Glen Markowitz, MD
Columbia University Medical Center

Drug Induced Glomerulopathy

1. Pamidronate: In a series, this most commonly caused a collapsing FSGS, and a unifying diagnosis was a combination of malignancy and pamidronate within 1-4 years. Full blown nephrotic syndrome was evident in all. Fortunately, many had good response to drug withdrawal.

The Breakdown:

38 cases of collapsing FSGS,

3 cases of MCD,

4 reports of FSGS NOS

50% of cases have had significant improvement after drug withdrawal.

2. Bisphosphonate Dosing in Renal Insufficiency:

CrCl >60, can give full dose of pamidronate and zaledronate

CrCl 30-60, 90mg over 2-3 hours of pamidronate and reduced dose of zalendronate

CrCl <30, 90mg over 4-6 hours of pamidronate and no zalendronate

3. Interferon: Alpha, beta, and gamma. All are administrated IM or Subq. All can cause constitutional symptoms, cytopenias, and increased LFTS.

A Series Glomerular Breakdown:

MCD (8 cases) mostly alpha interferon, occasional beta

Collapsing FSGS (3 cases)

FSGS NOS (10 cases) alpha interferon in most cases and gamma in 1

Additionally, CJASN 2010 by Markowitz et al had a review on collapsing FSGS, another 11 cases including all three types of interferon. Ten of 11 had interferon footprints or tubuloreticular inclusions on electron microscopy

4. Miscellaneous culprits of FSGS:

Lithium, sirolimus, anabolic steroids, heroin

5. Drug-induced thrombotic microangiopathic pattern of disease:

Underlying cause: Endothelial damage

Laboratory findings: Anemia, schistocytes, depressed haptoglobin, and elevated LDH.

Histology: Glomeruli with thrombi and endothelial swelling, thrombosis in microvasculature. Chronicity causes mesangiolysis and GBM duplications

The Culprits: Cyclosporine, quinine, anti-platelet agents, mitomycin C, anti VEGF agents, tyrosine kinase inhibitors, radiation therapy

Post written by Dr. Kenar Jhaveri, eAJKD Blog Editor, and edited by Dr. Kellie Calderon, eAJKD Advisory Board member.

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