articular symptoms, nail wrinkles and other than 1 year to diagnose RV, while Guedes observed 420 patients with rheumatoid arthritis from 1981 to 1994, 66 (16%) had subcutaneous nodules, 5 years later Easy to develop into the eye, dry mouth, easy to develop vasculitis, systemic damage is more serious, but there are 2 cases of long-term stationary rheumatoid arthritis patients with vasculitis (ulcerative keratitis) performance, most believe that blood circulation complex increased Increased rheumatoid factor is prone to vasculitis, can invade large, medium and small blood vessels, mainly involving middle and small arteries and veins and capillaries, causing full-thickness arteritis. It is speculated that renal mesangial cells have a clearing of circulating immune complexes. The function that stimulates mesangial damage causes glomerulonephritis.
(two) pathogenesis
Because of the different types of renal damage caused by different causes in RA patients, the pathogenesis of various types of renal damage is also different, and most of the mechanisms are unknown.
Prevention
Kidney damage prevention for rheumatoid arthritis
Rheumatoid arthritis is a systemic disease characterized by joint inflammation. Rheumatoid arthritis kidney damage is mainly caused by chronic inflammation and drug toxicity for treating rheumatoid arthritis; although the current cause of rheumatoid arthritis is unknown. However, it should have the concept that prevention is better than cure, and effective prevention of rheumatoid arthritis can prevent the occurrence of kidney damage.
1. Strengthen exercise, exercise body, often do gymnastics, practice qigong, play tai chi or walk aerobic exercise, etc., can enhance resistance and reduce illness.
2. Avoid being exposed to the cold, prevent the wet environment from being cold, rain or damp. For example, do not wear wet clothes, shoes or socks, do not live in a humid place, do not drink ice water.
3. Avoid excessive fatigue In addition to diet, you should try not to be too tired, make the body sick, know how to work and leisure.
4. Maintaining a mood of pleasure Rheumatoid arthritis patients are sometimes psychologically or mentally irritated, suffering from excessive sorrow and suffering from this disease, so it is important to adjust the mood.
5. Prevention and control of infections Rheumatoid arthritis often occurs after infection with tonsillitis, sinusitis or dental caries, so it should be prevented from infection of various diseases, and should be cured early if it occurs.
Complication
Renal damage complications of rheumatoid arthritis Complications cerebral infarction hemiplegia pancreatitis diffuse intravascular coagulation
This disease often leads to multiple organ involvement, the main complications are joint destruction and deformation, subcutaneous nodules of varying sizes in the joint kyphosis, acute or chronic cerebral infarction or hemiplegia caused by central nervous system involvement, intestinal vasculitis causes intestinal deficiency Blood, abdominal cramps, bloody stools, and even intestinal perforation, patients with multiple mononeuritis, subcutaneous infarction, lung exudation, pancreatitis, small intestinal bleeding, severe renal insufficiency, and more death from disseminated intravascular coagulation (DIC).
Symptom
Renal damage symptoms of rheumatoid arthritis Common symptoms Hypertension nocturia increased chronic kidney damage hematuria proteinuria nodules joint stiffness
RA has a variety of onsets, can conceal onset, can also be acute, mostly chronic fluctuations, and is involved in multiple organs, the main manifestations of common joint damage is symmetrical invasive joint synovitis, patients often have joint swelling, Pain, stiffness, joint movement disorder, mainly proximal interphalangeal joints, metacarpophalangeal joints, wrist joints, followed by knees, shoulders, ankles, hip joints, serum-like rheumatoid factor-positive people easily develop within 2 years of onset To joint destruction, 65% to 70% of progressive joint deformation, dysfunction, 15% to 20% is seizure, 10% can be long-term relief, extra-articular symptoms are mainly caused by vasculitis and perivascular inflammation, 15% ~ 25% of patients had subcutaneous nodules of varying sizes in the joint kyphosis, adhering to the periosteum, tendon or tendon sheath, often appearing symmetrically, and the subcutaneous nodules could last for months or years; blisters and purpura can appear on the skin. Multiple papules, etc., the main manifestations of eye dryness, scleritis, uveitis, retinitis, ulcerative keratitis, should pay attention to the eye performance caused by the toxicity of the treatment drug, such as hormones can cause increased intraocular pressure and cataract.
A small number of patients with peripheral neuropathy nerve or muscle tissue biopsy showed necrotic vasculitis, often with hypoesthesia and dyskinesia, when the central nervous system can cause acute or chronic cerebral infarction or hemiplegia.
The abdominal manifestations of intestinal vasculitis are intestinal ischemia, abdominal cramps, bloody stools, and even intestinal perforation, sometimes misdiagnosed as appendicitis, but the condition remains worse after surgery. The pathology of the appendix shows that the muscle biopsy shows systemic vasculitis, after the use of immunosuppressive agents. The condition can be relieved. A 15-year-old boy with rheumatoid arthritis has multiple mononeuritis, subcutaneous infarction, lung exudation, pancreatitis, small intestinal bleeding, and death from disseminated intravascular coagulation (DIC).
The performance of the kidney is microscopic hematuria, proteinuria, with hypertension, 15% of renal dysfunction, and 24 hours of urinary protein, IgG, -microprotein, 55% of rheumatoid arthritis were detected by sensitive radioimmunoassay. Quantitative abnormalities of proteinuria, including drug treatment and vasculitis accounted for 25%, the remaining 75% without cause, early renal puncture is to identify vasculitis and primary rheumatoid arthritis kidney damage, amyloidosis, drug-induced interstitial nephritis A powerful indicator.
Pulmonary manifestations of pleurisy, alveolitis, pulmonary fibrosis, pulmonary nodules, pleural effusion showed increased protein, decreased sugar, elevated LDH, PH acidic, and found monocytes and neutrophils.
Cardiac manifestations of pericarditis, myocarditis, endocarditis, coronary arteritis and embolism can cause acute myocardial infarction.
Examine
Examination of renal damage in rheumatoid arthritis
1. Urine examination Careful urine test analysis is another important means to distinguish different types of kidney damage. Membranous nephropathy and secondary amyloid become non-inflammatory, typically moderate to severe proteinuria with less active urine sediment. Compared with normal normal serum creatinine concentration, focal glomerulonephritis and rheumatoid vasculitis usually have more active urine deposits (red blood cells, white blood cells and other cell granules) and analgesics Nephropathy is usually associated with milder hematuria, rib pain caused by renal papillary necrosis and chronic renal failure. Glomerular basement membrane thinning is usually associated with asymptomatic microscopic hematuria, but the association between clinical and pathology is not absolute. In order to confirm the diagnosis, some patients still need a renal biopsy.
2. Blood test
(1) Serum rheumatoid factor (RF): There are three kinds of RF such as IgG, IgM and IgA. The latex agglutination method currently used detects IgM RF, and the active period is 50%-80% positive, and the positive rate in remission period is low.
(2) C-reactive protein is positive during the active period, and the erythrocyte sedimentation rate is increased.
(3) Serum ANCA: Some RV patients may have P-ANCA positive, and the target antigen is MPO or other antigen.
(4) joint fluid examination: the number of cells is 2000 ~ 75000 / mm3, mainly neutrophils, low viscosity, sugar can be reduced.
3. Joint X-ray film stage I: osteoporosis; stage II: joint space stenosis; stage III: bone tooth-like destruction; stage IV: joint subluxation, fibrous and bony rigidity.
4. Tissue biopsy Skin muscle nerve biopsy showed necrotic full-thickness vasculitis with mononuclear cell infiltration, stenosis, and obstruction.
5. Arteriography can show stenotic or obstructed blood vessels, but no specificity.
6. Renal puncture pathological segmental segmental necrotic glomerulonephritis (FSNGN) with crescent formation, may have immune complex IgG, IgM, IgA deposition, in addition, there may be small lesions associated with rheumatoid immune response, Mesangial hyperplasia, membranous nephropathy, and inflammation-related amyloidosis, except for drug-related interstitial nephritis.
Diagnosis
Diagnosis and diagnosis of renal damage in rheumatoid arthritis
Diagnostic criteria
1. Have rheumatoid arthritis performance.
2. More serious systemic damage to the subcutaneous nodules, skin ulcers, ulcerative keratitis, pericarditis, myocarditis, pleurisy, pneumonia, small intestine infarction, multiple mononeuritis, kidney damage.
3. Skin biopsy showed necrotic full-thickness vasculitis with mononuclear cell infiltration.
4. Renal pathology showed focal segmental necrotic glomerulonephritis (FSNGN) with crescent formation, immunofluorescence may have IgG, IgM, IgA deposition.
Differential diagnosis
1. Primary vasculitis (nodular polyarteritis, micro-polyarteritis, Wegener's granulomatosis) Clinical manifestations and renal pathology are similar to RV, but renal pathological immunofluorescence is negative, ANCA positive rate is high, Wegner The granuloma is CANCA, anti-PR3 positive, and the micro polyarteritis is P-ANCA, which is positive for MPO.
2. Systemic lupus erythematosus has multi-system damage, as well as serum immunological abnormalities: C3 decline, anti-nuclear antibody positive, anti-ds-DNA, anti-smith antibody positive, identification is not difficult.
3. Gout can have joint swelling and pain, and more invading the metatarsophalangeal joint, easy to attack after high protein diet, self-limiting, invading the early stage of the kidney for interstitial nephritis, advanced renal hardening, can show proteinuria, hematuria, uremia, Can be associated with tophi, kidney stones, but no system damage.
