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Kidney Week

Abstract: PO1575

To Treat or Not to Treat? Therapeutic Challenges in a Case of Advanced Renal Sarcoid

Session Information

Category: Glomerular Diseases

  • 1203 Glomerular Diseases: Clinical, Outcomes, and Trials

Authors

  • Larned, Catherine, Walter Reed National Military Medical Center, Bethesda, Maryland, United States
  • Thurlow, John Stephen, Walter Reed National Military Medical Center, Bethesda, Maryland, United States
  • Watson, Maura A., Walter Reed National Military Medical Center, Bethesda, Maryland, United States
Introduction

Use of potentially toxic therapy in patients with low chance of renal recovery is clinically challenging. Kidney biopsy with significant interstitial fibrosis and tubular atrophy (IFTA) and reduced estimated glomerular filtration rate (eGFR) suggests unlikely recovery. We describe a patient with advanced IFTA who recovered substantial kidney function with treatment.

Case Description

A 55-year-old man was diagnosed with pulmonary and renal sarcoidosis. Renal biopsy at diagnosis showed granulomatous interstitial nephritis with non-caseating granulomas and 20% IFTA. Prednisone was started but was discontinued by the patient for onerous side effects. Serum creatinine (SrCr) stabilized at 1.5-1.8 mg/dL. He returned two years later with SrCr 5.8 mg/dL (eGFR 12 ml/min/1.73m2). Urinalysis was bland. Serum calcium was 10 mg/dL, phosphorus 4.0 mg/dL and intact PTH 20 pg/mL. He lacked pulmonary or systemic symptoms to merit empiric treatment, and he was hesitant to receive steroids due to prior side effects. Given new concurrent diagnosis of a monoclonal gammopathy and sclerotic bone lesions, repeat renal biopsy was performed that showed granulomatous interstitial nephritis and 50% IFTA consistent with sarcoid. Despite concern for lack of recoverable kidney function due to high chronicity and reduced eGFR, treatment with high-dose prednisone was started based on the unknown time course of recurrence in a relatively young active patient. SrCr improved to 3.0-3.2 mg/dL (eGFR 23-25ml/min/1.73m2). He was compliant with steroid taper and his renal function remained stable. The gammopathy was not renally significant and sclerotic bone lesions were attributed to sarcoidosis.

Discussion

In this patient with active sarcoidosis, presenting with eGFR 12 ml/min/1.73m2 and 50% IFTA on biopsy, it would be reasonable to presume limited benefit and defer steroid treatment, especially given patient reluctance. However, there was significant recovery with treatment. This should prompt reconsideration of the prognostic value of renal pathology in sarcoidosis, especially in view of known heterogenous involvement.

The views expressed are those of the authors and do not reflect the official policy of the Department of the Army/Navy/Air Force, the Department of Defense, or the United States government.