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Ogura S, Moriyama T, Miyabe Y, Karasawa K, Nitta K. Evaluation of appropriate treatment for IgA nephropathy with mild proteinuria and normal renal function. Clin Exp Nephrol 2021; 25:1103-1110. [PMID: 34101029 DOI: 10.1007/s10157-021-02086-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 05/27/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Tonsillectomy and steroid pulse therapy (TSP) for immunoglobulin A nephropathy (IgAN) is frequently employed in many Japanese institutions; however, performing this invasive treatment in patients with mild IgAN is controversial. This study aimed to evaluate the appropriate treatment for IgAN patients with mild proteinuria. METHODS In this retrospective cohort analysis, 122 IgAN patients with mild proteinuria (0.5-1.0 g/day) and estimated glomerular filtration rate of ≥ 60 mL/min/1.73 m2 were classified into three groups as follows: patients treated with TSP (n = 32), oral prednisolone (oPSL, n = 33), and conservative therapy (CONS, n = 47). The clinical and histological backgrounds, 5-year remission rates of urinary findings, and 10-year renal survival rates were analyzed. RESULTS The backgrounds were similar among the three groups. The remission rates of hematuria, proteinuria, and both were significantly higher for TSP and oPSL than for CONS; however, they were similar for TSP and oPSL. In the multivariate Cox regression analysis, TSP and oPSL were independent factors for the remission of urinary findings compared with CONS; however, the relapse rates of urinary abnormalities were similar among the three groups. No patient progressed to end-stage renal disease (ESRD) within 10 years. Adverse effects of corticosteroid therapy were significantly more frequent in oPSL than in TSP. CONCLUSION In IgAN patients with mild proteinuria and stable renal function, similar to oPSL, TSP showed higher remission rates of hematuria and/or proteinuria than CONS, and no case progressed to ESRD regardless of the treatment methods. Therefore, appropriate treatments should be carefully considered for each patient.
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Affiliation(s)
- Shota Ogura
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takahito Moriyama
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Yoei Miyabe
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kazunori Karasawa
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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A cross-sectional study in patients with IgA nephropathy of correlations between clinical data and pathological findings at the time of renal biopsy: a Japanese prospective cohort study. Clin Exp Nephrol 2021; 25:509-521. [PMID: 33595730 DOI: 10.1007/s10157-021-02022-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 01/15/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND The correlations between clinical data and pathological findings at the time of renal biopsy were investigated in IgA nephropathy patients. METHODS 771 patients diagnosed with IgA nephropathy by renal biopsy were enrolled. The correlations between clinical variables including eGFR, daily proteinuria, mean arterial pressure (MAP), serum uric acid (UA) values, and pathological parameters were examined. These patients were further divided into three groups: children (< 19 years old), young adults (19-60 years), and elderly patients (> 60 years). RESULTS Daily proteinuria was moderately correlated with all pathological parameters (Rs = 0.23-0.49). The mesangial score, the percentage of glomeruli that contained endocapillary hypercellularity, cellular/fibrocellular crescents or tuft necrosis, and segmental glomerulosclerosis (GS) affected daily proteinuria most on multiple linear regression analysis (MLRA). eGFR, MAP, and serum UA levels were mainly correlated with the degree of GS and interstitial lesions. In children, the degree of cellular/fibrocellular crescents or tuft necrosis was correlated with not only daily proteinuria, but also decreased eGFR (Rs = 0.51, - 0.24). Endocapillary hypercellularity was the only independent variable related to daily proteinuria on MLRA. CONCLUSION In all age cohorts of IgA nephropathy patients, daily proteinuria was correlated with all histological parameters, including both acute and chronic glomerular lesions, and the mesangial score. Independent variables for daily proteinuria were the meangial score, acute histological lesions, and segmental GS on MLRA, whereas the remaining independent variable in the pediatric group was endocapillary hypercellurality. The clinical pathological correlation at the time of biopsy varied depending on the age group.
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Moriyama T, Karasawa K, Miyabe Y, Akiyama K, Iwabuchi Y, Ogura S, Takabe T, Sugiura N, Seki M, Hanafusa N, Uchida K, Nitta K. Long-Term Beneficial Effects of Tonsillectomy on Patients with Immunoglobulin A Nephropathy. KIDNEY360 2020; 1:1270-1283. [PMID: 35372877 PMCID: PMC8815505 DOI: 10.34067/kid.0003932020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/01/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND Tonsillectomy may treat IgA nephropathy (IgAN) by reducing the levels of galactose-deficient IgA1. Therefore, we aimed to analyze the long-term effects of tonsillectomy on patients with IgAN, as an initial treatment and as a treatment at any time in their lives. METHODS In this retrospective cohort analysis, 1147 patients with IgAN were grouped according to whether they had undergone tonsillectomy at any time, >1 year after renal biopsy (study 1), or within 1 year after renal biopsy (study 2). The patients were propensity-score matched or divided into four groups according to their proteinuria and renal function. The 20-year renal survival rates were evaluated until serum creatinine levels doubled (primary end point) and ESKD occurred (secondary end point). RESULTS Patients in both studies had similar background characteristics after propensity score matching. In study 1, the renal survival rates for the primary and secondary end points were significantly higher for patients who underwent tonsillectomy at any time or >1 year after renal biopsy compared with those who did not. In study 2, the renal survival rates for the primary and secondary end points were significantly higher for patients who underwent tonsillectomy soon after renal biopsy compared with those who did not (primary end point, 98% versus 69%, P=0.001; secondary end point, 100% versus 75%, P=0.0001). A stratified analysis showed that significant treatment efficacy was observed for patients with proteinuria >1.0 g/d. Multivariate Cox regression analyses showed that tonsillectomy was associated with disease progression (hazard ratio, 0.27; P=0.04). Complications associated with tonsillectomy occurred in 8% of patients. CONCLUSIONS Among patients with IgAN, tonsillectomy at any time of life, or soon after renal biopsy, prevents disease progression, and the procedure is relatively safe.
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Affiliation(s)
- Takahito Moriyama
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kazunori Karasawa
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yoei Miyabe
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kenichi Akiyama
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yuko Iwabuchi
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Shota Ogura
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Tomo Takabe
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Naoko Sugiura
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Momoko Seki
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Norio Hanafusa
- Department of Blood Purification, Tokyo Women’s Medical University, Tokyo, Japan
| | - Keiko Uchida
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
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Impact of the number of steroid pulses in tonsillectomy combined with steroid pulse therapy: a nationwide retrospective study in Japan. Clin Exp Nephrol 2020; 25:19-27. [PMID: 32880761 DOI: 10.1007/s10157-020-01960-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/21/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Steroid pulse therapy with tonsillectomy is known as a major treatment for IgA nephropathy (IgAN). However, its protocol was different among institutions and the effects of varying the number of steroid pulses remain unclear. METHODS From a total of 1,174 IgAN patients in a multicenter retrospective cohort analysis in Japan, 195 patients were treated by tonsillectomy combined with corticosteroid. They were divided into four groups based on the number of administered steroid pulses from 0 to three (TSP0-3), and remission of urinary abnormalities and renal survival until 1.5-fold increase in serum creatinine level from baseline were analyzed among the four groups and between TSP1 and TSP3. RESULTS Among the four groups, renal function was relatively good when the estimated glomerular filtration rate was approximately 80-90 mL/min/1.73m2 and proteinuria was relatively mild (< 1.0 g/gCre). The ratio of patients who developed renal dysfunction was < 5% in all groups, and the cumulative renal survival rate by Kaplan-Meier analysis was similar among groups (log-rank test, p = 0.37), despite varying clinical backgrounds and treatments. After adjustment of the background variables between TSP1 and TSP3, the remission rates of urinary abnormalities were similar and the renal survival rate also remained similar (66.8 vs. 85.4%, p = 0.45). CONCLUSIONS In patients with mild proteinuria and good renal function, the number of steroid pulses did not affect the renal outcome in steroid pulse therapy with tonsillectomy. The adaptation and protocols, such as the number of steroid pulses, should be determined for each IgAN patient's background.
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Validation of the revised Oxford classification for IgA nephropathy considering treatment with corticosteroids/immunosuppressors. Sci Rep 2020; 10:11151. [PMID: 32636449 PMCID: PMC7341848 DOI: 10.1038/s41598-020-68087-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/18/2020] [Indexed: 11/18/2022] Open
Abstract
The Oxford classification for IgA nephropathy (IgAN) was updated in 2017. We have validated the revised Oxford classification considering treatment with corticosteroids/immunosuppressors. In this retrospective analysis, 871 IgAN patients were enrolled. Patients were divided into two groups, those treated with or without corticosteroids/immunosuppressors. The 20-year renal prognosis up to end-stage renal disease was assessed using the Oxford classification. In all patients, the renal survival rate was 87.5% at 10 years and 72.6% at 20 years. The T score alone was significantly related to renal prognosis in the Kaplan–Meier analysis and multivariate Cox regression analysis. In the non-treatment group (n = 445), E, S, T, and C scores were significantly related to renal survival rates, however, in the treatment group (n = 426), T score alone was significantly related to renal prognosis on Kaplan–Meier analysis, indicating that corticosteroids/immunosuppressors improved renal prognosis in E1, S1, and C1. In patients with E1, S1, or C1, the treatment group showed significantly better renal prognosis than the non-treatment group in univariate and multivariate analysis. The Oxford classification and T score were used to determine renal prognosis in IgAN patients. Corticosteroids/immunosuppressors improved renal prognosis, especially E1, S1, and C1 scores.
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Natale P, Palmer SC, Ruospo M, Saglimbene VM, Craig JC, Vecchio M, Samuels JA, Molony DA, Schena FP, Strippoli GFM. Immunosuppressive agents for treating IgA nephropathy. Cochrane Database Syst Rev 2020; 3:CD003965. [PMID: 32162319 PMCID: PMC7066485 DOI: 10.1002/14651858.cd003965.pub3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND IgA nephropathy is the most common glomerulonephritis world-wide. IgA nephropathy causes end-stage kidney disease (ESKD) in 15% to 20% of affected patients within 10 years and in 30% to 40% of patients within 20 years from the onset of disease. This is an update of a Cochrane review first published in 2003 and updated in 2015. OBJECTIVES To determine the benefits and harms of immunosuppression strategies for the treatment of IgA nephropathy. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 9 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs of treatment for IgA nephropathy in adults and children and that compared immunosuppressive agents with placebo, no treatment, or other immunosuppressive or non-immunosuppressive agents. DATA COLLECTION AND ANALYSIS Two authors independently assessed study risk of bias and extracted data. Estimates of treatment effect were summarised using random effects meta-analysis. Treatment effects were expressed as relative risk (RR) and 95% confidence intervals (95% CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Risks of bias were assessed using the Cochrane tool. Evidence certainty was evaluated using GRADE methodology. MAIN RESULTS Fifty-eight studies involving 3933 randomised participants were included. Six studies involving children were eligible. Disease characteristics (kidney function and level of proteinuria) were heterogeneous across studies. Studies evaluating steroid therapy generally included patients with protein excretion of 1 g/day or more. Risk of bias within the included studies was generally high or unclear for many of the assessed methodological domains. In patients with IgA nephropathy and proteinuria > 1 g/day, steroid therapy given for generally two to four months with a tapering course probably prevents the progression to ESKD compared to placebo or standard care (8 studies; 741 participants: RR 0.39, 95% CI 0.23 to 0.65; moderate certainty evidence). Steroid therapy may induce complete remission (4 studies, 305 participants: RR 1.76, 95% CI 1.03 to 3.01; low certainty evidence), prevent doubling of serum creatinine (SCr) (7 studies, 404 participants: RR 0.43, 95% CI 0.29 to 0.65; low certainty evidence), and may lower urinary protein excretion (10 studies, 705 participants: MD -0.58 g/24 h, 95% CI -0.84 to -0.33;low certainty evidence). Steroid therapy had uncertain effects on glomerular filtration rate (GFR), death, infection and malignancy. The risk of adverse events with steroid therapy was uncertain due to heterogeneity in the type of steroid treatment used and the rarity of events. Cytotoxic agents (azathioprine (AZA) or cyclophosphamide (CPA) alone or with concomitant steroid therapy had uncertain effects on ESKD (7 studies, 463 participants: RR 0.63, 95% CI 0.33 to 1.20; low certainty evidence), complete remission (5 studies; 381 participants: RR 1.47, 95% CI 0.94 to 2.30; very low certainty evidence), GFR (any measure), and protein excretion. Doubling of serum creatinine was not reported. Mycophenolate mofetil (MMF) had uncertain effects on the progression to ESKD, complete remission, doubling of SCr, GFR, protein excretion, infection, and malignancy. Death was not reported. Calcineurin inhibitors compared with placebo or standard care had uncertain effects on complete remission, SCr, GFR, protein excretion, infection, and malignancy. ESKD and death were not reported. Mizoribine administered with renin-angiotensin system inhibitor treatment had uncertain effects on progression to ESKD, complete remission, GFR, protein excretion, infection, and malignancy. Death and SCr were not reported. Leflunomide followed by a tapering course with oral prednisone compared to prednisone had uncertain effects on the progression to ESKD, complete remission, doubling of SCr, GFR, protein excretion, and infection. Death and malignancy were not reported. Effects of other immunosuppressive regimens (including steroid plus non-immunosuppressive agents or mTOR inhibitors) were inconclusive primarily due to insufficient data from the individual studies in low or very low certainty evidence. The effects of treatments on death, malignancy, reduction in GFR at least of 25% and adverse events were very uncertain. Subgroup analyses to determine the impact of specific patient characteristics such as ethnicity or disease severity on treatment effectiveness were not possible. AUTHORS' CONCLUSIONS In moderate certainty evidence, corticosteroid therapy probably prevents decline in GFR or doubling of SCr in adults and children with IgA nephropathy and proteinuria. Evidence for treatment effects of immunosuppressive agents on death, infection, and malignancy is generally sparse or low-quality. Steroid therapy has uncertain adverse effects due to a paucity of studies. Available studies are few, small, have high risk of bias and generally do not systematically identify treatment-related harms. Subgroup analyses to identify specific patient characteristics that might predict better response to therapy were not possible due to a lack of studies. There is no evidence that other immunosuppressive agents including CPA, AZA, or MMF improve clinical outcomes in IgA nephropathy.
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Affiliation(s)
- Patrizia Natale
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Marinella Ruospo
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Valeria M Saglimbene
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Joshua A Samuels
- UT‐Houston Health Science CenterDivision of Pediatric Nephrology and Hypertension6431 Fannin Street, MSB 3‐121HoustonTXUSA77030
| | - Donald A Molony
- UT‐Houston Health Science CenterInternal MedicineDivision of Renal Diseases and Hypertension64312 Fannin StHoustonTXUSA77030
| | | | - Giovanni FM Strippoli
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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Kumon S, Moriyama T, Kamiyama T, Karasawa K, Nitta K. The impact of tonsillectomy combined with steroid pulse therapy in patients with advanced IgA nephropathy and impaired renal function. Clin Exp Nephrol 2019; 24:295-306. [PMID: 31845064 DOI: 10.1007/s10157-019-01828-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 12/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Preventing progression to end-stage renal disease (ESRD) in advanced IgA nephropathy (IgAN) patients with impaired renal function remains challenging. We analyzed the efficacy of tonsillectomy combined with steroid pulse therapy (TSP). METHODS In this retrospective analysis, IgAN patients with proteinuria > 0.5 g/day and estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 were divided into three groups: patients treated with TSP (TSP group; n = 23), oral prednisolone (oPSL group; n = 41), and conservative therapy (CONS group, n = 51). We analyzed the clinical and histological backgrounds, remission of urinary findings, and renal survival rate to a 25% decline in eGFR from baseline, and incidence of ESRD. RESULTS There were significant differences in the patients' backgrounds among the groups. Therefore, we adjusted the background using propensity score marching between TSP group and oPSL or CONS group. The 5-year remission rate of hematuria was significantly higher in the TSP group than in the oPSL group, and that of both hematuria and proteinuria was significantly higher in the TSP group than in the CONS group. The 10-year renal survival rate was significantly higher in the TSP group than in the oPSL and CONS groups. In a multivariate Cox regression analysis, TSP was found to be an independent factor for the 25% decline in eGFR in entire cohort. The adverse effect frequency in the TSP group was similar to the CONS group. CONCLUSIONS TSP can effectively induce remission of urinary abnormality and improve the prognosis without frequent adverse effects in IgAN patients with impaired renal function.
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Affiliation(s)
- Saeko Kumon
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takahito Moriyama
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Takahiro Kamiyama
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kazunori Karasawa
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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Adachi M, Sato M, Miyazaki M, Hotta O, Hozawa K, Sato T, Taguma Y, Katori Y. Steroid pulse therapy transiently destroys the discriminative histological structure of tonsils in IgA nephropathy: Tonsillectomy should be performed before or just after steroid pulse therapy. Auris Nasus Larynx 2018; 45:1206-1213. [PMID: 29789195 DOI: 10.1016/j.anl.2018.04.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 03/21/2018] [Accepted: 04/25/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Tonsillectomy combined with steroid-pulse therapy is a widely accepted method for the treatment of IgA nephropathy (IgAN) in Japan. However, the indication of tonsillectomy for IgAN is still controversial, and the timing of tonsillectomy is not clearly defined for the protocol of this therapy. Based on the results of a randomized control trial in Japan, the Evidence-Based Clinical Practice Guidelines for IgA nephropathy 2014 (edited in Japan) recommended tonsillectomy combined with steroid-pulse therapy for Grade C1. However, this is not widely accepted worldwide. To clarify the validity and timing of tonsillectomy, we evaluated how the three-consecutive steroid-pulse therapy method affects the tonsil tissues of IgAN patients. METHODS We examined tonsil specimens from 35 IgAN patients and 8 chronic tonsillitis patients. We compared the proportion of follicular area to total tonsillar area and the number of germinal centers between each group on hematoxylin and eosin stained pathological specimens to clarify the histopathological characteristics of tonsils from IgAN patients. Based on these findings, we examined the tonsils of patients after three-consecutive steroid-pulse therapy treatments (n=34) to determine the influence of this therapy on the tonsil tissues of IgAN patients. Moreover, we observed chronological changes in tonsil tissues after steroid-pulse therapy. RESULTS The extrafollicular area was enlarged in IgAN patients before steroid-pulse therapy compared with chronic tonsillitis patients. Just after steroid-pulse therapy, the follicles became very small with blurry outlines, and the number of germinal centers was remarkably decreased. With a gradual decrease in oral prednisolone, the tonsil tissue structure was gradually restored. CONCLUSION Tonsillectomy combined with steroid-pulse therapy is considered a reasonable treatment for IgAN. Steroid-pulse therapy-induced histological changes in tonsils were transient, indicating tonsillectomy should be performed before or just after steroid-pulse therapy.
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Affiliation(s)
- Mika Adachi
- Departmnet of Otolaryngology-Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan.
| | - Mitsuhiro Sato
- Departmnet of Nephrology, Sendai Hospital of Japan Community of Health Care Organization, 3-16-1 Tsutsumi-machi, Aoba-ku, Sendai, Miyagi 981-8501, Japan
| | - Mariko Miyazaki
- Depertment of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Osamu Hotta
- Hotta Osamu Clinic, 2-39 Rokuchonome minami-machi, Wakabayashi-ku, Sendai, Miyagi 984-0013, Japan
| | - Koji Hozawa
- Hozawa ENT Clinic, 2-14-18 Kokubun-cho, Aoba-ku, Sendai, Miyagi 980-0803, Japan
| | - Toshinobu Sato
- Departmnet of Nephrology, Sendai Hospital of Japan Community of Health Care Organization, 3-16-1 Tsutsumi-machi, Aoba-ku, Sendai, Miyagi 981-8501, Japan
| | - Yoshio Taguma
- Departmnet of Nephrology, Sendai Hospital of Japan Community of Health Care Organization, 3-16-1 Tsutsumi-machi, Aoba-ku, Sendai, Miyagi 981-8501, Japan
| | - Yukio Katori
- Departmnet of Otolaryngology-Head and Neck Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
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Katsumata H, Yamamoto I, Komatsuzaki Y, Kawabe M, Okabayashi Y, Yamakawa T, Katsuma A, Nakada Y, Kobayashi A, Tanno Y, Miki J, Yamada H, Ohkido I, Tsuboi N, Yamamoto H, Yokoo T. Successful treatment of recurrent immunoglobulin a nephropathy using steroid pulse therapy plus tonsillectomy 10 years after kidney transplantation: a case presentation. BMC Nephrol 2018. [PMID: 29540152 PMCID: PMC5852954 DOI: 10.1186/s12882-018-0858-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background Both prevention and treatment of recurrent immunoglobulin A nephropathy (IgAN) in kidney transplant recipients are important since recurrent IgAN seems to affect long-term graft survival. We present here a case of recurrent IgAN that was successfully treated using steroid pulse therapy plus tonsillectomy 10 years after kidney transplantation. Case presentation A 46-year-old male was admitted for an episode biopsy with a serum creatinine level of 1.8 mg/dl and proteinuria (0.7 g/day). Histological features showed recurrent IgAN (only focal segmental mesangial proliferation) and severe arteriolar hyalinosis partly associated with calcineurin inhibitor toxicity, with limited interstitial fibrosis and tubular atrophy (5%) (IF/TA) 8 years after transplantation. Sodium restriction and conversion from cyclosporine to tacrolimus successfully reduced his proteinuria to the level of 0.15 g/day. However, 2 years later, his proteinuria increased again (1.0 g/day) and a second episode biopsy showed global mesangial proliferation with glomerular endocapillary and extracapillary proliferation accompanied by progressive IF/TA (20%). The steroid pulse therapy plus tonsillectomy successfully decreased his proteinuria and he achieved clinical remission 3 years after this treatment. Conclusion This case, presented with a review of relevant literature, demonstrates the difficulty and importance of the treatment of recurrent IgAN and calcineurin inhibitor arteriolopathy, especially in long-term kidney allograft management.
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Affiliation(s)
- Haruki Katsumata
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Izumi Yamamoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yo Komatsuzaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Mayuko Kawabe
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yusuke Okabayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takafumi Yamakawa
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Ai Katsuma
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yasuyuki Nakada
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Akimitsu Kobayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yudo Tanno
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Jun Miki
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroki Yamada
- Department of Urology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ichiro Ohkido
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroyasu Yamamoto
- Department of internal Medicine, Atsugi City Hospital, Kanagawa, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan
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Yang P, Chen X, Zeng L, Hao H, Xu G. The response of the Oxford classification to steroid in IgA nephropathy: a systematic review and meta-analysis. Oncotarget 2017; 8:59748-59756. [PMID: 28938678 PMCID: PMC5601774 DOI: 10.18632/oncotarget.19574] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 06/02/2017] [Indexed: 11/25/2022] Open
Abstract
Background The present review is aimed to evaluate the correlation between pathological features and the response to steroid in the patients with IgA nephropathy according to the Oxford classification, mesangial hypercellularity (M), endocapillary hypercellularity (E), segmental glomerulosclerosis (S), tubular atrophy and interstitial fibrosis (T). Methods We searched Chinese Biomedical Database, EMBASE, Cochrane Library, PubMed and MEDLINE with all spellings of “IgA nephropathy”, “Oxford Classification”, and “steroid”. Results 5 studies with 637 patients were eligible for inclusion. The analysis showed that M1, S1, and T1/2 was strongly associated with the prediction to steroid resistance when compared with M0 [odds ratio (OR) 1.89, 95% confidence interval (CI) 1.01 - 3.56, P < 0.05], S0 (OR 2.24, 95% CI 0.99 - 5.08, P = 0.05) and T0 (OR 2.16, 95% CI 1.29 - 3.63, P = 0.004) respectively. There is no difference in steroid sensitivity between E0 and E1 (P = 0.55). The pooled OR of steroid resistance for E1 versus T1/2 is 0.50 (P = 0.04). Conclusion IgA nephropathy patients with serious pathological changes (M1, S1, and T1/2) were more resistant to steroid than slight ones (M0, S0, and T0), and E1 is better response to steroid therapy than T1/2.
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Affiliation(s)
- Pingping Yang
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Xi Chen
- Grade 2013, The Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Lei Zeng
- Department of Pathology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Hua Hao
- Department of Pathology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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Duan J, Liu D, Duan G, Liu Z. Long-term efficacy of tonsillectomy as a treatment in patients with IgA nephropathy: a meta-analysis. Int Urol Nephrol 2016; 49:103-112. [PMID: 27722990 DOI: 10.1007/s11255-016-1432-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 09/27/2016] [Indexed: 12/12/2022]
Abstract
PURPOSE IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide and will lead some unfavorable outcomes such as end-stage renal disease. The efficacy of tonsillectomy remains controversial in both Asian and Caucasian ethnicity. Our meta-analysis was aiming at exploring its long-term efficacy and providing further evidences for clinical treatment. METHODS Prospective and retrospective studies that compared the rate of clinical remission and/or end-stage renal disease in IgAN patients who applied tonsillectomy were involved in our meta-analysis. The online databases we searched were PubMed, Embase, Cochrane Library, and Web of Science RESULTS: Nineteen studies with a total of 3483 participants are involved in our meta-analysis. It is found that treatment of tonsillectomy is significantly associated with a higher rate of clinical remission (15 studies, 3059 participants; pooled OR 3.30, 95 % CI 2.47-4.40). Meanwhile, tonsillectomy shows positive effect on refraining from developing end-stage renal disease (9 studies, 1804 participants; pooled OR 0.33, 95 % CI 0.16-0.69). In following two subgroup analyses, we integrate studies with more than 5 years of follow-up from clinical remission group and end-stage renal disease group. Both of them show that tonsillectomy has favorable long-term efficacy, pooled OR 3.37 (95 % CI 2.68-4.24) and 0.20 (95 % CI 0.12-0.33), respectively. CONCLUSIONS Long-term efficacy of tonsillectomy indicates that this treatment is helpful in inducing clinical remission and inhibiting development of end-stage renal disease in patients with IgAN and should be considered for addition into standard clinical treatment.
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Affiliation(s)
- Jiayu Duan
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Research Institute of Nephrology, Zhengzhou University, Zhengzhou, Henan, China
| | - Dongwei Liu
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Research Institute of Nephrology, Zhengzhou University, Zhengzhou, Henan, China
| | - Guangcai Duan
- Henan Collaborative Innovation Center of Molecular Diagnosis and Laboratory Medicine, Xinxiang Medical University Xinxiang, Xinxiang, Henan, China.
| | - Zhangzuo Liu
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Research Institute of Nephrology, Zhengzhou University, Zhengzhou, Henan, China.
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