Granulomatous sarcoid nephritis

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      A patient with impaired renal function due to granulomatous sarcoid replacement of the renal parenchyma is described through two separate courses of therapy with corticosteroids. Serial measurements of renal function, periodic renal scintiscans and intravenous pyelograms, and serial histologic studies of the kidney by percutaneous renal biopsy are presented.
      The variety of modes by which sarcoidosis may affect the kidneys is reviewed. Hypercalcemia or hypercalciuria is responsible for most instances of renal disease from sarcoidosis. In the present case, kidney damage resulted from extensive replacement of renal parenchyma by sarcoid lesions in the absence of hypercalcemia or hypercalciuria. The value of renal biopsy is seriously limited by reason of the focal nature of the disease and the chance of sampling error. Renal scintiscan provided not only presumptive evidence for diagnosis but also a method to assess the extent of the disease and the effect of therapy. Serial determination of renal function demonstrated improvement following each course of therapy. However, a gradual decrease in creatinine clearance was observed during the prolonged second course of steroid therapy without increase in sarcoid “lesions” by scintiscan. It is considered likely that fibrosis associated with regression or healing of active granulomas may have been responsible. It is concluded that alternate periods of exacerbation followed by regression with steroid therapy should be avoided because of the potential of progressive fibrosis and destruction of renal parenchyma.
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