title: Collapsing focal segmental glomerulosclerosis following treatment with high-dose pamidronate.
abstract: Collapsing focal segmental glomerulosclerosis (FSGS) is a distinct clinicopathologic entity seen most commonly in young African American patients who present with renal insufficiency and nephrotic syndrome. The only epidemiologic factor previously linked to collapsing FSGS is HIV infection. Here clinicopathologic findings are reported for a distinctive population of seven patients, who were older, Caucasian, and HIV negative and developed collapsing FSGS during active treatment of malignancy (multiple myeloma in six patients and metastatic breast carcinoma in one). Although oncologic treatment regimens included vincristine for four patients, doxorubicin for five patients, cisplatin for two patients, and total-body irradiation for one patient, the only agent common to all patients was pamidronate (Aredia). All patients had normal renal function before the administration of pamidronate. Patients began therapy with pamidronate at or below the recommended dose of 90 mg, intravenously, monthly, which was increased to 180 mg monthly in two patients and 360 mg monthly in three patients. Patients received pamidronate for 15 to 48 mo before presentation with renal insufficiency (mean serum creatinine, 3.6 mg/dl) and full nephrotic syndrome (mean 24-h urinary protein excretion, 12.4 g/d). Pamidronate, which is a member of the class of bisphosphonates, is widely used in the treatment of hypercalcemia of malignancy and osteolytic metastases. At the recommended dose of 90 mg, intravenously, monthly, renal toxicity is infrequent; however, higher doses have produced nephrotoxicity in animal models. The temporal association between pamidronate therapy and the development of renal insufficiency, the use of escalating doses that exceed recommended levels, and the distinctive pattern of glomerular and tubular injury strongly suggest a mechanism of drug-associated podocyte and tubular toxicity. These data provide the first association of collapsing FSGS with toxicity to a therapeutic agent.
authors.affiliation: Department of Pathology, Columbia College of Physicians and Surgeons, New York, New York.
authors.forename: Glen S
authors.initials: GS
authors.lastname: Markowitz
authors.affiliation: Department of Medicine, Division of Nephrology, Columbia College of Physicians and Surgeons, New York, New York.
authors.forename: Gerald B
authors.initials: GB
authors.lastname: Appel
authors.affiliation: Division of Nephrology, Department of Internal Medicine, Morristown Memorial Hospital/Atlantic Health System, Morristown, New Jersey.
authors.forename: Paul L
authors.initials: PL
authors.lastname: Fine
authors.affiliation: Nephrology Division, Baylor University Medical Center, Dallas, Texas.
authors.forename: Andrew Z
authors.initials: AZ
authors.lastname: Fenves
authors.affiliation: Division of Nephrology, Department of Internal Medicine, Hilton Head Medical Center, Hilton Head Island, South Carolina.
authors.forename: Nicholas R
authors.initials: NR
authors.lastname: Loon
authors.affiliation: Department of Medicine, New York Medical College, New York, New York.
authors.forename: Sundar
authors.initials: S
authors.lastname: Jagannath
authors.affiliation: Department of Medicine, Division of Nephrology, Medical Center of Delaware, Newark, Delaware.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Kuhn
authors.affiliation: Lehigh Valley Nephrology Associates, Bethlehem, Pennsylvania.
authors.forename: Adam D
authors.initials: AD
authors.lastname: Dratch
authors.affiliation: Department of Pathology, Columbia College of Physicians and Surgeons, New York, New York.
authors.forename: Vivette D
authors.initials: VD
authors.lastname: D'Agati
mesh_terms: D000368:Aged; D000970:Antineoplastic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D001943:Breast Neoplasms / Q000188:drug therapy; D004164:Diphosphonates / Q000008:administration & dosage / Q000009:adverse effects*; D005260:Female; D005923:Glomerulosclerosis, Focal Segmental / Q000139:chemically induced* / Q000473:pathology; D006801:Humans; D007150:Immunohistochemistry; D008297:Male; D008854:Microscopy, Electron; D008875:Middle Aged; D009101:Multiple Myeloma / Q000188:drug therapy; D000077268:Pamidronate
chemical_list: D000970:Antineoplastic Agents; D004164:Diphosphonates; D000077268:Pamidronate