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Towheed ST, Zanjir W, Ren KYM, Garland J, Clements-Baker M. Renal Manifestations of IgG4-Related Disease: A Concise Review. Int J Nephrol 2024; 2024:4421589. [PMID: 38957780 PMCID: PMC11217581 DOI: 10.1155/2024/4421589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 04/28/2024] [Accepted: 06/10/2024] [Indexed: 07/04/2024] Open
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated disorder marked by fibro-inflammatory masses that can infiltrate multiple organ systems. Due to its relatively recent discovery and limited understanding of its pathophysiology, IgG4-related disease may be difficult to recognize and is consequently potentially underdiagnosed. Renal involvement is becoming regarded as one of the key features of this disease. To date, the most well-recognized renal complication of IgG4-related disease is tubulointerstitial nephritis, but membranous glomerulonephritis, renal masses, and retroperitoneal fibrosis have also been reported. This concise review has two objectives. First, it will briefly encapsulate the history, epidemiology, and presentation of IgG4-related disease. Second, it will examine the reported renal manifestations of IgG4-related disease, exploring the relevant histology, imaging, clinical features, and treatment considerations. This synthesis will be highly relevant for nephrologists, rheumatologists, general internists, and renal pathologists to raise awareness and help improve early recognition of IgG4-related kidney disease (IgG4-RKD).
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2
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Gilani SI, Buglioni A, Cornell LD. IgG4-related kidney disease: Clinicopathologic features, differential diagnosis, and mimics. Semin Diagn Pathol 2024; 41:88-94. [PMID: 38246802 DOI: 10.1053/j.semdp.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Abstract
IgG4-related kidney disease (IgG4-RKD) encompasses all forms of kidney disease that are part of IgG4-related disease (IgG4-RD). First recognized as IgG4-related tubulointerstitial nephritis (IgG4-TIN), and then IgG4-related membranous glomerulonephritis (IgG4-MGN), we now recognize additional patterns of interstitial nephritis, glomerular disease, and vascular disease that can be seen as part of IgG4-RKD. The clinical presentation is variable and can include acute or chronic kidney injury, proteinuria or nephrotic syndrome, mass lesion(s), and obstruction. While usually associated with other organ involvement by IgG4-RD, kidney-alone involvement is present in approximately 20 % of IgG4-RKD. Compared to IgG4-RD overall, patients with IgG4-RKD are more likely to show increased serum IgG4 or IgG, and more likely to have hypocomplementemia. In this review, we extensively cover other types of autoimmune and plasma cell-rich interstitial nephritis, mass forming inflammatory diseases of the kidney, and other mimics of IgG4-TIN, in particular ANCA-associated disease.
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Affiliation(s)
- Sarwat I Gilani
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center at San Antonio, TX, USA
| | - Alessia Buglioni
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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3
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Nagahata K, Osanami A, Nakamura H, Amaike H, Kanda M, Takahashi H. IgG4-related tubulointerstitial nephritis: renal capsule-like rim. QJM 2023; 116:953-954. [PMID: 37369024 DOI: 10.1093/qjmed/hcad157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Indexed: 06/29/2023] Open
Affiliation(s)
- K Nagahata
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, South West 16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
| | - A Osanami
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
| | - H Nakamura
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, South West 16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
| | - H Amaike
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, South West 16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
| | - M Kanda
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, South West 16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
| | - H Takahashi
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, South West 16, Chuo-ku, Sapporo, Hokkaido 060-8543, Japan
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Soma Y, Kato M, Shimura G, Kamio M, Iida M. Renal biopsy diagnosis of IgG4-related kidney disease with minor hematuria and mild renal dysfunction: lessons for the clinical nephrologist. J Nephrol 2023; 36:639-642. [PMID: 36441499 DOI: 10.1007/s40620-022-01506-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/13/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Yu Soma
- Department of Nephrology, Yokosuka General Uwamachi Hospital, Yokosuka, Japan.
| | - Miku Kato
- Department of Nephrology, Yokosuka General Uwamachi Hospital, Yokosuka, Japan
| | - Gaku Shimura
- Department of Nephrology, Yokosuka General Uwamachi Hospital, Yokosuka, Japan
| | - Manabu Kamio
- Department of Internal Medicine, Yokosuka General Uwamachi Hospital, Yokosuka, Japan
| | - Maki Iida
- Department of Pathology, Yokosuka General Uwamachi Hospital, Yokosuka, Japan
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Hum RM, Elyoussfi S, Parker BJ, Reid G, Kanigicherla DA. A Case of IgG4-Related Disease and Membranous Nephropathy Associated with Thrombospondin Type-1 Domain-Containing 7A. GLOMERULAR DISEASES 2022; 2:139-144. [PMID: 36751668 PMCID: PMC9710322 DOI: 10.1159/000524014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 02/14/2022] [Indexed: 11/19/2022]
Abstract
Background IgG4-related disease (IgG4-RD) is a systemic multi-organ inflammatory disorder which affects the kidney 20% of the time. Patients with intrinsic IgG4-related kidney disease (IgG4-RKD) often have tubulointerstitial nephritis (TIN) whereas glomerular lesions like membranous nephropathy (MN) are less common. Antibodies to thrombospondin type-1 domain-containing 7A (THSD7A) have been described in primary MN, but never in association with IgG4-RKD. Case Report We report the first case of IgG4-MN associated with THSD7A antibodies in serum and positivity on glomerular staining, in a 57-year-old Caucasian male with IgG4-RD affecting the pancreas, liver, lacrimal glands, extraocular muscles, and kidneys. This patient presented initially with glomerular disease including significant proteinuria consistent with MN. Glomerular staining for THSD7A antigen and serum THSD7A antibody titres was positive. Treatment with corticosteroids and cyclophosphamide successfully induced remission with resolution of proteinuria, and improvement in renal function. However, despite maintenance azathioprine, the patient relapsed 39 months later. On relapse, there was minimal proteinuria but a significant rise in creatinine. Subsequent renal biopsy showed less glomerular disease and instead a TIN pattern. Subsequent treatment with Rituximab and corticosteroids successfully induced remission. Conclusion The role of THSD7A autoantibodies in MN is emerging, and as both IgG4-MN and presence of THSD7A antibody are rare occurrences in themselves, we speculate that there may be an undiscovered association between THSD7A and IgG4-MN. Routine testing for THSD7A in IgG4-MN may help to identify the link.
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Affiliation(s)
- Ryan Malcolm Hum
- Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, The University of Manchester, Manchester, UK,The Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK,Manchester Institute of Nephrology & Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK,*Ryan Malcolm Hum,
| | - Sarah Elyoussfi
- Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, The University of Manchester, Manchester, UK,Manchester Institute of Nephrology & Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Benjamin J. Parker
- Division of Musculoskeletal & Dermatological Sciences, School of Biological Sciences, The University of Manchester, Manchester, UK,The Kellgren Centre for Rheumatology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Graeme Reid
- Manchester Institute of Nephrology & Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK,Department of Adult Histopathology, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Durga A.K. Kanigicherla
- Manchester Institute of Nephrology & Transplantation, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
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6
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Al-Zubaidi M, McCombie S, Swarbrick N, Hayne D. Unique case of IgG4-related disease of the renal pelvis involving the inferior vena cava masquerading as locally advanced urothelial cancer. BMJ Case Rep 2022; 15:e247945. [PMID: 35131798 PMCID: PMC8823079 DOI: 10.1136/bcr-2021-247945] [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] [Accepted: 12/17/2021] [Indexed: 11/04/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic disease which can affect any organ or tissue in the body but most commonly affects the pancreas, biliary ducts, salivary glands, ocular system and lymph nodes; renal involvement is relatively uncommon and there are no previous reported cases of inferior vena cava involvement. Herein, a 48-year-old Asian man with an unremarkable medical history was found to have an obstructing right renal pelvis mass extending to and involving the inferior vena cava, highly suspicious for upper tract urothelial carcinoma that could not be ruled out based on ureteroscopy and urine cytology. Open radical nephroureterectomy with enbloc resection of a segment of the inferior vena cava and left renal vein ostium was performed, with reconstruction of the inferior vena cava and left renal vein with polytetrafluoroethylene grafts. Final histopathology confirmed the diagnosis of IgG4-related disease. This case demonstrates that IgG4-related disease can mimic upper tract urothelial cancer and should be considered as a diagnosis in atypical presentations of tumours of the upper urinary tract.
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Affiliation(s)
- Mohammed Al-Zubaidi
- Department of Urology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Steve McCombie
- Department of Urology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- Harry Perkins Institute of Medical Research, Murdoch, Western Australia, Australia
| | - Nicole Swarbrick
- Histopathlogy (Pathwest), Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Dickon Hayne
- Department of Urology, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
- Harry Perkins Institute of Medical Research, Murdoch, Western Australia, Australia
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Singh S, Pokhariyal S, Nandwani A, Duggal R. Diagnostic Dilemma: Cardiorenal Syndrome As an Unusual Presentation of IgG4-Related Disease. Indian J Nephrol 2022; 32:512-515. [PMID: 36568604 PMCID: PMC9775612 DOI: 10.4103/ijn.ijn_143_21] [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: 05/21/2021] [Revised: 08/05/2021] [Accepted: 09/14/2021] [Indexed: 12/27/2022] Open
Abstract
IgG4-related kidney disease (IgG4 RKD) is a rare clinical entity characterized by lymphoplasmacytic infiltration rich in IgG4-positive plasma cells along with fibrosis affecting several organs. Tubulointerstitial nephritis is commonly the predominant finding on kidney biopsy. Our patient was admitted with a provisional diagnosis of cardiorenal syndrome of unknown etiology. The patient was dialysis dependent for around 45 days following which kidney biopsy revealed features of acute tubulointerstitial nephritis (ATIN) with IgG4-positive plasma cells and no glomerular involvement. Positron emission tomography-computed tomography was supportive of findings of sialadenitis along with myocarditis. Our patient responded to treatment with steroids with definitive improvement in both renal and cardiac functions. This case highlights the importance of IgG4 RKD as an important differential in patients with ATIN presenting as a clinical syndrome.
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Affiliation(s)
- Shailendra Singh
- Department of Nephrology, Manipal Hospitals, Dwarka, Delhi, India,Address for correspondence: Dr. Shailendra Singh, Department of Nephrology, Associate Consultant, Manipal Hospitals, Dwarka, Delhi, India. E-mail:
| | | | - Ashish Nandwani
- Department of Nephrology, Manipal Hospitals, Dwarka, Delhi, India
| | - Rajan Duggal
- Department of Histopathology and Cytopathology, BLK Super Specialty Hospital, Delhi, India
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8
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Tian M, Luan J, Jiao C, Chang Q, Kopp JB, Zhou H. Co-occurrence of IgA nephropathy and IgG4-Tubulointersitial nephritis effectively treated with tacrolimus: a case report. BMC Nephrol 2021; 22:279. [PMID: 34384379 PMCID: PMC8358553 DOI: 10.1186/s12882-021-02477-w] [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: 05/24/2021] [Accepted: 07/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cases of concurrent immunoglobulin A nephropathy (IgAN) and IgG4-related tubulointerstitial nephritis (IgG4-TIN) are rare and previous case reports have lacked important data. KDIGO suggests a treatment with systemic glucocorticoids in IgAN patients. Glucocorticoids are recommended as the first-line therapy for IgG4-TIN. The use of tacrolimus as a long-term maintenance treatment has not been described. We report the case of a man who developed IgAN and IgG4-TIN without abnormalities in extra-renal tissue, without renal function abnormalities or impairment as well, and was treated by tacrolimus as a long-term maintenance during 45 months follow-up. CASE PRESENTATION A 56-year-old Chinese man first presented to our hospital with the chief complaint of foamy urine for 1 year and hematuria for 3 months, with a medical history of hypertension. Testing revealed a notable increase in serum IgG4 level without abnormalities in renal function or imaging, or in dysfunction other organs. Renal biopsy showed mesangial extracellular matrix proliferation, increased mesangial cell numbers and infiltration of plasma cells. Immunofluorescence showed mesangial positivity for IgA and C3. Immunohistochemistry staining showed widespread IgG4 and increased CD38 and CD138 expression. Electron microscopy showed immune complexes located on the tubular basement membrane. He was diagnosed with IgAN and IgG4-TIN. He received glucocorticoids, leflunomide and tacrolimus to induce remission. He was given tacrolimus as long-term maintenance treatment. When tacrolimus was temporarily withdrawn, proteinuria recurred. After resuming tacrolimus therapy, he again entered complete remission. After 45 months of therapy, he remains in complete remission and the serum IgG4 level is normal. CONCLUSIONS The finding of concurrent IgAN and IgG4-TIN without abnormalities in renal function, imaging or extra-renal tissue is rare and their coexistence may be coincidental. Long-term treatment with tacrolimus proved effective and he has remained in remission during 45 months follow-up.
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Affiliation(s)
- Mi Tian
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao St, Shenyang, 110004, Liaoning, China
| | - Junjun Luan
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao St, Shenyang, 110004, Liaoning, China
| | - Congcong Jiao
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao St, Shenyang, 110004, Liaoning, China
| | - Qing Chang
- Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jeffrey B Kopp
- Renal Diagnostics and Therapeutics Unit, NIDDK/NIH, Bethesda, MD, USA
| | - Hua Zhou
- Department of Nephrology, Shengjing Hospital of China Medical University, 36 Sanhao St, Shenyang, 110004, Liaoning, China.
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9
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Liu B, Huang Y, Tang L, Guan J, Zhou X, Zhan H. Inflammatory pseudotumor of Castleman disease and IgG4-related disease masquerading as kidney malignancy. Diagn Pathol 2021; 16:74. [PMID: 34376196 PMCID: PMC8353839 DOI: 10.1186/s13000-021-01134-y] [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: 02/17/2021] [Accepted: 07/28/2021] [Indexed: 12/24/2022] Open
Abstract
Background With widespread clinical application of imaging techniques, renal space-occupying lesions have been identified at an increasing frequency. Here, we report two rare cases, Castleman disease (CD) and IgG4-related disease (IgG4-RD), presenting primarily with the symptoms and imaging findings of kidney malignancy. Case presentation In case 1, an occupying lesion located in the right renal pelvis was detected using magnetic resonance imaging in a 32-year-old female who presented with hematuria and lumbago. First misdiagnosed as carcinoma of the renal pelvis, the patient underwent right radical nephroureterectomy. However, postoperative pathological and immunohistochemistry studies finally confirmed the diagnosis of CD. In case 2, a 45-year-old male presented with the chief complaint of anuria. Nephrostomy and renal biopsy indicated lymphoma, following which, antegrade urography and computed tomography urography were performed, which revealed bilateral hydronephrosis and mass lesions around the renal pelvis. Partial resection of the masses and frozen section examination indicated the diagnosis of CD. However, the results of postoperative histopathology and immunohistochemistry combined with serum IgG4 were consistent with IgG4-RD. Both the patients recovered well after drug treatment without recurrence of the diseases. Conclusions Inflammatory pseudotumor of CD and IgG4-RD with kidney involvement are primarily diagnosed by postoperative histopathology and can pose a preoperative diagnostic challenge because these lesions can masquerade as kidney malignancy. Therefore, we recommend core biopsy as a nonnegligible procedure to evaluate renal masses and potentially prevent unnecessary surgical treatment.
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Affiliation(s)
- Bolong Liu
- Department of Urology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yong Huang
- Department of Urology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Luying Tang
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jiexia Guan
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xiangfu Zhou
- Department of Urology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
| | - Hailun Zhan
- Department of Urology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China.
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10
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Capecchi R, Giannese D, Moriconi D, Bonadio AG, Pratesi F, Croia C, Egidi MF, Puxeddu I, Tavoni AG, Migliorini P. Renal Involvement in IgG4-Related Disease: From Sunlight to Twilight. Front Med (Lausanne) 2021; 8:635706. [PMID: 33869249 PMCID: PMC8044528 DOI: 10.3389/fmed.2021.635706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/10/2021] [Indexed: 12/12/2022] Open
Abstract
IgG4-Related Disease (IgG4-RD) is a fibroinflammatory condition characterized by a typical histopathological pattern (dense lymphoplasmacytic infiltrate with prevalent IgG4+ plasma cells and storiform fibrosis), which may involve the kidney both directly (IgG4-related kidney disease, IgG4-RKD) or indirectly, as a consequence of post-renal ureteral obstruction due to retroperitoneal fibrosis (IgG4-RD RF). The most frequent presentation of IgG4-RKD is IgG4-related tubulointerstitial nephritis (TIN), but a glomerular disease can be present, in most of the cases a membranous nephropathy. Albeit steroid-responsive, in some cases renal manifestations may lead to progressive and permanent organ damage. In this review we describe four clinical cases representative of typical and less typical renal manifestations of IgG4-RD, emphasizing a potential, subclinical, early involvement of the kidney in the disease.
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Affiliation(s)
- Riccardo Capecchi
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Domenico Giannese
- Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Diego Moriconi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy.,Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | | | - Federico Pratesi
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Cristina Croia
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Maria F Egidi
- Nephrology, Dialysis and Transplantation Unit, Azienda Ospedaliero Universitaria Pisana, Pisa, Italy
| | - Ilaria Puxeddu
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Antonio G Tavoni
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Paola Migliorini
- Clinical Immunology and Allergy Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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11
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Spatola L, Ravera F, Sghirlanzoni MC, Verdesca S, Menegotto A, Querques M, Camozzi ML, Colombo V, Minetti EE. An enigmatic case of IgG4-related nephropathy and an updated review of the literature. Clin Exp Med 2021; 21:493-500. [PMID: 33683496 DOI: 10.1007/s10238-021-00696-x] [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: 10/29/2020] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
IgG4-related disease (IgG4-RD) is still an underestimated disorder which affects multiple organs, and its recognition as a distinct clinical disease has been only proved in the recent decades. The renal involvement has been documented in approximately 15% of patients with IgG4-RD, and the typical manifestation is a tubulo-interstitial nephritis. The main histological findings in IgG4-RD are typically a dense tissue infiltration of IgG4-positive plasma cells, storiform fibrosis, obliterative phlebitis, and frequently elevated IgG4 serum levels. Herein we report our atypical and peculiar clinical presentation of an IgG4-related nephropathy (IgG4-RN) and the remarkable response to rituximab (RTX) treatment at the renal imaging with computerized tomography assessment. The current nephrological evidences support the renal function recovery after steroids or steroids plus RTX therapy, even if the renal imaging data are not always shown. In a complex and enigmatic clinical scenario such as the IgG4-RN, both the renal biopsy and the renal imaging before and after the immunosuppressive therapy become mandatory tools to thoroughly define the diagnosis, the management and the response to the immunological therapy.
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Affiliation(s)
- Leonardo Spatola
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy.
| | - Federica Ravera
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
| | - Maria Chiara Sghirlanzoni
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
| | - Simona Verdesca
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
| | - Alberto Menegotto
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
| | - Marialuisa Querques
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
| | - Mario Livio Camozzi
- Division of Pathology, ASST Grande Ospedale Territoriale Niguarda, 20162, Milan, Italy
| | - Valeriana Colombo
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
| | - Enrico Eugenio Minetti
- Division of Nephrology, Dialysis and Renal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162, Milan, Italy
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12
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Quattrocchio G, Barreca A, Demarchi A, Fenoglio R, Ferro M, Del Vecchio G, Massara C, Rollino C, Sciascia S, Roccatello D. Long-term effects of intensive B cell depletion therapy in severe cases of IgG4-related disease with renal involvement. Immunol Res 2020; 68:340-352. [PMID: 33174125 PMCID: PMC7674183 DOI: 10.1007/s12026-020-09163-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/30/2020] [Indexed: 12/19/2022]
Abstract
IgG4-related disease (IgG4-RD) is an immune-mediated disorder often showing elevated serum IgG4 concentrations, dense T and B lymphocyte infiltration, and IgG4-positive plasma cells and storiform fibrosis. We prospectively evaluated for 4 years 5 patients with histologically proven IgG4-RD of whom 3 had tubulointerstitial nephritis (TIN) and 2 had retroperitoneal fibrosis (RPF). They received an intensive B depletion therapy with rituximab. The estimated glomerular filtration rate of TIN patients after 1 year increased from 9 to 24 ml/min per 1.73 m2. IgG/IgG4 dropped from 3236/665 to 706/51 mg/dl, C3/C4 went up from 49/6 to 99/27 mg/dl, and the IgG4-RD responder index fell from 10 to 1. CD20+ B cells decreased from 8.7 to 0.5%. A striking drop in interstitial plasma cell infiltrate as well as normalization of IgG4/IgG-positive plasma cells was observed at repeat biopsy. Both clinical and immunological improvement persisted over a 4-year follow-up. Treating these patients who were affected by aggressive IgG4-RD with renal involvement in an effort to induce a prolonged B cells depletion with IgG4 and cytokine production decrease resulted in a considerable rise in eGFR, with IgG4-RD RI normalization and a noteworthy improvement in clinical and histological features. Furthermore, the TIN subgroup was shown not to need for any maintenance therapy.
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Affiliation(s)
- Giacomo Quattrocchio
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy.
| | - Antonella Barreca
- Department of Biomedical Sciences, University of Turin, Turin, Italy
| | | | - Roberta Fenoglio
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Michela Ferro
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Giulio Del Vecchio
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Carlo Massara
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Cristiana Rollino
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Savino Sciascia
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Universitary Unit, and Center of Research of Immunopathology and Rare Diseases (CMID) San Giovanni Bosco Hospital, and Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
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13
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Oh JW, Rha SE, Choi MH, Oh SN, Youn SY, Choi JI. Immunoglobulin G4-related Disease of the Genitourinary System: Spectrum of Imaging Findings and Clinical-Pathologic Features. Radiographics 2020; 40:1265-1283. [PMID: 32870766 DOI: 10.1148/rg.2020200043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disease characterized by focal or diffuse organ infiltration of IgG4-bearing plasma cells. The diagnosis of IgG4-RD is based on a combination of clinical, serologic, radiologic, and histopathologic findings. IgG4-RD has been reported to affect almost all organ systems. The kidney is the most frequently involved of the genitourinary organs. The most common renal manifestation of IgG4-RD is IgG4-RD tubulointerstitial nephritis, followed by membranous glomerulonephropathy and, less frequently, obstructive nephropathy involving the renal pelvis, ureter, or retroperitoneum. Renal parenchymal lesions may appear as multiple nodular lesions, diffuse patchy infiltrative lesions, or a single nodular lesion. Multiple small nodular cortical lesions are the most common imaging findings of IgG4-RD involving the kidney. Renal pelvic, sinus, or perinephric lesions can also occur. IgG4-RD involvement of other genitourinary organs including the ureter, bladder, urethra, and male and female reproductive organs is rare compared with kidney involvement but may show variable imaging findings such as a localized mass within or surrounding the involved organ or diffuse enlargement of the involved organ. Imaging findings of IgG4-RD involving the genitourinary system are nonspecific but should be differentiated from inflammatory and neoplastic lesions that mimic IgG4-RD. The online slide presentation from the RSNA Annual Meeting is available for this article. ©RSNA, 2020.
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Affiliation(s)
- Ji Woon Oh
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Sung Eun Rha
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Moon Hyung Choi
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Soon Nam Oh
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Seo Yeon Youn
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
| | - Joon-Il Choi
- From the Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea (J.W.O., S.E.R., S.N.O., S.Y.Y., J.C.); and Department of Radiology, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (M.H.C.)
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14
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Bhattad PB, Joseph DL, Peterson E. IgG4-Related Disease Manifesting as Hypocomplementemic Tubulointerstitial Nephritis: A Rare Case Report and Literature Review. J Investig Med High Impact Case Rep 2020; 8:2324709620952213. [PMID: 32830581 PMCID: PMC7448130 DOI: 10.1177/2324709620952213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/20/2020] [Accepted: 07/27/2020] [Indexed: 11/29/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a chronic fibrosing inflammatory systemic disorder that has been recognized relatively recently in the medical literature. Little is known about the exact disease pathogenesis and epidemiology. IgG4-RD may be asymptomatic or may have minimal symptoms or involve multiple organs with overt symptoms. The different phenotypes of IgG4-RD can lead to delayed or incorrect diagnosis. We report the case of a 66-year-old male with coal worker's pneumoconiosis who presented with progressive kidney disease and was diagnosed with tubulointerstitial nephritis due to IgG4-RD. The patient was noted to have progressive kidney disease, skin involvement, worsening interstitial lung disease, complete vision loss in the left eye, and retroperitoneal fibrosis. Serologic workup revealed elevated inflammatory markers, IgG4 and IgG1 levels, and hypocomplementemia. A tissue biopsy helped us establish a definitive diagnosis of IgG4-RD and initiate treatment with glucocorticoids to prevent further progression of kidney disease and other end-organ damage.
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Affiliation(s)
| | - David L. Joseph
- James H. Quillen Veterans Affairs Medical Center, Johnson City, TN, USA
| | - Eric Peterson
- James H. Quillen Veterans Affairs Medical Center, Johnson City, TN, USA
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15
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Aljishi M, Thet Z, Han T, Madhan K. Acute Tubulointerstitial Nephritis as a Sole Manifestation of Immunoglobulin G4-Related Disease. J Med Cases 2019; 10:348-353. [PMID: 34434307 PMCID: PMC8383568 DOI: 10.14740/jmc3395] [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: 12/01/2019] [Accepted: 12/10/2019] [Indexed: 11/23/2022] Open
Abstract
This is a case report of a patient who developed severe acute kidney disease with kidney biopsy showing interstitial nephritis, plasma cell infiltration and immunoglobulin G4 (IgG4) expression consistent with IgG4-related kidney disease. There were no other systemic features of IgG4-related disease. The patient was treated with corticosteroids and mycophenolate. This case highlights the need to consider IgG4-related kidney disease even in the absence of other systemic features. Isolated renal involvement is underrecognized and can lead to missed diagnosis. It also illustrates that mycophenolate can be used as a steroid sparing agent in this condition; an observation that adds to the limited literature in this field.
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Affiliation(s)
- Manaf Aljishi
- Renal Department, Rockhampton Hospital, Queensland, Australia.,University of Queensland, St Lucia QLD 4072, Australia
| | - Zaw Thet
- Renal Department, Rockhampton Hospital, Queensland, Australia
| | - Thin Han
- Medicine and Nephrology, Rockhampton Hospital, Rockhampton QLD 4700, Australia
| | - Krishan Madhan
- Renal Medicine Department, Hervey Bay Hospital, Queensland, Australia
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16
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Abstract
RATIONALE IgG4-related disease (IgG4-RD) is a systemic chronic inflammatory disorder that can affect almost every organ. IgG4-RD includes IgG4-related kidney disease (IgG4-RKD), but lesions affecting the kidney alone or first are very rare, and a complete understanding is lacking. Computed tomography (CT) and magnetic resonance imaging (MRI) findings can show the typical characteristics of IgG4-RKD and provide information for accurate and rapid diagnosis. PATIENT CONCERNS We report a case of a 60-year-old woman who was admitted to our hospital for dizziness and instability while walking, her bilateral eyelids were also slightly swollen. She had no medical history. DIAGNOSES CT and MRI images of the patient revealed multiple local and diffuse patchy lesions in the bilateral renal parenchyma and mass-like tissue in the bilateral renal pelvis, accompanied by right hydronephrosis. A pathological examination of renal samples showed numerous lymphocyte and plasma cell infiltration. Immunohistochemistry demonstrated approximately 50% of the IgG-positive plasma cells to be IgG4+. The serum IgG level was obviously elevated, with both C3and C4 levels were reduced. The patient was diagnosed with IgG4-RKD. INTERVENTIONS The patient received corticosteroid therapy at another hospital. OUTCOMES The bilateral kidney lesions were smaller on follow-up CT images. LESSONS IgG4-RKD exhibits some characteristic imaging features. Despite the relatively low incidence of IgG4-RKD, it should be included in differential diagnoses when images show multiple lesions in kidneys with mild and delayed enhancement and hypointensity on T2WI in middle-aged to elderly patients.
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17
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Zhang NN, Wang YY, Kong LX, Zou WZ, Dong B. IgG4-related kidney disease (IgG4-RKD) with membranous nephropathy as its initial manifestation: report of one case and literature review. BMC Nephrol 2019; 20:263. [PMID: 31311519 PMCID: PMC6635993 DOI: 10.1186/s12882-019-1419-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 06/11/2019] [Indexed: 12/14/2022] Open
Abstract
Background IgG4-related disease (IgG4-RD) often affects multiple organs and tissues, especially the kidneys, and is characterized by interstitial nephritis, obstructive nephropathy, and in rare cases glomerulopathy (including membranous nephropathy). Case presentation In this article, we report a patient with nephrotic syndrome as the only initial manifestation. Membranous nephropathy was confirmed by renal biopsy, but without any renal interstitial lesions. The nephrotic syndrome completely resolved after treatment with immunosuppressants but recurred after drug withdrawal, which was accompanied by acute kidney injury. Ultimately, IgG4-related interstitial nephritis with membranous nephropathy was confirmed by a second renal biopsy. After routine administration of steroids and cyclophosphamide, renal function returned to normal after 2 months, and nephrotic syndrome was ameliorated after 5 months. Conclusion Special attention should be paid to this rare condition in the clinical setting. In patients with membranous nephropathy (MN) that is accompanied by multi-system damage, impaired renal function, elevated IgG4 levels (absolute or relative value), negative PLA2R, and/or renal interstitial plasma cell infiltration, the possibility of IgG4-related kidney disease (IgG4-RKD) should be carefully assessed.
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Affiliation(s)
- Nan-Nan Zhang
- Department of Nephrology, Fangshan Hospital of Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Yan-Yun Wang
- Department of Nephrology, Fangshan Hospital of Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Ling-Xin Kong
- Department of Nephrology, Fangshan Hospital of Beijing University of Chinese Medicine, Beijing, 102400, China.
| | - Wan-Zhong Zou
- Department of Nephrology, People's Hospital of Peking University, Beijing, 110102, China
| | - Bao Dong
- Department of Nephrology, People's Hospital of Peking University, Beijing, 110102, China
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18
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Wong ETY, Lahiri M, Teh M, Leo CCH. IgG4-Related Kidney Disease: A Curious Case of Interstitial Nephritis with Hypocomplementemia. Case Rep Nephrol Dial 2019; 9:49-54. [PMID: 31192228 PMCID: PMC6547283 DOI: 10.1159/000500296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/10/2019] [Indexed: 01/13/2023] Open
Abstract
IgG4-related kidney disease has been relatively newly recognized over the last two decades as a combination of an autoimmune and allergic disorder, with elevated serum IgG4 level and hypocomplementemia among its characteristic features. Here we report the case of a man with interstitial nephritis presenting with acute kidney injury and hypocomplementemia but normal serum IgG4 level and provide a literature review of IgG4-related kidney disease. This case highlights the importance of IgG4-related kidney disease as an important differential diagnosis in any patient presenting with a clinical syndrome mimicking acute interstitial nephritis with hypocomplementemia. A high index of suspicion with a low threshold for performing a native kidney biopsy would be paramount as patients do respond well to corticosteroid therapy.
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Affiliation(s)
- Emmett Tsz Yeung Wong
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore, Singapore
| | - Manjari Lahiri
- Division of Rheumatology, University Medicine Cluster, National University Hospital, Singapore, Singapore
| | - Ming Teh
- Department of Pathology, National University Hospital, Singapore, Singapore
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19
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Pucar PA, Nolan J, Hissaria P. Immunoglobulin G 4 related disease: a single-centre experience from South Australia. Intern Med J 2019; 49:1099-1104. [PMID: 31059167 DOI: 10.1111/imj.14331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 04/16/2019] [Accepted: 04/27/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND IgG4 related disease (IgG4RD) is a newly described multisystem fibro-inflammatory disorder. There is a paucity of literature describing the Australian experience of this rare condition. AIMS To characterise the Royal Adelaide Hospital IgG4RD cohort with biopsy-proven disease. METHODS A search of the Frome Road SA Pathology database was performed for all tissue biopsies containing the phrase 'IgG4 positive'. Case notes were reviewed for clinical details, laboratory and radiology results. Histological features according to the Boston Criteria were used. Patients with available case notes, highly suggestive or probable histology and clinical features to suggest IgG4RD were included. RESULTS Twenty patients had definite or probable IgG4RD and suggestive clinical features; median age 59 (20-76), male : female 1.5:1. There was considerable delay in diagnosis (median diagnosis at 64 months). Organ involvement included: 11 exocrine gland, seven pancreatobiliary, seven nodal, seven soft tissue, five retro-orbital, three retroperitoneal fibrosis and two renal. Systemic symptoms at diagnosis were seen in eight patients. Seven (35%) had an elevated serum IgG4 (>1.35 g/L) at diagnosis. Only 12 (60%) required immunosuppressive treatment (corticosteroids); of these, four (20%) required a steroid-sparing agent and four (20%) required B-cell depleting therapy (rituximab). The median duration of follow up was 18 months. CONCLUSIONS This is the first characterised Australian cohort with generalised IgG4RD, a rare, relatively indolent and under-recognised multisystem disorder. Diagnosis is difficult given lack of awareness of this rare condition among physicians, its presentation as a great disease mimic, challenges with histopathological assessment and the absence of a suitable serum biomarker.
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Affiliation(s)
- Phillippa A Pucar
- Immunology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Immunology Department, SA Pathology, Adelaide, South Australia, Australia
| | - James Nolan
- Department of Anatomical Pathology, SA Pathology, Adelaide, South Australia, Australia
| | - Pravin Hissaria
- Immunology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Immunology Department, SA Pathology, Adelaide, South Australia, Australia
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20
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Kawano M, Saeki T, Nakashima H. IgG4-related kidney disease and retroperitoneal fibrosis: An update. Mod Rheumatol 2019; 29:231-239. [DOI: 10.1080/14397595.2018.1554321] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Hitoshi Nakashima
- Faculty of Medicine, Division of Nephrology and Rheumatology, Department of Internal Medicine, Fukuoka University, Fukuoka, Japan
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21
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Wang R, He D, Zhao L, Liang S, Liang D, Xu F, Zhang M, Zhu X, Chen H, Xie H, Zeng C, Tang Z, Liu Z. Role of complement system in patients with biopsy-proven immunoglobulin G4–related kidney disease. Hum Pathol 2018; 81:220-228. [DOI: 10.1016/j.humpath.2018.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/25/2018] [Accepted: 07/03/2018] [Indexed: 12/19/2022]
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22
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DeQuattro K, Urisman A, Margaretten M. A 36-Year-Old Man With Renal Failure, Fever, and Hypocomplementemia. Arthritis Care Res (Hoboken) 2018; 71:449-455. [PMID: 30295438 DOI: 10.1002/acr.23770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/25/2018] [Indexed: 01/05/2023]
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23
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Arai H, Toda N, Kamimatsuse R, Nishioka K, Endo S, Akiyama S, Maruyama S, Matsubara T, Yokoi H, Yanagita M. A Refractory Case of Secondary Membranous Nephropathy Concurrent with IgG4-related Tubulointerstitial Nephritis. Intern Med 2018; 57:2873-2877. [PMID: 29709946 PMCID: PMC6207830 DOI: 10.2169/internalmedicine.0836-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A 58-year-old man with type 1 autoimmune pancreatitis was referred to nephrologists for severe proteinuria. Laboratory data revealed a high serum IgG4 level, hypoalbuminemia, and massive proteinuria, which were compatible with nephrotic syndrome. The renal pathological findings confirmed the diagnosis of secondary membranous nephropathy concurrent with IgG4-related tubulointerstitial nephritis. Despite the improvement of interstitial markers, the proteinuria was refractory to prednisolone, requiring cyclosporine to achieve complete remission. Membranous nephropathy is a rare manifestation of IgG4-related kidney disease. This case shows that the therapeutic response to prednisolone significantly differs between glomerular lesions and interstitial lesions of IgG4-related kidney disease.
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Affiliation(s)
- Hiroyuki Arai
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
| | - Naohiro Toda
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
| | - Ryo Kamimatsuse
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
- Department of Nephrology, Kyoto City Hospital, Japan
| | - Keisuke Nishioka
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
- Department of Nephrology, Osaka Red Cross Hospital, Japan
| | - Shuichiro Endo
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
| | - Shinichi Akiyama
- Division of Nephrology, Department of Internal Medicine, Nagoya University, Graduate School of Medicine, Japan
| | - Shoichi Maruyama
- Division of Nephrology, Department of Internal Medicine, Nagoya University, Graduate School of Medicine, Japan
| | - Takeshi Matsubara
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
| | - Hideki Yokoi
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
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24
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Abstract
Immunoglobulin G4-related disease is a fibroinflammatory systemic disease that is characterized by focal or diffuse organ infiltration by immunoglobulin G4-bearing plasma cells. Immunoglobulin G4-related disease may affect any organ, and a high index of suspicion is necessary for early detection to avoid irreversible fibrosis, organ dysfunction, and death. Tumor-forming lesions are common radiological features of immunoglobulin G4-related disease that need to be differentiated from malignancies. The diagnostic approach requires the integration of clinical, biochemical, and radiographic manifestations with classic histopathologic features, which remain crucial to diagnosis. The histology of immunoglobulin G4-related disease is determined by a dense lymphoplasmacytic infiltrate, storiform fibrosis, and obliterative phlebitis in the presence of increased immunoglobulin G4-positve plasma cells. Although immunoglobulin G4-related disease forms a distinct, clinically independent disease category, many questions and problems remain unanswered, especially on its pathogenesis and the role of immunoglobulin G4. Advances in the understanding of immunoglobulin G4-related disease are likely to change the diagnostic approach in the future and create potential targets for therapeutic purposes. Here we describe the concept of immunoglobulin G4-related disease and the most recent knowledge in the clinico-pathological characteristics on this emerging disease. This study can guide clinicians in early diagnosis and prevent unnecessary surgical resections.
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Affiliation(s)
| | | | - Metin Özdemirli
- Department of Pathology, Medstar Georgetown University Hospital, Washington, USA
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25
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Quattrocchio G, Barreca A, Demarchi A, Solfietti L, Beltrame G, Fenoglio R, Ferro M, Mesiano P, Murgia S, Del Vecchio G, Massara C, Rollino C, Roccatello D. IgG4-related kidney disease: the effects of a Rituximab-based immunosuppressive therapy. Oncotarget 2018; 9:21337-21347. [PMID: 29765543 PMCID: PMC5940417 DOI: 10.18632/oncotarget.25095] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 03/24/2018] [Indexed: 12/17/2022] Open
Abstract
IgG4-related disease (IgG4-RD) is a recently recognized disorder, characterized by elevated serum IgG4 concentrations, dense tissue infiltration of IgG4-positive plasma cells and storiform fibrosis. Treatment is usually based on steroids, however, relapses and long-term adverse effects are frequent. We prospectively studied 5 consecutive patients with histologically-proven IgG4-RD and renal involvement, treated with an extended Rituximab protocol combined with steroids. Two doses of intravenous cyclophosphamide were added in 4 patients. Five patients with IgG-RD were investigated: three had tubulointerstitial nephritis (TIN), while two had retroperitoneal fibrosis (RPF). In the patients with TIN, renal biospy was repeated after 1 year. In the patients with TIN, estimated glomerular filtration rate (eGFR) at 12 months increased from 9 to 24 ml/min per 1.73 m2; IgG/IgG4 decreased from 3,236/665 to 706/51 mg/dl; C3/C4 increased from 49/6 to 99/27 mg/dl; CD20+ B-cells decreased from 8.7% to 0.5%; Regulatory T-cells decreased from 7.2% to 2.5%. These functional and immunologic changes persisted at 24 months and in two patients at 36 months. A repeat renal biopsy in the patients with TIN showed a dramatic decrease in interstitial plasma cell infiltrate with normalization of IgG4/IgG positive plasma cells. The patients with RPF showed a huge regression of retroperitoneal tissue. In this sample of patients with aggressive IgG4-RD and renal involvement, treatment aimed at depleting B cells and decreasing antibody and cytokine production was associated with a substantial, persistent increase in eGFR, and a definite improvement in immunologic, radiologic and histological parameters.
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Affiliation(s)
- Giacomo Quattrocchio
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Andrea Demarchi
- Surgical Pathology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Laura Solfietti
- Center of Research of Immunopathology and Rare Diseases (CMID), San Giovanni Bosco Hospital, and University of Turin, Turin, Italy
| | - Giulietta Beltrame
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Roberta Fenoglio
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Michela Ferro
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Paola Mesiano
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Stefano Murgia
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Giulio Del Vecchio
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Carlo Massara
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Cristiana Rollino
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy.,Center of Research of Immunopathology and Rare Diseases (CMID), San Giovanni Bosco Hospital, and University of Turin, Turin, Italy
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26
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Salvadori M, Tsalouchos A. Immunoglobulin G4-related kidney diseases: An updated review. World J Nephrol 2018; 7:29-40. [PMID: 29359118 PMCID: PMC5760510 DOI: 10.5527/wjn.v7.i1.29] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/10/2017] [Accepted: 12/28/2017] [Indexed: 02/06/2023] Open
Abstract
This review will encompass definition, pathogenesis, renal clinical manifestations and treatment of immunoglobulin G4-related diseases (IgG4-RDs). IgG4-RD is a recently recognized clinical entity that often involves multiple organs and is characterized by high levels of serum immunoglobulins G4, dense infiltration of IgG4+ cells and storiform fibrosis. Cellular immunity, particularly T-cell mediated immunity, has been implicated in the pathogenesis of IgG4-RDs. The most frequent renal manifestations of IgG4-RD are IgG4-related tubulointerstitial nephritis, membranous glomerulopathy and obstructive nephropathy secondary to urinary tract obstruction due to IgG4-related retroperitoneal fibrosis. IgG4-RD diagnosis should be based on specific histopathological findings, confirmed by tissue immunostaining, typical radiological findings and an appropriate clinical context. The first line treatment is the steroids with two warnings: Steroid resistance and relapse after discontinuation. In the case of steroid resistance, B cell depleting agents as rituximab represent the second-line treatment. In the case of relapse after discontinuation, steroid treatment may be associated with steroid sparing agents. Since the disease has been only recently identified, more prospective, long-term studies are needed to an improved understanding and a more correct and safe treatment.
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Affiliation(s)
- Maurizio Salvadori
- Renal Unit, Department of Transplantation, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Division of Nephrology, Nephrology and Dialysis Unit, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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27
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Zheng K, Teng F, Li XM. Immunoglobulin G4-related kidney disease: Pathogenesis, diagnosis, and treatment. Chronic Dis Transl Med 2017; 3:138-147. [PMID: 29063068 PMCID: PMC5643773 DOI: 10.1016/j.cdtm.2017.05.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Indexed: 12/19/2022] Open
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a recently recognized clinical entity that often involves multiple organs; it is characterized by high levels of serum immunoglobulin G4 (IgG4), dense infiltration of IgG4+ cells, and storiform fibrosis. Cellular immunity, particularly T cell-mediated immunity, has been implicated in the pathogenesis of IgG4-RD. The most frequent renal manifestations of IgG4-RD are IgG4-related tubulointerstitial nephritis, membranous glomerulonephropathy (MGN), and obstructive nephropathy secondary to urinary tract obstruction due to IgG4-related retroperitoneal fibrosis, prostatitis, or ureter inflammation. Kidney function impairment can be acute or chronic. In IgG4-MGN, proteinuria can be in the nephrotic range. The diagnosis of IgG4-related kidney disease should not be based solely on serum IgG4 levels or the number of tissue-infiltrating IgG4+ plasma cells. Diagnosis should be based on specific histopathological findings, confirmed by tissue immunostaining and an appropriate clinical context. Steroid treatment is the first-line therapy. For relapsing or refractory cases, immunosuppressants could be combined with steroids. In hydronephrosis patients, appropriate immunosuppressive therapy could preclude the implantation of a double J ureteral catheter.
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Abo M, Takato H, Watanabe S, Kase K, Sakai T, Koba H, Hara J, Sone T, Kimura H, Kasahara K. Immunoglobulin G4-related disease preceded by lung involvement: A case report. Medicine (Baltimore) 2017; 96:e7086. [PMID: 28614225 PMCID: PMC5478310 DOI: 10.1097/md.0000000000007086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Immunoglobulin G4-related disease (IgG4-RD) is a systemic condition involving various organs and vessels including the pancreas, bile duct, salivary glands, periorbital tissues, kidneys, lungs, lymph nodes, meninges, and aorta. Recently, some cases of IgG4-RD have been reported, in which only pulmonary lesions were present. It is not known whether IgG4-RD can be diagnosed on the basis of pulmonary lesions only, because increases in serum IgG4 levels and infiltration of IgG4-positive plasma cells into the lung tissue also occur in other inflammatory conditions. A case of IgG-RD that was followed-up for 7 years after onset is described. PATIENT CONCERNS Initially, only pulmonary lesions were present; however, other lesions in the submandibular glands, pancreas, periarterial region, and other areas occurred over time, with a gradual increase in serum IgG4 levels. DIAGNOSES, INTERVENTIONS, AND OUTCOMES Histopathology results from the patient's submandibular gland confirmed the diagnosis of IgG4-RD. Following diagnosis, the patient was treated with corticosteroids immediately, and his symptoms disappeared rapidly. LESSONS Because other diseases, including malignancies, mimic IgG4-RD in clinical and histopathological features, an absolute diagnosis is necessary to avoid missing the presence of underlying diseases. This case more provides insight into the clinical pathology of IgG4-RD.
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Huart J, Grosch S, Bovy C, Moutschen M, Krzesinski JM. IgG4-related membranous glomerulonephritis and generalized lymphadenopathy without pancreatitis: a case report. BMC Nephrol 2017; 18:139. [PMID: 28446143 PMCID: PMC5405476 DOI: 10.1186/s12882-017-0561-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/20/2017] [Indexed: 12/24/2022] Open
Abstract
Background IgG4-related disease is a recently described pathologic entity. This is the case of a patient with nephrotic syndrome and lymphadenopathy due to IgG4-related disease. Such a kidney involvement is quite peculiar and has only been described a few times recently. Renal biopsy showed a glomerular involvement with membranous glomerulonephritis in association with a tubulo-interstitial nephropathy. Moreover, the patient was not suffering from pancreatitis. Case presentation The patient is a middle-aged man of Moroccan origin. He has developed recurrent episodes of diffuse lymphadenopathies, renal failure and nephrotic syndrome. Renal biopsies showed membranous glomerulonephritis. Discussion and conclusion The diagnostic approach of this atypical presentation is discussed in this case report as well as diagnostic criteria, therapeutic strategies, biomarkers and pathophysiology of IgG4-related disease. IgG4-related membranous glomerulonephritis is a well-established cause of membranous glomerulonephritis. It must be sought after in every patient with a previous diagnosis of IgG4-related disease and in every patient with this histological finding on renal biopsy. Corticoids are still the first-line treatment of IgG4-related disease. New therapeutic strategies are needed to avoid glucocorticoids long term side-effects. Interestingly, the patient was prescribed cyclophosphamide in addition to glucocorticoids for an immune thrombocytopenia. This treatment had a very good impact on his IgG4-related disease.
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Affiliation(s)
- Justine Huart
- Division of Nephrology, University of Liège Hospital (ULg CHU), Liège, Belgium.
| | - Stéphanie Grosch
- Division of Nephrology, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Christophe Bovy
- Division of Nephrology, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Michel Moutschen
- Division of Infectious diseases and General Internal Medecine, University of Liège Hospital (ULg CHU), Liège, Belgium
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Zhang P, Cornell LD. IgG4-Related Tubulointerstitial Nephritis. Adv Chronic Kidney Dis 2017; 24:94-100. [PMID: 28284385 DOI: 10.1053/j.ackd.2016.12.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Revised: 12/01/2016] [Accepted: 12/01/2016] [Indexed: 12/18/2022]
Abstract
Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a fibroinflammatory disorder that can involve nearly any organ. The disorder has increasingly become known as a distinct clinical entity during the last decade. IgG4-related tubulointerstitial nephritis (IgG4-TIN) is the most common manifestation of IgG4-RD in the kidney. Many patients with IgG4-TIN are diagnosed after IgG4-RD has been recognized in other organ systems, but the kidney may also be the first or only site involved. The presenting clinical features of IgG4-TIN are most commonly kidney insufficiency, kidney mass lesion(s), or both. On biopsy, IgG4-TIN shows a dense lymphoplasmacytic infiltrate, increased IgG4+ plasma cells, storiform fibrosis, and often tubular basement membrane immune complex deposits. Elevation of serum IgG4 often accompanies IgG4-RD; however, it is not specific in reaching the diagnosis. Like IgG4-RD in other organs, IgG4-TIN characteristically responds promptly to steroids, although there is a high relapse rate on discontinuation of immunosuppression. The pathogenesis of IgG4-RD is not understood.
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Lin W, Zhang P, Chen H, Chen Y, Yang H, Zheng W, Zhang X, Zhang F, Zhang W, Lipsky PE. Circulating plasmablasts/plasma cells: a potential biomarker for IgG4-related disease. Arthritis Res Ther 2017; 19:25. [PMID: 28183334 PMCID: PMC5301376 DOI: 10.1186/s13075-017-1231-2] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 01/12/2017] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Immunoglobulin G4 (IgG4)-related disease (IgG4-RD) is a multisystem fibroinflammatory disease. We previously reported that a circulating cell population expressing CD19+CD24-CD38hi was increased in patients with IgG4-RD. In this study, we aimed to document that this cell population represented circulating plasmablasts/plasma cells, to identify the detailed phenotype and gene expression profile of these IgG4-secreting plasmablasts/plasma cells, and to determine whether this B-cell lineage subset could be a biomarker in IgG4-related disease (IgG4-RD). METHODS A total of 42 untreated patients with IgG4-RD were evaluated. Peripheral B-cell subsets, including CD19+CD24-CD38hi plasmablasts/plasma cells, CD19+CD24+CD38- memory B cells, CD19+CD24intCD38int naïve B cells, and CD19+CD24hiCD38hi regulatory B cells, were assessed and sorted by flow cytometry. Microarray analysis was used to measure gene expression of circulating B-cell lineage subsets. Further characterization of CD19+CD24-CD38hi plasmablasts/plasma cells was carried out by evaluating additional surface markers, including CD27, CD95, and human leukocyte antigen (HLA)-DR, by flow cytometric assay. In addition, various B-cell lineage subsets were cultured in vitro and IgG4 concentrations were measured by cytometric bead array. RESULTS In untreated patients with IgG4-RD, the peripheral CD19+CD24-CD38hi plasmablast/plasma cell subset was increased and positively correlated with serum IgG4 levels, the number of involved organs, and the IgG4-related Disease Responder Index. It decreased after treatment with glucocorticoids. Characterization of the plasmablast/plasma cell population by gene expression profiling documented a typical plasmablast/plasma cell signature with higher expression of X-box binding protein 1 and IFN regulatory factor 4, but lower expression of paired box gene 5 and B-cell lymphoma 6 protein. In addition, CD27, CD95, and HLA-DR were highly expressed on CD19+CD24-CD38hi plasmablasts/plasma cells from patients with IgG4-RD. Furthermore, CD19+CD24-CD38hi plasmablasts/plasma cells secreted more IgG4 than other B-cell populations. CONCLUSIONS Circulating CD19+CD24-CD38hi plasmablasts/plasma cells are elevated in active IgG4-RD and decreased after glucocorticoid treatment. This IgG4-secreting plasmablast/plasma cell population might be a potentially useful biomarker for diagnosis and assessing response to treatment.
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Affiliation(s)
- Wei Lin
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.,Department of Rheumatology, Hebei General Hospital, Shijiazhuang, China
| | - Panpan Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Hua Chen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Yu Chen
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Hongxian Yang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Wenjie Zheng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Xuan Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China
| | - Fengxiao Zhang
- Department of Rheumatology, Hebei General Hospital, Shijiazhuang, China
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, 100730, China.
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Katabathina VS, Khalil S, Shin S, Lath N, Menias CO, Prasad SR. Immunoglobulin G4-Related Disease: Recent Advances in Pathogenesis and Imaging Findings. Radiol Clin North Am 2017; 54:535-51. [PMID: 27153787 DOI: 10.1016/j.rcl.2015.12.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a novel, immune-mediated, multisystem disease characterized by the development of tumefactive lesions in multiple organs. IgG4-RD encompasses many fibroinflammatory diseases that had been thought to be confined to single organs. Delayed diagnosis or misdiagnosis as malignancies leading to aggressive treatment may be averted by identification of the multisystem nature of IgG4-RD. Most cases show exquisite response to steroid therapy; steroid-resistant cases are being treated by novel therapeutic agents, including B-cell depleting agents such as rituximab. Cross-sectional imaging studies play a pivotal role in the initial diagnosis, assessing response to therapy and long-term surveillance.
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Affiliation(s)
- Venkata S Katabathina
- Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - Suhare Khalil
- Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Sooyoung Shin
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Narayan Lath
- Department of Radiology, Singapore General Hospital, Outram road, Singapore 169608, Singapore
| | | | - Srinivasa R Prasad
- Department of Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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IgG4-Related Kidney Disease in a Patient With History of Breast Cancer: Findings on 18F-FDG PET/CT. Clin Nucl Med 2017; 41:e388-9. [PMID: 27187735 DOI: 10.1097/rlu.0000000000001252] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A 64-year-old African American woman with history of stage III breast carcinoma, 3 years after complete response to therapy, presents with progressive fatigue, increasing arthralgia, and unintentional weight loss of 15 lb in 3 months. An F-FDG PET demonstrated new diffuse FDG avidity of the renal parenchyma, new FDG-avid foci in pancreas and lungs, and new FDG-avid lymph nodes above and below the diaphragm. While a retroperitoneal lymph node biopsy was inconclusive, a kidney biopsy resulted in diagnosis of diffuse, severe, IgG4-related tubulointerstitial nephritis. Treatment with corticosteroid led to complete resolution of the symptoms and PET findings.
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Kobayashi H, Uehara M, Oda A, Matsubara E, Baba H, Matsumiya R, Yoshikawa N, Hosono O, Tanaka H. Normal pressure hydrocephalus, a possible complication in IgG4-related disease. INTERDISCIPLINARY NEUROSURGERY 2016. [DOI: 10.1016/j.inat.2016.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
Immunofluorescence staining plays a vital role in nephropathology, but the panel of antibodies used has not changed for decades. Further classification of immunoglobulin (Ig)G-containing immune-type deposits with IgG subclass staining (IgG1, IgG2, IgG3, and IgG4) has been shown to be of diagnostic utility in glomerular diseases, but their value in the evaluation of renal biopsies has not been addressed systematically in large renal biopsy material. Between January 2007 and June 2014, using direct immunofluorescence, we stained every renal biopsy for the IgG subclasses if there was moderate to prominent glomerular IgG staining and/or IgG-predominant or IgG-codominant glomerular staining. The total number of biopsies stained was 1084, which included 367 cases of membranous glomerulonephritis, 307 cases of lupus nephritis, 74 cases of fibrillary glomerulonephritis, 53 cases of proliferative glomerulonephritis with monoclonal IgG deposits, and 25 cases of antiglomerular basement membrane disease, among others. We found that monoclonality of IgG deposits cannot always be reliably determined on the basis of kappa and lambda light chain staining alone, particularly if concomitant (frequently nonspecific) IgM staining is present. In IgG heavy and heavy and light chain deposition disease (3 cases), subclass staining is very helpful, and in proliferative glomerulonephritis with monoclonal IgG deposits subclass staining is necessary. IgG subclass staining is useful in differentiating primary from secondary membranous glomerulonephritis. In proliferative glomerulonephritis with polyclonal IgG deposition, IgG1 dominance/codominance with concomitant IgG3 and IgG2 but weak or absent IgG4 staining favors an underlying autoimmune disease. IgG subclass staining is a very useful diagnostic method in a selected cohort of renal biopsies, particularly in biopsies with glomerulonephritis with monoclonal IgG deposits.
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Dillon J, Dart A, Sutherland T. Imaging features of immunoglobulin G4-related disease. J Med Imaging Radiat Oncol 2016; 60:707-713. [PMID: 27562417 DOI: 10.1111/1754-9485.12511] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 07/23/2016] [Indexed: 12/20/2022]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a fibroinflammatory condition that was first recognised as a systemic disease in 2003, when patients with autoimmune pancreatitis were found to have extrapancreatic manifestations. Since 2003, IgG4-RD has been described in a diverse range of other organs including the biliary tree, orbits, lacrimal glands, salivary glands, lungs, kidneys, aorta, retroperitoneum, lymph nodes, pachymeninges, prostate and pituitary gland. The disease frequently occurs in the absence of pancreatic involvement. The imaging manifestations of IgG4-RD are broad and variable depending on the organ involved. The majority of individual organ appearances are non-specific and differentiation between IgG4-RD and potentially more serious conditions is not usually possible based on radiological findings in one organ alone. However, if there are simultaneous findings typical of IgG4-RD in multiple organs then this is a key diagnostic clue and IgG4-RD should be considered as one of the main differentials. This review article examines the spectrum of imaging appearances of IgG4-RD. Increased awareness of the spectrum of radiological appearances of IgG4-RD throughout the body and subsequent consideration of the condition may potentially avoid invasive treatment and lead to more prompt corticosteroid therapy.
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Affiliation(s)
- Jonathan Dillon
- Medical Imaging Department, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Andrea Dart
- Norwest Medical Imaging, Bella Vista, New South Wales, Australia
| | - Tom Sutherland
- Medical Imaging Department, St Vincent's Hospital, Melbourne, Victoria, Australia
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Multicentric Castleman Disease With Tubulointerstitial Nephritis Mimicking IgG4-related Disease: Two Case Reports. Am J Surg Pathol 2016; 40:495-501. [PMID: 26598921 DOI: 10.1097/pas.0000000000000575] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Multicentric Castleman disease is a benign lymphoproliferative disorder with heterogenous clinical symptoms and involves systemic organs in addition to lymph nodes. Elevated serum IgG4 levels and IgG4-positive plasma cell (IgG4+PC) infiltrates have been reported in lymph nodes, lung and skin in some multicentric Castleman disease cases, resembling IgG4-related disease (IgG4-RD) histologically. However, no report has been available regarding IgG4+PC infiltration in the kidneys of multicentric Castleman disease. Here, we report 2 cases of multicentric Castleman disease complicated by IgG4-related disease (IgG4-RD) histologically. However, there has been no report published on PC-rich tubulointerstitial nephritis, lymphadenopathy, with numerous IgG4+PC infiltration, and elevated serum IgG4 levels, mimicking IgG4-RD. The blood examinations revealed systemic inflammation and elevated C-reactive protein and interleukin-6 levels. Corticosteroid therapy was partially effective in both cases, and combination therapy of corticosteroid and tocilizumab was needed in both cases. Moreover, after triple therapy with corticosteroid, rituximab and cyclophosphamide were used in 1 case to tame the severe inflammation. The present cases suggest that if continuously elevated serum C-reactive protein levels and partial corticosteroid responsiveness are encountered, multicentric Castleman disease should be considered rather than IgG4-RD as a differential diagnosis even if serum IgG4 is elevated and IgG4+PCs infiltrate systemic organs.
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Lu Z, Yin J, Bao H, Jiao Q, Wu H, Wu R, Xue Q, Wang N, Zhang Z, Wang F. Coexistence of Acute Crescent Glomerulonephritis and IgG4-Related Kidney Disease. Case Rep Nephrol Dial 2016; 6:89-95. [PMID: 27504450 PMCID: PMC4965529 DOI: 10.1159/000448025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 06/28/2016] [Indexed: 12/24/2022] Open
Abstract
Introduction IgG4-related disease (IgG4-RD) is a fibroinflammatory disorder that may involve almost each organ or system. IgG4-related kidney disease (IgG4-RKD) refers to renal lesions associated with IgG4-RD. The most frequent morphological type of renal lesions is IgG4-related tubulointerstitial nephritis (IgG4-TIN) which is associated with increased IgG4-positive plasma cell infiltration and interstitial fibrosis. Case Report Herein, we present a rare case with coexisting IgG4-RKD and acute crescent glomerulonephritis with concomitant severe tubulointerstitial lesions instead of classic IgG4-TIN. Conclusion IgG4-RKD and acute crescent glomerulonephritis can occur in the same patient. This case may give us a clearer viewpoint of the disease.
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Affiliation(s)
- Zeyuan Lu
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jianyong Yin
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hongda Bao
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qiong Jiao
- Department of Pathology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Huijuan Wu
- Department of Pathology, Fudan University School of Medicine, Shanghai, China
| | - Rui Wu
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qin Xue
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Niansong Wang
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zhigang Zhang
- Department of Pathology, Fudan University School of Medicine, Shanghai, China
| | - Feng Wang
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Mann S, Seidman MA, Barbour SJ, Levin A, Carruthers M, Chen LYC. Recognizing IgG4-related tubulointerstitial nephritis. Can J Kidney Health Dis 2016; 3:34. [PMID: 27429760 PMCID: PMC4947514 DOI: 10.1186/s40697-016-0126-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/02/2016] [Indexed: 12/24/2022] Open
Abstract
PURPOSE OF THE REVIEW Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disorder affecting nearly all organs, including the kidney. Tubulointerstitial nephritis (IgG4-TIN) is the most common form of IgG4-related kidney disease (IgG4-RKD) and is the focus of this concise review. OBJECTIVE The study aims to describe when IgG4-TIN should be suspected and to summarize the diagnosis, treatment, and natural history of the disease. SOURCES OF INFORMATION Ovid MEDLINE, Google Scholar, and PubMed were searched for full-text English language articles up to January 2016. References included in the manuscript were chosen at the authors' discretion based on their relevance to the subject of the review. FINDINGS IgG4-TIN should be considered in patients presenting with abnormal urinalysis, abnormal kidney function, renal lesions on imaging, and elevated IgG, IgE, or hypocomplementemia. Diagnosis of IgG4-TIN requires a combination of histologic features (plasma cell-enriched TIN with >10 IgG4+ plasma cells/hpf, +/- TBM immune complex deposits in many cases) and at least one of the following:Characteristic radiologic findings (small peripheral low-attenuation cortical nodules, round or wedge-shaped lesions, or diffuse patchy involvement)Elevated serum IgG4 levelCharacteristic findings of IgG4-RD in other organs Other conditions such as lupus, vasculitis, diabetic nephropathy, and lymphoma must be excluded, as these can also present with IgG4+ plasma cells in the renal parenchyma. IgG4-TIN is generally responsive to steroids and B cell depletion with rituximab, but relapses are common and patients require close long-term follow-up. LIMITATIONS Available data on IgG4-TIN are from retrospective observational studies. IMPLICATIONS IgG4-TIN is a distinct and emerging subtype of interstitial nephritis. Nephrologists must be aware of this entity and how to definitively diagnose and treat it. Prospective studies and ideally multi-center clinical trials are needed to study the epidemiology, treatment, and natural history of this disease.
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Affiliation(s)
- Shawna Mann
- />Department of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver,, BC V5Z 1M9 Canada
| | - Michael A. Seidman
- />Department of Pathology and Laboratory Medicine, Providence Health Care, 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Sean J. Barbour
- />Division of Nephrology, University of British Columbia, 2775 Laurel Street, 5th Floor, Vancouver, BC BC V5T 3A5 Canada
| | - Adeera Levin
- />Division of Nephrology, University of British Columbia, 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Mollie Carruthers
- />Division of Rheumatology, University of British Columbia, 839 West Broadway, Vancouver, BC V5Z 1J9 Canada
| | - Luke Y. C. Chen
- />Division of Hematology, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, BC V5Z 1M9 Canada
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Utility of FDG PET/CT for Differential Diagnosis of Patients Clinically Suspected of IgG4-Related Disease. Clin Nucl Med 2016; 41:e237-43. [DOI: 10.1097/rlu.0000000000001153] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Quattrocchio G, Roccatello D. IgG4-related nephropathy. J Nephrol 2016; 29:487-93. [PMID: 26972314 DOI: 10.1007/s40620-016-0279-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 01/31/2016] [Indexed: 02/08/2023]
Abstract
IgG4-related disease (IgG4-RD) is a recently recognized disorder, often with multiple organ involvement, characterized by dense tissue infiltration of IgG4-positive plasma cells, storiform fibrosis, obliterative phlebitis and frequently elevated serum IgG4 concentration. The kidney can be involved either directly or indirectly. The most frequent direct renal manifestations of IgG4-RD are IgG4-related tubulointerstitial nephritis (TIN) and membranous glomerulonephropathy. Retroperitoneal fibrosis (RPF) is another condition that is frequently IgG4-related and that can indirectly affect the kidney causing ureteral obstruction and hydronephrosis. Contrast-enhanced computerized tomography, magnetic resonance imaging and (18)F-fluorodeoxyglucose positron emission tomography/computed tomography show different imaging findings and are useful tools for monitoring therapeutic response. Steroid treatment is the first line of therapy, but relapsing or refractory forms of the disease are frequently observed and require more aggressive therapeutic approaches. At our centre, we treated three cases of aggressive IgG4-related TIN and two cases of IgG4-related RPF with an intensified, immune suppressive protocol, obtaining good results without severe adverse effects.
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Affiliation(s)
- Giacomo Quattrocchio
- Nephrology and Dialysis Unit, Giovanni Bosco Hospital, Turin, Italy. .,Second level Master in Practical Rheumatology, University of Turin, Turin, Italy.
| | - Dario Roccatello
- Nephrology and Dialysis Unit, Giovanni Bosco Hospital, Turin, Italy.,Department of Rare, Immunologic, Center of Research of Immunopathology and Rare Diseases (CMID), Hematologic and Immunohematologic Diseases, Giovanni Bosco Hospital, Turin, Italy.,University of Turin, Turin, Italy
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Abstract
Interstitial nephritis is responsible for about 12 % of end-stage renal disease in Germany. It comprises an etiologically heterogenous group of inflammatory renal disorders which primarily affect the renal interstitium and tubuli. Drugs, predominantly antibiotics, nonsteroidal anti-inflammatory drugs and proton pump inhibitors are causative in the majority of cases. Rheumatic diseases frequently affect the kidneys, either the glomeruli or the interstitial tissues. Inflammatory interstitial processes can be accompanied by complex functional tubular disorders. This review gives an overview about clinical and laboratory findings of interstitial nephritis in the context of rheumatic diseases. Sarcoidosis, tubulointerstitial nephritis and uveitis (TINU) syndrome, primary Sjogren's syndrome, and IgG4-related disease often show an interstitial nephritis when the kidneys are affected. Other diseases, such as systemic lupus erythematosus, systemic sclerosis, drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome, and granulomatosis with polyangiitis are more rarely associated with predominant interstitial nephritis. Glucocorticoids are the mainstay of therapy for most cases; in refractory cases or when side effects occur, second-line immunosuppressants such as mycophenolate mofetil, azathioprine and others, rarely biologics, can be used.
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Affiliation(s)
- P Korsten
- Klinik für Nephrologie und Rheumatologie, Universitätsmedizin Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Deutschland
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Saeki T, Kawano M, Mizushima I, Yamamoto M, Wada Y, Ubara Y, Nakashima H, Ito T, Yamazaki H, Narita I, Saito T. Recovery of renal function after glucocorticoid therapy for IgG4-related kidney disease with renal dysfunction. Clin Exp Nephrol 2016; 20:87-93. [PMID: 26141243 PMCID: PMC4756038 DOI: 10.1007/s10157-015-1140-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 06/17/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although renal dysfunction in IgG4-related kidney disease (IgG4-RKD) shows rapid resolution with glucocorticoid therapy, little is known about the appropriate initial glucocorticoid dose for induction therapy or long-term renal outcome. METHODS We retrospectively examined the differences in recovery of renal function according to the dose of glucocorticoid used for induction therapy and the long-term renal outcome in 43 patients with definite IgG4-RKD (mostly IgG4-tubulointerstitial nephritis), in whom the estimated glomerular filtration rate (eGFR) before glucocorticoid therapy was <60 ml/min. RESULTS Most patients were treated with glucocorticoid alone and had been maintained on glucocorticoid. The initial dose of prednisolone employed was ≤0.6 mg/kg/day (mean 0.47) in 27 patients (group L), and >0.6 mg/kg/day (mean 0.81) in 16 patients (group H). In both groups, the pretreatment eGFR was significantly improved at 1 month after the start of glucocorticoid therapy and the degree of improvement showed no significant inter-group difference. Relapse of IgG4-RKD occurred in 16.7% of the group L patients and 13.3% of the group H patients (p = 0.78). Among 29 patients who were followed up for over 36 months (mean 74 months) and had been maintained on glucocorticoid, none showed progression to end-stage renal disease and there was no significant difference between eGFR at 1 month after treatment and eGFR at the last review. CONCLUSION In glucocorticoid monotherapy for IgG4-RKD, a moderate dose is sufficient for induction, and recovery of renal function can be maintained for a long period on low-dose maintenance, although relapse can occur even in patients receiving maintenance therapy.
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Affiliation(s)
- Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Senshu 2-297-1, Nagaoka, 940-2085, Japan.
| | - Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Ichiro Mizushima
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Motohisa Yamamoto
- Department of Gastroenterology, Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yoko Wada
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yoshifumi Ubara
- Nephrology Center and Okinaka Memorial Institute, Toranomon Hospital, Tokyo, Japan
| | - Hitoshi Nakashima
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Tomoyuki Ito
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Senshu 2-297-1, Nagaoka, 940-2085, Japan
| | - Hajime Yamazaki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Senshu 2-297-1, Nagaoka, 940-2085, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takao Saito
- General Medical Research Center, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
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IgG4-related disease: what urologists should know. Int Urol Nephrol 2016; 48:301-12. [DOI: 10.1007/s11255-015-1189-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 12/13/2015] [Indexed: 12/24/2022]
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Qiao X, Wang L, Wang C, Gao L, Yao S, Wu L, Zhang X. IgG4-related tubulointerstitial nephritis associated with only lymphadenopathy and without elevated serum IgG4 or renal imaging abnormalities: a case report and literature review. Int J Clin Exp Med 2015; 8:19548-19555. [PMID: 26770608 PMCID: PMC4694508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 10/13/2015] [Indexed: 06/05/2023]
Abstract
IgG4-related tubulointerstitial nephritis (IgG4-TIN) is the most common renal manifestation of IgG4-related kidney disease (IgG4-RKD) and may cause acute or chronic renal dysfunction. Imaging often shows heterogeneous densities in the kidneys, such as a mass or multiple nodules. Serology usually demonstrates high levels of serum IgG4 and total IgG. Most patients have other organs involvement by IgG4 related disease. Although lymphadenopathy is frequently observed in patients with IgG4-TIN, it is rarely presented as the only extrarenal lesion. Herein, we present a rare case of IgG4-TIN associated with only lymphadenopathy and without elevated serum IgG4 or renal imaging abnormalities. A 61-year-old Chinese man was admitted to our hospital with seven months history of generalized lymphadenopathy and five months history of renal dysfunction. His renal imaging was normal. He had no current or previous clinical, radiographic, and/or histologic evidence of other organ involvement except for the lymphadenopathy. Renal biopsy indicated plasma cell-rich TIN with an increased number of IgG4-positive plasma cells and storiform fibrosis. Repeated lymph nodes biopsy revealed IgG4-related lymphadenopathy. However, he did not have elevated serum IgG4 or total IgG levels. Oral prednisone therapy improved his renal function and lymphadenopathy. These findings supported our final diagnosis of IgG4-TIN. Clinicians should be aware of this condition and steroid therapy should be considered for such patients. An early diagnosis and appropriate therapy can induce remission and preserve renal function.
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Affiliation(s)
- Xi Qiao
- Department of Nephrology, Second Hospital of Shanxi Medical UniversityWu Yi Road 382, Taiyuan 030001, Shanxi, China
- Shanxi Kidney Disease InstituteWu Yi Road 382, Taiyuan 030001, Shanxi, China
| | - Lihua Wang
- Department of Nephrology, Second Hospital of Shanxi Medical UniversityWu Yi Road 382, Taiyuan 030001, Shanxi, China
- Shanxi Kidney Disease InstituteWu Yi Road 382, Taiyuan 030001, Shanxi, China
| | - Chen Wang
- Department of Pathology, Second Hospital of Shanxi Medical UniversityWu Yi Road 382, Taiyuan 030001, Shanxi, China
| | - Lifang Gao
- Department of Pathology, Second Hospital of Shanxi Medical UniversityWu Yi Road 382, Taiyuan 030001, Shanxi, China
| | - Shulei Yao
- Department of Nephrology, Second Hospital of Shanxi Medical UniversityWu Yi Road 382, Taiyuan 030001, Shanxi, China
- Shanxi Kidney Disease InstituteWu Yi Road 382, Taiyuan 030001, Shanxi, China
| | - Liran Wu
- Department of Pathology, Second Hospital of Shanxi Medical UniversityWu Yi Road 382, Taiyuan 030001, Shanxi, China
| | - Xiaoqin Zhang
- Department of Pathology, Second Hospital of Shanxi Medical UniversityWu Yi Road 382, Taiyuan 030001, Shanxi, China
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Tang X, Zhu B, Chen R, Hu Y, Zhang Y, Zhu X, Chen H, Wang Y. Evaluation of diagnostic criteria for IgG4-related tubulointerstitial nephritis. Diagn Pathol 2015; 10:83. [PMID: 26126500 PMCID: PMC4487857 DOI: 10.1186/s13000-015-0311-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Accepted: 06/02/2015] [Indexed: 12/24/2022] Open
Abstract
Background IgG4-TIN is the most common pattern of renal involvement in IgG4-related disease. There are several proposed diagnostic criteria of IgG4-TIN recently. Two of them proposed by the Mayo Clinic and JSN are predominant. However, histopathological criteria of the number of IgG4+ plasma cells and several histological features are still under discussion due to low amount of tissue in renal biopsy specimens and low frequency of this kind of specimens. We aimed to screen IgG4-TIN on archived renal biopsy samples and evaluated the application of two proposed diagnostic criteria. Methods We selected 480 interstitial inflammation samples for light and electron microscopy and immunohistochemistry of CD138, IgG and IgG4 test. The Mayo Clinic proposed criteria diagnosed high-probability IgG4-TIN and JSN criteria confirmed IgG4-TIN. Results Twelve high-probability IgG4-TIN were screened by histology, imaging, serology and other organ involvement according to the Mayo Clinic proposed criteria. The previous principal pathological diagnoses were IgAN (n=4), CreGN (n=4), tubulointerstitial nephritis (n=3) and LN (n=1). Three cases showed storiform fibrosis and a bird’s eye pattern. The distribution of IgG4+ plasma cells was focal, multifocal or diffuse, with a mixed mild, moderate or strong stainingpattern. Their treatment and clinical outcomes varied depending on different levels of proteinuria, serum creatinine, eGFR and original glomerular disease presentation. Therefore, we applied strict histological criteria of storiform fibrosis and evenly distributed IgG4+ plasma cells by JSN to confirm typical IgG4-TIN. Two cases were finally diagnosed as real IgG4-TIN. One was previously diagnosed as idiopathic interstitial nephritis with rapid response to corticosteroid therapy. The other was CreGN with immune complex deposits, which had poor outcome and long-term hemodialysis. Conclusions IgG4-TIN might present concurrently with glomerular disease. The proposed criteria by the Mayo Clinic is flexible, sensitive, and superior in the identification of early-stage or atypical IgG4-TIN, with enhanced risk of misdiagnosis as compared to the proposed criteria by JSN, which is stricter, more specific, and might overlook early-stage or atypical IgG4-TIN. We propose a new set of criteria to improve pathologist-derived diagnosis.
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Affiliation(s)
- Xuanli Tang
- Department of Nephrology (Key laboratory of Zhejiang province, management of kidney disease), Hangzhou hospital of traditional Chinese medicine, Hangzhou, 310007, China.
| | - Bin Zhu
- Department of Nephrology (Key laboratory of Zhejiang province, management of kidney disease), Hangzhou hospital of traditional Chinese medicine, Hangzhou, 310007, China.
| | - Riping Chen
- Department of Pathology, Zhejiang Academy of Medical Science, Hangzhou, 310007, China.
| | - Yunqin Hu
- Department of Nephrology (Key laboratory of Zhejiang province, management of kidney disease), Hangzhou hospital of traditional Chinese medicine, Hangzhou, 310007, China.
| | - Yinghua Zhang
- Department of Nephrology (Key laboratory of Zhejiang province, management of kidney disease), Hangzhou hospital of traditional Chinese medicine, Hangzhou, 310007, China.
| | - Xiaoling Zhu
- Department of Nephrology (Key laboratory of Zhejiang province, management of kidney disease), Hangzhou hospital of traditional Chinese medicine, Hangzhou, 310007, China.
| | - Hongyu Chen
- Department of Nephrology (Key laboratory of Zhejiang province, management of kidney disease), Hangzhou hospital of traditional Chinese medicine, Hangzhou, 310007, China.
| | - Yongjun Wang
- Department of Nephrology (Key laboratory of Zhejiang province, management of kidney disease), Hangzhou hospital of traditional Chinese medicine, Hangzhou, 310007, China.
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48
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Ghably JG, Borthwick T, O'Neil TJ, Youngberg GA, Datta AA, Krishnaswamy G. IgG4-related disease: a primer on diagnosis and management. Ann Allergy Asthma Immunol 2015; 114:447-54. [DOI: 10.1016/j.anai.2015.04.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 04/07/2015] [Accepted: 04/13/2015] [Indexed: 01/06/2023]
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Zhang H, Ren X, Zhang W, Yang D, Feng R. IgG4-related kidney disease from the renal pelvis that mimicked urothelial carcinoma: a case report. BMC Urol 2015; 15:44. [PMID: 26013281 PMCID: PMC4446108 DOI: 10.1186/s12894-015-0041-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Accepted: 05/20/2015] [Indexed: 12/24/2022] Open
Abstract
Background IgG4-related kidney disease is a comprehensive term for renal lesions associated with IgG4-related disease, which mainly manifests as plasma cell-rich tubulointerstitial nephritis with increased IgG4+ plasma cells and fibrosis. IgG4-related kidney disease in the renal pelvis is rare. Case presentation We describe a 53-year-old Asian woman who was referred to our hospital with a space-occupying renal lesion discovered by medical examination. A physical examination and laboratory evaluation revealed no significant abnormalities. Computed tomography scans showed a soft-tissue mass with an irregular border and mild homogeneous enhancement in the right renal pelvis and calyces. A positron emission tomography/computed tomography scan revealed soft-tissue density shadows with increased radionuclide uptake. To investigate a suspected pelvic carcinoma, a right ureteronephrectomy was performed. A pathologic examination of the renal sections showed a dense lymphoplasmacytic infiltrate rich in IgG4+ plasma cells, with fibrosis beneath the urothelial epithelium of the renal pelvis. Postoperatively, the serum IgG4 level was significantly elevated. The patient was diagnosed with IgG4-related kidney disease. Conclusion We present a case of IgG4-related kidney disease mimicking urothelial carcinoma in the renal pelvis. When a buried and solitary hypovascular tumor is detected in the kidney, we must consider IgG4-related kidney disease as a differential diagnosis. Accordingly, elevated serum IgG4, radiologic findings, and pathologic examination may improve the diagnosis.
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Affiliation(s)
- Hui Zhang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuaifu Yuan, Beijing, 100730, PR China.
| | - Xinyu Ren
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuaifu Yuan, Beijing, 100730, PR China.
| | - Wen Zhang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, PR China.
| | - Di Yang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuaifu Yuan, Beijing, 100730, PR China.
| | - Ruie Feng
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, 1 Shuaifu Yuan, Beijing, 100730, PR China.
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Zaarour M, Weerasinghe C, Eter A, El-Sayegh S, El-Charabaty E. An Overlapping Case of Lupus Nephritis and IgG4-Related Kidney Disease. J Clin Med Res 2015; 7:575-81. [PMID: 26015827 PMCID: PMC4432904 DOI: 10.14740/jocmr2189w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2015] [Indexed: 12/24/2022] Open
Abstract
We report a case of a 71-year-old Filipino female who was admitted to the hospital for abdominal pain, vomiting and diarrhea of 8 days duration. The patient was found to have marked acute kidney injury (AKI), which required hemodialysis in the next 3 days. Extensive workup revealed hematuria, subnephrotic range proteinuria, elevated anti-nuclear antibody (ANA) and elevated total immunoglobulin G (IgG) levels, with normal IgG4 and anti-dsDNA levels. On kidney biopsy, mild membranous glomerulonephritis was found, along with autoimmune tubulointerstitial nephritis (TIN) with a “full-house” pattern of immune deposits. These findings were suggestive of lupus interstitial nephritis. However, IgG4+ plasma cells were detected in the interstitium by immunostaining, favoring a diagnosis of IgG4-related kidney disease (IgG4-RKD). Our case highlights the difficulty in differentiating lupus nephritis (LN) from IgG4-RKD in some patients, raising the suspicion that these two entities can co-exist.
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Affiliation(s)
- Mazen Zaarour
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Chanudi Weerasinghe
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Ahmad Eter
- Department of Medicine, Division of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
| | - Suzanne El-Sayegh
- Department of Medicine, Division of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
| | - Elie El-Charabaty
- Department of Medicine, Division of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
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