Mesangial IgA nephritis

Uncoupling of glomerular IgA deposition and disease progression in alymphoplasia mice with IgA nephropathy

Previous clinical and experimental studies have indicated that cells responsible for IgA nephropathy (IgAN), at least in part, are localized in bone marrow (BM). Indeed, we have demonstrated that murine IgAN can be experimentally reconstituted by bone marrow transplantation (BMT) from IgAN prone mice in not only normal mice, but also in alymphoplasia mice (aly/aly) independent of IgA⁺ cells homing to mucosa or secondary lymphoid tissues. The objective of the present study was to further assess whether secondary lymph nodes (LN) contribute to the progression of this disease. BM cells from the several lines of IgAN prone mice were transplanted into aly/aly and wild-type mice (B6). Although the transplanted aly/aly showed the same degree of mesangial IgA and IgG deposition and the same serum elevation levels of IgA and IgA-IgG immune-complexes (IC) as B6, even in extent, the progression of glomerular injury was observed only in B6. This uncoupling in aly/aly was associated with a lack of CD4⁺ T cells and macrophage infiltration, although phlogogenic capacity to nephritogenic IC of renal resident cells was identical between both recipients. It is suggested that secondary LN may be required for the full progression of IgAN after nephritogenic IgA and IgA/IgG IC deposition.

Potential immunopathogenic role of the mucosa-bone marrow axis in IgA nephropathy: insights from animal models

Impaired immune regulation along the mucosa-bone marrow axis has been postulated to play an important role in the pathogenesis of IgA nephropathy. Animal models have allowed us to study such changes in detail. Accumulating evidence from a number of animal models suggest that there is dysregulation of innate and cellular immunity in IgA nephropathy, resulting in changes to the mucosal immune system. These changes appear to be linked closely to a disruption of mucosal tolerance, resulting in the abnormal priming and dissemination of cells to sites such as the bone marrow where they are responsible for the synthesis of nephritogenic IgA. These findings suggest that future treatment strategies should focus on manipulating the priming and dissemination of these memory cells to prevent the appearance of nephritogenic IgA in the systemic compartment.

IgA nephropathy--human disease and animal model

IgA nephropathy is one of the most common chronic glomerulonephritides worldwide. Since the first publication on IgA nephropathy, a number of clinical and pathological investigations have revealed that the clinical course of patients with IgA nephropathy is extremely diverse, with approximately 10-20% of the patients developing end-stage chronic renal failure. Glomerular changes similar to IgA nephropathy have also been observed in patients with Schoenlein-Henoch purpura, and with other diseases such as liver cirrhosis and chronic inflammatory diseases of the lung. The broad spectrum of clinical and pathological features of IgA nephropathy encompasses a syndrome which includes both primary and secondary IgA nephropathy. The common etiology and pathogenesis of primary and secondary IgA nephropathy appear to be closely related to immunological abnormalities in the production of IgA induced by antigenic stimulation of the common mucosal immune system. IgA is one of the most important humoral factors of the mucosal immune defense system and functions as an antibody against various extrinsic and intrinsic substances. This review describes the Arthus type of IgA immune complex deposition in the glomeruli which can result from persistent or repeated increases in circulating IgA immune complexes. The latter occurs as a consequence of overproduction of IgA antibodies and/or impairment in clearance of IgA immune complexes by the mononuclear phagocytic system. The present review also focuses on the biology of the IgA-mediated immune system and on the etiology, pathogenesis, and animal models of IgA nephropathy.

Etiology of IgA nephropathy syndrome

Since Berger's original paper on mesangial IgA-IgG deposition with hematuria, there have been a number of clinical and pathological studies regarding IgA immune complexes, the mechanisms of glomerular IgA deposition leading to glomerular injury and animal models of IgA nephropathy. During the last quarter of this century, glomerular changes such as IgA nephropathy have also been observed in cases associated with other diseases, such as systemic lupus erythematosus, Schoenlein-Henoch purpura, liver cirrhosis and chronic inflammatory diseases of the lung. This evidence supports the idea of an IgA nephropathy syndrome. On the other hand, IgA is thought to be an important humoral factor at the mucosal immune system and appears to have an antibody function against various etiologic candidates of extrinsic or intrinsic substances at the mucosal and systemic immune system. Glomerular IgA deposition in IgA nephropathy syndrome is thought to result from elevated levels of circulating immune complexes or aggregated IgA due to an overproduction of polymeric IgA as antibodies in the serum and due to the clearance impairment of IgA immune complexes in the hepatic and splenic phagocytic system. The glomerular IgA subclass is not one-sided, but should be evaluated in comparison with the age of patients at renal biopsy; this indicates the approximate age of onset. Cirrhotic IgA glomerulonephritis is not related to Hepatitis B or C virus infection, but to the pathophysiologic condition of liver cirrhosis. Various etiologic candidates such as viral, microbial, dietary antigens or auto-antigens have been listed and experimental models of IgA nephropathy syndrome have provided some clues in understanding the etiology of primary IgA nephropathy. However much still remains to be clarified and some specific epitopes common among these etiologic candidates will have to be identified.

Reversible renal failure due to IgA nephropathy associated with osteomyelitis

Clinical features of acute glomerulonephritis, with microscopic hematuria, red blood cell (RBC) casts, proteinuria, and acute renal insufficiency developed in a patient with chronic osteomyelitis. Before the development of osteomyelitis, renal function and findings on urinalysis were normal. Complete eradication of osteomyelitis by surgical amputation led to resolution of the abnormal urinary findings, and renal function returned to near pre-osteomyelitis levels. Although acute glomerular disease has been reported to occur as a rare complication of osteomyelitis, the unique feature of the present case was the histological finding of IgA nephropathy. There was no arthritis, purpura, skin rash, or gastrointestinal involvement to suggest a diagnosis of Henoch-Schönlein purpura and there was no evidence of chronic liver disease. The temporal relationship between the onset of the renal disease, which followed the development of chronic osteomyelitis, and its resolution following removal of the focus of infection, suggests that the IgA nephropathy may have been related directly to the osteomyelitis (secondary IgA nephropathy). Glomerular diseases associated with chronic bacterial infections, including osteomyelitis, are discussed, with emphasis on infections that have been associated with the development or exacerbation of IgA nephropathy.

Macroscopic hematuria and proteinuria preceding renal IgA deposition in patients with IgA nephropathy

Although the clinical onset of IgA nephropathy is frequently impossible to define, macroscopic hematuria apparently heralds the onset of the disease in some patients. We describe the clinical course and renal histologic findings of four adults with IgA nephropathy who were diagnosed by the characteristic immunohistologic features in a second renal biopsy specimen. IgA was not detected in the initial renal biopsy specimens obtained 9 months to 4 years earlier. The first renal biopsy had been performed to evaluate macroscopic hematuria (recurrent in three patients), accompanied by pathologic proteinuria in two patients. Our observations suggest that the pathognomonic immunohistologic findings of IgA nephropathy may follow the clinical onset and raise questions about the presumed pathogenetic role of IgA in the early stages of this disease.

Therapeutic options in IgA nephropathy

IgA nephropathy (IgAN) is a common form of glomerulonephritis that leads to end-stage renal disease at variable rates in 20% to 30% of cases. A rational approach to therapy requires an understanding of pathogenetic mechanisms that are largely unknown. Several therapeutic approaches have been used, generally in uncontrolled trials, aimed at lowering levels of circulating immune complexes, affecting cellular immunity, or removing antigens through dietary restriction. Thus far, no clear-cut beneficial effects are evident. Alternative means of changing glomerular hemodynamics through prevention of harmful mediators await exploration.

Response of circulating immune complexes to food challenge in relapsing IgA nephropathy

The response of circulating immune complexes (CIC) to food challenge was assessed in 15 subjects with IgA nephropathy (IgAN) and recurrent macroscopic haematuria. CIC were measured by solid-phase C1q binding assay (SP-C1q), immunoglobulin class-specific polyethylene glycol (PEG) precipitation assays (PEG-G, PEG-A, PEG-M) and by an antigen (ovalbumin)-specific radioimmunoassay after acid dissociation (OA-IC). CIC were measured when the subjects were fasting and hourly for 6 h after a test meal containing eggs. All 15 subjects were tested while clinically quiescent (remission) and 6 were tested again during episodes of macroscopic haematuria (relapse). The PEG-A CIC response to food challenge was significantly exaggerated in IgAN remission compared with controls at 3-6 h after food. There were also non-significant increases in PEG-G, though not in PEG-M. Paired data showed further exaggeration of PEG-G, PEG-A and PEG-M responses to food during IgAN relapse, but significance was not attained if the findings in 1 subject were separated. In this individual a florid clinical relapse with transient decline in renal function was associated with very high levels of PEG-IC, and only in this patient in relapse was OA-IC detectable, confirming that some PEG-precipitated material represented antigen-antibody complexes containing food antigen.

Clinical and therapeutic studies in mesangial immunoglobulin A glomerulonephritis

A long-term clinical and therapeutic study was performed in 47 patients with mesangial IgA glomerulonephritis. The male to female ration was 2.9:1. An episode of gross haematuria or the incidental discovery of asymptomatic microscopic haematuria with associated mild proteinuria heralded the apparent onset of renal disease. At the onset of observation 18 patients (38.2%) had high blood pressure. Other 17 patients developed hypertension during observation. Anaemia was uncommon. No essential abnormalities in serum protein and lipid patterns were found. Twenty-nine patients (61.6%) had higher levels of serum immunoglobulins--most frequently of IgA (42.5%). Twenty-two patients had low serum C3 levels (46.8%). The percentage of patients with renal failure increased from 21.2 to 36.1 during observation. Male sex, hypertension, proteinuria higher than 2 g/24 h, elevated ESR, high serum IgA levels, longer duration of the disease and older age of patients suggest an unfavourable outcome. Long-term treatment with a combination of azathioprine/acenocumarol, or indomethacin, or levamisole has no effect on the clinical manifestation and evolution.

Complement membrane attack (MAC) in idiopathic IgA-glomerulonephritis

Antigens of the membrane attack complex of complement (MAC), such as C5, C6, C9 and MAC-related neoantigen(s), were demonstrated in the mesangium of 23 cases with IgA-glomerulonephritis (IgA-GN) and two cases with Henoch-Schönlein purpura nephritis (HSP). High specificity of the polyclonal antibodies was verified by dot-blot analysis. Control specimens lacking immunoglobulin deposits were negative for MAC-related antigens. Markers of classical pathway activation (Clq and C4) were observed only in two of 24 and one of 23 cases of IgA-GN and HSP, respectively. Glomerular distribution patterns (mesangial vs. mesangio-peripheral) of immunoglobulin or complement deposits were correlated for IgA and C3b/iC3b (P less than 0.002), for IgA and properdin (P less than 0.002) and for IgA and MAC neoantigens (P less than 0.01). Double immunostaining experiments revealed co-localization of IgA and MAC neoantigens at identical mesangial and capillary sites. Glomerular distribution of the less pronounced IgG or IgM deposits did not correlate with that of any complement-derived antigen. The pattern of MAC-related antigens was found to be uniformly either mesangial or mesangio-peripheral. Staining for MAC-related antigens was less intense in IgA-GN cases with minimal glomerular lesions than in cases with more advanced non-sclerosing lesions. IgA, C3d, and MAC localized in corresponding glomerular sites. This is consistent with complete local activation of complement by glomerular IgA deposits via the alternative pathway. The possibility exists that MAC plays a pathogenetic role, such as by irritation of bystander cells, in IGA-GN and HSP.

IgA-associated renal diseases: antibodies to environmental antigens in sera and deposition of immunoglobulins and antigens in glomeruli

Levels of IgA1, IgA2, IgM, and IgG antibodies specific for 10 ubiquitous food and bacterial antigens were examined by radioimmunoassay in the sera of 29 patients with IgA-associated renal diseases and 22 normal individuals. No significant differences were observed between patient and normal groups in the levels of IgA1 antibodies, and IgA2 antibodies were detected in only a few individuals in either group. Minor differences in IgM or IgG antibodies were seen against some antigens. Significant positive correlations between IgA1 and IgG and between IgA1 and IgM antibodies to casein were found in the patient group. Analysis of the molecular form of serum IgA1 antibodies revealed that although the pattern of polymeric and monomeric forms varied between individuals and between antibody specificities, there was no preponderance of one form in either patient or normal groups. Examination of kidney biopsies from 50 patients with IgA-associated renal diseases revealed that IgA1 represented the predominant subclass deposited in the glomerular mesangium; glomeruli from three patients contained both IgA1 and IgA2. Seventy-eight percent of the patients also had deposits of IgM, although IgA and IgM deposits did not always coincide. When IgG was present in glomeruli (45% of patients), the IgG1 subclass predominated. J chain was detectable in glomeruli of only four patients. C3 was detected in glomeruli of 95% of the patients, although the distribution of C3 did not always coincide with that of IgA. Indirect immunofluorescence staining with rabbit antisera to various environmental antigens showed that milk protein antigens could be deposited in association with IgA in the glomerular mesangium.

Pathogenesis and treatment of immune-mediated renal disease

There is now convincing evidence to suggest that most forms of glomerulonephritis and tubulointerstitial nephropathy involve the immune system in the destructive process. Such involvement can be mediated by a humoral immune response, a cell-mediated immune response, or a coordinated response of both limbs of the immune system derived from complementary T- and B-cell interactions.

Glomerulonephritis: approaches to classification

Glomerulonephritis has many mechanisms and may take a variety of patterns. Almost as many classifications of glomerulonephritis exist as there have been classifiers. None is perfect. Morphological classification of glomerulonephritis is inadequate alone but provides useful information about the pattern of response to the injurious mechanism and may allow accurate assessment of prognosis. In this paper some approaches to the classification of glomerulonephritis are discussed, the major categories are reviewed and a prognostic method of classification is proposed.

IgA nephropathy--accumulated experience and current concepts

Primary IgA nephropathy is the most common form of glomerulonephritis in Australia. The condition presents in a variety of ways, but commonly with synpharyngitic hematuria, most often in young men in the third and fourth decades. The course of the disease is indolent but there is progression to renal failure in up to one quarter of cases. Renal biopsy morphology is variable but the essential immunofluorescence finding is diffuse mesangial IgA staining of greater intensity but often in association with other immunoglobulins. C3 is usually also present. Mesangial cellularity is increased in some two-thirds of cases, one third being of a minor focal or variable extent and one-third diffuse. Focal segmental lesions, hyaline nodules and vascular changes are frequent. Crescents are also often present. The etiology of the disease is uncertain but has been linked with HLA antigens, elevated serum IgA levels, IgA polymers, immune complexes and impaired T cell function. Secondary forms of mesangial IgA deposition occur with mucosal defects, hyperglobulinemia or impaired hepatobiliary clearance, and these may offer some insight into the immunopathogenesis of the primary disease.

Clearance of circulating IgA immune complexes is mediated by a specific receptor on Kupffer cells in mice

To characterize the physiology of circulating IgA immune complexes (IgA-IC), the dynamics of IgA-IC removal by the liver were examined. After intravenous injection, covalently cross-linked IgA antibodies to the dinitrophenyl determinant were rapidly removed from the circulation by the liver. Immunofluorescence microscopy and light and electron microscope autoradiography showed that the IgA-IC were associated with Kupffer cells. With increasing doses of injected IgA-IC the clearance velocity approached a maximum, thus prolonging the circulation of IgA-IC. All these observations indicated a receptor-mediated process. Saturating doses of various potential receptor-blocking agents, heat-aggregated mouse IgG, microaggregated human serum albumin, and purified dimeric IgA did not influence the clearance pattern and hepatic uptake of radiolabeled IgA-IC. Mouse livers were also perfused via the portal vein with 1 microgram of IgA-IC. In the presence or absence of serum proteins, 43% of the perfused IgA-IC were removed in a single passage. This liver uptake was not reduced with simultaneous perfusion of large doses of aggregated mouse IgG, aggregated human serum albumin, or purified free dimeric mouse IgA. In contrast, the liver uptake of radiolabeled IgA-IC was decreased by 88% with the addition of 1 mg unlabeled IgA-IC. These observations support the conclusion that removal of IgA-IC from circulation is mediated by a specific IgA receptor on Kupffer cells.