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Takeuchi M, Shojima M, Matsueda S, Nagae H, Kuroiwa M, Fujita A, Kawano M, Inoue D, Komori T, Takeuchi M, Ooshima K, Kuroki Y, Katafuchi R. A rare manifestation of IgG4-related disease and secondary hypereosinophilic syndrome: A case report. Mod Rheumatol Case Rep 2024; 8:329-338. [PMID: 38407323 DOI: 10.1093/mrcr/rxae009] [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: 10/25/2023] [Revised: 01/24/2024] [Accepted: 02/04/2024] [Indexed: 02/27/2024]
Abstract
We report a case of IgG4-related disease (IgG4-RD) with marked eosinophilia. A 79-year-old woman was admitted due to diarrhoea and weight loss. Cervical lymphadenopathy, bilateral submandibular glands swelling, anaemia (Hb8.5 g/dl), hypereosinophilia (9750/μl), elevated serum creatinine (1.57 mg/dl), pancreatic amylase (191 IU/l), and IgG4 (3380 mg/dl) were found. Diffusion-weighted image on magnetic resonance imaging showed high-intensity signals inside both the pancreas and the kidneys. The echogram of submandibular glands revealed cobblestone pattern. Kidney biopsy revealed acute tubulointerstitial nephritis. Biopsies of lip, gastrointestinal tract, and bone marrow showed infiltration of lymphoplasmacytic cells and IgG4-positive plasma cells (30-67/HPF). Gastrointestinal and bone marrow biopsies also showed eosinophilic infiltration. Adrenal insufficiency, rheumatic disease, tuberculosis, parasite infection, drug-induced eosinophilia, and eosinophilic leukaemia were all ruled out. We started treatment with 40 mg of prednisolone (PSL) and her general condition rapidly improved. The eosinophil count, serum IgG4, and serum creatinine decreased. We gradually tapered PSL and maintained 5 mg/day. During the 5 years of treatment, she had no recurrence of the symptom. According to the 2019 American College of Rheumatology/European League Against Rheumatism classification criteria for IgG4-RD, eosinophils >3000/μl is one of the exclusion criteria. If we comply with this criterion, the diagnosis of IgG4-RD should be avoided. However, our case fit the diagnostic criteria of type I autoimmune pancreatitis, IgG4-related sialadenitis, and global diagnosis of IgG4-RD. We finally diagnosed our case as IgG4-RD with secondary hypereosinophilic syndrome. This case suggests that IgG4-RD with eosinophils >3000/μl does exist in the real world.
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Affiliation(s)
- Miyoshi Takeuchi
- Kidney Unit, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Masumi Shojima
- Kidney Unit, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Shumei Matsueda
- Kidney Unit, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Hiroshi Nagae
- Kidney Unit, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Mika Kuroiwa
- Division of Hematology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Aya Fujita
- Division of Pathology, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Mitsuhiro Kawano
- Innovative Clinical Research Center, Department of Rheumatology, Kanazawa University Hospital, Ishikawa, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Hospital, Ishikawa, Japan
| | - Takahiro Komori
- Department of Radiology, Kanazawa University Hospital, Ishikawa, Japan
| | - Mai Takeuchi
- Department of Pathology, Kurume University, Fukuoka, Japan
| | - Koichi Ooshima
- Department of Pathology, Kurume University, Fukuoka, Japan
| | - Yusuke Kuroki
- Kidney Unit, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
| | - Ritsuko Katafuchi
- Kidney Unit, National Hospital Organization Fukuokahigashi Medical Center, Fukuoka, Japan
- Kidney Unit, Medical Corporation Houshikai Kano Hospital, Fukuoka, Japan
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Hyodo T, Hara S, Goto S, Fujii H, Nishi S, Horinouchi T, Nozu K, Yoshikawa N, Yoshimoto A, Itoh T. Immunohistological analysis reveals IgG1-dominant immunophenotype of tubulointerstitial nephritis unassociated with IgG4-related diseases. Int Urol Nephrol 2024; 56:2363-2369. [PMID: 38381285 PMCID: PMC11189997 DOI: 10.1007/s11255-024-03966-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 01/29/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE Tubulointerstitial nephritis (TIN) has various etiologies, including IgG4-related disease (IgG4-RD), autoimmune diseases, antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), and others. IgG4-positive plasma cell infiltration can occasionally be found in TIN unrelated to IgG4-RD. Therefore, there may be problems with usage of IgG4 immunostaining to differentiate between TIN with and TIN without IgG4-RD. This study aimed to compare the proportion of plasma cells that are positive for each IgG subclass and to clarify the predominant IgG subclass trends and clinical characteristics associated with IgG4-RD and non-IgG4-related interstitial nephritis. METHODS The study enrolled 44 cases of TIN: 6 of IgG4-RD, 8 of autoimmune disease, 9 of AAV, and 21 of unknown disease group. In addition to clinical characteristics, IgG subclass composition of interstitial plasma cells was evaluated among 4 groups by immunohistochemistry. RESULTS IgG1 was the predominant IgG subclass in TIN unrelated to IgG4-RD. In the IgG4-RD group, the IgG subclass rate was high in both IgG1 and IgG4. The rate of average IgG4-positive cells was significantly lower in the autoimmune disease group and unknown disease group compared with the IgG4-RD group. CONCLUSION The present study revealed IgG1-dominant immune profiles of TIN unrelated to IgG4-RD. Further investigation is required to elucidate the clinicopathological differences between IgG1-dominant and IgG4-dominant groups in IgG4-RD.
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Affiliation(s)
- Toshiki Hyodo
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan.
| | - Shigeo Hara
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
- Department of Diagnostic Pathology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shunsuke Goto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hideki Fujii
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | | | - Akihiro Yoshimoto
- Department of Nephrology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tomoo Itoh
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
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3
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Towheed ST, Zanjir W, Ren KYM, Garland J, Clements-Baker M. Renal Manifestations of IgG4-Related Disease: A Concise Review. Int J Nephrol 2024; 2024:4421589. [PMID: 38957780 PMCID: PMC11217581 DOI: 10.1155/2024/4421589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 04/28/2024] [Accepted: 06/10/2024] [Indexed: 07/04/2024] Open
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated disorder marked by fibro-inflammatory masses that can infiltrate multiple organ systems. Due to its relatively recent discovery and limited understanding of its pathophysiology, IgG4-related disease may be difficult to recognize and is consequently potentially underdiagnosed. Renal involvement is becoming regarded as one of the key features of this disease. To date, the most well-recognized renal complication of IgG4-related disease is tubulointerstitial nephritis, but membranous glomerulonephritis, renal masses, and retroperitoneal fibrosis have also been reported. This concise review has two objectives. First, it will briefly encapsulate the history, epidemiology, and presentation of IgG4-related disease. Second, it will examine the reported renal manifestations of IgG4-related disease, exploring the relevant histology, imaging, clinical features, and treatment considerations. This synthesis will be highly relevant for nephrologists, rheumatologists, general internists, and renal pathologists to raise awareness and help improve early recognition of IgG4-related kidney disease (IgG4-RKD).
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Fukuda H, Kitamura M, Sawase A, Uramatsu T, Yamashita H, Tsushima H, Irie J, Katafuchi E, Kato S, Takeuchi M, Ohshima K, Nakayama T, Mukae H, Nishino T. Tubulointerstitial nephritis with storiform fibrosis in a patient with angioimmunoblastic T-cell lymphoma. CEN Case Rep 2024:10.1007/s13730-024-00901-2. [PMID: 38902495 DOI: 10.1007/s13730-024-00901-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/09/2024] [Indexed: 06/22/2024] Open
Abstract
We present a case of an angioimmunoblastic T-cell lymphoma (AITL) and tubulointerstitial nephritis with storiform fibrosis in a 76-year-old man. The patient exhibited lymphadenopathy, polyclonal hypergammaglobulinemia, and renal dysfunction and was diagnosed with AITL on the basis of lymph node biopsy findings. The serum IgG4 level was highly elevated. Renal biopsy revealed IgG4-positive plasma cells and storiform fibrosis without infiltration of AITL, and the findings indicated IgG4-related kidney disease (IgG4-RKD). Following THPCOP therapy for AITL, the renal function improved. While diagnosing IgG4-RKD in a patient with AITL poses challenges, follicular helper T cell involvement appeared crucial in AITL and renal tubulointerstitial lesions in this case.
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Affiliation(s)
- Haruka Fukuda
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
- Department of Nephrology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Mineaki Kitamura
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
- Department of Nephrology, Nagasaki Harbor Medical Center, Nagasaki, Japan.
| | - Atsushi Sawase
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
- Department of Nephrology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Tadashi Uramatsu
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
- Department of Nephrology, Nijigaoka Hospital, Nagasaki, Japan
| | - Hiroshi Yamashita
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
- Department of Nephrology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Hideki Tsushima
- Department of Hematology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Junji Irie
- Department of Pathology, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Eisuke Katafuchi
- Department of Pathology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Seiya Kato
- Division of Pathology, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Mai Takeuchi
- Department of Pathology, Kurume University, Kurume, Japan
| | - Koichi Ohshima
- Department of Pathology, Kurume University, Kurume, Japan
| | - Toshiyuki Nakayama
- Department of Pathology, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Tsuge S, Mizushima I, Horita M, Kawahara H, Sanada H, Yoshida M, Takahashi Y, Zoshima T, Nishioka R, Hara S, Suzuki Y, Ito K, Kawano M. High serum IgA levels in patients with IgG4-related disease are associated with mild inflammation, sufficient disease-specific features, and favourable responses to treatments. Mod Rheumatol 2024; 34:621-631. [PMID: 37307433 DOI: 10.1093/mr/road056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/21/2022] [Accepted: 06/08/2023] [Indexed: 06/14/2023]
Abstract
OBJECTIVES Although elevated serum immunoglobulin A (IgA) levels are thought to exclude a diagnosis of IgG4-related disease (IgG4-RD), IgG4-RD has been definitively diagnosed in some patients despite elevated serum IgA levels. This study aimed to clarify the prevalence of elevated IgA levels in patients with IgG4-RD and to compare the clinical features of IgG4-RD patients with and without elevated IgA levels. METHODS The clinical features of 169 IgG4-RD patients were retrospectively compared among those with and without elevated serum IgA levels. RESULTS Of the 169 patients with IgG4-RD, 17 (10.1%) had elevated serum IgA levels. Those with elevated serum IgA levels showed higher serum C-reactive protein levels and lower prevalence of relapse than those without. Other clinical features did not differ significantly, including inclusion scores of the American College of Rheumatology/European League Against Rheumatism classification criteria. Cox regression analysis showed that elevated serum IgA levels were associated with a lower incidence of relapse. Moreover, patients with elevated serum IgA levels showed prompt improvement in response to glucocorticoids in the IgG4-RD responder index. CONCLUSIONS Some patients diagnosed with IgG4-RD have high serum IgA levels. These patients may form a subgroup, characterized by good response to glucocorticoids, less frequent relapse, mildly elevated serum C-reactive protein levels, and possible complications of autoimmune diseases.
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Affiliation(s)
| | | | - Makoto Horita
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroyuki Kawahara
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hajime Sanada
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Misaki Yoshida
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | | | - Takeshi Zoshima
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Ryo Nishioka
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Satoshi Hara
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Yasunori Suzuki
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kiyoaki Ito
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
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Elbanna KY, Kowa JY, Mirajkar N, Khalili K, Kim TK. Radiology domain in the diagnosis of IgG4-RD according to the 2019 American College of Rheumatology and European League Against Rheumatism classification. Insights Imaging 2024; 15:94. [PMID: 38530483 DOI: 10.1186/s13244-024-01638-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/21/2024] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVES To evaluate the performance of radiology-related inclusion criteria of the 2019 ACR-EULAR classification system in the diagnosis of IgG4-related disease (IgG4-RD). METHODS This retrospective single-institution study included patients who received a diagnosis of IgG4-RD between January 2010 and December 2020. Two abdominal radiologists independently reviewed baseline imaging studies and scored radiology findings according to the 2019 ACR-EULAR classification criteria. Additional scores were assigned based on serological, histopathological, and immunostaining features. RESULTS Seventy-four patients (58 males and 16 females) with a mean age of 59.3 ± 13.9 years diagnosed with IgG4-RD were included. 51/74 (68.9%) were classified as having IgG4-RD according to the 2019 ACR-EULAR classification criteria. To reach a score ≥ 20 in these 51 patients, the radiology domain was sufficient in 20/51 (39.2%) and adding the serology domain was required for another 20/51 (39.2%). The remaining 11/51 patients (21.6%) required the histopathology and immunostaining domains. Radiological involvement of two or more organs at presentation was significantly associated with a score of ≥ 20 and seen in 43/51 (84.3%) compared to 5/23 (21.7%) of the non-classified group (p < 0.001). The group classified as having IgG4-RD showed a significantly higher proportion of elevated IgG4 levels (39/51, 76.5%) than the non-classified group (8/23, 34.8%) (< 0.001). CONCLUSION The study findings support the effectiveness of the radiology-related inclusion criteria of the 2019 ACR-EULAR classification system in diagnosing IgG4-RD. Combining radiology and serology domains achieved the cut-off in 80% of IgG-RD patients, enabling non-invasive diagnosis. The classification of IgG4-RD was significantly associated with multi-organ involvement, particularly affecting the pancreas and biliary system. CRITICAL RELEVANCE STATEMENT This study is the first to evaluate the diagnostic performance of the radiology domain in the 2019 ACR-EULAR classification criteria. The study results confirm its utility and potential to enable non-invasive diagnosis when combined with serological testing in a significant proportion of patients. KEY POINTS • A significant proportion of patients can be diagnosed with IgG4-RD using the radiology and serology domains exclusively. • Multi-organ involvement is significantly associated with classifying patients as IgG4-RD, with the pancreas and biliary system most frequently affected. • A high level of inter-reader agreement in the scoring of the radiology domain supports its reliability.
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Affiliation(s)
- Khaled Y Elbanna
- University Medical Imaging Toronto, University Health Network, Toronto, ON, Canada.
| | - Jie-Ying Kowa
- University Medical Imaging Toronto, University Health Network, Toronto, ON, Canada
| | - Nikhil Mirajkar
- University Medical Imaging Toronto, University Health Network, Toronto, ON, Canada
| | - Korosh Khalili
- University Medical Imaging Toronto, University Health Network, Toronto, ON, Canada
| | - Tae Kyoung Kim
- University Medical Imaging Toronto, University Health Network, Toronto, ON, Canada
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Mizushima I, Morikage N, Ito E, Kasashima F, Matsumoto Y, Sawa N, Yoshifuji H, Saeki T, Shintani-Domoto Y, Shimada S, Takayama T, Amiya E, Ozawa M, Takahashi M, Fujinaga Y, Katsumata T, Obitsu Y, Izawa A, Kanno H, Oyama-Manabe N, Ishizaka N, Nagasawa T, Takahashi H, Ohki T, Kawano M, Kasashima S. Validation of the Diagnostic Criteria for IgG4-Related Periaortitis/Periarteritis and Retroperitoneal Fibrosis (IgG4PA/RPF) 2018, and Proposal of a Revised 2023 Version for IgG4-Related Cardiovascular/Retroperitoneal Disease. Circ J 2024:CJ-24-0026. [PMID: 38494710 DOI: 10.1253/circj.cj-24-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND In 2018, diagnostic criteria were introduced for IgG4-related periaortitis/periarteritis and retroperitoneal fibrosis (PA/RPF). This study assessed the existing criteria and formulated an improved version.Methods and Results: Between August 2022 and January 2023, we retrospectively analyzed 110 Japanese patients diagnosed with IgG4-related disease (IgG4-RD) involving cardiovascular and/or retroperitoneal manifestations, along with 73 non-IgG4-RD patients ("mimickers") identified by experts. Patients were stratified into derivation (n=88) and validation (n=95) groups. Classification as IgG4-RD or non-IgG4-RD was based on the 2018 diagnostic criteria and various revised versions. Sensitivity and specificity were calculated using experts' diagnosis as the gold standard for the diagnosis of true IgG4-RD and mimickers. In the derivation group, the 2018 criteria showed 58.5% sensitivity and 100% specificity. The revised version, incorporating "radiologic findings of pericarditis", "eosinophilic infiltration or lymphoid follicles", and "probable diagnosis of extra-PA/-RPF lesions", improved sensitivity to 69.8% while maintaining 100% specificity. In the validation group, the original and revised criteria had sensitivities of 68.4% and 77.2%, respectively, and specificities of 97.4% and 94.7%, respectively. CONCLUSIONS Proposed 2023 revised IgG4-related cardiovascular/retroperitoneal disease criteria show significantly enhanced sensitivity while preserving high specificity, achieved through the inclusion of new items in radiologic, pathological, and extra-cardiovascular/retroperitoneal organ categories.
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Affiliation(s)
- Ichiro Mizushima
- Department of Nephrology and Rheumatology, Kanazawa University Hospital
| | - Noriyasu Morikage
- Division of Vascular Surgery, Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine
| | - Eisaku Ito
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | | | | | - Naoki Sawa
- Department of Nephrology and Rheumatology, Toranomon Hospital
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University
| | - Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital
| | | | - Shogo Shimada
- Department of Cardiac Surgery, The University of Tokyo
| | - Toshio Takayama
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo
| | - Makiko Ozawa
- Department of Internal Medicine, Matsumoto Dental University Hospital
| | | | | | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical and Pharmaceutical University
| | - Yukio Obitsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | | | - Hiroyuki Kanno
- Department of Pathology, Shinshu University School of Medicine
| | | | | | - Tasuku Nagasawa
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital
| | - Hiroki Takahashi
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine
| | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Mitsuhiro Kawano
- Department of Nephrology and Rheumatology, Kanazawa University Hospital
| | - Satomi Kasashima
- Department of Clinical Laboratory Science, Graduate School of Health Science, Kanazawa University
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Tsujimae M, Masuda A, Takagi M, Kato T, Nakano R, Fujita K, Hirata Y, Kakuyama S, Furumatsu K, Nakagawa T, Ogisu K, Fujigaki S, Iemoto T, Ezaki T, Yagi Y, Ikegawa T, Yamanaka K, Sato Y, Juri N, Kobayashi T, Sakai A, Shiomi H, Sanuki T, Arisaka Y, Okabe Y, Kodama Y. Relapse and side effects of steroid therapy beyond 3 years in autoimmune pancreatitis: A multicenter retrospective study. Pancreatology 2024; 24:223-231. [PMID: 38320953 DOI: 10.1016/j.pan.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 01/12/2024] [Accepted: 01/14/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND The impact of extended steroid administration on patients with autoimmune pancreatitis after a 3-year maintenance period remains poorly understood. This study analyzed the advantage and disadvantage of continuing steroid therapy beyond 3 years. METHODS In this retrospective multicenter study across 17 institutions, patients who successfully completed 3 years of maintenance therapy without experiencing relapse were categorized into two groups: the maintenance therapy discontinuation group, who discontinued steroid therapy after the initial 3-year period, and maintenance therapy continuation group, who continued steroid therapy beyond 3 years. The cumulative relapse rate after 3 years of maintenance therapy was the primary outcome. Relapse predictors were compared using the Gray test for cumulative relapse incidence by specific factor. RESULTS Of 211 patients, 105 experienced no relapse during the 3-year maintenance therapy and were divided into two groups: 69 in the maintenance therapy discontinuation group and 36 in the maintenance therapy continuation group. The relapse rate was lower in the maintenance therapy continuation group than in the maintenance therapy discontinuation group (P = 0.035). Predictors of relapse after 3 years included cessation of maintenance therapy (hazard ratio [HR] = 3.76; 95 % confidence interval [CI] = 1.07-13.3, P = 0.040) and renal involvement (HR = 2.88; 95 % CI = 1.04-7.99, P = 0.042). The maintenance therapy continuation group showed a significantly higher prevalence of macrovascular complications, compared with the maintenance therapy discontinuation group (P = 0.005). CONCLUSIONS Cessation of steroid maintenance therapy and renal involvement were predictors of relapse after 3 years of maintenance therapy. However, the long-term use of steroids may increase the risk of macrovascular complications.
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Affiliation(s)
- Masahiro Tsujimae
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan.
| | - Megumi Takagi
- Department of Gastroenterology and Hepatology, Osaka Saiseikai Nakatsu Hospital, Osaka, Japan
| | - Takao Kato
- Department of Gastroenterology, Hyogo Prefectural Awaji Medical Center, Sumoto, Japan
| | - Ryota Nakano
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Japan
| | - Koichi Fujita
- Department of Gastroenterology and Hepatology, Yodogawa Christian Hospital, Osaka, Japan
| | - Yuichi Hirata
- Department of Gastroenterology, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Saori Kakuyama
- Department of Gastroenterology, Takatsuki General Hospital, Takatsuki, Japan
| | - Keisuke Furumatsu
- Department of Gastroenterology, Akashi Medical Center, Akashi, Japan
| | - Takashi Nakagawa
- Department of Gastroenterology, Chibune General Hospital, Osaka, Japan
| | - Kyohei Ogisu
- Department of Gastroenterology, Nissei Hospital, Osaka, Japan
| | - Seiji Fujigaki
- Department of Gastroenterology, Hyogo Prefectural Harima Himeji Medical Center, Himeji, Japan
| | - Takao Iemoto
- Department of Gastroenterology, Kita-harima Medical Center, Ono, Japan
| | - Takeshi Ezaki
- Department of Gastroenterology, National Hospital Organization Kobe Medical Center, Kobe, Japan
| | - Yosuke Yagi
- Department of Internal Medicine, Shiso Municipal Hospital, Shiso, Japan
| | - Takuya Ikegawa
- Department of Gastroenterology, Japanese Red Cross Kobe Hospital, Kobe, Japan
| | - Kodai Yamanaka
- Department of Gastroenterology, Konan Medical Center, Kobe, Japan
| | - Yu Sato
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Japan
| | - Noriko Juri
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology and Hepatobiliary and Pancreatic Diseases, Department of Internal Medicine, Hyogo Medical University, Japan
| | - Tsuyoshi Sanuki
- Department of Gastroenterology, Hyogo Prefectural Harima Himeji Medical Center, Himeji, Japan
| | | | - Yoshihiro Okabe
- Department of Gastroenterology, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
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9
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Gilani SI, Buglioni A, Cornell LD. IgG4-related kidney disease: Clinicopathologic features, differential diagnosis, and mimics. Semin Diagn Pathol 2024; 41:88-94. [PMID: 38246802 DOI: 10.1053/j.semdp.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Abstract
IgG4-related kidney disease (IgG4-RKD) encompasses all forms of kidney disease that are part of IgG4-related disease (IgG4-RD). First recognized as IgG4-related tubulointerstitial nephritis (IgG4-TIN), and then IgG4-related membranous glomerulonephritis (IgG4-MGN), we now recognize additional patterns of interstitial nephritis, glomerular disease, and vascular disease that can be seen as part of IgG4-RKD. The clinical presentation is variable and can include acute or chronic kidney injury, proteinuria or nephrotic syndrome, mass lesion(s), and obstruction. While usually associated with other organ involvement by IgG4-RD, kidney-alone involvement is present in approximately 20 % of IgG4-RKD. Compared to IgG4-RD overall, patients with IgG4-RKD are more likely to show increased serum IgG4 or IgG, and more likely to have hypocomplementemia. In this review, we extensively cover other types of autoimmune and plasma cell-rich interstitial nephritis, mass forming inflammatory diseases of the kidney, and other mimics of IgG4-TIN, in particular ANCA-associated disease.
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Affiliation(s)
- Sarwat I Gilani
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, TX, USA
| | - Alessia Buglioni
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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Mizushima I, Saeki T, Kobayashi D, Sawa N, Hayashi H, Taniguchi Y, Nakata H, Yamada K, Matsui S, Yasuno T, Masutani K, Nagasawa T, Takahashi H, Ubara Y, Yanagita M, Kawano M. Improved Renal Function in Initial Treatment Improves Patient Survival, Renal Outcomes, and Glucocorticoid-Related Complications in IgG4-Related Kidney Disease in Japan. Kidney Int Rep 2024; 9:52-63. [PMID: 38312790 PMCID: PMC10831353 DOI: 10.1016/j.ekir.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction We aimed to clarify long-term renal prognosis, complications of malignancy, glucocorticoid (GC) toxicity, and mortality in immunoglobulin G4 (IgG4)-related kidney disease (IgG4-RKD). Methods Reviewing the medical records of 95 patients with IgG4-RKD, we investigated clinical and pathologic features at baseline, the course of renal function, complications of malignancy, GC toxicity, and mortality during follow-up (median 71 months). The standardized incidence ratio (SIR) of malignancy and standardized mortality ratio were calculated using national statistics. Factors related to outcomes were assessed by Cox regression analyses. Results At diagnosis, the median estimated glomerular infiltration rate (eGFR) was 46 ml/min per 1.73 m2. GC achieved initial improvement. Additional renal function recovery within 3-months of initial treatment occurred in patients with highly elevated serum IgG and IgG4 levels and hypocomplementemia. During follow-up, 68%, 17%, and 3% of the patients had chronic kidney disease (CKD), >30% eGFR decline, and end-stage renal disease (ESRD), respectively. Age-adjusted and sex-adjusted Cox regression analyses indicated that eGFR (hazard ratio [HR], 0.71) and extensive fibrosis (HR, 2.58) at treatment initiation had a significant impact on the time to CKD. Ten patients died, and the standardized mortality ratio was 0.94. The SIR of malignancy was 1.52. The incidence rate (IR) of severe infection was 1.80/100 person-years. Cox regression analyses showed that the best eGFR within 3 months after treatment initiation were associated with lower mortality (HR 0.67) and fewer severe infections (HR 0.63). Conclusion This study suggests that more renal function recovery through early treatment initiation may improve patient survival, renal outcomes, and some GC-related complications in IgG4-RKD.
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Affiliation(s)
- Ichiro Mizushima
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Naoki Sawa
- Department of Nephrology Center, Toranomon Hospital, Kawasaki, Japan
| | - Hiroki Hayashi
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoshinori Taniguchi
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi University, Nankoku-shi, Japan
| | - Hirosuke Nakata
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto City, Japan
| | - Kazunori Yamada
- Department of Hematology and Immunology, Kanazawa Medical University, Kahoku-gun, Japan
| | - Shoko Matsui
- Health Administration Center, University of Toyama, Toyama City, Japan
| | - Tetsuhiko Yasuno
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Jonan-Ku, Japan
| | - Kosuke Masutani
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Jonan-Ku, Japan
| | - Tasuku Nagasawa
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hiroki Takahashi
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yoshifumi Ubara
- Department of Nephrology Center, Toranomon Hospital, Kawasaki, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto City, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
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11
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Hara S, Yoshida M, Sanada H, Suzuki Y, Sato Y, Mizushima I, Kawano M. Pediatric IgG4-related disease: a descriptive review. Expert Rev Clin Immunol 2024; 20:97-119. [PMID: 37874048 DOI: 10.1080/1744666x.2023.2274358] [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: 06/16/2023] [Accepted: 10/19/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION IgG4-related disease (IgG4-RD) is an immune-mediated systemic fibroinflammatory condition characterized by serum IgG4 elevation and IgG4-positive plasma cell infiltration into various organs. It generally occurs in elderly males. Pediatric cases have been reported, albeit rarely, accordingly lack of recognition of such cases could delay therapeutic intervention leading to poorer outcomes. AREAS COVERED The present review is a descriptive review of all published case reports, cohort studies, and reviews of pediatric IgG4-RD listed in PubMed. Characteristics of pediatric IgG4-RD were clarified, including sex, organ involvement, serological and histological findings, and treatment. We assessed how many published cases met current classification and comprehensive diagnostic criteria. EXPERT OPINION The characteristics of pediatricIgG4-RD differed from adult IgG4-RD in terms of sex and involved organs. There was no clear male dominance in numbers of cases, and surface organ involvement such as ophthalmic diseases were more common in the pediatric IgG4-RD. Organ involvement tended to be indolent and unilateral, causing difficulty in definitively diagnosing pediatric IgG4-RD. Only about 20% of published cases met IgG4-RD classification or comprehensive diagnostic criteria. Physicians should be careful in diagnosing pediatric IgG4-RD after excluding mimickers. International collaboration toward high-quality evidence to support diagnosis and treatment of pediatric IgG4-RD is advised.
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Affiliation(s)
- Satoshi Hara
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Misaki Yoshida
- Department of Nephrology and Urology, Fukui Red Cross Hospital, Fukui, Fukui, Japan
| | - Hajime Sanada
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Yasunori Suzuki
- Department of Nephrology and Urology, Fukui Red Cross Hospital, Fukui, Fukui, Japan
| | - Yasuharu Sato
- Department of Molecular Hematopathology, Okayama University Graduate School of Health Sciences, Kita-ku, Okayama, Okayama, Japan
| | - Ichiro Mizushima
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
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Furuto Y, Hashimoto H, Namikawa A, Morikawa T, Shibuya Y. Remission Induction of IgG4-related Membranous Nephropathy with Multitarget Therapy. Intern Med 2023; 62:3175-3181. [PMID: 36927975 PMCID: PMC10686725 DOI: 10.2169/internalmedicine.1023-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 02/06/2023] [Indexed: 03/15/2023] Open
Abstract
IgG4-related membranous nephropathy (MN) is often refractory to glucocorticoid (GC) therapy, and treatment remains unclear. We herein report a 67-year-old Japanese man with IgG4-related MN and tubulointerstitial nephritis. A post-gastroscopy antibody test revealed Helicobacter pylori infection. After eradication, his proteinuria decreased indefinitely. We started prednisolone (30 mg/day), long-term GCs, and immunosuppressant therapy. However, remission proved challenging to achieve, with persistent proteinuria present at 1.0-2.0 g/gCr. We performed multitarget therapy for refractory IgG4-related MN, achieving proteinuria remission (<0.3 g/gCr). Multitarget therapy with low-dose GCs can resolve refractory IgG4-related MN through remission induction of proteinuria and minimize the risks associated with GC therapy.
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Affiliation(s)
- Yoshitaka Furuto
- Department of Hypertension and Nephrology, NTT Medical Center Tokyo, Japan
| | | | - Akio Namikawa
- Department of Hypertension and Nephrology, NTT Medical Center Tokyo, Japan
| | - Teppei Morikawa
- Department of Diagnostic Pathology, NTT Medical Center Tokyo, Japan
| | - Yuko Shibuya
- Department of Hypertension and Nephrology, NTT Medical Center Tokyo, Japan
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Kawano M, Saeki T, Ubara Y, Matsui S. Recent advances in IgG4-related kidney disease. Mod Rheumatol 2023; 33:242-251. [PMID: 35788361 DOI: 10.1093/mr/roac065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/01/2022] [Accepted: 06/21/2022] [Indexed: 11/14/2022]
Abstract
Recent advances in the management and understanding of immunoglobulin (Ig)G4-related kidney disease (RKD) have emphasized the importance of urgent treatment in IgG4-related tubulointerstitial nephritis. On the other hand, to avoid long-term glucocorticoid toxicity, strategies for early withdrawal of steroids or combination of immunosuppressants, such as rituximab, and the minimum dose of steroids have been pursued. However, disease recurrence after reducing or stopping steroid therapy hampers early withdrawal of glucocorticoid maintenance therapy. In addition, knowledge has accumulated in diagnostic approaches including differential diagnosis of anti-neutrophil cytoplasmic antibodies-associated vasculitis, idiopathic multicentric Castleman's disease, and Rosai-Dorfman disease with kidney lesion, which leads to earlier and precise diagnosis of IgG4-RKD. This review summarizes recent progress in the differential diagnosis of IgG4-RKD and related treatment strategies and recent topics of hypocomplementaemia, membranous glomerulonephritis, and IgG4-related pyelitis and periureteral lesion.
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Affiliation(s)
- Mitsuhiro Kawano
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Yoshifumi Ubara
- Department of Nephrology and Rheumatology, Toranomon Hospital, Kawasaki, Japan
| | - Shoko Matsui
- Health Administration Center, University of Toyama, Toyama, Japan
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Yueh HZ, Wei JCC, Zhang L. Comment on "The risk of malignancy in patients with IgG4-related disease: a systematic review and meta-analysis" by Yu et al. Arthritis Res Ther 2022; 24:122. [PMID: 35610724 PMCID: PMC9128108 DOI: 10.1186/s13075-022-02789-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
With great interest, we have read the recent article “The risk of malignancy in patients with IgG4-related disease: a systematic review and meta-analysis” by Yu et al. While we have a great appreciation for the work conducted by the authors there are some methodological issues need to be considered. First, the period of articles included in the study, almost before 2013, implied that most follow-up days in these articles were earlier than the established date of a unified definition of IgG4-RD, 2011. Thus, it may lead to misclassification bias in the study. Second, IgG4-RD is a fibrous-inflammatory process that often involves multiple organs; however, malignant tumors related to IgG4-RD proposed in the study were only confined to four diseases. Therefore, we suggest adding subgroup analysis for more malignancies depending on the prevalence of IgG4-RD involved organs to ensure better clinical practice. Third, the causation between IgG4-RD and malignancy remains obscure currently. The time course for development in different malignancies varies significantly so that we cannot infer that malignancies discovered after IgG4-RD are directly relevant. With problems mentioned above, we recommend solutions to make this article more convincing.
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Affiliation(s)
- Hann-Ziong Yueh
- Department of Education, Chung Shan Medical University Hospital, Taichung, Taiwan
| | - James Cheng-Chung Wei
- Department of Allergy, Immunology & Rheumatology, Chung Shan Medical University Hospital, Taichung, Taiwan.,Institute of Medicine, Chung Shan Medical University, Taichung, Taiwan.,Graduate Institute of Integrated Medicine, China Medical University, Taichung, Taiwan
| | - Liyun Zhang
- Department of Rheumatology, Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, Shanxi, China.
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15
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American College of Rheumatology and the European League Against Rheumatism classification criteria for IgG4-related disease: an update for radiologists. Jpn J Radiol 2022; 40:876-893. [PMID: 35474439 DOI: 10.1007/s11604-022-01282-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/09/2022] [Indexed: 10/18/2022]
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated, multiorgan, chronic inflammatory disease. The three-step classification criteria proposed in 2019 by the American College of Rheumatology and the European League Against Rheumatism (ACR/EULAR) encompass a wide range of clinical, radiological, serological, and histopathological findings. The ACR/EULAR proposed a three-step classification process, i.e., entry step, exclusion step, and scoring system. Radiologists need to know that the radiological findings observed in the five domains of the lacrimal and salivary glands, chest, pancreas and biliary ducts, kidney, and retroperitoneum are independently weighted with different points in the scoring system. A total score < 20 points indicates that the patient should not be classified as having IgG4-RD; conversely, a total score ≥ 20 points indicates that the patient should be classified as having IgG4-RD. In this review, the 2019 ACR/EULAR classification criteria are discussed, focusing on the interpretation of each radiological item, with the aim of applying them to the diagnosis of IgG4-RD in clinical practice.
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Kurahashi S, Toda N, Fujita M, Tanigaki K, Takeoka J, Hirashima H, Muso E, Io K, Sakurai T, Komiya T. Acute Tubulointerstitial Nephritis in Rosai-Dorfman Disease Mimicking IgG4-related Disease. Intern Med 2022; 61:1027-1032. [PMID: 34544952 PMCID: PMC9038462 DOI: 10.2169/internalmedicine.8046-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Rosai-Dorfman-Destombes disease (RDD) is a non-Langerhans cell histiocytosis characterized by the accumulation of histiocytes inside the lymph nodes or extranodally. The association between RDD and IgG4-related disease (IgG4-RD) is discussed. We herein report a case of RDD manifesting as acute tubulointerstitial nephritis mimicking IgG4-RD. The first renal biopsy showed severe tubulointerstitial nephritis with infiltration of S100-positive histiocytes and IgG4-positive plasma cells; storiform fibrosis and obliterative phlebitis were not confirmed. After prednisolone therapy, IgG4-positive cells and S100-positive histiocytes were decreased, but the IgG4/IgG ratio increased despite clinical improvement. These findings indicated extranodal RDD in the kidney presenting as tubulointerstitial nephritis.
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Affiliation(s)
| | - Naohiro Toda
- Department of Nephrology, Kansai Electric Power Hospital, Japan
| | - Masaaki Fujita
- Department of Rheumatology, Kansai Electric Power Hospital, Japan
| | | | - Jun Takeoka
- Department of Nephrology, Kansai Electric Power Hospital, Japan
| | | | - Eri Muso
- Department of Nephrology, Kansai Electric Power Hospital, Japan
| | - Katsuhiro Io
- Department of Hematology, Kansai Electric Power Hospital, Japan
| | - Takaki Sakurai
- Department of Diagnostic Pathology, Kansai Electric Power Hospital, Japan
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A rare cause of chronic tubulointerstitial nephritis in childhood: Answers. Pediatr Nephrol 2022; 37:571-575. [PMID: 34734329 DOI: 10.1007/s00467-021-05326-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 10/19/2022]
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Su T, Wang H, Wang S, Yang L. Clinicopathological Patterns and Predictors of the Functional Restoration of Immunoglobulin G4-Related Kidney Disease: A Chinese Single-Center Cohort Study. Front Med (Lausanne) 2021; 8:736098. [PMID: 34692728 PMCID: PMC8526789 DOI: 10.3389/fmed.2021.736098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 09/06/2021] [Indexed: 12/15/2022] Open
Abstract
Background: Immunoglobulin G4-related disease (IgG4-RD) is a systemic immunoreactivity-based fibro-inflammatory disease. Immunoglobulin G4-related kidney disease (IgG4-RKD) is a frequently overlooked diagnosis. This study aimed to describe IgG4-RKD and examine the factors relevant to the renal outcomes of IgG4-RD. Methods: We studied a prospective IgG4-RKD cohort between January 2012 and December 2020 with close follow-up. Clinicopathologic data at kidney biopsy were collected and analyzed. We aimed to explore independent risk factors for long-term renal outcome and disease relapse. Patients with an eGFR<45 ml/min per 1.73m2 at 12 months were defined as having poor outcomes. Results: The included 42 patients with IgG4-RKD had a mean age of 58.5 ± 8.7 years (male-to-female ratio = 5:1). The IgG4-RD responder index (RI) was 12.2 ± 3.3. A total of 66.7% of the patients presented with acute on kidney disease or acute on chronic kidney disease. Eight patients (19.0%) showed nephrotic-range proteinuria, and nine (21.4%) had high-titer IgG4-autoantibodies, including antineutrophil cytoplasmic antibody and anti-phospholipase A2 receptor. A kidney biopsy was conducted in 40 patients. Thirty-seven (90.0%) patients were diagnosed with IgG4-related tubulointerstitial nephritis, and 19 (47.5%) of them had concurrent glomerular diseases (membranous nephropathy [MN], n = 3; crescentic glomerulonephritis [CrGN], n = 11; diabetic kidney disease, n = 3; and both MN and CrGN, n = 2). IgG4-RD RI had a close relationship with serum C3 (R = −0.509, P = 0.001), C4 (R = −0.314, P = 0.049) levels, and peripheral blood eosinophil count (PBEC; R = 0.377, P = 0.024), factors that were not included in RI scores. Correlation analysis disclosed that IgG4-RD RI (R = 0.422, P = 0.007), organs involved (R = 0.452, P = 0.003), and C3 (R = −0.487, R = 0.002) were correlated with the percentage decrease of serum creatinine at 1 month. However, multivariate regression analysis failed to identify any clinicopathological parameters that could predict short-term renal restoration and IgG4-RKD relapse. Ten out of 29 variables, of most importance, were identified by the least absolute shrinkage and selection operator (LASSO) regression analysis. By multivariate logistic regression a higher serum IgG4 (OR = 0.671, P = 0.010), IgG1 (OR = 1.396, P = 0.049), IgG3 (OR = 19.154, P = 0.039), and erythrocyte sedimentation rate (ESR; OR = 1.042, P = 0.032) were found to be independent factors for poor long-term outcome. Conventional immunosuppressive medications and/or rituximab were prescribed, and in 83.3% of the patients, the kidney function improved. Repeat kidney biopsies confirmed the remission of interstitial inflammation in two patients under immunosuppressive therapy. However, the disease relapse rate was as high as 31.0%. Conclusions: We strongly recommend a kidney biopsy in active IgG4-RD, especially when there is proteinuria and renal dysfunction, because concurrent glomerular involvement and active interstitial inflammation should be assessed. A higher serum IgG1, IgG3, and ESR were independent factors for the poor long-term renal outcome; however, elevated IgG4 predicted a good renal prognosis, and appropriate and timely immunosuppressive therapy can help achieve a better prognosis.
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Affiliation(s)
- Tao Su
- Department of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
| | - Hui Wang
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China.,Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
| | - Suxia Wang
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China.,Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
| | - Li Yang
- Department of Nephrology, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
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