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Thrombosis in the lupus kidney.

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117
LETTERS
Thrombosis in the lupus kidney
To the Editor:
Glomerular damage in systemic lupus erythematosus (SLE) is modulated by a complex series of
events which ultimately determine whether there is a
recovery of normal structure and function or ultimate
progression to glomerular sclerosis. Unfortunately,
the standard histopathologic classification of the renal
lesions in SLE may not correlate well with progression
to glomerular sclerosis.
Abnormalities of the coagulation system are
also seen in SLE. In a recent publication, the presence
of glomerular thrombi, as demonstrated by the acid
picro-Mallory V (Lendrum) technique, was significantly associated with the subsequent development or
increase of glomerular sclerosis (I). By contrast, some
of the long accepted histologic abnormalities in lupus
nephritis such as cellular crescents, necrosis, and
endothelial and mesangial cellularity were not in any
way related to a subsequent increase of glomerular
sclerosis. From a clinical point of view, the presence
of glomerular thrombi was associated with in vitro
abnormality of the coagulation system, and particularly with the finding of low (180,000/mm3) platelet
counts (1).
The finding of glomerular thrombi on renal
histology was correlated with the type of antibody
response in 17 patients who were part of another series
(2). These 17 patients underwent 33 renal biopsies. Of
the 33 specimens, 12 (36.3%) had evidence of glomerular thrombi.
An attempt was next made to see if glomerular
thrombosis in renal biopsy specimens correlated in
any way with the type of autoantibody formed or the
clinical features of S L E (Table 1). All 17 patients had
elevated double-stranded DNA (dsDNA) binding by
the Farr technique. Six of these patients (12 biopsies)
also had elevated binding values for antibodies to poly
A, a synthetic single-stranded RNA (ssRNA) analog,
while the remaining 11 patients (21 biopsies) had poly
A binding values within the normal range. Only 1
(8.3%) biopsy from the first group of patients had
evidence of glomerular thrombosis while 1 I (52.3%)
from those patients with elevated dsDNA binding
alone were so affected. Three individuals in this latter
group eventually required either dialysis or transplantation, whereas none in the former group progressed to
renal failure. Two of the patients with renal failure
died from infectious complications, as did 1 other
Table 1. Correlation of antibody response with evidence of
thrombosis on renal biopsy
Antibody response
dsDNA
No. patients
No. biopsies
Thrombosis
Initial biopsy
All biopsies
Subsequent course
Renal failure
Death
dsDNA
+ poly A
II
21
6
12
5 (45%)
1 1 (52.3%)
1 (16.7%)
1 (8.3%)
3
3
0
0
patient with antibodies to dsDNA alone. There were
no deaths among the patients producing both poly A
and dsDNA antibodies.
Prospective studies correlating clinical information, evidence of glomerular thrombosis, and in vitro
coagulation data to provide more definitive information are currently in progress. The acid picro Mallory
V technique provides very useful information on the
renal histology in patients with SLE, particularly since
the specimen of renal tissue available for examination
by light microscopy is usually much larger and can be
examined in more detail than that available for immunofluorescent microscopy.
We must stress, however, that the acid picro
Mallory V technique does not work optimally with
most of the fixatives used to process the renal biopsies. In the study cited, Mossman’s fixative (corrosive
formalin) was used (1). It is also important to examine
in depth every capillary loop in every glomerulus in a
renal biopsy specimen, for the lesion of lupus nephritis
is pleomorphic and the occurrence of thrombi may be
highly segmental and focal.
K. D. GRANT,MD
K. S. KANT,MD
V. E. POLLAK,MD
M. A. WEISS, MD
E. V. HESS, MD
Department of Medicine
(Divisions of Immunology and Nephrology)
Department of Pathology
University of Cincinnati Medical Center
Cincinnati, Ohio
1. Kant KS, Pollak VE, Weiss MA, Glueck HI, Miller MA,
Hess EV: Glomerular thrombosis in systemic lupus erythematosus: prevalence and significance. Medicine
60~71-85, 1981
2. Grant KD, Adams LE, Crowe WE, Hess EV: A reappraisal of serologic tests in the rheumatic diseases resulting in new data and insights. In preparation
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