Sunday, September 24, 2017

Consult Rounds: Cryoglobulins and the Kidney

Cryoglobulins and the Kidney

Cryoglobulins are Igs that reversibilly precipitate at temperatures <37C.  This results in symptoms that can lead to rashes, vasculitis, ulcers, ischemia, joint pains, and eventually in 25% cases – renal injury.

Two mechanisms: immune complex GN vs high viscosity related.  All have nephritic/nephrotic syndrome with various levels of kidney function.
1/3 with purpura and arthralgia
¾ with low C4 and ½ with low C3
All 3 types of cryoglobulins reported with renal disease
Most commonly it occurs in settings of type II (“mixed”) cryo secondary to hepatitis C virus.  Most patients with type II or III cryoglobulins have a positive rheumatoid factor.  The pathology pattern of injury is either membranoproliferative or diffuse proliferative GN.
          Type 1 Cryo( monoclonal IgM or IgG) – MM, MGUS, WM, lymphomas and CLL
          Type 2 Cryo(monoclonal IgM + polyclonal IgG)- CLL, lymphoma, SLE, Hep C

          Type 3 Cryo(polyclonal)- lymphoproliferative diseases, SLE


Treatment of underlying cause- Hep, SLE, Myeloma
Alkylating Agents
Anti CD-20 agents( good response in some cases)
Plasmapheresis ( adjunct) if skin involved and early renal

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