Association between renal outcome and the number of steroid pulse therapies after tonsillectomy in patients with IgA nephropathy

Histological Correlation between Tonsillar and Glomerular Lesions in Patients with IgA Nephropathy Justifying Tonsillectomy: A Retrospective Cohort Study

Tonsillectomy with steroid pulse therapy (SPT) has been established as an effective treatment for immunoglobulin A nephropathy (IgAN) in Japan. However, the underlying mechanisms supporting tonsillectomy remain unclear. This study assessed palatine tonsils from 77 patients with IgAN, including 14 and 63 who received SPT before and after tonsillectomy, respectively. Tonsils from 21 patients with chronic tonsillitis were analyzed as controls. Specific tonsillar lesions were confirmed in patients with IgAN, correlating with active or chronic renal glomerular lesions and SPT. T-nodule and involution of lymphoepithelial symbiosis scores in tonsils correlated with the incidence of active crescents and segmental sclerosis in the glomeruli, respectively. The study revealed an essential role of the tonsil-glomerular axis in early active and late chronic phases. Moreover, the SPT-preceding group demonstrated no changes in the T-nodule score, which correlated with active crescent formation, but exhibited a considerable shrinkage of lymphatic follicles that produced aberrant IgA1. The study underscores the involvement of innate and cellular immunity in IgAN and advocates for tonsillectomy as a necessary treatment alongside SPT for IgAN, based on a stepwise process.

Potential benefits and related treatment effects of calcineurin inhibitors combined with steroid for IgA nephropathy: a systematic review and meta-analysis

BACKGROUND

IgA nephropathy is not uncommon for clinical practice. Within multiple options of treatment, it is alternatively to consider less well-studied immunosuppressants such as calcineurin inhibitors (CNI). The knowledge of CNI with steroid in the treatment of IgA nephropathy can be clarified via a systematic review and meta-analysis of randomized clinical trials.

METHODS

We performed the systematic search and meta-analysis for the randomized clinical trials of the CNI treatment in IgA nephropathy. The comparison between CNI combined with steroid and steroid-alone treatment was performed to find if the CNI combined with steroid can achieve more complete remission for IgA nephropathy. In addition, the related treatment effects were analyzed. After restricted selection, 16 studies with a total of 998 subjects with IgA nephropathy were enrolled. The focused outcome was complete remission, proteinuria, serum creatinine, and estimated glomerular filtration rate.

RESULTS

The meta-analysis showed higher odds ratio of complete remission if the patients received CNI with steroid combined treatment. The proteinuria can be significantly reduced under the combined treatment of CNI and steroid. However, the CNI with steroid combined treatment showed a non-superior effect on the parameters of serum creatinine and estimated glomerular filtration rate.

CONCLUSIONS

In current meta-analysis, the CNI combined with steroid treatment might show a trend to achieve complete remission status and reduce the proteinuria of IgA nephropathy when compared to steroid-alone treatment. However, no significant effects were observed in parameters of serum creatinine and estimated glomerular filtration rate.

Comparison of administration of single- and triple-course steroid pulse therapy combined with tonsillectomy for immunoglobulin A nephropathy

Immunoglobulin A nephropathy (IgAN) is a form of chronic glomerulonephritis that can cause end-stage renal disease. Recently, tonsillectomy combined with corticosteroid pulse (TSP) has been shown to be effective for achieving clinical remission and favorable renal outcome in patients with IgAN. However, the standard regimen of corticosteroid use in TSP has not been established. Herein, we compared the effect of single- or triple-course steroid pulse therapy combined with tonsillectomy in patients with IgAN.This retrospective, observational cohort study included 122 patients with IgAN enrolled from January 2004 to December 2018 at 2 independent institutions. We divided the patients into 2 groups; single-course (TSP1: n = 70) and triple-course (TSP3: n = 52) of corticosteroid pulse therapy (1 course comprised 3 consecutive days' infusion of 0.5 g methylprednisolone) combined with tonsillectomy. The primary outcome for renal survival was defined as the first occurrence of ≧30% decrease in estimated glomerular filtration rate from baseline. Secondary outcomes included the incidence of clinical remission and recurrence of the disease.Regarding clinical parameters and findings at baseline, there were no significant differences between the 2 groups. The 8-years renal survival in the 2 groups was not significantly different according to Kaplan-Meier curves (TSP1; 82.5% vs TSP3; 69.2%, log-rank test P = .39). The cumulative incidence rates of remission of hematuria (94.4% vs 85.4%, P = .56) and clinical remission (85.0% vs 64.8%, P = .07) were comparable in both groups, while those of proteinuria showed higher rates in TSP1 than TSP3 (88.4% vs 65.4%, P = .02). The cumulative incidence of relapse of hematuria (5.6% vs 2.3%, P = .42) and proteinuria (7.1% vs 3.3%, P = .41) showed no significant differences in the 2 groups. Cox regression analyses showed that the number of courses of corticosteroid pulse therapy was not significantly associated with renal outcome (TSP1 vs TSP3; Hazard ratios 0.69, 95% confidence intervals 0.29-1.64, P = .39).The effect of single-course corticosteroid pulse therapy is not statistically, significantly different from triple-course in TSP protocol for improving renal outcome and preventing relapse in patients with IgAN. Single-course corticosteroid pulse therapy may become a treatment option for patients with IgAN.

Impact of the number of steroid pulses in tonsillectomy combined with steroid pulse therapy: a nationwide retrospective study in Japan

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.

Tonsillar immunology in IgA nephropathy

As one of the most common types of primary glomerulonephritis, IgA nephropathy (IgAN) is often characterized by the immunoprecipitation of IgA1 in mesangial area. In clinical terms, IgA nephropathy can be treated with tonsillectomy or conservative treatment, basing on modern immunology knowledge in which the mucosa immune system (MIS), especially the widely distributed mucosa-associated lymphoid tissue (MALT) is focused accordingly In terms of basic research, IgAN has been shown correlated with multiple factors, including serum Gd-IgA1 level, IgA-IgG immunity, tonsil-associated bacteria,GADD34, CX3CR1, FOXP3 and the expression of other related intrinsic immune antibody. Therefore, it is reasonable there could be mutual correlation among IgAN-associated factors. The purpose of this study is to review the new progress on the treatment and prevention of IgAN diseases and related mechanisms of IgAN tonsils, which will be of great significance for the therapy of IgAN patients.