PSORIASIS – Kidney Disease

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The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

CHART 1: Comorbidities Associated with Psoriasis

    Renal Disease

    Chronic Kidney Disease

1, 2, 3

Numerous case reports have described the coexistence of psoriasis and kidney disease (Glomerulonephritis – acute inflammation of the glomeruli, which are structures in the kidneys that are made up of tiny blood vessels). Various types of kidney disease have been discussed in case studies and clinical research papers, including:-

  1. IgA nephropathy

    Berger’s disease, is a kidney disease that occurs when an antibody called immunoglobulin A (IgA) lodges in the kidneys causing inflammation.

  1. Focal segmental glomerulosclerosis

    a rare disease that attacks the kidney’s filtering units (glomeruli) causing serious scarring which leads to permanent kidney damage and even failure.

  1. Membranous nephropathy

    thickening of a part of the glomerular basement membrane.The glomerular basement membrane is a part of the kidneys that helps filter waste and extra fluid from the blood, and

  1. Proteinuria

    the presence of excess proteins in the urine.

  1. Urinary albumin excretion (UAE)

    the presence of excess albumin in the urine.

The exact causative relationship between Psoriasis and kidney disease is unknown; however, over several decades the incidence of the disease occurring in psoriasis patients has been well documented and researched. It has been suggested that given the strong relationship of the metabolic syndrome with psoriasis and kidney disease, it is perhaps not surprising that these diseases may coexist within a psoriasis sufferer.  Some mechanisms that have been put forward include immunologic mechanisms such as defects in T cell function as well as increased levels of immune complexes that underlie glomerular injury in psoriasis and tubular injury induced by raised uric acid concentrations in people with psoriasis. When the mechanisms that cause the systemic and kidney/renal disorders are analyzed, the systemic inflammatory process appears to play a fundamental role.1

Immunoglobulin A Nephropathy (IgAN)  – is the most common type of glomerular disease in psoriasis patients presenting with hematuria (presence of blood in the urine), a variable degree of proteinuria and occasionally also with a decreased glomerular filtration rate. Several cases of IgAN-accompanied psoriasis have been described in the literature. In one case study of a psoriasis patient with IgAN, the researchers found that the diffuse mesangioproliferative glomerulonephritis was accompanied by vascular nephrosclerosis (hardening of the small blood vessels in the kidneys) and tubulointerstitial nephritis (swelling caused by tubulointerstitial injury) with diffuse fibrosis and tubular atrophy. 2

IgAN is sometimes present in association with seronegative spondyloarthropathies, including psoriatic arthritis. All of the seronegative spondyloarthropathies are associated with mucosal or skin inflammation, which may lead to an increased production of IgA and elevated serum IgA levels. One clinical study found that 14 patients (67%) from a group of 21 patients had evidence of IgA-containing circulating immune complexes at some time in the course of their psoriasis. 2

In a large population based cohort study the risk of moderate to advanced kidney disease in patients with psoriasis was extensively studied. Some 136,529 patients with mild psoriasis and 7354 patients with severe psoriasis based on treatment patterns were compared with 689,702 healthy patients. The researchers reported that “The combined results indicated that, although no association is seen in patients with truly mild disease (less than 2% body surface area affected), as consistent with other previous studies, associations were seen in moderate and severe psoriasis, which are estimated to affect over 20% of patients with psoriasis worldwide. The relative risk of chronic kidney disease was especially increased in younger patients, however, the clinical relevance of the absolute risk of chronic kidney disease attributable to psoriasis increases with age. In patients aged 40-50 with severe disease based on treatment patterns, psoriasis accounts for one extra case of chronic kidney disease per 134 patients per year, and in those aged 50-60, it accounts for one additional case per 62 patients per year.” 3

Urinary albumin excretion (UAE) (Microalbuminuria) is considered to be a marker of glomerular damage and can be used to predict diabetic or hypertensive nephropathy. Early detection of glomerular damage, when it is minimal and/or at a reversible stage is extremely important. Studies performed in patients with psoriasis have found increased UAE in psoriatics compared with healthy controls. Study results have also revealed a significant correlation between UAE and PASI scores (severity of lesions). 4

The researchers strongly recommended that “Closer monitoring for renal insufficiency should be considered for patients with moderate to severe psoriasis (those with 3% or more body surface area affected), and nephrotoxic drugs should be used with caution in this at risk population. 3

 

Commonly-used drugs which can affect renal function
  • Diuretics
  • Beta blockers Acebutolol (Sectral), Atenolol (Tenormin); Bisoprolol (Zebeta)
  • Vasodilatorshydralazine (Apresoline) and minoxidil (Loniten)
  • ACE inhibitorsincluding Capoten (captopril), Vasotec (enalapril), Prinivil, Zestril (lisinopril), Lotensin (benazepril), Monopril (fosinopril), Altace (ramipril), Accupril (quinapril), Aceon (perindopril),  Mavik  (trandolapril), Univasc (moexipril)
  • Aminoglycosides including gentamicin, tobramycin, amikacin, streptomycin, neomycin, and paromomycin 
  • Contrast Dye used in some diagnostic tests such as MRIs.
  • Compound analgesics NSAIDs (e.g. aspirin, ibuprofen, diclofenac. paracetamol)
  • Antiviral agentsincluding acyclovir (brand name Zovirax)
  • Lithium
  • Antibiotics including ciprofloxacin, methicillin, vancomycin, sulfonamides.
  • Chemotherapy drugsincluding interferons, pamidronate, cisplatin, carboplatin, cyclosporine, tacrolimus, quinine, mitomycin C, bevacizumab; etanercept, methotrexate and anti-thyroid drugs, including propylthiouracil, used to treat overactive thyroid.

Signs and symptoms of chronic kidney disease include:

  • high blood pressure
  • changes in the amount and number of times urine is passed
  • changes in the appearance of your urine (e.g. colour is extremely dark, frothy or foaming urine)
  • blood in your urine
  • puffiness in your legs, ankles or around your eyes
  • pain in your kidney area
  • tiredness
  • loss of appetite
  • difficulty sleeping
  • headaches
  • lack of concentration
  • itching
  • shortness of breath
  • nausea and vomiting
  • bad breath and a metallic taste in your mouth
  • muscle cramps
  • pins and needles in your fingers or toes.

As you can see these symptoms are very general and may be caused by other illnesses, however, it is extremely important to seek medical advice if you know that you may be susceptible to kidney disease (i.e. runs in the family) or you know that you are taking medication that could cause kidney disease.

References:

  • Wan, Joy et al. “Risk of Moderate to Advanced Kidney Disease in Patients with Psoriasis: Population Based Cohort Study.”The BMJ 347 (2013): f5961. PMC. Web. 22 Mar. 2017.
  • Zadražil et al.; IgA nephropathy associated with psoriasis vulgaris: a contribution to the entity of “psoriatic nephropathy”; J NEPHROL 2006; 19:382-386
  • Wan J. et al.; Risk of moderate to advanced kidney disease in patients with psoriasis: population based cohort study; 2013; 347: f5961., Published online 2013 Oct 15. doi:  10.1136/bmj.f5961; PMCID: PMC3805477
  • Dervisoglu E. et al.; The spectrum of renal abnormalities in patients with psoriasis; Int Urol Nephrol; DOI 10.1007/s11255-011-9966-1

PSORIASIS AND COMORBIDITIES

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WHAT IS COMORBIDITY?

Comorbidity is a concurrence of multiple diseases or disorders in association with a given disease, in this case, psoriasis.

INCREASED RISK

The patient with psoriasis has an increased risk of developing one or more of a number of other diseases/conditions that share many immunological features with psoriasis.

CHART 1: Comorbidities Associated with Psoriasis

Occular Inflammation –

Iritis

Uveitis

Episcleritis

Psychological and Psychiatric Disorders – Depression

anxiety

Suicide

Addiction

Inflammatory Bowel Disease –

Crohn’s Disease

Ulcerative Colitis

Celiac Disease

Irritable Bowel Syndrome

Metabolic Syndrome –

Cardiovascular Disease – Arterial hypertension/ Atherosclerosis Nonalcoholic fatty liver disease Lymphoma

Chronic obstructive pulmonary disease

Sleep apnea

Celiac disease

Parkinson’s disease

Lymphomas

Insulin Resistant Diabetes

Obesity

Dyslipidemia (Raised cholesterol)

Psoriatic Arthritis

Spondyloarthropathies

Periodontitis

Desquamative gingivitis 

Fissured and geographical tongue 

Renal Disease

Chronic Kidney Disease

Sudden sensorineural hearing loss (SSNHL) 

1, 2, 3

Overall, ophthalmological (eye) problems occur in about 10% of the cases of psoriasis and include blepharitis, conjunctivitis, keratitis, xerophthalmia, corneal abscess, cataract, orbital myositis, symblepharon, chorioretinopathy, uveitis and ectropion with trichiasis and madarosis secondary to eyelid involvement.

The association between obesity and psoriasis has been the subject of several reviews and studies confirm that a positive correlation exists between body weight and the prevalence and severity of psoriasis. It has been proposed that psoriasis might lead to obesity through progressive social isolation, poor eating habits, depression, increased alcohol consumption, and decreased physical  activity (more pronounced in patients with psoriatic arthritis). But another hypothesis is that obesity predisposes patients to psoriasis.

Dollarphotoclub_89167346 Obesity dollarphotoclub_78137972-liver-disease dollarphotoclub_92450146-diabetes

It is considered, however, that the low-grade chronic proinflammatory state present in both these conditions increases the risk of comorbidity, including a higher likelihood of developing diabetes or metabolic syndrome, and an increase in cardiovascular disease. 6

It is very important for newly diagnosed psoriasis patients to be screened for diabetes, liver disease, renal disease, and dyslipidaemia (high cholesterol) at the time of diagnosis, due to the fact that treatment for psoriasis may complicate treatment for the comorbid condition, or the comorbid condition may complicate the treatment for psoriasis.

SSNHL is defined as hearing loss of at least 30 dB (decibels) in 3 sequential frequencies in the standard pure tone audiogram for 3 days or less. The condition has an estimated incidence of between 5 and 30 cases per 100,000 per year. According to background information provided by the study authors, the average age at which SSNHL occurs is 50 to 60 years, and it equally affects men and women. Most cases are unilateral (one ear), with only 5% being bilateral (two ear involvement). The condition can be mild, moderate, or severe to profound and can affect high, low, or all frequencies. Tinnitus occurs in about 80% of patients and vertigo in about 30%. Up to 80% of patients report a feeling of ear fullness.7 Auto-immunity is described as an etiology of Sudden or Progressive Sensory neural Hearing Loss; similarly autoimmunity is described as an etiology for many skin diseases like Psoriasis etc. In one study researchers found that Psoriasis patients have, after 6 years of follow up; a 1.51 times higher risk incidence of developing SSNHL than those in the control group.8

For psoriasis patients who have had their psoriasis for several years, it is important that they have a yearly medical check up to ensure that they have not developed any comorbid conditions.

Changing one’s lifestyle may also be of benefit in either delaying comorbidity, or in controlling both their psoriasis and their comorbid condition. Such changes would include cessation of smoking, reducing or ceasing intake of alcohol, reducing sugar intake, changing ones diet to include more green vegetables, less red meat and if obese, losing weight.

 Read our BLOGS – Psoriasis and Diet – Part 1 and 2, Psoriasis and Alcohol, Psoriasis and Smoking

REFERENCES

  • Arzu K?l?ç, Seray Cakmak; PSORIASIS AND COMORBIDITIES; EMJ Dermatol. 2013;1:78-85.
  • Howa Yeung et al.;Psoriasis Severity and the Prevalence of Major Medical Comorbidity – A Population-Based Study; JAMA Dermatol. 2013;149(10):1173-1179. doi:10.1001/jamadermatol.2013.5015
  • Aurangabadkar SJ. Comorbidities in psoriasis. Indian J Dermatol Venereol Leprol 2013;79, Suppl S1:10-7
  • Agnieszka B. Owczarczyk-Saczonek , Roman Nowicki; The association between smoking and the prevalence of metabolic syndrome and its components in patients with psoriasis aged 30 to 49 years; Postep Derm Alergol 2015; XXXII (5): 331–336 DOI: 10.5114/pdia.2015.54743
  • Dediol I. et al.; ASSOCIATION OF PSORIASIS AND ALCOHOLISM: PSYCHODERMATOLOGICAL ISSUE; Psychiatria Danubina, 2009; Vol. 21, No. 1, pp 9–13
  • Carrascosa J.M. et al.; Obesity and Psoriasis: Inflammatory Nature of Obesity, Relationship Between Psoriasis and Obesity, and Therapeutic Implications; Actas Dermosifiliogr.2014;105:31-44 – Vol. 105 Num.1 DOI: 10.1016/j.adengl.2012.08.024
  • Schreiber BE. et al.; Sudden sensorineural hearing loss.; Lancet.2010 Apr 3;375(9721):1203-11. doi: 10.1016/S0140-6736(09)62071-7.
  • Sesha Prasad, M. Sreedhar Rao, A. V. S. Hanumantha Rao, D. Satyanarayana, S. Muneeruddin Ahmed, M. Mahendra Kumar. “Audiological Evaluation in Auto: Immune Skin Diseases- A Clinical Study of 124 Patients”. Journal of Evolution of Medical and Dental Sciences 2015; Vol. 4, Issue 30, April 13; Page: 5128-5137, DOI: 10.14260/jemds/2015/749