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Nephrology grand rounds

Nephrology grand rounds. 4/8/08. Schistosomiasis and renal disease. Brad Weaver. Schistosome. Parasitic blood fluke of trematode family Prevalent in tropics – 200 million people affected Acute infection - swimmer’s itch and Katayama fever

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Nephrology grand rounds

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  1. Nephrology grand rounds 4/8/08

  2. Schistosomiasis and renal disease Brad Weaver

  3. Schistosome • Parasitic blood fluke of trematode family • Prevalent in tropics – 200 million people affected • Acute infection - swimmer’s itch and Katayama fever • Chronic infection – deposited eggs invade tissue and get lodged in portal circulation causing inflammation and fibrosis • Two types of renal disease • Urinary obstruction from S. haematobium • Immune complex deposition disease from other species

  4. S. haematobium • Direct invasion of urinary system • Acquired in North Africa, Turkey, the Middle East, and India • Eggs migrate from vesical venous plexus into bladder wall and then are excreted in urine • Often presents with hematuria • Chronic inflammation and fibrosis of bladder wall can cause: • Hydronephrosis and calcification of urinary tract • Bladder cancer

  5. S. mansoni and S. japonicum • Acquired in tropical areas of Africa, Asia, South America, and the Caribbean • Eggs released from mesenteric venous plexus can travel to intestine OR enter portal blood flow and get lodged in liver sinusoids • Eggs in liver sinusoids can cause: • Inflammation and progressive fibrosis • Secondary portal hypertension and liver failure

  6. Glomerular disease • Immune complex deposition • Affects 10-15% with chronic infection • Two observations • Antibodies to schistosomal antigens can be detected in glomeruli • Schistosomal antigens can be detected in glomeruli by indirect immunofluorescense • Wide variety of clinical manifestations • Proteinuria • Nephrotic syndrome • ESRD Sobh et al. Kidney Int 1987; 31:1006.

  7. The “liver effect” • Interplay between portal hypertension/portosystemic shunting and glomerular disease • Kupffer cells of the liver remove circulating immune complexes and Schistosome antigens • As liver disease worsens in chronic Schistosome infections, there is increased delivery of immune complexes and antigens to glomeruli

  8. Pathology - AFRAN classification • Class I – mesangial proliferative glomerulonephritis • Class II – exudative glomerulonephritis, many neutrophils and monocytes, associated with dual salmonella infection • Class III – MPGN, more common in non-blacks • Class IV – FSGS, more common in blacks • Class V - amyloidosis

  9. Pathology cont. • AFRAN classes I and II have good prognosis and do not progress • AFRAN classes III and IV are progressive diseases, often lead to ESRD, and are not modified by antihelminthic drugs or immunosuppressive agents (prednisone and cyclophosphamide)

  10. Diagnosis and treatment • Peripheral eosinophilia present in up to 2/3 of those infected • Egg detection by microscopy • Most common method of diagnosis of Schistosomal infection • Stool O&P for all species except S. haematobium (urine micro) • Maximal egg excretion occurs between 10am and 2pm • Other tests available, lack standardization: ELISA, PCR • Treatment: praziquantel (Biltricide) 600mg tid x 1 day

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