Horseshoe Kidney, Focal and Sclerosing Glomerulonephritis and Primary Hypothyroidism

Dr. Roger Gabriel, St. Mary’s Hospital, GB-London W2 1NY (UK) Dear Sir, We were interested to read the report of Chen and Wang-Shen [1] of a horseshoe kidney complicated by the development of a membranous glomerulonephropathy. There is a hypothyroid patient currently on long-term follow-up at this hospital who has focal and sclerosing glomerulonephritis in a horseshoe kidney. We believe these associations have not previously been reported. A 52-year-old 80-kg man was referred in January 1987 with peripheral oedema for approximately 6 months. There was no past history referable to the urinary tract. In 1983 a diagnosis of primary hypothyroidism had been made [free T4 61 nM/1 (4.7 μg/l00 ml); T4 63 nΛÍ/1 (4.9 μg/l00 ml); TSH 28.5 MU/1, normal < 6.5, with positive thyroglobulin and microsomal antibodies]. Physical examination at the time of referral showed a standing diastolic blood pressure of 100 mm Hg together with moderate peripheral oedema. Urine microscopy showed multiple granular casts and erythrocytes. There was proteinuria of 7.7–14.4 g/day. Serum albumin was 24 g/l (2.4 g/l00 ml), serum creatinine 129 μM/1 (1.5 mg/l00 ml), estimated clearance 70 ml/min/70 kg [2], serum cholesterol 13.5 mM/1 (523 mg/l00 ml) (normal 4.5–6.5; 174–252), serum triglyceride 4.35 mM/1 (385 mg/l00 ml) (normal 0.60–2.10; 53–186); LDL and VLDL evaluation indicated a type II B phenotype; the concentrations of serum immunoglobulins were normal; serum contained circulating immune complexes containing Clq, IgG and IgA; DNA binding was 10% (normal range < 30%); activities of haemolytic complement, C4 and C3, were both within the normal range. An intravenous urogram showed a horseshoe kidney. Intravenous digital substraction arteri-ography demonstrated a single artery supplying the right moiety of the horseshoe kidney and two renal arteries to the left. A percutaneous renal biopsy of the right moiety was performed without difficulty under ultrasound control. By light and immunoperoxidase microscopy typical [3] focal and segmental glomerulosclerosis affecting 45% of glomeruli was diagnosed. The peripheral oedema was treated with frusemide. After 5 months, the serum creatinine had risen to 147 μM/1 (1.7 mg/l00 ml) and the estimated clearance had fallen to 53 ml/min/70 kg. Ciclosporin 100 mg at night was commenced and to date the patient has been followed 28 months during which time renal function has not deteriorated further, as judged by