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Nguyen T, Brodsky S, Maroz N. Progression to End-Stage Renal Disease Due to IgG4-Related Nephritis Refractory to Rituximab. Cureus 2023; 15:e36327. [PMID: 37077588 PMCID: PMC10108657 DOI: 10.7759/cureus.36327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2023] [Indexed: 03/20/2023] Open
Abstract
An 81-year-old woman was referred to nephrology for a follow-up on progressive chronic kidney disease. She has a past medical history of hypertension, T2DM, breast cancer, and secondary hyperparathyroidism related to renal disease. A renal biopsy showed patchy interstitial fibrosis and tubular atrophy with an increased number of IgG4-positive plasma cells. A diagnosis of IgG4-related kidney disease was made based on clinical presentation and pathology. The patient ultimately required the initiation of hemodialysis, despite the administration of steroids and rituximab.
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Oh JW, Rha SE, Choi MH, Oh SN, Youn SY, Choi JI. Immunoglobulin G4-related Disease of the Genitourinary System: Spectrum of Imaging Findings and Clinical-Pathologic Features. Radiographics 2020; 40:1265-1283. [PMID: 32870766 DOI: 10.1148/rg.2020200043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disease characterized by focal or diffuse organ infiltration of IgG4-bearing plasma cells. The diagnosis of IgG4-RD is based on a combination of clinical, serologic, radiologic, and histopathologic findings. IgG4-RD has been reported to affect almost all organ systems. The kidney is the most frequently involved of the genitourinary organs. The most common renal manifestation of IgG4-RD is IgG4-RD tubulointerstitial nephritis, followed by membranous glomerulonephropathy and, less frequently, obstructive nephropathy involving the renal pelvis, ureter, or retroperitoneum. Renal parenchymal lesions may appear as multiple nodular lesions, diffuse patchy infiltrative lesions, or a single nodular lesion. Multiple small nodular cortical lesions are the most common imaging findings of IgG4-RD involving the kidney. Renal pelvic, sinus, or perinephric lesions can also occur. IgG4-RD involvement of other genitourinary organs including the ureter, bladder, urethra, and male and female reproductive organs is rare compared with kidney involvement but may show variable imaging findings such as a localized mass within or surrounding the involved organ or diffuse enlargement of the involved organ. Imaging findings of IgG4-RD involving the genitourinary system are nonspecific but should be differentiated from inflammatory and neoplastic lesions that mimic IgG4-RD. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2020.
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Affiliation(s)
- Ji Woon Oh
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Sung Eun Rha
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Moon Hyung Choi
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Soon Nam Oh
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Seo Yeon Youn
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Joon-Il Choi
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
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Nishizawa Y, Honda K, Aoyama Y, Hosoda Y, Tamura T, Horimoto A, Omae K, Higuchi C, Sakura H, Nitta K, Ogawa T. Low-density lipoprotein apheresis for PLA2R-related membranous glomerulonephritis accompanied by IgG4-related tubulointerstitial nephritis. CEN Case Rep 2020; 9:395-403. [PMID: 32557252 DOI: 10.1007/s13730-020-00494-6] [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: 03/12/2020] [Accepted: 06/06/2020] [Indexed: 12/16/2022] Open
Abstract
IgG4-related disease preferentially involves the kidney by tubulointerstitial nephritis with IgG4-positive plasma cell filtration and/or membranous glomerulonephritis. We reported the case of a 68-year-old man with IgG4-related tubulointerstitial nephritis combined with antiphospholipase A2 receptor (PLA2R)-related membranous glomerulonephritis, in which distinguishing between idiopathic PLA2R-related and IgG4-related secondary membranous glomerulonephritis was difficult. We diagnosed him as having IgG4-related disease, based on a serum IgG4 level of 170 mg/dL and the presence of IgG4-related parotiditis. On renal biopsy, there was tubulointerstitial nephritis with IgG4-positive plasma cell filtration, which was compatible with IgG4-related disease and membranous glomerulonephritis, with concomitant positive staining for PLA2R on immunofluorescence microscopy. The renal function immediately recovered after steroid treatment, probably because of the improvement in the tubulointerstitial lesions, but his nephrotic syndrome was steroid-resistant. Low-density lipoprotein (LDL) apheresis therapy was effective for membranous glomerulonephritis and increased his serum albumin from 1.4 to 2.8 g/dL. Although IgG4-related kidney disease usually accompanies secondary membranous glomerulonephritis, the positive PLA2R staining suggested a concomitant primary membranous glomerulonephritis. The recent treatment strategy, including LDL apheresis, for primary and secondary membranous glomerulonephritis was discussed briefly in this report.
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Affiliation(s)
- Yoko Nishizawa
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan.
| | - Kazuho Honda
- Department of Anatomy, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa, Tokyo, 142-8555, Japan
| | - Yumi Aoyama
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Yumi Hosoda
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Tomomi Tamura
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Ai Horimoto
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Kiyotsugu Omae
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Chieko Higuchi
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Hiroshi Sakura
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, 8-1, Kawadacho, Shinjyuku, Tokyo, 162-8666, Japan
| | - Tetsuya Ogawa
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
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Ling J, Wang H, Pan W, Li S, Guan J, Zhang X, Guo Y. Clinical and imaging features of IgG4-related kidney disease. Abdom Radiol (NY) 2020; 45:1915-1921. [PMID: 32179977 DOI: 10.1007/s00261-020-02477-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE To assess the clinical and imaging features of IgG4-RKD for understanding and diagnosis of this disease. METHODS CT and MR images of 34 patients with IgG4-RKD were retrospectively analyzed by two radiologists in consensus. RESULTS The serum IgG4 level was found being increased in all patients. Renal involvement was bilateral (24/34, 70.6%) or unilateral (10/34,29.4%), multiple (29/34, 85.3%) or solitary (5/34, 14.7%). The lesions were wedge-shaped (21) or mass-like (4) in the renal parenchyma, whereas diffusely decreased renal density was noted in 2 patients. All lesions showed progressive contrast enhancement. The 4 mass-like lesions were misdiagnosed as renal malignancy. In 15 patients with follow-up imaging examinations, the number and size of renal lesions decreased after oral hormone treatment. The serum IgG4 levels were significantly decreased after therapy in all patients. CONCLUSION IgG4-RKD has various imaging appearances. Although the mass-like appearance mimics renal malignancy in some patients, progressive contrast enhancement in the lesion with elevated serum IgG4 suggests IgG4-RKD.
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Affiliation(s)
- Jian Ling
- Department of Radiology, The Eastern Hospital of the First Affiliated Hospital, Sun Yat-Sen University, No.183 Huangpu Eastern Road, Guangzhou, 510700, Guangdong, People's Republic of China
| | - Huanjun Wang
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Weibin Pan
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Shurong Li
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Jian Guan
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Xiaoling Zhang
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China
| | - Yan Guo
- Department of Radiology, The First Affiliated Hospital of Sun Yat-Sen University, No.58 Zhongshan Road 2, Guangzhou, 510080, Guangdong, People's Republic of China.
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Hasegawa K, Hanayama Y, Obika M, Miyoshi T, Ogawa H, Kondo E, Kataoka H, Sato Y, Otsuka F. Clinical and biochemical characteristics of patients having general symptoms with increased serum IgG4. Mod Rheumatol 2019; 30:721-728. [PMID: 31369303 DOI: 10.1080/14397595.2019.1642291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To differentiate patients with IgG4-related diseases (RD) from patients with other hyper IgG4 conditions who visit general medicine department.Methods: Fifty-six patients with high serum IgG4 levels (>135 mg/dL) were classified into three groups based on the final diagnosis: definite and possible IgG4-RD and others. Clinical and laboratory characteristics of the three groups of patients were retrospectively analyzed.Results: Major manifestations were renal dysfunction and general malaise, while thirst was the most frequent symptom in the definite group, in which submandibular glands and lymph nodes were likely to be affected. Biopsy of minor salivary glands was the least diagnostic for IgG4-RD despite the high frequency of biopsy. In the definite group, serum levels of IgG4 and IgG, IgG4/IgG ratio and basophil number were increased, while serum levels of CRP, IgA and complements were decreased. A negative correlation between serum levels of IgG4 and IgM was found in the definite group.Conclusion: The results indicated that in patients with renal dysfunction, malaise, thirst or weight loss, measurements of the levels of basophils, immunoglobulins and complements are helpful for diagnosing IgG4-RD. Considering distribution of affected tissues and localization of diagnostic biopsies, physical examination and laboratory workup are required for early diagnosis.
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Affiliation(s)
- Kou Hasegawa
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yoshihisa Hanayama
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Mikako Obika
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Tomoko Miyoshi
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroko Ogawa
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Eisei Kondo
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hitomi Kataoka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Fumio Otsuka
- Department of General Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
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Zhang NN, Wang YY, Kong LX, Zou WZ, Dong B. IgG4-related kidney disease (IgG4-RKD) with membranous nephropathy as its initial manifestation: report of one case and literature review. BMC Nephrol 2019; 20:263. [PMID: 31311519 PMCID: PMC6635993 DOI: 10.1186/s12882-019-1419-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 06/11/2019] [Indexed: 12/14/2022] Open
Abstract
Background IgG4-related disease (IgG4-RD) often affects multiple organs and tissues, especially the kidneys, and is characterized by interstitial nephritis, obstructive nephropathy, and in rare cases glomerulopathy (including membranous nephropathy). Case presentation In this article, we report a patient with nephrotic syndrome as the only initial manifestation. Membranous nephropathy was confirmed by renal biopsy, but without any renal interstitial lesions. The nephrotic syndrome completely resolved after treatment with immunosuppressants but recurred after drug withdrawal, which was accompanied by acute kidney injury. Ultimately, IgG4-related interstitial nephritis with membranous nephropathy was confirmed by a second renal biopsy. After routine administration of steroids and cyclophosphamide, renal function returned to normal after 2 months, and nephrotic syndrome was ameliorated after 5 months. Conclusion Special attention should be paid to this rare condition in the clinical setting. In patients with membranous nephropathy (MN) that is accompanied by multi-system damage, impaired renal function, elevated IgG4 levels (absolute or relative value), negative PLA2R, and/or renal interstitial plasma cell infiltration, the possibility of IgG4-related kidney disease (IgG4-RKD) should be carefully assessed.
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Affiliation(s)
- Nan-Nan Zhang
- Department of Nephrology, Fangshan Hospital of Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Yan-Yun Wang
- Department of Nephrology, Fangshan Hospital of Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Ling-Xin Kong
- Department of Nephrology, Fangshan Hospital of Beijing University of Chinese Medicine, Beijing, 102400, China.
| | - Wan-Zhong Zou
- Department of Nephrology, People's Hospital of Peking University, Beijing, 110102, China
| | - Bao Dong
- Department of Nephrology, People's Hospital of Peking University, Beijing, 110102, China
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Vivier D, Sharma SK, Zeglis BM. Understanding the in vivo fate of radioimmunoconjugates for nuclear imaging. J Labelled Comp Radiopharm 2018; 61:672-692. [PMID: 29665104 PMCID: PMC6432633 DOI: 10.1002/jlcr.3628] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 03/16/2018] [Accepted: 04/03/2018] [Indexed: 12/17/2022]
Abstract
Over the past 25 years, antibodies have emerged as extraordinarily promising vectors for the delivery of radionuclides to tumors for nuclear imaging. While radioimmunoconjugates often produce very high activity concentrations in target tissues, they also are frequently characterized by elevated activity concentrations in healthy organs as well. The root of this background uptake lies in the complex network of biological interactions between the radioimmunoconjugate and the subject. In this review, we seek to provide an overview of these interactions and thus paint a general picture of the in vivo fate of radioimmunoconjugates. To cover the entire story, we have divided our discussion into 2 parts. First, we will address the path of the entire radioimmunoconjugate as it travels through the body. And second, we will cover the fate of the radionuclide itself, as its course can diverge from the antibody under certain circumstances. Ultimately, our goal is to provide the nuclear imaging field with a resource covering these important-yet often underestimated-pathways.
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Affiliation(s)
- Delphine Vivier
- Department of Chemistry, Hunter College and the Graduate Center of the City University of New York, New York, NY, USA
| | - Sai Kiran Sharma
- Department of Radiology and the Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Brian M. Zeglis
- Department of Chemistry, Hunter College and the Graduate Center of the City University of New York, New York, NY, USA
- Department of Radiology and the Molecular Pharmacology Program, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Radiology, Weill Cornell Medical College, New York, NY, USA
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