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Saowapa S, Chaisrimaneepan N, Adu Y, Thongpiya J, Yingchoncharoen P, Bell AL, Polpichai N, Siladech P, Payne JD. Massive hemoptysis with end stage renal disease (ESRD): An initial symptom of rare disease. Clin Case Rep 2024; 12:e8614. [PMID: 38455858 PMCID: PMC10918702 DOI: 10.1002/ccr3.8614] [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: 12/07/2023] [Revised: 01/18/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024] Open
Abstract
Microscopic polyangiitis is a rare autoimmune vasculitis, that could present with renal-pulmonary symptoms, posing diagnostic challenges in patients with preexisting kidney disease. Timely diagnosis is crucial to improve patient outcomes.
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Affiliation(s)
- Sakditad Saowapa
- Department of MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | | | - Yaw Adu
- Department of MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Jerapas Thongpiya
- Department of MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | | | - Amanda L. Bell
- Department of MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
| | - Natchaya Polpichai
- Department of Internal MedicineWeiss Memorial HospitalChicagoIllinoisUSA
| | - Pharit Siladech
- Faculty of Medicine Ramathibodi HospitalMahidol UniversityBangkokThailand
| | - J. Drew Payne
- Department of MedicineTexas Tech University Health Sciences CenterLubbockTexasUSA
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Li W, Chen R, Chen W, Huang F, Xia X. Clinicopathological Features and Outcomes of IgA Nephropathy with Serum Antineutrophil Cytoplasmic Autoantibody Positivity. Am J Nephrol 2023; 54:416-424. [PMID: 37725925 DOI: 10.1159/000533982] [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: 06/10/2023] [Accepted: 08/28/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION IgA nephropathy (IgAN) with serum antineutrophil cytoplasmic autoantibody (ANCA) positivity is uncommon. This study analyzed the clinicopathologic features and prognosis of IgAN patients with serum ANCA positivity. METHODS 2,864 IgAN patients were tested for ANCA by the indirect immunofluorescence assay and chemiluminescence immunoassay. Patients with serum ANCA positivity (n = 85) were identified, and their clinical, pathological, and prognostic characteristics were analyzed. They were compared with ANCA-negative IgAN patients (n = 170) and ANCA-associated systemic vasculitis (AAV) with renal involvement patients (n = 85) selected randomly. RESULTS 2.97% (85/2,864) of IgAN were ANCA positive, and 4 patients were diagnosed as having crescentic IgAN with ANCA positivity. The clinicopathological characteristics of ANCA-positive IgAN patients were comparable to ANCA-negative IgAN patients, but they had higher antinuclear antibody (ANA)-positive rates, lower levels of renal interstitial inflammation, and fewer immune depositions than ANCA-negative IgAN patients. Compared with AAV patients, ANCA-positive IgAN patients were younger and had fewer extrarenal manifestations, milder renal damage, and more immune complex depositions. The renal outcomes were similar between IgAN patients with and without ANCA positivity. Multivariate Cox analysis revealed that in IgAN patients with ANCA positivity, male, ANA positivity, higher serum creatinine and proteinuria, and more severe renal tubular atrophy/interstitial fibrosis were risk factors for adverse renal outcomes. CONCLUSION The clinical, pathological features and prognosis of ANCA-positive IgAN patients were similar to those of ANCA-negative IgAN patients except for higher ANA-positive rate, milder renal inflammation, and fewer immune depositions. ANA positivity was an independent risk factor for adverse renal outcomes in ANCA-positive IgAN patients.
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Affiliation(s)
- Wenchao Li
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Ruifan Chen
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Fengxian Huang
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
| | - Xi Xia
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, Guangzhou, China
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Coexistence of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and IgA nephropathy. Immunol Res 2023; 71:1-14. [PMID: 36227529 DOI: 10.1007/s12026-022-09322-8] [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: 04/26/2022] [Accepted: 09/14/2022] [Indexed: 01/20/2023]
Abstract
Co-occurrence of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and IgA nephropathy (IgAN) is extremely uncommon. To date, only a few case reports have described such patients. Here, we describe the clinical presentation, pathologic features, treatment response, and outcome data of five patients with the rare form of co-existing AAV and IgAN and compared the characteristics of these patients to AAV patients with pauci-immune glomerulonephritis (n = 10) and IgAN patients (n = 10) that were selected as controls by stratified random sampling. In addition, we summarize all the previously reported cases of AAV and IgAN. In total, including the current study, 16 AAV/IgAN overlap cases were reported. Our five patients with the coexistence of AAV and IgAN were younger than the ten AAV patients with pauci-immune glomerulonephritis (22.6 ± 8.2 years versus 48.9 ± 15.7 years, respectively, P = 0.004). Histologically, they had a significantly lower percentage of glomeruli with fibrous crescents compared with AAV patients (0.0% versus 4.0%, P = 0.038). Compared with ten IgAN patients, our five AAV/IgAN patients had higher levels of ESR (P = 0.032) and CRP (P = 0.031). After accepting treatment with a combination of steroid and immunosuppressants, all patients showed a positive response to therapy, except for one patient in our cohort and another previously reported patient. We described the clinical presentation, pathologic features, treatment response, and outcome data of five patients with overlapping AAV and IgAN. They had mild glomerular pathological lesions and a positive response to aggressive immunosuppressive therapy. They were quite similar to pauci-immune AAV patients in clinical features, except for younger age. They had a lower percentage of glomeruli with fibrous crescents compared with AAV patients. In contrast to IgAN patients, they had higher levels of ESR and CRP. The mechanism of the coexistence of IgAN and AAV needs further study.
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The Presence of ANCA in IgA Crescentic Nephropathy Does Not Lead to Worse Prognosis with Intensive Rescue Treatment. J Clin Med 2022; 11:jcm11237122. [PMID: 36498699 PMCID: PMC9738508 DOI: 10.3390/jcm11237122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/17/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Immunoglobulin A nephropathy (IgAN) is the most common glomerulonephritis worldwide. The concomitant presence of both crescentic proliferation and anti-neutrophil cytoplasmic autoantibodies (ANCA) in this pathology represents a rare coincidence. However, it is not clear to what extent the presence of ANCA (IgA or IgG) in these patients could have any clinical significance. The aim of the current work is to describe the presence of ANCA (IgA or IgG) in patients with IgAN and crescentic proliferation and its possible clinical implications. METHODS We retrospectively recruited all patients in our center with a histological diagnosis of IgAN with crescentic proliferation between January 2013 and December 2020. The main demographic and clinicopathologic data, fundamental histological characteristics, as well as the treatments implemented and main kidney outcomes, were collected and analyzed at a 6 and 12-month follow-up. RESULTS Between January 2013 and December 2020, a total of 17 adults were diagnosed with concomitant crescentic proliferation through a kidney biopsy of IgAN. Five (29.4%) patients showed ANCA, three (60%) showed IgA-ANCA and two (40%) showed IgG-ANCA. All ANCA-positive patients had some degree of crescentic proliferation. At diagnosis, the mean age of patients was 48 years old (range: 27-75). Nine of them were women (52%) and the most common clinical presentation was hypertension (71%). At the time of biopsy, the mean serum creatinine and proteinuria were 2.2 mg/dL (DS 1.42) and 3.5 g/mgCr (DS 1.22), respectively, with no statistical differences between ANCA-positive and -negative patients. Histological analyses showed that 11 out of the 12 (91%) ANCA-negative IgAN patients displayed less than 25% cellular crescents, whereas 100% of ANCA-positive IgAN patients displayed more than 25% cellular crescents (p = 0.04). Notably, five (30%) patients displayed fibrinoid necrosis, with four of them (80%) being IgAN-ANCA-positive (p = 0.01). Only one ANCA-negative patient needed renal replacement therapy (RRT) upon admission (5%). The mean serum creatinine and proteinuria were 1.94 mg/dL (DS 1.71) and 1.45 g/gCr (DS 1.78), respectively, within 6 months of immunosuppressive therapy. At 12-month follow-up, the mean creatinine was 1.57 mg/dL (DS 1). Four (23.5%) patients needed RRT at the end of the follow-up and four (23.5%) patients died. CONCLUSIONS Probably due to the limited number of IgAN-ANCA-positive and IgAN-ANCA-negative patients, no significant differences were found between the clinical and laboratory characteristics. IgAN-ANCA-negative patients seemed to display less extracapillary proliferation than IgAN-ANCA-positive patients, who tended to show significantly higher fibrinoid necrosis. There were no differences regarding renal prognosis and patient survival after aggressive immunosuppressive therapy within 6 and 12 months when comparing the two samples.
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5
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Zamoner W, Reis PFD, Silva VDS. Crescent IgA Nephropathy and its association with anti-neutrophil cytoplasm antibody: what do we know? J Bras Nefrol 2022; 44:1-2. [PMID: 35312743 PMCID: PMC8943863 DOI: 10.1590/2175-8239-jbn-2022-e001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 11/22/2022] Open
Affiliation(s)
- Welder Zamoner
- Universidade Estadual Paulista "Júlio de Mesquita Filho", Faculdade de Medicina de Botucatu, Botucatu, SP, Brasil
| | - Pâmela Falbo Dos Reis
- Universidade Estadual Paulista "Júlio de Mesquita Filho", Faculdade de Medicina de Botucatu, Botucatu, SP, Brasil
| | - Vanessa Dos Santos Silva
- Universidade Estadual Paulista "Júlio de Mesquita Filho", Faculdade de Medicina de Botucatu, Botucatu, SP, Brasil
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Yu L, Huang G, Lu Z, Wang J, Gu W, Li J, Mao J. Glomerular IgA Deposition and Serum Antineutrophil Cytoplasmic Antibody Positivity in a Child With Dystrophic Epidermolysis Bullosa: Case Report and Literature Review. Front Pediatr 2022; 10:939069. [PMID: 35899130 PMCID: PMC9309483 DOI: 10.3389/fped.2022.939069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Patients with epidermolysis bullosa (EB) could develop significant urological complications, such as hydroureteronephrosis, renal amyloidosis and IgA nephropathy (IgAN). Here, we presented a 12-year-old boy carrying pathogenic COL7A1 mutation with diagnosis of dystrophic epidermolysis bullosa (DEB). The patient had concomitant gross hematuria and proteinuria. Pathological examinations and immunostaining of renal biopsy showed glomeruli with mesangial hypercellularity and deposition of IgA, which were indicative of IgAN. Interestingly, serological evaluation showed antineutrophil cytoplasmic antibody (ANCA) directed against myeloperoxidase and proteinase 3. Treatment with glucocorticoid, immunosuppressants, angiotensin-converting enzyme inhibitor and antibiotics efficiently improved hemato-proteinuria, and ANCAs became negative as well. This case of DEB presented a unique collection of clinical manifestations and pathological alterations. IgAN and serum positive ANCA were possibly associated with sustained infection secondary to DEB, and can be managed by empirical treatment for primary IgAN.
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Affiliation(s)
- Ling Yu
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guoping Huang
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Zhihong Lu
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jingjing Wang
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Weizhong Gu
- Department of Pathology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Junping Li
- Department of Pathology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jianhua Mao
- Department of Nephrology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Bhuwania P, Veerappan I, Sethuraman R. A Rare Case of Type 4 Rapidly Progressive Glomerulonephritis (Atypical) with Mesangial IgA Deposits: A Case Report. Indian J Nephrol 2021; 31:488-491. [PMID: 34880562 PMCID: PMC8597790 DOI: 10.4103/ijn.ijn_364_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/06/2020] [Accepted: 10/18/2020] [Indexed: 11/05/2022] Open
Abstract
Rapidly progressive glomerulonephritis can result from glomerular deposition of anti-GBM antibody, immune complexes, or may involve pauci-immune mechanisms. The coexistence of IgA nephropathy, anti-GBM, and anti-neutrophilic cytoplasmic antibodies is unheard of, and the pathogenic role of these antibodies in IgA nephropathy or vice versa remains unclear. Herein, we describe a case of a patient with type 4 rapidly progressive glomerulonephritis who was found to have significant mesangial IgA deposits. The prognosis of this remains unclear but our patient responded well to cytotoxic therapy and plasmapheresis and achieved remission by 6 months. The findings suggest an overlap syndrome of IgA nephropathy-associated type 4 crescentic glomerulonephritis that resembles the former histologically and the latter in its potential to respond to aggressive therapy if detected relatively early in its course.
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Affiliation(s)
- Puneet Bhuwania
- Department of Nephrology, KG Hospital and PG Institute, Coimbatore, Tamil Nadu, India
| | - Ilangovan Veerappan
- Department of Nephrology, KG Hospital and PG Institute, Coimbatore, Tamil Nadu, India
| | - Ramaswami Sethuraman
- Department of Nephrology, KG Hospital and PG Institute, Coimbatore, Tamil Nadu, India
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8
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Tan SL, Potezny T, Li JY. The successful use of rituximab in crescentic IgA nephropathy with concurrent ANCA positivity. Nephrology (Carlton) 2021; 27:216-217. [PMID: 34322932 DOI: 10.1111/nep.13950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/14/2021] [Accepted: 07/17/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Sarah L Tan
- Department of Renal Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Tessa Potezny
- Department of Renal Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Jordan Y Li
- Department of Renal Medicine, Flinders Medical Centre, Adelaide, South Australia, Australia.,College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Dias CB, Jorge LB, Woronik V, Cavalcante LB, Yu L. IgA nephropathy in patients with serum anti-neutrophil cytoplasmic autoantibody (ANCA) positivity: case series. ACTA ACUST UNITED AC 2021; 44:42-47. [PMID: 34289006 PMCID: PMC8943862 DOI: 10.1590/2175-8239-jbn-2021-0018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 06/06/2021] [Indexed: 01/11/2023]
Abstract
Some cases of patients with IgA nephropathy diagnosed via kidney biopsy and antineutrophil cytoplasmic antibody (ANCA) positivity have been reported. This article describes a case series comprising patients with IgA nephropathy and ANCA positivity seen at a medical center in the city of São Paulo, Brazil, from 1996 to 2016. A total of 111 patients underwent diagnostic kidney biopsies for IgA nephropathy. Five were ANCA-positive at the time of diagnosis; their mean age was 45 ± 15.3 years and they were predominantly females with a mean proteinuria of 2.2 ± 0.9 g/day and a median serum creatinine level of 2.5 (2.0 - 8,6) mg/dL; all had hematuria. Four of the five were cANCA-positive (80%); all had normal serum C3 and C4 levels; and 80% were positive for ANA. One case presented an association with infection, but no associations were found with medication. One patient had granuloma and another had a collapsing lesion. This article describes the cases of five ANCA-positive patients (with predominantly cANCA positivity) submitted to diagnostic kidney biopsies for IgA nephropathy; one patient had a collapsing lesion, but progressed well.
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Affiliation(s)
- Cristiane Bitencourt Dias
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Fisiologia Renal, São Paulo, SP, Brasil
| | - Lectícia Barbosa Jorge
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Nefrologia, São Paulo, SP, Brasil
| | - Viktoria Woronik
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Laboratório de Fisiologia Renal, São Paulo, SP, Brasil
| | - Lívia Barreira Cavalcante
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Departamento de Patologia, São Paulo, SP, Brasil
| | - Luis Yu
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Serviço de Nefrologia, São Paulo, SP, Brasil
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Pillebout E, Sunderkötter C. IgA vasculitis. Semin Immunopathol 2021; 43:729-738. [PMID: 34170395 DOI: 10.1007/s00281-021-00874-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
Abstract
IgA vasculitis (IgAV) is an inflammation of small vessels caused by perivascular deposition of IgA and activation of neutrophils. It may present as systemic vasculitis (IgAV - Henoch-Schönlein purpura) or as a variant restricted to the skin (skin-limited IgAV), while IgA nephropathy presents a variant restricted to the kidneys. Systemic IgAV affects children more frequently than adults (150 to 200 for 1; incidence 1 in 1 million/year). In the latter, disease more often leads to chronic renal disease. The dominant clinical features include round or oval and retiform palpable purpura predominantly on the lower legs, arthralgia or arthritis, gastrointestinal bleeding or pain and glomerulonephritis with mesangial IgA deposits (IgAVN). Pulmonary, cardiac, genital and neurological involvement occurs, but is rare. Immune complexes containing galactose-deficient IgA1 play a pivotal role in the pathophysiology of IgAV; via the Fc alpha receptor (CD89), they induce neutrophilic inflammation around cutaneous vessels and mesangial proliferation and inflammation in the glomerulus. In case of self-limited disease, only symptomatic treatment is recommended. Treatment of severe IgAV, nephritis or gastrointestinal manifestations, is not established, but some studies reported a benefit of corticosteroids, combined with immunosuppressive drugs. Short-term outcome depends on the severity of gastrointestinal manifestations, while long-term prognosis depends on the severity of nephritis.
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Affiliation(s)
- Evangéline Pillebout
- Nephrology Unit, Saint Louis Hospital, INSERM 1149, CRI, 1 Av C. Vellefaux, 75010, Paris, France.
| | - Cord Sunderkötter
- Department of Dermatology and Venereology, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle/Saale, Germany
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Ștefan G, Terinte-Balcan G, Stancu S, Zugravu A, Gherghiceanu M, Mircescu G. IgA nephropathy with serum ANCA positivity: case series and literature review. Rheumatol Int 2021; 41:1347-1355. [PMID: 33999289 DOI: 10.1007/s00296-021-04888-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/07/2021] [Indexed: 12/15/2022]
Abstract
The co-occurrence of IgA nephropathy (IgAN) and positive anti-neutrophil cytoplasmic autoantibodies (ANCA) serology is uncommon. In the present case series and literature review, we aimed to clarify the impact of ANCA on pathogenesis, clinical and histopathology presentation, and outcome in IgAN patients. We report four patients with an overlap lesion of IgAN-ANCA positive. Also, we performed a narrative review of all biopsy-proven published case series. Only 1.2% patients had ANCA in our 330-biopsy-proven IgAN cohort. We compared our data with previous reports-6 case series and 3 small retrospective studies-a total of 103 patients. All patients but one had eGFR below 15 mL/min at diagnosis. Besides rapidly decreasing eGFR, all presented with proteinuria around 1.5 g/day and dysmorphic microhematuria, suggesting glomerular inflammation. Systemic symptoms suggestive for ANCA vasculitis were seen in half of our patients, but only one patient had hemorrhagic alveolitis. Patients from our cohort responded to the intensive immunosuppressive regimens used in ANCA-positive vasculitis with renal involvement. However, in the follow-up, one patient had a relapse followed by septic shock related to immunosuppression and one patient started hemodialysis. In the review, we found that IgAN-ANCA -positive patients are characterized by vasculitis-like lesions and clinically by a rapidly progressive decline in kidney function, which was reversed by an aggressive induction immunosuppressive protocol used in ANCA vasculitis. Checking ANCA serology seems useful in patients with rapidly progressive IgAN for therapeutic and prognostic reasons.
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Affiliation(s)
- Gabriel Ștefan
- "Dr. Carol Davila" Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania. .,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - George Terinte-Balcan
- Ultrastructural Pathology, "Victor Babes" National Institute of Pathology, Bucharest, Romania
| | - Simona Stancu
- "Dr. Carol Davila" Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Adrian Zugravu
- "Dr. Carol Davila" Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Mihaela Gherghiceanu
- Department of Cell Biology and Histology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Ultrastructural Pathology, "Victor Babes" National Institute of Pathology, Bucharest, Romania
| | - Gabriel Mircescu
- "Dr. Carol Davila" Teaching Hospital of Nephrology, Romanian Renal Registry, Street Calea Grivitei, No. 4, 010731, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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Lin W, Shen C, Zhong Y, Ooi JD, Eggenhuizen P, Zhou YO, Luo H, Huang J, Chen JB, Wu T, Meng T, Xiao Z, Ao X, Peng W, Tang R, Yin H, Xiao X, Zhou Q, Xiao P. Glomerular Immune Deposition in MPO-ANCA Associated Glomerulonephritis Is Associated With Poor Renal Survival. Front Immunol 2021; 12:625672. [PMID: 33841408 PMCID: PMC8027492 DOI: 10.3389/fimmu.2021.625672] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 03/02/2021] [Indexed: 12/15/2022] Open
Abstract
Background Rapidly progressive glomerulonephritis caused by antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is typically characterized as pauci-immune glomerulonephritis. However, immune complex (IC) deposition in the glomerulus has been reported in a growing number of studies. Here, we assess the presence of glomerular immune deposits alongside renal outcome in myeloperoxidase (MPO)-ANCA associated glomerulonephritis (MPO-ANCA GN). Methods Clinical and histopathologic characteristics of 97 patients with MPO-ANCA GN classified by renal biopsy from January 2008 to December 2019 were extracted retrospectively from electronic medical records. The extent of immune deposits in the kidney (C3, C4, C1q, IgA, IgG, IgM) at diagnosis were analyzed by immunofluorescence (IF). Patients were followed up for a median period of 15 months. The response to treatment and outcomes of renal and histological lesion changes were also assessed. Results In our study, 41% (40/97) of patients showed positive IF (≥2+) for at least one of the six immunoglobulin or complement components tested. Patients with IC deposits showed higher levels of serum creatinine (p=0.025), lower platelet counts (p=0.009), lower serum complement C3 (sC3) (≤790 ml/L) (p=0.013) and serum IgG (p=0.018) than patients with pauci-immune (PI) deposition at diagnosis. End-stage renal disease was negatively associated with eGFR (HR 0.885, 95% CI 0.837 to 0.935, p<0.0001), platelet count (HR 0.996, 95% CI 0.992 to 1.000, p=0.046) and serum globulin (HR 0.905, 95% CI 0.854 to 0.959, p=0.001). Patients with lower sC3 levels showed a worse renal outcome than the patients with normal sC3 at diagnosis (p=0.003). Analysis of the components of the renal deposits found that patients with IgG deposits exhibited a poorer renal outcome compared to patients that were IgG negative (p=0.028). Moreover, Bowman’s capsule rupture occurred less frequently in patients with IgM deposition compared with IgM negative counterparts (p=0.028). Vascular lesions and granuloma-like lesions had been seen more frequently in cases with IgA deposition than those without IgA deposition (p=0.03 and 0.015, respectively). Conclusion In conclusion, patients with immune complex deposits in the kidney showed less platelet count, lower sC3 and sIgG levels, and higher serum creatinine levels. Patients with low sC3 at initial and with continued low sC3 during the treatment displayed a trend toward poorer kidney survival. Moreover, the IC group showed a worse renal outcome than the PI group, further enforcing the present strategy of introducing complement targeted therapies in AAV.
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Affiliation(s)
- Wei Lin
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, China
| | - Chanjuan Shen
- Department of Hematology, The Affiliated Zhuzhou Hospital Xiangya Medical College, Central South University, Zhuzhou, China
| | - Yong Zhong
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Joshua D Ooi
- Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
| | - Peter Eggenhuizen
- Centre for Inflammatory Diseases, Monash University, Clayton, VIC, Australia
| | - Ya-Ou Zhou
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, China
| | - Hui Luo
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, China
| | - Jing Huang
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, China
| | - Jin-Biao Chen
- Department of Medical Records and Information, Xiangya Hospital, Central South University, Changsha, China
| | - Ting Wu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Ting Meng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Zhou Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiang Ao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Weisheng Peng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Rong Tang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Hongling Yin
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangcheng Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Qiaoling Zhou
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
| | - Ping Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
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Alvarez JC, Rodelo J, Arias LF, Álvarez C. Immunoglobulin A Nephropathy With Extracapillary Proliferation and Positive Anti-Neutrophil Cytoplasmic Antibodies: A Rare Cause of Dual Glomerulonephritis. Cureus 2020; 12:e11068. [PMID: 33224662 PMCID: PMC7676950 DOI: 10.7759/cureus.11068] [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] [Indexed: 11/05/2022] Open
Abstract
The coexistence of immunoglobulin A (IgA) nephropathy and associated pauci-immune anti-neutrophil cytoplasmic antibody (ANCA) glomerulonephritis represents a rare concurrence of two common forms of glomerulonephritis; the pathogenesis, treatment, and prognosis of this dual glomerulopathy are not well described. This illustrative case can present this association in an HIV-positive patient and how despite the coexistence of these two entities, the patient had control of his kidney disease with low doses of steroids, contrary to the different reports of cases in the literature in which the treatment is often more aggressive. In this case report, we review the literature on this dual glomerulonephritis and confront clinical and treatment aspects regarding the different clinical cases reported in the databases.
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Affiliation(s)
- Jose C Alvarez
- Internal Medicine, University of Antioquia, Medellin, COL
| | - Joaquin Rodelo
- Nephrology, Nephrology Unit, San Vicente Foundation University Hospital, Medellin, COL
| | - Luis F Arias
- Pathology, University of Antioquia, Medellin, COL
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Antineutrophil cytoplasmic autoantibody (ANCA) positive immunoglobulin A (IgA) nephropathy: Case reports and review of literature. THE EGYPTIAN RHEUMATOLOGIST 2020. [DOI: 10.1016/j.ejr.2020.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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The Clinicopathologic Characteristics and Complement Activation of Antineutrophil Cytoplasmic Antibody-associated Vasculitides With Glomerular IgA Deposition. Appl Immunohistochem Mol Morphol 2019; 28:e87-e93. [DOI: 10.1097/pai.0000000000000819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Jiang L, Dong B, Yan Y, Zheng S, Hu Y, Zuo L, Shi H. Clinicopathological analysis of IgA nephropathy combined with other glomerular diseases. Medicine (Baltimore) 2019; 98:e17388. [PMID: 31593089 PMCID: PMC6799395 DOI: 10.1097/md.0000000000017388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
It is not rare to find Immunoglobulin A (IgA) nephropathy (IgAN) combined with other glomerular diseases, which can be called compound IgAN (cIgAN). Till now, clinical-pathological investigation of cIgAN was lacking, especially the severity of "background IgAN lesions." This research aimed to investigate the incidence, clinical and pathological characteristics of cIgAN, and thus improve the understanding of the clinical significance of this combination.Patients with cIgAN diagnosed in Peking University People's Hospital from November 2012 to April 2018 were retrospectively analyzed. Patients with IgAN without compound glomerular diseases (sIgAN) were enrolled as a control group.Among 1407 patients diagnosed with IgAN, 80 (5.69%) were cIgAN patients. Compared with sIgAN, cIgAN patients had a significantly lower prevalence of microscopic hematuria and more urine protein. There were 10 pathological types of glomerular diseases combined with IgAN, led by diabetic nephropathy 37 (46.25%) and membranous nephropathy 14 (17.5%). Histologically, although the mesangial hypercellularity was comparable in 2 groups, cIgAN patients had a lower prevalence of endocapillary proliferation, segmental glomerulosclerosis, and cellular or fibrocellular crescents formation, as well as weaker immunofluorescence intensity for IgA and C3 (all P < .05). Eight out of 27 (29.63%) cIgAN patients with follow-up data (5-48 months) developed irreversible end-stage renal disease requiring dialysis.The order of incidence of concomitant diseases was similar to that of the pure diseases. The "background IgAN associated lesions" except mesangial hypercellularity were relatively mild in cIgAN group. Those might suggest that in some cases, IgAN seems to be a chance finding, and the combined diseases may play a more important role in the clinicopathological features of the patients than the nephritis caused by IgA deposition. While diagnosing IgAN, other combined glomerular diseases need to be carefully considered by nephrologists and pathologists.
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Affiliation(s)
| | - Bao Dong
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Yu Yan
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | | | | | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
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Yasukawa M, Kitagawa S, Togashi R, Asakawa S, Nagura M, Arai S, Yamazaki O, Tamura Y, Kondo F, Ohashi R, Uchida S, Shibata S, Fujigaki Y. A Patient with MPO-ANCA-positive IgA Nephropathy Diagnosed with the Clinical Onset of Macrohematuria. Intern Med 2019; 58:2051-2056. [PMID: 30918194 PMCID: PMC6702016 DOI: 10.2169/internalmedicine.2475-18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
A 21-year-old woman presented with renal dysfunction during macrohematuria. A kidney biopsy revealed IgA nephropathy with a small percentage of crescent formation and macrohematuria-associated tubular injury. Macrohematuria-associated acute kidney injury could explain her renal dysfunction. However, she was seropositive for myeloperoxidase (MPO)-anti-neutrophil cytoplasmic antibody (ANCA) and showed fibrin deposition around one arteriole. Corticosteroids and mycophenolate mofetil were administered as for ANCA vasculitis, and the serum creatinine, abnormal urinalysis and MPO-ANCA titer all gradually ameliorated. The presence of extra-glomerular vasculitis, which was probably induced by ANCA, suggested that MPO-ANCA was an exacerbating factor for her prolonged renal dysfunction. This condition has so far only rarely been addressed in ANCA-positive IgA nephropathy.
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Affiliation(s)
- Minoru Yasukawa
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Sachiko Kitagawa
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Ryo Togashi
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shinichiro Asakawa
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Michito Nagura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeyuki Arai
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Osamu Yamazaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Fukuo Kondo
- Department of Pathology, Teikyo University Hospital, Japan
| | - Ryuji Ohashi
- Department of Diagnostic Pathology, Nippon Medical School Musashikosugi Hospital, Japan
| | - Shunya Uchida
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
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Pauci-immune Crescentic Glomerulonephritis in a Patient With Immunoglobulin A Nephropathy and Serum Antineutrophil Cytoplasmic Autoantibody Positivity. Arch Rheumatol 2018; 33:99-101. [PMID: 29901005 DOI: 10.5606/archrheumatol.2018.6502] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/09/2017] [Indexed: 11/21/2022] Open
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Abstract
PURPOSE OF REVIEW To provide an update on recent developments since the publication of the Oxford Classification of IgA nephropathy and to consider lesions that were not included in the original classification. RECENT FINDINGS Over 20 validation studies of the Oxford Classification have been published. Tubular atrophy/interstitial fibrosis is consistently the strongest predictor of renal survival, whereas mesangial hypercellularity predicts rate of loss of renal function. Endocapillary hypercellularity and crescents are associated with lower renal survival and more rapid loss of renal function in patients not receiving immunosuppression, whereas crescents in at least 25% of glomeruli predict lower renal survival irrespective of treatment; a C score has been added to the MEST scores in the 2016 revision of the classification. Repeat biopsy studies have demonstrated response of endocapillary and extracapillary hypercellularity to immunosuppression. Podocytopathic changes in segmental sclerosis are associated with higher levels of proteinuria, renal function decline and worse renal survival. Combination of histological and clinical variables allow for earlier outcome prediction. SUMMARY Recent evidence supports the use of the Oxford Classification of IgA nephropathy in wider populations. Combination of histological, clinical and biomarker data promises more accurate prognostication and identification of patients who will benefit from immunosuppression.
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Anti-Myeloperoxidase Antibodies Associate with Future Proliferative Lupus Nephritis. Autoimmune Dis 2017; 2017:1872846. [PMID: 29435367 PMCID: PMC5757094 DOI: 10.1155/2017/1872846] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 11/30/2017] [Accepted: 12/05/2017] [Indexed: 11/18/2022] Open
Abstract
Background The subclinical pathophysiology of proliferative lupus nephritis (PLN) has not been fully elucidated. Myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA) is associated with PLN, but prediagnostic levels have not been reported. Methods We performed a retrospective case-control Department of Defense Serum Repository (DoDSR) study comparing MPO-ANCA levels in longitudinal prediagnostic serum samples for 23 biopsy confirmed proliferative lupus nephritis (PLN) patients to DoDSR identified age, sex, race, and age of serum matched healthy and SLE without LN disease controls. We also compared the temporal relationship of MPO-ANCA to anti-double stranded DNA antibodies (dsDNAab). Results A greater proportion of PLN patients had prediagnostic MPO-ANCA levels above ≥3 U/mL and ≥6 U/mL compared to SLE without LN (91% versus 43%, p < 0.001; 57% versus 5%, p < 0.001, resp.). In subgroup analysis, the MPO-ANCA threshold of ≥3 U/mL was significant at <1 year (88% versus 39%, p = 0.007) and 1-4 years (87% versus 38%, p = 0.009) prior to diagnosis. Statistically significant subclinical MPO-ANCA levels (≥3 U/mL) occurred prior to statistically significant dsDNAab ≥ 3 IU/ml (89% versus 11%, p = 0.003). Conclusions Subclinical MPO-ANCA levels could distinguish future PLN from SLE without LN. MPO-ANCA manifests prior to clinical disease and subclinical dsDNAab to suggest that it may contribute directly to PLN pathogenicity.
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Xie L, He J, Liu X, Tang S, Wang W, Li F, Zhang Y, Zhang J, Huang Y, Zhao J, Li Y, Zhang J. Clinical value of systemic symptoms in IgA nephropathy with ANCA positivity. Clin Rheumatol 2017; 37:1953-1961. [DOI: 10.1007/s10067-017-3931-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/21/2017] [Accepted: 11/24/2017] [Indexed: 01/05/2023]
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22
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Koratala A, Zeng X, Kazory A. ANCA-positive IgA nephropathy without necrotising or crescentic glomerulonephritis: a clinical conundrum. BMJ Case Rep 2017; 2017:bcr-2017-222171. [PMID: 29170179 DOI: 10.1136/bcr-2017-222171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
IgA nephropathy, the most prevalent form of primary glomerular disease, usually portends a favourable outcome. Antineutrophil cytoplasmic autoantibodies (ANCAs) have been reported in association with IgA nephropathy in a small subset of patients, mostly presenting with rapidly progressive glomerulonephritis and necrotising crescentic lesions. Herein, we describe a case of IgA nephropathy, positive serum cytoplasmic and perinuclear ANCAs with anti-myeloperoxidase antibody, and preserved renal function without any histological evidence of necrotising or crescentic glomerulonephritis. Based on available mechanistic and clinical data, we opine that such patients could benefit from close monitoring of renal function.
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Affiliation(s)
- Abhilash Koratala
- Department of Nephrology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Xu Zeng
- Department of NephroPathology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Amir Kazory
- Department of Nephrology, University of Florida College of Medicine, Gainesville, Florida, USA
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Nissaisorakarn P, D'Agati V, Anis K, Jim B. ANCA and IgA glomerulonephritis all in one: prognosis and complications. BMJ Case Rep 2017; 2017:bcr-2017-222080. [PMID: 29018146 DOI: 10.1136/bcr-2017-222080] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We present the case of a 75-year-old Hispanic woman with known stage 3 chronic kidney disease, long-standing hypertension and type 2 diabetes mellitus who presented with right-sided abdominal pain and acute kidney injury, nephrotic range proteinuria with positive antimyeloperoxidase antibody. A renal biopsy revealed IgA nephropathy with superimposed pauci-immune antineutrophilic cytoplasmic antibody (ANCA)-associated crescentic glomerulonephritis. The patient was treated with pulse intravenous methylprednisolone, cyclophosphamide and plasmapheresis. One week after her second dose of cyclophosphamide, she was readmitted for infectious complications including influenza A respiratory infection, Rothia bacteraemia associated with diarrhoea and herpes zoster of the trunk. In this report, we review the prevalence, treatment and prognosis of coexistent IgA nephropathy and pauci-immune ANCA-associated crescentic glomerulonephritis. We propose that a reduced-dose treatment regimen should be considered in elderly patients due to their higher risk of infectious complications. Current literature suggests that this treatment approach may reduce infectious complications without compromising therapeutic efficacy.
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Affiliation(s)
- Pitchaphon Nissaisorakarn
- Division of Nephrology, Department of Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, NY, USA
| | - Vivette D'Agati
- Department of Pathology, Columbia University Medical Center, New York, USA
| | - Kisra Anis
- Division of Nephrology, Department of Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, NY, USA
| | - Belinda Jim
- Division of Nephrology, Department of Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, NY, USA
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24
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Divyaveer S, Tiwari V, Patil M, Mahajan C, Bhattacharya TD, Banerjee A, Bhattacherjee K, Raychaudhury A, Pandey R. An unusual case of rapidly progressing glomerulonephritis in pregnancy; "triple positivity" or a co incidence? J Nephropathol 2017. [DOI: 10.15171/jnp.2017.44] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Kucuk A, Solak Y, Gaipov A, Bagcaci S, Esen H, Turk S, Tunc R. Co-existing proteinase 3-antineutrophil cytoplasmic antibody-associated vasculitis with immunoglobulin A nephropathy. Korean J Intern Med 2016; 31:194-6. [PMID: 26767877 PMCID: PMC4712428 DOI: 10.3904/kjim.2016.31.1.194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 10/12/2014] [Accepted: 12/04/2014] [Indexed: 12/04/2022] Open
Affiliation(s)
- Adem Kucuk
- Division of Rheumatology, Necmettin Erbakan University, Konya, Turkey
- Correspondence to Adem Kucuk, M.D. Division of Rheumatology, Necmettin Erbakan University, 42090, Meram, Konya, Turkey Tel: +90-332-223-6548 Fax: +90-332-223-6182 E-mail:
| | - Yalcin Solak
- Division of Nephrology, Necmettin Erbakan University, Konya, Turkey
| | | | - Sinan Bagcaci
- Division of Physical Medicine and Rehabilitation, Necmettin Erbakan University, Konya, Turkey
| | - Hasan Esen
- Division of Pathology, Necmettin Erbakan University, Konya, Turkey
| | - Suleyman Turk
- Division of Nephrology, Necmettin Erbakan University, Konya, Turkey
| | - Recep Tunc
- Division of Rheumatology, Necmettin Erbakan University, Konya, Turkey
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Rojas-Rivera J, Fernández-Juárez G, Praga M. Rapidly progressive IgA nephropathy: a form of vasculitis or a complement-mediated disease? Clin Kidney J 2015; 8:477-81. [PMID: 26413269 PMCID: PMC4581398 DOI: 10.1093/ckj/sfv095] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/02/2015] [Indexed: 01/07/2023] Open
Abstract
A rapidly progressive and crescentic IgA nephropathy (IgAN) is uncommon, but it has a high risk of progression to end-stage renal disease and variable response to immunosuppression. The importance of a positive anti-neutrophil cytoplasmic antibody (ANCA) serology in this group of patients is not fully understood but may have prognostic significance. On the other hand, there is growing evidence of the role of complement in the pathogenesis of IgAN, especially in cases of crescentic IgAN. Therapies directed against the complement system are a potential and rational therapeutic approach. In this issue, two clinical studies of crescentic IgAN are presented. The first work, is a retrospective case-control study describing clinical presentation, histological findings and response to treatment of crescentic IgAN/positive ANCA patients, comparing them with IgAN/negative ANCA patients and ANCA vasculitis patients. The second is a case report showing the effect of eculizumab, a humanized monoclonal antibody that is a terminal cascade complement inhibitor, as salvage therapy for crescentic IgAN resistant to conventional immunosuppression. Both studies broaden our approach to patients with aggressive forms of IgAN.
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Affiliation(s)
- Jorge Rojas-Rivera
- Spanish Study Group of Glomerular Disease (GLOSEN) , Hospital Universitario Fundación Jiménez Díaz , Madrid , Spain
| | - Gema Fernández-Juárez
- Spanish Study Group of Glomerular Disease (GLOSEN) , Hospital Fundación Alcorcón , Madrid , Spain
| | - Manuel Praga
- Spanish Study Group of Glomerular Disease (GLOSEN) , Hospital Universitario 12 de Octubre , Madrid , Spain
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Yang YZ, Shi SF, Chen YQ, Chen M, Yang YH, Xie XF, Zou R, Lv JC, Liu LJ, Zhang H. Clinical features of IgA nephropathy with serum ANCA positivity: a retrospective case-control study. Clin Kidney J 2015; 8:482-8. [PMID: 26413270 PMCID: PMC4581394 DOI: 10.1093/ckj/sfv078] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 07/27/2015] [Indexed: 11/30/2022] Open
Abstract
Background The coexistence of IgA nephropathy (IgAN) and antineutrophil cytoplasmic autoantibodies (ANCAs) is relatively rare. Only a few studies have reported the features of these patients. Methods We studied the clinical and histological features of 20 ANCA-positive IgAN patients. They were compared with ANCA-negative IgAN patients (n = 40) and ANCA-associated systemic vasculitis (AASV) patients (n = 40) with a randomly selected and matched proportion of crescentic glomeruli. Furthermore, 9 ANCA-positive crescentic IgAN patients out of the 20 cases were compared with two control groups with crescentic nephritis. Results ANCA-positive IgAN patients showed older age, lower haemoglobin and higher inflammatory indicator levels at baseline, and a higher percentage of general symptoms and pulmonary involvement, compared with ANCA-negative IgAN patients, and were comparable to AASV patients. Histologically, there was a significantly higher percentage of fibrinoid necrosis in glomeruli in ANCA-positive IgAN patients and in AASV patients compared with ANCA-negative IgAN patients (35, 25 and 0%, respectively, P = 0.003). After immunosuppressive therapy, ANCA-positive crescentic IgAN patients were more likely to withdraw from dialysis (75 versus 9.1%, P = 0.03) and not to reach end-stage renal disease within 6 months (11.1 versus 66.7%, P = 0.01) compared with ANCA-negative crescentic IgAN patients. Conclusions IgAN patients with ANCA positivity showed more severe clinical and histological features when compared with ANCA-negative IgAN patients and were comparable to AASV patients. However, renal prognosis was relatively better in ANCA-positive crescentic IgAN patients after aggressive immunosuppressive therapy in the short term, compared with ANCA-negative patients.
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Affiliation(s)
- Ya-Zi Yang
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China , Peking University First Hospital, Institute of Nephrology, Peking University , Beijing , PR China
| | - Su-Fang Shi
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China , Peking University First Hospital, Institute of Nephrology, Peking University , Beijing , PR China
| | - Yu-Qing Chen
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China , Peking University First Hospital, Institute of Nephrology, Peking University , Beijing , PR China
| | - Min Chen
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China , Peking University First Hospital, Institute of Nephrology, Peking University , Beijing , PR China
| | - Yi-He Yang
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China , Peking University First Hospital, Institute of Nephrology, Peking University , Beijing , PR China
| | - Xin-Fang Xie
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China , Peking University First Hospital, Institute of Nephrology, Peking University , Beijing , PR China
| | - Rong Zou
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China , Peking University First Hospital, Institute of Nephrology, Peking University , Beijing , PR China
| | - Ji-Cheng Lv
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China , Peking University First Hospital, Institute of Nephrology, Peking University , Beijing , PR China
| | - Li-Jun Liu
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China , Peking University First Hospital, Institute of Nephrology, Peking University , Beijing , PR China
| | - Hong Zhang
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China , Peking University First Hospital, Institute of Nephrology, Peking University , Beijing , PR China
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Suzuki T, Iyoda M, Yamaguchi Y, Shibata T. A case of sporadic medullary cystic kidney disease type 1 (MCKD1) with kidney enlargement complicated by IgA nephropathy. Pathol Int 2015; 65:379-82. [PMID: 25818408 DOI: 10.1111/pin.12292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Accepted: 02/27/2015] [Indexed: 11/28/2022]
Abstract
Medullary cystic kidney disease (MCKD) is a progressive tubulointerstitial nephropathy, and it leads to end-stage kidney disease (ESKD). It is an autosomal dominant inherited disease, and is categorized into two types according to the localizing chromosome and timing of ESKD onset. Its pathogenesis has not been revealed clearly, thus accumulation of the cases is very valuable. We report here the first reported case of MCKD with kidney enlargement complicated by IgA nephropathy. A 70-year-old male was admitted to our hospital because of renal dysfunction and bilateral kidney enlargement. He was diagnosed as having MCKD complicated by IgA nephropathy (IgA-N) by renal biopsy. We speculated that he had MCKD type 1 on the basis of the late onset of renal failure and no significant evidence of mutation in the UMOD gene that is associated with MCKD type 2. Thereafter, his kidney function decreased progressively and he started to receive hemodialysis. This is an interesting case of MCKD1 in terms of its sporadic nature, kidney enlargement, and complication of IgA-N.
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Affiliation(s)
- Taihei Suzuki
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Masayuki Iyoda
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | | | - Takanori Shibata
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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29
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Pulmonary Limited MPO-ANCA Microscopic Polyangiitis and Idiopathic Lung Fibrosis in a Patient with a Diagnosis of IgA Nephropathy. Case Rep Nephrol 2015; 2015:378170. [PMID: 26266064 PMCID: PMC4525752 DOI: 10.1155/2015/378170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 06/22/2015] [Accepted: 06/28/2015] [Indexed: 11/17/2022] Open
Abstract
We present a case of a male patient with chronic renal insufficiency, due to crescentic glomerulonephritis with IgA deposits, who successively developed (idiopathic) thrombocytopenic purpura (ITP) and MPO-ANCA microscopic polyangiitis (MPA) with pulmonary fibrosis. The patient presented with cough, weight loss, and dyspnea on exertion. CT imaging and pulmonary function tests were compatible with interstitial pneumonitis with pulmonary fibrosis. Laboratory results showed high MPO-ANCA titers; the urinary sediment was bland. The patient was treated successfully with cyclophosphamide and methyl-prednisolone. This unique case illustrates the diagnostic and therapeutic challenges of an unusual presentation of microscopic polyangiitis presenting first as isolated kidney disease with recurrence in the form of pneumonitis without renal involvement, in association with renal IgA deposits and ITP as coexisting autoimmune conditions.
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30
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Wang J, Marchina S, Norton AC, Wan CY, Schlaug G. Predicting speech fluency and naming abilities in aphasic patients. Front Hum Neurosci 2013; 7:831. [PMID: 24339811 PMCID: PMC3857577 DOI: 10.3389/fnhum.2013.00831] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 11/18/2013] [Indexed: 11/17/2022] Open
Abstract
There is a need to identify biomarkers that predict degree of chronic speech fluency/language impairment and potential for improvement after stroke. We previously showed that the Arcuate Fasciculus lesion load (AF-LL), a combined variable of lesion site and size, predicted speech fluency in patients with chronic aphasia. In the current study, we compared lesion loads of such a structural map (i.e., AF-LL) with those of a functional map [i.e., the functional gray matter lesion load (fGM-LL)] in their ability to predict speech fluency and naming performance in a large group of patients. The fGM map was constructed from functional brain images acquired during an overt speaking task in a group of healthy elderly controls. The AF map was reconstructed from high-resolution diffusion tensor images also from a group of healthy elderly controls. In addition to these two canonical maps, a combined AF-fGM map was derived from summing fGM and AF maps. Each canonical map was overlaid with individual lesion masks of 50 chronic aphasic patients with varying degrees of impairment in speech production and fluency to calculate a functional and structural lesion load value for each patient, and to regress these values with measures of speech fluency and naming. We found that both AF-LL and fGM-LL independently predicted speech fluency and naming ability; however, AF lesion load explained most of the variance for both measures. The combined AF-fGM lesion load did not have a higher predictability than either AF-LL or fGM-LL alone. Clustering and classification methods confirmed that AF lesion load was best at stratifying patients into severe and non-severe outcome groups with 96% accuracy for speech fluency and 90% accuracy for naming. An AF-LL of greater than 4 cc was the critical threshold that determined poor fluency and naming outcomes, and constitutes the severe outcome group. Thus, surrogate markers of impairments have the potential to predict outcomes and can be used as a stratifier in experimental studies.
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Affiliation(s)
- Jasmine Wang
- Neuroimaging and Stroke Recovery Laboratory, Department of Neurology, Beth Israel Deaconess Medical Center and Harvard Medical School Boston, MA, USA
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Granulomatosis with polyangiitis associated with IgA nephropathy. CEN Case Rep 2013; 2:204-208. [PMID: 28509292 DOI: 10.1007/s13730-013-0065-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 01/21/2013] [Indexed: 10/27/2022] Open
Abstract
Granulomatosis with polyangiitis (GPA), previously referred to as Wegener's granulomatosis, is a rare necrotizing granulomatous vasculitis, especially in children. GPA affects small- to medium-sized vessels, leading to involvement of multiple organs, including the upper and lower respiratory tracts and kidneys. Glomerular lesions associated with GPA typically present as crescentic glomerulonephritis with necrotizing lesions, with little or no staining for immunoglobulins and complement proteins. We report a unique pediatric case of GPA associated with IgA nephropathy, a representative immune-mediated glomerular disease. The initial renal biopsy specimen revealed fibrous sclerosis and mild mesangial proliferation without deposition of IgA. However, after clinical remission of GPA by treatment, the serum IgA level continued to be significantly higher than normal, and her paranasal sinusitis was poorly controlled. An acute upper respiratory infection resulted in worsened urinary findings without any systemic signs of GPA. The second renal biopsy specimen revealed deposition of IgA and C3 in the mesangium. The patient was treated with oral prednisolone alone, which led to complete remission of proteinuria within 1 month. IgA nephropathy is possibly associated with GPA during remission stage, and serum IgA level may be a valuable indicator to predict its association.
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Lv J, Yang Y, Zhang H, Chen W, Pan X, Guo Z, Wang C, Li S, Zhang J, Zhang J, Liu L, Shi S, Wang S, Chen M, Cui Z, Chen N, Yu X, Zhao M, Wang H. Prediction of outcomes in crescentic IgA nephropathy in a multicenter cohort study. J Am Soc Nephrol 2013; 24:2118-25. [PMID: 24029421 DOI: 10.1681/asn.2012101017] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Crescentic IgA nephropathy (IgAN), defined as >50% crescentic glomeruli on kidney biopsy, is one of the most common causes of rapidly progressive GN. However, few studies have characterized this condition. To identify risk factors and develop a prediction model, we assessed data from patients ≥ 14 years old with crescentic IgAN who were followed ≥ 12 months. The discovery cohort comprised 52 patients from one kidney center, and the validation cohort comprised 61 patients from multiple centers. At biopsy, the mean serum creatinine (SCr) level ± SD was 4.3 ± 3.4 mg/dl, and the mean percentage of crescents was 66.4%± 15.8%. The kidney survival rates at years 1, 3, and 5 after biopsy were 57.4%± 4.7%, 45.8%± 5.1%, and 30.4%± 6.6%, respectively. Multivariate Cox regression revealed initial SCr as the only independent risk factor for ESRD (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.10 to 1.57; P=0.002). Notably, the percentage of crescents did not associate independently with ESRD. Logistic regression showed that the risk of ESRD at 1 year after biopsy increased rapidly at SCr>2.7 mg/dl and reached 90% at SCr>6.8 mg/dl (specificity=98.5%, sensitivity=64.6% for combined cohorts). In both cohorts, patients with SCr>6.8 mg/dl were less likely to recover from dialysis. Analyses in additional cohorts revealed a similar association between initial SCr and ESRD in patients with antiglomerular basement membrane disease but not ANCA-associated systemic vasculitis. In conclusion, crescentic IgAN has a poor prognosis, and initial SCr concentration may predict kidney failure in patients with this disease.
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Affiliation(s)
- Jicheng Lv
- Renal Division, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
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Yamaguchi H, Takizawa H, Ogawa Y, Takada T, Yamaji I, Ura N. A case report of the anti-glomerular basement membrane glomerulonephritis with mesangial IgA deposition. CEN Case Rep 2013; 2:6-10. [PMID: 28509211 DOI: 10.1007/s13730-012-0029-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 06/29/2012] [Indexed: 12/28/2022] Open
Abstract
A 46-year-old Japanese male with a past medical history of microscopic hematuria presented with nausea, vomiting, and abdominal pain for which he had been diagnosed with rapidly progressive glomerulonephritis with a peak serum creatinine of 6.6 mg/dL and anti-glomerular basement membrane antibody of 214 EU. Light microscopy showed cellular crescent formation, and immunofluorescence illustrated both linear staining of IgG along the glomerular basement membrane and granular staining of IgA and C3 in the mesangial area; however, the PAS staining of mesangial expansions and mesangial proliferations were not observed. Clinical and histological findings suggested anti-glomerular basement membrane glomerulonephritis with mesangial IgA deposition, suggesting IgA nephropathy, a rare condition.
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Affiliation(s)
- Hiroshi Yamaguchi
- Department of Nephrology, Teine Keijinkai Hospital, 1-12-1-40 Maeda, Teine-ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Hideki Takizawa
- Department of Nephrology, Teine Keijinkai Hospital, 1-12-1-40 Maeda, Teine-ku, Sapporo, Hokkaido, 006-8555, Japan.
| | - Yayoi Ogawa
- Hokkaido Renal Pathology Center, Sapporo, Hokkaido, Japan
| | - Tamaki Takada
- Department of Nephrology, Teine Keijinkai Hospital, 1-12-1-40 Maeda, Teine-ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Izumi Yamaji
- Department of Nephrology, Teine Keijinkai Hospital, 1-12-1-40 Maeda, Teine-ku, Sapporo, Hokkaido, 006-8555, Japan
| | - Nobuyuki Ura
- Department of General Internal Medicine, Teine Keijinkai Hospital, Sapporo, Hokkaido, Japan
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Havill JP, Levine SM, Kuperman M, Hellmann DB, Geetha D. Falling through the cracks of vasculitis classification-a report of three patients. NDT Plus 2011; 4:327-30. [PMID: 25984180 PMCID: PMC4421729 DOI: 10.1093/ndtplus/sfr054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 03/16/2011] [Indexed: 12/02/2022] Open
Affiliation(s)
- John P Havill
- Division of Nephrology, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Stuart M Levine
- Division of Rheumatology, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Michael Kuperman
- Department of Pathology, Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | - David B Hellmann
- Division of Rheumatology, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Stangou M, Ekonomidou D, Giamalis P, Liakou H, Tsiantoulas A, Pantzaki A, Papagianni A, Efstratiadis G, Alexopoulos E, Memmos D. Steroids and azathioprine in the treatment of IgA nephropathy. Clin Exp Nephrol 2011; 15:373-380. [PMID: 21301920 DOI: 10.1007/s10157-011-0415-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Accepted: 01/17/2011] [Indexed: 11/26/2022]
Abstract
AIM IgA nephropathy (IgAN) is a very common glomerulonephritis among young adults, but the best therapeutic approach has not been fully elucidated. This study evaluated the effect of two different treatment regimes in IgAN, steroids alone or in combination with azathioprine. METHODS Among 122 patients with primary IgA nephropathy diagnosed in the 2000-2007 period, 22 fulfilled the inclusion criteria for the study: estimated glomerular filtration rate (eGRF) ≥30 ml/min/1.73 m(2), urine protein (Upr) ≥1 g/24 h, blood pressure (BP) <130/80 mmHg, and previous treatment with renin-angiotensin system inhibitors (RAASi) and polyunsaturated fatty acids (PFA) for at least 6 months. Patients were randomized to receive either methylprednisolone alone (MP group) or MP in combination with azathioprine (MP + Aza group) for 12 months, while treatment with RAASi + PFA continued unchanged in both groups. RESULTS At the completion of the trial, renal function in the MP group remained stable, eGFR from 52 ± 26.7 to 53.6 ± 27.3 ml/min/1.73 m(2), p = NS, and Upr decreased from 2.4 ± 0.9 to 0.8 ± 0.5 g/24 h, p < 0.001. In the MP + Aza group, eGFR slightly increased from 57.4 ± 28.7 to 66 ± 31 ml/min/1.73 m(2), p = NS, and Upr decreased from 2.4 ± 1 to 0.7 ± 0.7 g/24 h, p < 0.001. Four patients from the MP group with partial remission at the end of the trial had a complete response when converted to Aza. Eleven patients (5 from the MP and 6 from the MP + Aza group) relapsed after stopping treatment and were restarted on lower doses. CONCLUSIONS Both, steroid treatment alone and steroids in combination with azathioprine seem to be effective in reducing the severity of proteinuria and stabilizing renal function in IgAN. Patients who do not respond to steroids may have a better response with the combination of steroids and azathioprine.
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Affiliation(s)
- Maria Stangou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.
| | - Domniki Ekonomidou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Panagiotis Giamalis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Helen Liakou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Apostolis Tsiantoulas
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Afroditi Pantzaki
- Department of Histopathology, Hippokration Hospital, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - George Efstratiadis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Efstathios Alexopoulos
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Dimitrios Memmos
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
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Endo Y, Minato H, Taki R, Kato M, Kore-Eda S, Miyachi Y, Tanioka M. Myeloperoxidase-antineutrophil cytoplasmic antibody-negative microscopic polyangiitis with pulmonary haemorrhage and IgA nephropathy. Case Rep Dermatol 2011; 3:22-7. [PMID: 21931574 PMCID: PMC3175359 DOI: 10.1159/000324422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
AIM To report a case of a patient with myeloperoxidase-antineutrophil cytoplasmic antibody (ANCA)-negative microscopic polyangiitis (MPA) and IgA nephropathy associated with severe pulmonary haemorrhage. CASE REPORT A 59-year-old man presented with ANCA-negative systemic vasculitis accompanied by purpura, nephritis and pulmonary haemorrhage. A skin biopsy specimen revealed pandermal leucocytoclastic vasculitis without IgA deposition and a kidney biopsy showed mesangial nephritis with IgA deposition. Considering these findings, the patient was diagnosed as having MPA with IgA nephropathy. DISCUSSION In most cases, MPA presents with rapidly progressive necrotizing glomerulonephritis and sometimes lung haemorrhage, while IgA nephropathy is less common among MPA cases. As recent research suggested that in MPA immunoglobulin deposition in the kidney may be an exacerbating factor for renal dysfunction and poor prognosis, close observation is required in these cases.
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Affiliation(s)
- Yuichiro Endo
- Department of Dermatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Nasr SH, Fidler ME, Valeri AM, Cornell LD, Sethi S, Zoller A, Stokes MB, Markowitz GS, D'Agati VD. Postinfectious glomerulonephritis in the elderly. J Am Soc Nephrol 2010; 22:187-95. [PMID: 21051737 DOI: 10.1681/asn.2010060611] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Postinfectious glomerulonephritis (PIGN) is primarily a childhood disease that occurs after an upper respiratory tract infection or impetigo; its occurrence in older patients is not well characterized. Here, we report 109 cases of PIGN in patients ≥65 years old diagnosed by renal biopsy. The male to female ratio was 2.8:1. An immunocompromised background was present in 61%, most commonly diabetes or malignancy. The most common site of infection was skin, followed by pneumonia and urinary tract infection. The most common causative agent was staphylococcus (46%) followed by streptococcus (16%) and unusual gram-negative organisms. Hypocomplementemia was present in 72%. The mean peak serum creatinine was 5.1 mg/dl, and 46% of patients required acute dialysis. The most common light microscopic patterns were diffuse (53%), focal (28%), and mesangial (13%) proliferative glomerulonephritis. IgA-dominant PIGN occurred in 17%. Of the 72 patients with ≥3 months of follow-up (mean, 29 months), 22% achieved complete recovery, 44% had persistent renal dysfunction, and 33% progressed to ESRD. The presence of diabetes, higher creatinine at biopsy, dialysis at presentation, the presence of diabetic glomerulosclerosis, and greater tubular atrophy and interstitial fibrosis predicted ESRD. In summary, the epidemiology of PIGN is shifting as the population ages. Older men and patients with diabetes or malignancy are particularly at risk, and the sites of infection and causative organisms differ from the typical childhood disease. Prognosis for these older patients is poor, with fewer than 25% recovering full renal function.
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Affiliation(s)
- Samih H Nasr
- Mayo Clinic, Division of Anatomic Pathology, Hilton 10-20, 200 First Street, SW, Rochester, MN 55905, USA.
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