Colchicine in the treatment of renal amyloidosis secondary to familial Mediterranean fever

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(1)1098. Nephrol Dial Transplant (2000) 15: 1098. presented with marked biochemical, but not clinical, evidence of nephrotic syndrome, particularly no oedema. We entertained the hypothesis (despite the absence of direct evidence) that the patient’s glomerulonephritis was due to HIV-antigencontaining immune complexes. In view of the threatening nature of the nephrotic syndrome, this consideration led to aggressive treatment of the HIV infection, ultimately triple therapy comprising Indinavir, Stavudin and Lamivudine. As described, this caused partial remission of the nephrotic syndrome and reduction of the virus load. Partial remission of the nephrotic syndrome with such aggressive therapy is encouraging, but to exclude coincidence, confirmation by other observations is required. It is for this purpose that we felt that communication of this unusual clinical course to clinical nephrologists was useful. Acknowledgements. We thank Professor Ritz for translating the text from Spanish to English.. 1Servicio de Nefrologia 2Servicio de Medicina Interna 3Servicio Anatomia Pato´logica Hospital Son Dureta Palma de Mallorca Spain. A. Alarcoń-Zurita1 A. Salas2 E. Antoń3 A. Morey1 M. A. Munar1 P. Losada1 J. Martinez1. 1. Gardenswartz MH, Lemer CW, Seligson GR et al. Renal disease in patients with AIDS: A clinicopathologic study. Clin Nephrol 1984; 21: 197–204 2. D’Agati V, Suh JI, Carbone L et al. The pathology of HIV nephropathy: A detailed morphologic and comparative study. Kidney Int 1989; 35: 1358–1370 3. Rao TK, Friedman IEA, Nicastri AD. The types of renal disease in the acquired immunodeficiency syndrome. N Engl J Med 1987; 316: 1062–1068 4. Kimmel P, Phillips TM, Ferreira-Centeno A et al. HIV-associated immune mediated renal disease. Kidney Int 1993; 44: 1327–1340 5. Rarick MU, Espina B, Mocharnuck R et al. Thrombotic thrombocytopenic purpura in patients with human immunodeficiency virus infection. A report of three cases and review of the literature. Am J Hematol 1992; 40: 103–109 6. Yoshikawa N, Ito H, Yamada Y et al. Membranous glomerulonephritis associated with hepatitis B antigen in children: a comparison with idiopathic membranous glomerulonephritis. Clin Nephrol 1985; 23: 28–34 7. Gonzalo A, Barcena R, Mampaso F et al. Membranoproliferative glomerulonephritis and hepatitis C infection. Nephron 1993; 63: 475–476 8. D’Agati V, Appel GB. HIV infection and the kidney. J Am Soc Nephrol 1997; 6: 139–152 9. Ifudu O, Rao TKS, Tan CC et al. Zidovudine is beneficial in human immunodeficiency virus-associated nephropathy. Am J Nephrol 1995; 5: 217–221 10. Michel C, Dosquet P, Ronco P et al. Nephropathy associated with infection by human immunodeficiency virus: A report of 11 cases including 6 treated with zidovudine. Nephron 1992; 62: 434–440. Colchicine in the treatment of renal amyloidosis secondary to familial Mediterranean fever Sir, We have read with interest the Letter to the Editor by Simsek and colleagues [1] reporting the efficacy of colchicine in a nephrotic paediatric patient with amyloidosis due to familial Mediterranean fever (FMF ) with resolution of proteinuria. Several studies have clearly shown the effect of colchicine in. the prevention of amyloidosis, but once the kidney is involved it is disputed whether this treatment could still alter the progression of renal disease. There are anecdotal reports on the successful treatment at the late stage of renal amyloidosis, however these are mainly on adults [2,3] and very few on paediatric patients [4,5]. Reversal of the nephrotic syndrome was noticed by Hojberg and Mertz [4] in two brothers (aged 6 and 10 years) with FMF and amyloidosis proven by rectal biopsy: one of them had complete remission. Majeed et al. [5] observed the disappearance of proteinuria in two children with FMF. However, these two patients were not nephrotic, and no biopsy had been performed, so the authors could only assume, but not prove, that they indeed had renal amyloidosis. We have observed three paediatric patients who seem to support the observation of Simsek et al. [1]. All three—two girls and one boy, aged 11–15 years—presented only at the nephrotic stage of FMF with serum albumin 8–20 g/l and with proteinuria of 3–9 g/24 h; serum creatinine was still in the normal range (51–63 mmol/l ). Amyloidosis was confirmed by renal biopsy in each of them. Therapy with colchicine (1.8 mg/day) was initiated and was continued during the follow-up period of 55–69 months. These three patients did not only maintain good renal function, but in addition had full reversal of the nephrotic syndrome within 3–16 months with disappearance of proteinuria (trace to 0.066 g/l ) at 26–40 months. They remained proteinuria free during the further follow-up of 15–30 months. Thus, there still is a chance of reversal of the nephrotic syndrome when therapy with colchicine is initiated only at the nephrotic stage of renal amyloidosis. However, this response is not predictable. Indeed, we have only seen a moderate (or no) response to colchicine administration in several other cases who started treatment similarly late. Obviously, treatment with colchicine should be started as early as possible in the course of FMF. 1Division of Nephrology Medical Centre ‘Arabkir’ Yerevan Armenia 2Republican Centre of Paediatric Pathology Yerevan Armenia 3Division of Nephrology University Children’s Hospital Zurich Switzerland. Ashot Sarkissian1 Marina Papazian1 Armen Sanamyan2 Ernst Leumann3. 1. Simsek B, Islek I, Simsek T, Ku¨çu¨ko¨du¨k S, Cengiz K. Regression of nephrotic syndrome due to amyloidosis secondary to familial Mediterranean fever following colchicine treatment. Nephrol Dial Transplant 2000; 15: 281–282 2. Zemer D, Livneh A, Langevitz P. Reversal of the nephrotic syndrome by colchicine in amyloidosis of familial Mediterranean fever. Ann Intern Med 1992; 116: 426 3. Rosenbaum M, Rosner I. Regression of amyloidosis with colchicine in familial Mediterranean fever in an Ashkenazi patient. Clin Exp Rheumatol 1995; 13: 126 4. Hojberg AS, Mertz H. Nefrotisk syndrom ved familiaer middelhavsfeber—effekt of colchicinbehandling. Ugeskr Laeger 1995; 157: 4035–4037 5. Majeed HA, Ravashdeh M, El-Shanti H, Qubain H, KhuriBulos N, Shahin HM. Familial Mediterranean fever in children: the expanded clinical profile. Q J Med 1999; 92: 309–318 6. Sarkissian A, Papazian M, Sanamiam A, Babloyan A. Does colchicine alter the course of amyloidosis in children with familial Mediterranean fever? Pediatr Nephrol 1998; 12: 76.

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