Nodular glomerulosclerosis: renal lesions in chronic smokers mimic chronic thrombotic microangiopathy and hypertensive lesions.

Cigarette smoking is associated with vascular lesions and chronic renal failure. In this report, we describe clinical and kidney biopsy findings for a 66-year-old woman with a history of long-term heavy cigarette smoking who developed proteinuria and decreasing renal function. This study also describes clinical and kidney biopsy findings for 9 patients with a history of smoking. None of these patients had hypertension, diabetes mellitus, or other risk factors that might result in vascular injury. Renal biopsy specimens showed a range of long-term changes with varying degrees of focal segmental or focal global glomerulosclerosis, nodular glomerulosclerosis, ischemic glomeruli, interstitial fibrosis and tubular atrophy, and mild to moderate arterial sclerosis and arteriolar hyalinosis. Electron microscopy often showed glomerular capillary wall thickening caused by subendothelial expansion by cellular elements and new basement formation resulting in segments of double contours. These changes indicate endothelial injury and glomerular capillary wall remodeling; the lesions mimic those seen in patients with chronic hypertension and chronic or healed thrombotic microangiopathies.

Crescentic glomerulonephritis and dense deposit disease in a woman with breast carcinoma on immunosuppressive chemotherapy.

The authors describe an unusual case of acute renal failure in a 50-year-old woman with a history of breast carcinoma. The breast carcinoma was treated with 4 cycles of chemotherapy. After chemotherapy, she felt fatigued and noticed decreased urine output. Her serum creatinine level had risen from 0.8 to 10.1 mg/dL (71 to 893 micromol/L). Renal biopsy was done that showed a severe crescentic glomerulonephritis secondary to dense deposit disease. This case is extremely unusual in that: (1) Dense deposit disease developed in a 50-year-old woman, whereas it is primarily a disease of children and young adults, and (2) the patient was being treated with immunosuppressive chemotherapy for breast carcinoma when dense deposit disease developed, thus posing a therapeutic dilemma.

ANCA-positive crescentic glomerulonephritis associated with minocycline therapy.

Minocycline is an oral antibiotic widely used for the long-term treatment of acne and rheumatoid arthritis. A few patients develop antineutrophil cytoplasmic antibodies (ANCAs) during minocycline therapy. In this report, the authors describe a case of severe pauci-immune crescentic and necrotizing glomerulonephritis associated with positive cytoplasmic ANCA (C-ANCA) titers and proteinase 3 (PR3) levels after minocycline therapy. Discontinuation of minocycline and initiation of immunosuppressive treatment resulted in improvement of renal function and decline in C-ANCA titers and PR3 levels. A high degree of suspicion, testing for ANCA titers, prompt discontinuation of the drug, and initiation of immunosuppressive treatment are crucial to the diagnosis and treatment of drug-induced ANCA-associated glomerulonephritis.