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Shi X, Guo T, Wen Y, Ye W, Ye W, Zheng K, Qin Y, Li X, Zhang F, Chen L. Rare renal proximal tubular dysfunctions in primary biliary cholangitis. Ren Fail 2024; 46:2302409. [PMID: 38275162 PMCID: PMC10823888 DOI: 10.1080/0886022x.2024.2302409] [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: 08/04/2023] [Accepted: 01/02/2024] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Renal involvement of primary biliary cholangitis (PBC) usually presents as distal renal tubular acidosis. Proximal tubular (PT) dysfunctions in PBC were rarely reported with unclear clinicopathological characteristics and renal prognosis. METHODS We identified 11 cases of PBC with PT dysfunctions (PBC-PT). Their medical document, kidney pathology, and follow-up data were retrospectively reviewed and analyzed. RESULTS The 11 PBC-PT patients were mainly middle-aged (57.8 ± 5.2 years) females (81.8%). Most of them were asymptomatic PBC (7, 63.6%) with a high prevalence of elevated serum immunoglobulin M (IgM, 81.8%) and G (IgG, 54.5%) levels. In the kidney, they had a mean estimated glomerular filtration rate (eGFR) level of 46.54 ± 23.03 ml/min/1.73m2, and 81.8% of them had eGFR below 60 ml/min/1.73m2. They showed different degrees of PT dysfunctions, including hyperuricosuria, hypouricemia, normoglycemic glycosuria, generalized aminoaciduria, hyperphosphaturia, and hypophosphatemia. Their kidney pathology showed tubulointerstitial nephritis with lymphoplasmacytic infiltrates, brush border defects, and proximal tubulitis. After glucocorticoids treatment, the PT dysfunctions manifesting as hypophosphatemia, hypouricemia, and renal glycosuria all recovered, and the eGFR levels were improved from 43.24 ± 19.60 ml/min/1.73m2 to 55.02 ± 21.14 ml/min/1.73m2 (p = 0.028), accompanied by significant improvements of serum IgM levels (from 5.97 ± 4.55 g/L to 2.09 ± 1.48 g/L, p = 0.019). CONCLUSIONS The PT dysfunctions were rare in PBC patients, and glucocorticoids treatment could benefit the improvements of eGFR and tubular functions.
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Affiliation(s)
- Xiaoxiao Shi
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Tianchen Guo
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yubing Wen
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Wei Ye
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Wenling Ye
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Ke Zheng
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Yan Qin
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Xuemei Li
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Fengchun Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Limeng Chen
- Department of Nephrology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
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Akagi R, Ishii A, Kaneko K, Kondo N, Yokoi H, Matsubara T, Minamiguchi S, Kanno Y, Yanagita M. A report of three cases of patients with tubulointerstitial nephritis with IgM-positive plasma cells, treatment, and serum-IgM as a sensitive marker for relapse. BMC Nephrol 2023; 24:201. [PMID: 37403069 PMCID: PMC10318630 DOI: 10.1186/s12882-023-03253-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 06/22/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Tubulointerstitial nephritis with IgM-positive plasma cells (IgMPC-TIN) is a newer disease about which there are many unclear points. Glucocorticoid therapy is effective in many cases of IgMPC-TIN; however, relapse during glucocorticoid tapering has been reported. Relapse and its treatment are poorly defined. CASE PRESENTATION Case 1 was a 61-year-old man with renal dysfunction and proteinuria. Tubulointerstitial nephritis and IgM-positive plasma cells were observed in a renal biopsy. He was diagnosed with IgMPC-TIN accompanied by Fanconi syndrome and distal renal tubular acidosis (d-RTA). Prednisolone (PSL; 30 mg daily, 0.45 mg/kg/day) treatment was highly effective, and PSL was gradually tapered and discontinued after 1 year. However, 1 month after PSL discontinuation, therapeutic markers were elevated. Therefore, PSL (10 mg daily, 0.15 mg/kg/day) was administered, and the markers indicated improvement. Case 2 was a 43-year-old woman referred for renal dysfunction and proteinuria. Laboratory data revealed that she had primary biliary cholangitis (PBC), d-RTA, and Fanconi syndrome. A renal biopsy showed accumulation of IgM-positive plasma cells in the tubulointerstitium without any glomerular changes. A diagnosis of IgMPC-TIN was made and the patient was started on PSL (35 mg daily, 0.6 mg/kg/day). Therapeutic markers decreased immediately and PSL was discontinued after 1 year. Three months later, the proteinuria and Fanconi syndrome worsened. PSL treatment was restarted (20 mg daily, 0.35 mg/kg/day) and markers indicated improvement. Case 3 was a 45-year-old woman with renal dysfunction and proteinuria. Tubulointerstitial nephritis and IgM-positive plasma cells were observed in a renal biopsy. The patient had PBC, Sjögren syndrome, d-RTA, and Fanconi syndrome, and the diagnosis of IgMPC-TIN was made. The patient was started on PSL (30 mg daily, 0.4 mg/kg/day) and disease markers decreased immediately. However, when PSL was tapered to 15 mg daily (0.2 mg/kg/day), the patient's serum IgM levels increased; therefore, we maintained the PSL at 15 mg daily (0.2 mg/kg/day). CONCLUSION We report three cases of relapsed IgMPC-TIN associated with reduction or discontinuation of glucocorticoid therapy. In these cases, elevation of serum IgM preceded that of other markers such as urinary β2-microglobulin, proteinuria, and glycosuria. We recommend monitoring serum IgM levels while tapering glucocorticoids; a maintenance dose of glucocorticoid should be considered if relapse is suspected or anticipated.
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Affiliation(s)
- Ryota Akagi
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Akira Ishii
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Keiichi Kaneko
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Naoya Kondo
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
- Department of Nephrology, Kyoto Katsura Hospital, 17 Yamadahirao-Cho, Nishikyo-Ku, Kyoto, 615-8257 Japan
| | - Hideki Yokoi
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Takeshi Matsubara
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
| | - Yoshihiko Kanno
- Department of Nephrology, Tokyo Medical University, 6-7-1 Nishi-Shinjuku, Shinjuku-Ku, Tokyo, 160-0023 Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507 Japan
- Institute for the Advanced Study of Human Biology (ASHBi), Kyoto University, Yoshida Konoe-Cho, Sakyo-Ku, Kyoto, 606-8501 Japan
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Er C, Dyson J, Jones D, Sayer J. Primary biliary cholangitis presenting with Fanconi syndrome: an important phenotype. BMJ Case Rep 2022; 15:e248461. [PMID: 35973749 PMCID: PMC9386236 DOI: 10.1136/bcr-2021-248461] [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] [Indexed: 11/04/2022] Open
Abstract
A woman in her 50s was referred to nephrology clinic due to progressive chronic kidney disease. She exhibited features of proximal renal tubulopathy, namely Fanconi syndrome, including normoglycaemic glycosuria, normal anion gap metabolic acidosis, and intermittent hypouricaemia and hypophosphataemia. Kidney biopsy showed tubulointerstitial inflammation and focal chronic damage. In addition, antimitochondrial antibodies were present and she had abnormal liver blood tests. A unifying diagnosis of primary biliary cholangitis with an associated renal tubulopathy and interstitial nephritis was made. She was commenced on sodium bicarbonate, ursodeoxycholic acid and oral prednisolone, leading to an improvement in liver biochemistry. Kidney function was stabilised, but a sustained improvement was not seen. This case acts as a reminder of the rare association of tubulointerstitial nephritis and Fanconi syndrome with primary biliary cholangitis, which may be an under-recognised phenotype.
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Affiliation(s)
- Chaoxui Er
- Renal Medicine, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - Jessica Dyson
- Hepatology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - David Jones
- Hepatology, Freeman Hospital, Newcastle-upon-Tyne, UK
| | - John Sayer
- Renal Medicine, Freeman Hospital, Newcastle-upon-Tyne, UK
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Minato M, Murakami T, Takahashi N, Ono H, Nishimura K, Tamaki M, Nagai K, Abe H, Iwano M, Joh K, Doi T. Glucocorticoid-dependent Tubulointerstitial Nephritis with IgM-positive Plasma Cells Presenting with Intracellular Crystalline Inclusions within the Rough Endoplasmic Reticulum. Intern Med 2021; 60:3129-3136. [PMID: 33840699 PMCID: PMC8545643 DOI: 10.2169/internalmedicine.7118-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Tubulointerstitial nephritis (TIN) with IgM-positive plasma cells (IgMPC-TIN) is an autoimmune kidney disease characterized by IgM/CD138-double-positive plasma cell infiltration in the tubulointerstitium. A 50-year-old man developed IgMPC-TIN and presented with crystalline inclusions in the rough endoplasmic reticulum. Intracellular crystal formation is a rare finding in paraprotein-related kidney diseases, but this case showed no pathogenic monoclonal immunoglobulin. Prednisolone (PSL, 30 mg) improved the TIN, but PSL tapering resulted in the recurrence of TIN. Combination therapy with 15 mg PSL and 150 mg mizoribine ultimately stabilized TIN. This case offers original evidence concerning the pathophysiology and treatment strategy of IgMPC-TIN.
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Affiliation(s)
- Masanori Minato
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Taichi Murakami
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
- Department of Nephrology, Ehime Prefectural Central Hospital, Japan
| | - Naoki Takahashi
- Department of Nephrology, Faculty of Medical Science, University of Fukui, Japan
| | - Hiroyuki Ono
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Kenji Nishimura
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Masanori Tamaki
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Kojiro Nagai
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Hideharu Abe
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Masayuki Iwano
- Department of Nephrology, Faculty of Medical Science, University of Fukui, Japan
| | - Kensuke Joh
- Department of Pathology, The Jikei University School of Medicine, Japan
| | - Toshio Doi
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
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Matsuoka-Uchiyama N, Tsuji K, Fukushima K, Kitamura S, Uchida HA, Sugiyama H, Takahashi N, Iwano M, Wada J. Tubulointerstitial Nephritis Cases With IgM-Positive Plasma Cells. Kidney Int Rep 2020; 5:1576-1580. [PMID: 32954083 PMCID: PMC7486177 DOI: 10.1016/j.ekir.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/30/2020] [Accepted: 06/09/2020] [Indexed: 11/05/2022] Open
Affiliation(s)
- Natsumi Matsuoka-Uchiyama
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kenji Tsuji
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Kazuhiko Fukushima
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shinji Kitamura
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Naoki Takahashi
- Department of Nephrology, Faculty of Medical Science, University of Fukui, Fukui, Japan
| | - Masayuki Iwano
- Department of Nephrology, Faculty of Medical Science, University of Fukui, Fukui, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Nakamori A, Akagaki F, Yamaguchi Y, Sugiura T. Relapsing Tubulointerstitial Nephritis with Antimitochondrial M2 Antibody Accompanied by Pulmonary Involvement. Intern Med 2020; 59:1179-1187. [PMID: 32051384 PMCID: PMC7270750 DOI: 10.2169/internalmedicine.4048-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
We herein report a 50-year-old woman who suffered from tubulointerstitial nephritis with antimitochondrial M2 antibody, distal renal tubular acidosis, and Fanconi syndrome. Our case also had interstitial pneumonia. After initially successful glucocorticoid therapy, tubulointerstitial nephritis and interstitial pneumonia relapsed. After the second successful round of glucocorticoid therapy, tubulointerstitial nephritis relapsed again and responded to glucocorticoid and azathioprine. This case might indicate (1) the association between pulmonary involvement and tubulointerstitial nephritis with antimitochondrial antibodies and (2) the need for a maintenance dose of glucocorticoid and immunosuppressants in tubulointerstitial nephritis with antimitochondrial antibodies.
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MESH Headings
- Acidosis, Renal Tubular/complications
- Acidosis, Renal Tubular/diagnosis
- Acidosis, Renal Tubular/drug therapy
- Autoantibodies/blood
- Diagnosis, Differential
- Fanconi Syndrome/complications
- Fanconi Syndrome/diagnosis
- Fanconi Syndrome/drug therapy
- Female
- Glucocorticoids/therapeutic use
- Humans
- Lung Diseases, Interstitial/complications
- Lung Diseases, Interstitial/diagnosis
- Lung Diseases, Interstitial/drug therapy
- Middle Aged
- Mitochondria/immunology
- Nephritis, Interstitial/complications
- Nephritis, Interstitial/diagnosis
- Nephritis, Interstitial/drug therapy
- Recurrence
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Affiliation(s)
- Aya Nakamori
- Department of Nephrology, Otemae Hospital, Japan
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