Awareness and Perceptions of the Impact of Tonsillectomy on the Level of Immunity and Autoimmune Diseases among the Adult Population in Abha City, Kingdom of Saudi Arabia

The widespread misconception that tonsillectomy leads to a decrease in immunity may lead to fear and avoidance of the operation. This can result in a deterioration of the situation, such as sleep-related breathing issues, frequent infections, and an increase in complications. The current research was conducted to assess the awareness and perception with respect to the impact of tonsillectomy on the immune system and to assess the awareness and perception of the relationship between autoimmune diseases and tonsillectomy. This 6-month descriptive cross-sectional online questionnaire survey was conducted among individuals who were 18 years and above living in Abha city, Saudi Arabia. Out of the 800 study subjects, 104 (13%) had undergone tonsillectomy. Statistically significant associations were found between age group, education, income, and occupation among those who had undergone tonsillectomy. Multivariate logistic regression analysis showed that ages 18-30 years and 31-40 years (OR: 2.36, 95% CI: 1.18-4.71, and OR: 1.46, 95% CI: 0.53-3.97) and education levels of high school, bachelors, and above (OR: 8.30, 95% CI: 3.05-22.58 and OR: 10.89, 95% CI: 4.23-28.05) were found to be associated with tonsillectomy status of the subjects. On the contrary, income levels of 5000-9000 and >9000 (OR: 0.65, 95% CI: 0.36-1.17 and OR: 0.78, 95%CI: 0.42-1.42) and male gender (OR: 0.79, 95% CI: 0.52-1.19) were found to be associated with non-tonsillectomy status of subjects. Almost 36% of study subjects thought that tonsillectomy affects immunity. Only 18% of study subjects thought that there is a relationship between tonsillectomy and autoimmune diseases. About one-third of the respondents had received this information from community members and social media. A small number of study subjects relied on public awareness programs. Therefore, social media can play a vital role in the community to remove misconceptions regarding tonsillectomy and its effect on immunity and autoimmune disease. Further educational interventional studies are required to see the correction to the public perception of tonsillectomy and its effect on immunity and autoimmune diseases.

The Role of Immune Modulation in Pathogenesis of IgA Nephropathy

IgA nephropathy (IgAN) is the most prevalent primary glomerulonephritis worldwide, with diverse clinical manifestations characterized by recurrent gross hematuria or microscopic hematuria, and pathological changes featuring poorly O-galactosylated IgA1 deposition in the glomerular mesangium. Pathogenesis has always been the focus of IgAN studies. After 50 years of research, most scholars agree that IgAN is a group of clinicopathological syndromes with certain common immunopathological characteristics, and multiple mechanisms are involved in its pathogenesis, including immunology, genetics, and environmental or nutritional factors. However, the precise pathogenetic mechanisms have not been fully determined. One hypothesis about the pathogenesis of IgAN suggests that immunological factors are engaged in all aspects of IgAN development and play a critical role. A variety of immune cells (e.g., dendritic cells, NK cells, macrophages, T-lymphocyte subsets, and B-lymphocytes, etc.) and molecules (e.g., IgA receptors, Toll-like receptors, complements, etc.) in innate and adaptive immunity are involved in the pathogenesis of IgAN. Moreover, the abnormality of mucosal immune regulation is the core of IgAN immunopathogenesis. The roles of tonsil immunity or intestinal mucosal immunity, which have received more attention in recent years, are supported by mounting evidence. In this review, we will explore the latest research insights on the role of immune modulation in the pathogenesis of IgAN. With a better understanding of immunopathogenesis of IgAN, emerging therapies will soon become realized.

New strategies and perspectives on managing IgA nephropathy

IgA nephropathy is an inflammatory renal disease characterised by the deposition of IgA in the glomerular mesangium and is the most commonly reported primary glomerulonephritis worldwide. Thirty to forty percent of patients with the disease develop progressive renal function decline, requiring renal replacement therapy within two decades of diagnosis. Despite this, accurate individual risk stratification at diagnosis and predicting treatment response remains a challenge. Furthermore, there are currently no disease specific treatments currently licensed to treat the condition due to long standing challenges in the nature and prevalence of the disease. Despite this, there have been exciting recent advances in the field that may represent paradigm shifts in the way IgA nephropathy is managed in the near future. In this review, we explore the evidence base informing current approaches to management and explore new strategies and future directions in the diagnosis and management of IgA nephropathy.

Tripterygium Wilfordii inhibits tonsillar IgA production by downregulating IgA class switching in IgA nephropathy

IgA nephropathy (IgAN) is characterized by high serum IgA levels and IgA deposition in the renal mesangium. Recent research has indicated that pathogenic IgA may originate from affected tonsils, where present enhancement of IgA production by IgA class switching and immuno-activation. Tripterygium Wilfordii (TW) was found to be especially effective in IgAN by its’ immunosuppression effect. Given this background, we investigated the mechanisms underlying the role of TW in the generation of IgA and IgA class switching in tonsillar GCs of IgAN patients. Immunohistochemistry and RT-PCR revealed that the expression of thymic stromal lymphopoietin (TSLP) and IgA inducing cytokines were decreased in the tonsils of IgAN patients with TW treatment compared with those without treatment, followed by significantly decreased of IgA-bearing cells. The location of TSLP and IgA inducing cytokines in tonsillar tissue was confirmed by double immunofluorescence. Importantly, TW inhibit TSLP and IgA production in isolated FDC-associated clusters. Serum TSLP levels were decreased and correlated with IgA downregulation in the tonsils and serum of IgAN patients. These data indicated that TW may be involved in IgA production in the tonsils of IgAN patients, inhibiting IgA class switching in IgAN patients through the cooperative roles of AID, TGF-β1, BAFF, and APRIL, highlighting a promising strategy for therapeutic intervention in IgAN.

Thymic stromal lymphopoietin in tonsillar follicular dendritic cells correlates with elevated serum immunoglobulin A titer by promoting tonsillar immunoglobulin A class switching in immunoglobulin A nephropathy

Immunoglobulin A (IgA) nephropathy (IgAN) is characterized by high serum IgA levels and IgA deposition in the renal mesangium. Previous studies suggest that elevated serum IgA partly originates from the tonsils. Here, we investigated the mechanisms of IgA production in the tonsils of patients with IgAN. Immunohistochemistry revealed that the number and relative percentage of IgA-bearing cells were significantly increased in the tonsils of IgAN patients. Compared with non-IgAN patients, enhanced IgA class switching and overexpression of thymic stromal lymphopoietin (TSLP), TSLP receptor (TSLPR), activation-induced cytidine deaminase (AID), transforming growth factor-β1 (TGF-β1), B cell-activating factor of the tumor necrosis factor family (BAFF), and a proliferation-inducing ligand (APRIL) were detected in follicular dendritic cells (FDCs) of tonsillar germinal centers from IgAN patients. Importantly, TSLP correlated with IgA production in isolated FDC-associated clusters. Serum TSLP levels were increased and correlated with IgA overexpression in the tonsils and serum of IgAN patients. These data indicated that TSLP overexpression in tonsillar FDCs may promote IgA class switching in IgAN patients through the cooperative roles of AID, TGF-β1, BAFF, and APRIL. Therefore, interactions between TSLP in FDCs and IgA production in tonsils may be an important mechanism contributing to the pathogenesis of IgAN.

The role of tonsillectomy in IgA nephropathy

The IgA nephropathy (IgAN) is a very common glomerulonephritis and can result in end-stage renal disease. From a clinical point of view, IgAN is characterised by repeated events of macrohaematuria associated with infections of the upper airways. In IgAN, the IgA released by the tonsillar lymphatic tissue into blood circulation are defective in glycosylation. These aberrant IgA can reach the glomeruli and deposit into mesangium causing an inflammation with cellular proliferation. The treatment is not yet well defined: steroids and immunosuppressive drugs are suggested in cases with a progressive disease. Tonsillectomy was proposed to reduce the infective events of upper airways and the lymphatic tissue producing undergalactosylated IgA. The experiences in literature coming from Asia report positive effects of tonsillectomy on IgAN. In patients with tonsillectomy, the renal signs improved (less haematuria and proteinuria) and the renal outcome was better (slower progression of renal damage). These were uncontrolled studies and tonsillectomy was associated with steroid and immunosuppressive treatment, so it is not possible to tell the real effect of tonsillectomy. In contrast, the European studies reported that the tonsillectomy was not associated with a better outcome of IgAN. A critical review of the subject reveals that most of the papers with positive results were uncontrolled retrospective experiences, while in a randomised controlled trial paper the advantages of tonsillectomy disappeared. In conclusion, this review, in agreement with the international guidelines, concludes that tonsillectomy does not play any role in the progression of IgAN.

Decreased expression of follicular dendritic cell-secreted protein correlates with increased immunoglobulin A production in the tonsils of individuals with immunoglobulin A nephropathy

Immunoglobulin A nephropathy (IgAN) is characterized by a qualitative abnormality of IgA in the circulation and IgA deposition in the renal mesangium. Recent research has indicated that pathogenic IgA may originate from affected tonsils. Follicular dendritic cell-secreted protein (FDC-SP), a small novel secretory protein that may regulate the induction of B-cell responses, has been suggested to control IgA production. Given this background, this study investigated the expression of FDC-SP and its correlation with IgA production in the tonsils of IgAN patients. Immunohistochemistry and reverse transcription-polymerase chain reaction were used to compare the expression of FDC-SP in the tonsils of IgAN patients with tonsillitis and of non-IgAN patients with chronic tonsillitis. The location of FDC-SP in tonsillar tissue was confirmed by double immunofluorescence. We found that FDC-SP expression significantly decreased and was correlated negatively with enhanced IgA production in the tonsils of IgAN patients. FDC-SP secreted by follicular dendritic cells may act on germinal center B cells and participate in the modulation of IgA generation in the tonsils. Our study demonstrated that FDC-SP may be involved in IgA production in the tonsils of IgAN patients, making this protein an attractive candidate immunomodulator, and highlighting a promising strategy for therapeutic intervention in IgAN.

Impact of tonsillectomy combined with steroid pulse therapy on immunoglobulin A nephropathy depending on histological classification: a multicenter study

BACKGROUND

In addition to corticosteroids and inhibition of the renin-angiotensin-aldosterone system, tonsillectomy with steroid pulse therapy (TSP) may have a beneficial impact on the clinical course of IgA nephropathy (IgAN). However, there is still much uncertainty regarding the indications for therapy, treatment protocol, and therapeutic options for IgAN.

METHODS

In this multicenter retrospective cohort study, we enrolled 284 patients with biopsy-proven IgAN who received TSP or corticosteroid therapy or conservative therapy. The effects of TSP on clinical remission (CR) were evaluated after a median follow-up period of 4.1 years in relation to histological classifications.

RESULTS

Among the 284 participants, 161 patients received TSP. During the observation time, 141 patients (49.6%) achieved CR, with a median time to remission of 397 days. In multivariate Cox regression analyses, TSP had an impact on achieving CR in only the group with histological grade 3 defined as glomerulosclerosis, crescent formation or adhesion to Bowman's capsule in 10-30% of all biopsied glomeruli, or mild cellular infiltration in the interstitium (hazard ratio (HR) 4.29, 95% confidence interval (95%CI) 1.88-11.19, P < 0.001). TSP independently contributed to a higher incidence of CR, particularly in the patient group showing evident mesangial hypercellularity (HR 2.54, 95%CI 1.38-5.08, P = 0.002).

CONCLUSIONS

TSP may have a beneficial effect on the clinical course in IgAN patients with mild to moderate glomerular and interstitial lesions, particularly with distinct mesangial cell proliferation.

Immunoglobulin and CD8⁺ T-cell distribution in histologically distinctive tonsils of individuals with tonsillar focal infection

CONCLUSION

This study demonstrated that the common immunological mechanism, which involves aberration of immunoglobulin and T-cell distribution in histologically distinctive tonsils, may be associated with the pathogenesis of tonsillar focal infection.

OBJECTIVES

Tonsillar focal infection comprises a group of relatively common diseases combined with chronic tonsillar infection, is associated with unusual immune responses in tonsils, and may cause lesions in another distant target organ. This study aimed to investigate the distribution of inflammatory T cells and T-cell regulatory elements, such as programmed cell death-1 (PD-1) and Fork head box protein 3 (Foxp3), immunoglobulin production, and histological characteristics in tonsils from patients with tonsillar focal infection.

METHODS

Immunohistochemistry and reverse transcription-polymerase chain reaction (PCR) were used to compare the expression of CD8(+) T cells, immunoglobulins, and cytokines associated with immunoglobulin production in the tonsils of patients with IgA nephropathy (IgAN), palmoplantar pustulosis (PPP), rheumatoid arthritis (RA), and chronic tonsillitis.

RESULTS

The overexpression of CD8(+) T cells combined with decreased expression of Foxp3 and PD-1 and the aberration of immunoglobulin production, which may be due to the elevated expression of activation-induced deaminase (AID), B-cell-activating factor of the TNF family (BAFF), supporting isotype switching, and B-cell survival in the histologically distinctive tonsils.

Tonsillectomy for IgA nephropathy: a meta-analysis

BACKGROUND

The efficacy of tonsillectomy in immunoglobulin A nephropathy (IgAN) remains controversial. Our meta-analysis was intended to investigate its efficacy as an adjunct or independent treatment.

STUDY DESIGN

Meta-analysis of prospective and retrospective studies using PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials.

SETTING & POPULATION

Patients with IgAN treated with or without tonsillectomy.

SELECTION CRITERIA FOR STUDIES

Studies that compared clinical remission or end-stage renal disease (ESRD) in patients with IgAN with or without tonsillectomy.

INTERVENTION

Tonsillectomy.

OUTCOMES

Clinical remission and ESRD.

RESULTS

14 studies (1,794 patients) were included and a random-effects model was applied. There were significantly greater odds of clinical remission with tonsillectomy (10 studies, 1,431 patients; pooled OR, 3.40; 95% CI, 2.58-4.48; P<0.001). Sensitivity analysis to exclude the effects of renin-angiotensin system inhibitors yielded consistent results (6 studies, 671 patients; pooled OR for remission, 2.80; 95% CI, 1.91-4.09; P<0.001). In subgroup analysis of the remission outcome, tonsillectomy plus steroid pulse therapy was superior to steroid pulse therapy alone (7 studies, 783 patients; pooled OR, 3.15; 95% CI, 1.99-5.01; P<0.001), and tonsillectomy plus conventional steroid therapy was superior to conventional steroid therapy alone (2 studies, 159 patients; pooled OR, 4.13; 95% CI, 1.23-13.94; P=0.02). Tonsillectomy was superior to general treatment (3 studies, 187 patients; pooled OR for remission, 2.21; 95% CI, 1.20-4.05; P=0.01). In addition, tonsillectomy was associated with decreased odds of ESRD (9 studies, 873 patients; pooled OR, 0.25; 95% CI, 0.12-0.52; P<0.001). 2 sensitivity analyses, one excluding studies with less than 5 years' follow-up and another excluding the confounding effect of renin-angiotensin system inhibitors, yielded nearly the same reduction in ESRD risk (6 studies, 691 patients; pooled OR, 0.20; 95% CI, 0.11-0.36; P<0.001; and 6 studies, 547 patients; pooled OR, 0.24; 95% CI, 0.14-0.44; P<0.001).

LIMITATIONS

Most included studies were retrospective cohort studies; we were unable to adjust uniformly for potential confounding variables.

CONCLUSIONS

As adjunct or independent therapy, tonsillectomy may induce clinical remission and reduce the rates of ESRD in patients with IgAN.

Effect of tonsillectomy and its timing on renal outcomes in Caucasian IgA nephropathy patients

PURPOSE

The role of tonsillectomy in the treatment of IgA nephropathy in Caucasian patients is controversial.

METHODS

A retrospective cohort study was conducted in 264 patients with biopsy-proven primary IgA nephropathy to examine the association between tonsillectomy and long-term renal survival, defined as the incidence of estimated glomerular filtration rates (eGFRs) of ≤30 ml/min/1.73 m(2) or end-stage renal disease (the composite of initiation of dialysis treatment or renal transplantation). The association of tonsillectomy with renal end-points was examined using the Kaplan-Meier method and Cox models.

RESULTS

One-hundred and sixty-six patients did not undergo tonsillectomy (Group I, follow-up 130 ± 101 months) and 98 patients underwent tonsillectomy (Group II, follow-up 170 ± 124 months). The mean renal survival time was significantly longer for both end-points between those patients who underwent tonsillectomy (Group II) versus patients without tonsillectomy (Group I) (p < 0.001 and p = 0.005). The mean renal survival time was significantly longer for both end-points between those patients who had macrohaematuric episodes versus patients who had no macrohaematuric episodes (p = 0.035 and p = 0.019). Tonsillectomy, baseline eGFR and 24-h proteinuria were independent risk factors for both renal end-points.

CONCLUSION

Tonsillectomy may delay the progression of IgA nephropathy mainly in IgA nephropathy patients with macrohaematuria. Prospective investigation of the protective role of tonsillectomy in Caucasian patients is needed.

The Relationship between the Efficacy of Tonsillectomy and Renal Pathology in the Patients with IgA Nephropathy

Objective. The aim of this study was to evaluate the effects of tonsillectomy as a treatment for IgA nephropathy in relation to renal pathological findings. Methods. This is a retrospective analysis of 13 patients having IgA nephropathy treated by tonsillectomy. Results. UP/UCre levels decreased from 820.8 to 585.4 one month postsurgery and then showed slight worsening to 637.3 at the most recent follow-up. There was no significant difference in the improvement rate between pathological grades I–III and IV. There was positive correlation between Pre-UP/UCre level and the reduction rate of UP/UCre, which was statistically significant (R = 0.667, R² = 0.445, and P = 0.01). Conclusions. Reduction of UP/UCre at one month postsurgery is considered to be an overall prognostic factor, and tonsillectomy is considered to be an effective therapy for IgA patients regardless of the grade of renal pathology.

IgG-Fc N-glycosylation at Asn297 and IgA O-glycosylation in the hinge region in health and disease

Immunoglobulins (Igs) are the major molecules secreted by B lymphocytes during an adaptive immune response. They are glycoproteins with distinctive glycosylation patterns, resulting in wide variations in the number, type and location of their oligosaccharides in each isotype and subclass. The sugars play specific structural roles, maintaining and modulating effector functions of Igs. Aberrant glycosylation might contribute to disease pathogenesis. This review will focus on the glycosylation of IgG and IgA because they have been studied more extensively than other immunoglobulins. Rheumatoid arthritis and IgA nephritis are used to describe the association of glycosylation aberration and disease pathogenesis.