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Shima Y, Nakanishi K, Mukaiyama H, Tanaka Y, Wada T, Tanaka R, Kaito H, Nozu K, Sako M, Iijima K, Yoshikawa N. Clinicopathological significance of glomerular capillary IgA deposition in childhood IgA nephropathy. Pediatr Nephrol 2021; 36:899-908. [PMID: 33011820 DOI: 10.1007/s00467-020-04772-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 07/26/2020] [Accepted: 09/09/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND IgA nephropathy (IgAN) is characterized by predominant mesangial IgA deposition. Some patients with IgAN demonstrate IgA deposition in glomerular peripheral capillaries (cap-IgA). The clinicopathological significance of cap-IgA remains incompletely investigated in children. METHODS We retrospectively analyzed 503 consecutive cases of biopsy-proven childhood IgAN between July 1976 and June 2013 to compare clinical and pathological features between IgAN patients with and without cap-IgA. RESULTS Among the 503 patients, 30 (6.0%) had cap-IgA. We found significant differences in proteinuria (2.0 vs. 0.5 g/day/m2, p < 0.0001), time from onset to kidney biopsy (2.2 vs. 8.3 months, p < 0.0001), and rate of proteinuria remission after treatment (23.3% vs. 48.0%, p = 0.007) between both groups. Pathological analysis revealed significant differences in M1 (83.3% vs. 56.0%, p = 0.002), ratio of subendothelial electron dense deposits (EDDs, 58.6% vs. 16.5%, p < 0.0001) and subepithelial EDDs (48.3% vs. 16.5%, p = 0.0001), and glomerular basement membrane (GBM) lysis (58.6% vs. 27.1%, p = 0.0006) between both groups. More than half of cap-IgA patients (17/30, 56.7%), whereas only 26.2% of non-cap-IgA patients (124/473), were treated with immunosuppressive treatments. Six of 30 cases (20%) with cap-IgA reached glomerular filtration rate (GFR) categories G3a-G5 (estimated GFR < 60 ml/min/1.73 m2) at most recent observation (mean observation period: 7.0 ± 4.0 years). According to Kaplan-Meier analysis, patients with cap-IgA had significantly lower kidney survival curves than non-cap-IgA patients (72.8% vs. 97.2% at 10 years, p < 0.0001). CONCLUSIONS Cap-IgA is associated with acute inflammation with GBM changes, resulting in refractory heavier proteinuria. Cap-IgA may represent a poor prognostic factor.
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Affiliation(s)
- Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Koichi Nakanishi
- Department of Pediatrics, Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara-cho, Nakagami-gun, Okinawa, 903-0125, Japan.
| | - Hironobu Mukaiyama
- Department of Pediatrics, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Yu Tanaka
- Department of Pediatrics, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Takuzo Wada
- Department of Pediatrics, Wakayama Medical University, Wakayama City, Wakayama, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Hiroshi Kaito
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Mayumi Sako
- Division for Clinical Trials, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Norishige Yoshikawa
- Clinical Research Center, Takatsuki General Hospital, Takatsuki City, Osaka, Japan
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Yang SR, Hua KF, Takahata A, Wu CY, Hsieh CY, Chiu HW, Chen CH, Mukhopadhyay D, Suzuki Y, Ka SM, Huang HS, Chen A. LCC18, a benzamide-linked small molecule, ameliorates IgA nephropathy in mice. J Pathol 2021; 253:427-441. [PMID: 33373038 DOI: 10.1002/path.5609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/19/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022]
Abstract
IgA nephropathy (IgAN), an immune complex-mediated process and the most common primary glomerulonephritis, can progress to end-stage renal disease in up to 40% of patients. Accordingly, a therapeutic strategy targeting a specific molecular pathway is urgently warranted. Aided by structure characterisation and target identification, we predicted that a novel ring-fused 6-(2,4-difluorophenyl)-3-(3-(trifluoromethyl)phenyl)-2H-benzo[e][1,3]oxazine-2,4(3H)-dione (LCC18) targets the NLRP3 inflammasome, which participates in IgAN pathogenesis. We further developed biomarkers for the disease. We used two complementary IgAN models in C57BL/6 mice, involving TEPC-15 hybridoma-derived IgA, and in gddY mice. Moreover, we created specific cell models to validate therapeutic effects of LCC18 on IgAN and to explain its underlying mechanisms. IgAN mice benefited significantly from treatment with LCC18, showing dramatically improved renal function, including greatly reduced proteinuria and renal pathology. Mechanistic studies showed that the mode of action specifically involved: (1) blocking of the MAPKs/COX-2 axis-mediated priming of the NLRP3 inflammasome; (2) inhibition of ASC oligomerisation and NLRP3 inflammasome assembly by inhibiting NLRP3 binding to PKR, NEK7 and ASC; and (3) activation of autophagy. LCC18 exerts therapeutic effects on murine IgAN by differentially regulating NLRP3 inflammasome activation and autophagy induction, suggesting this new compound as a promising drug candidate to treat IgAN. © 2020 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.
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Affiliation(s)
- Shin-Ruen Yang
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Kuo-Feng Hua
- Department of Biotechnology and Animal Science, National Ilan University, Ilan, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Akiko Takahata
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Chung-Yao Wu
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Yu Hsieh
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.,College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
| | - Hsiao-Wen Chiu
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Cheng-Hsu Chen
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | | | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Shuk-Man Ka
- Graduate Institute of Aerospace and Undersea Medicine, Department of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Hsu-Shan Huang
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan.,Graduate Institute of Cancer Biology and Drug Discovery, Taipei Medical University, Taipei, Taiwan
| | - Ann Chen
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan.,Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Crescentic IgA nephropathy in children. Pediatr Nephrol 2020; 35:1005-1014. [PMID: 31993782 DOI: 10.1007/s00467-020-04483-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/23/2019] [Accepted: 01/14/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES Crescentic IgA nephropathy (C-IgAN) is defined as IgAN with more than 50% of glomeruli showing crescents. C-IgAN in children is rare; we investigate in detail for the first time. METHODS We retrospectively analyzed the 515 consecutive children who were newly diagnosed with biopsy-proven IgAN between June 1976 and May 2010. We compared clinical and pathological findings between C-IgAN and non-C-IgAN. RESULTS Among 515 cases of childhood IgAN, 25 children (4.9%) had C-IgAN. Of these 25, 16 children (64%) were referred to hospitals by annual school screening. Clinical findings showed significant differences in gross hematuria (76 vs. 50%, p = .03), excretion of proteinuria (1.9 vs. 0.5 g/day/m2, p < .0001), eGFR (102 vs. 108 ml/min/1.73 m2, p = .03), and duration from onset to renal biopsy (4.0 vs. 8.0 months, p = .04) between groups. Pathological findings showed significant differences in M1 (88 vs. 55%, p = .02), E1 (83 vs. 53%, p = .008), and presence of tubular atrophy/interstitial fibrosis (88 vs. 53%, p < .0001) between groups. The 16 children with C-IgAN were treated with prednisolone and immunosuppressant. Four cases (16%) reached chronic renal failure (eGFR < 60) at the latest observation (mean observation period: 6.0 ± 3.6 years). Patients with C-IgAN had significantly lower renal survival curve than non-C-IgAN patients according to Kaplan-Meier analysis (77.1% vs. 92.6% at 13 years, p < .0001). Compared with previous reports, however, they had better renal outcome. CONCLUSIONS We confirmed the importance of school screening to find C-IgAN. Although most crescents (mean: 98.1%) of C-IgAN were cellular/fibrocellular, and acute lesions were well modified with combination therapy, the presence of tubular atrophy in C-IgAN may be the reason for poorer prognosis.
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Shima Y, Nakanishi K, Sako M, Saito-Oba M, Hamasaki Y, Hataya H, Honda M, Kamei K, Ishikura K, Ito S, Kaito H, Tanaka R, Nozu K, Nakamura H, Ohashi Y, Iijima K, Yoshikawa N. Lisinopril versus lisinopril and losartan for mild childhood IgA nephropathy: a randomized controlled trial (JSKDC01 study). Pediatr Nephrol 2019; 34:837-846. [PMID: 30284023 DOI: 10.1007/s00467-018-4099-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/23/2018] [Accepted: 09/24/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Persistent proteinuria seems to be a risk factor for progression of renal disease. Its reduction by angiotensin-converting inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) is renoprotective. Our previous pilot study showed that 2-year lisinopril therapy is effective and safe for children with mild IgA nephropathy. When combined with ACEI and ARB, reported results are of greater decrease in proteinuria than monotherapy in chronic glomerulonephritis, including IgA nephropathy. To date, however, there have been no randomized controlled trials in children. METHODS This is an open-label, multicenter, prospective, and randomized phase II controlled trial of 63 children with biopsy-proven proteinuric mild IgA nephropathy. We compared efficacy and safety between patients undergoing lisinopril monotherapy and patients undergoing combination therapy of lisinopril and losartan to determine better treatment for childhood proteinuric mild IgA nephropathy. RESULTS There was no difference in proteinuria disappearance rate (primary endpoint) between the two groups (cumulative disappearance rate of proteinuria at 24 months: 89.3% vs 89% [combination vs monotherapy]). Moreover, there were no significant differences in side effects between the two groups. CONCLUSIONS We propose lisinopril monotherapy as treatment for childhood proteinuric mild IgA nephropathy as there are no advantages of combination therapy. CLINICAL TRIAL REGISTRATION Clinical trial registry, UMIN ID C000000006, https://www.umin.ac.jp .
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Affiliation(s)
- Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, 207 Uehara Nishihara-Cho, Nakagami-Gun, Okinawa, 903-0125, Japan.
| | - Mayumi Sako
- Division of Clinical Trials, Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Mari Saito-Oba
- Department of Medical Statistics Faculty of Medicine, Toho University, Ota-Ku, Tokyo, Japan
| | - Yuko Hamasaki
- Department of Pediatric Nephrology, Faculty of Medicine, Toho University, Ota-Ku, Tokyo, Japan
| | - Hiroshi Hataya
- Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Fuchu, Tokyo, Japan
| | - Koichi Kamei
- Department of Nephrology and Rheumatology, National Center for Child Health and Development, Setagaya-Ku, Tokyo, Japan
| | - Kenji Ishikura
- Department of Nephrology and Rheumatology, National Center for Child Health and Development, Setagaya-Ku, Tokyo, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Hiroshi Kaito
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidefumi Nakamura
- Clinical Research Center, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
| | - Yasuo Ohashi
- Department of Integrated Science and Engineering for Sustainable Society, Chuo University, Bunkyo-Ku, Tokyo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
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5
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IgA nephropathy with presentation of nephrotic syndrome at onset in children. Pediatr Nephrol 2017; 32:457-465. [PMID: 27714465 DOI: 10.1007/s00467-016-3502-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Revised: 09/02/2016] [Accepted: 09/06/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Despite a low incidence, nephrotic syndrome (NS) can present with IgA nephropathy (IgAN). The clinical characteristics and long-term outcomes of pediatric patients with IgAN presenting with NS (NS-IgAN) at onset have not been fully elucidated. METHODS We retrospectively analyzed 426 patients, and compared clinical and pathological (Oxford) findings between those with NS-IgAN and those with non-NS-IgAN. RESULTS Among 426 patients, 30 (7.0 %) had NS-IgAN. Logistic analyses showed that male sex (OR: 7.6, p = 0.0002), M1 (OR: 10.3, p = 0.002), and E1 (OR: 15.2, p = 0.0001) were significantly related to NS. The mean observation period was 6.2 ± 3.2 years. Although NS-IgAN was associated with significantly lower renal survival than non-NS-IgAN according to Kaplan-Meier analysis (p = 0.02), renal survival of NS-IgAN was good (92.4 % at 10 years). The most significant prognostic factor for renal survival was remission of proteinuria after treatment, and NS at onset is also a significant prognostic factor for renal survival after adjusting for remission of proteinuria. Twenty children with NS-IgAN were treated with prednisolone alone, or prednisolone and immunosuppressant. Remission of proteinuria occurred in 21 patients. Three cases of NS-IgAN progressed to stage III-V chronic kidney disease at the most recent observation. They all demonstrated heavy proteinuria after the 2-year initial treatment. The significant factor for persistent proteinuria at 5 years was S1 in NS-IgAN. CONCLUSIONS The most significant factor for renal survival was responsiveness to treatment, not NS itself. As modifiable acute lesions are the dominant pathological findings in NS-IgAN, histological improvements achieved by appropriate treatments can result in a favorable prognosis.
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Higa A, Shima Y, Hama T, Sato M, Mukaiyama H, Togawa H, Tanaka R, Nozu K, Sako M, Iijima K, Nakanishi K, Yoshikawa N. Long-term outcome of childhood IgA nephropathy with minimal proteinuria. Pediatr Nephrol 2015; 30:2121-7. [PMID: 26238276 DOI: 10.1007/s00467-015-3176-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 06/25/2015] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Some patients with childhood immunoglobulin A nephropathy (IgAN) progress to end-stage renal disease within 20 years, while others achieve spontaneous remission even without medication. Prognosis of IgAN with minimal proteinuria (MP-IgAN, <0.5 g/day/1.73 m(2)) at diagnosis seems to be generally good. However, the long-term outcome for patients with childhood MP-IgAN has not yet been determined. METHODS We retrospectively analyzed 385 children newly diagnosed with biopsy-proven IgAN between June 1976 and July 2009 whose renal biopsy specimens could be evaluated by the Oxford classification criteria. Of these 385 children with IgAN, 106 (27.5%) were diagnosed with MP-IgAN. We compared clinical and pathological findings between the 106 patients with MP-IgAN and the remaining 279 patients to elucidate the characteristics of MP-IgAN in children. RESULTS Patients with MP-IgAN were identified through a school screening program (73.6%) or upon presentation with gross hematuria (26.4%). Patients with MP-IgAN had significantly milder pathological symptoms than those with IgAN. The most frequently used therapeutic regimes were angiotensin converting enzyme inhibitors (30.2%) and no therapy (36.8%). None of the patients with MP-IgAN reached stage III chronic kidney disease within 15 years after onset. Four patients with MP-IgAN (3.8 %) received immunosuppressive therapy during the course of the disease. CONCLUSION Our results indicate that the outcome of patients with a diagnosis of childhood MP-IgAN is good, but that careful long-term observation is required.
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Affiliation(s)
- Asumi Higa
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Taketsugu Hama
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Masashi Sato
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Hironobu Mukaiyama
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Hiroko Togawa
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Hyogo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Mayumi Sako
- Division for Clinical Trials, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Koichi Nakanishi
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan.
| | - Norishige Yoshikawa
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
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Shima Y, Nakanishi K, Hama T, Sato M, Mukaiyama H, Togawa H, Tanaka R, Kaito H, Nozu K, Iijima K, Yoshikawa N. Biopsy timing and Oxford classification variables in childhood/adolescent IgA nephropathy. Pediatr Nephrol 2015; 30:293-9. [PMID: 24912604 DOI: 10.1007/s00467-014-2862-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 05/13/2014] [Accepted: 05/14/2014] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although the Oxford classification of IgA nephropathy appears valid, we found crescents were significantly related to renal outcome in our cohort, whereas segmental glomerulosclerosis (S) was not. The timing of renal biopsy may significantly affect the variables in the Oxford classification. METHOD The relationship between biopsy timing and pathological variables (mesangial hypercellularity score [M], endocapillary hypercellularity [E], S, tubular atrophy/interstitial fibrosis [T], crescents, and global glomerulosclerosis [G]) was analyzed retrospectively in 250 children with IgA nephropathy. RESULTS The median time from disease onset to renal biopsy was 5.1 months (interquartile range, 2.7-15.4). M (ρ = -0.26, P < 0.0001), E (ρ = -0.34, P < 0.0001), and crescents (ρ = -0.14, P = 0.023) showed significant negative correlations, and S (ρ = 0.15, P = 0.018) and G (ρ = 0.25, P < 0.0001) showed significant positive correlations with time to biopsy (Spearman test). M, E, and crescents differed significantly in renal biopsies obtained before and after 3 years from onset (Wilcoxon test). Most crescents (92.9 %) were cellular/fibrocellular and were acute lesions. As crescents formed early after disease onset and decreased over time, they may be prognostic for acute phase, but not for chronic phase disease. CONCLUSIONS Renal biopsy timing may alter the significance of variables used in the Oxford classification.
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Affiliation(s)
- Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
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Luo MN, Yao CW, Xu BH, Xu YZ, Liu WJ, Feng YM, Tao JL, Liu HF. Continuation of immunosuppressive treatment may be necessary in IgA nephropathy patients with remission of proteinuria: Evaluation by repeat renal biopsy. Exp Ther Med 2013; 7:553-559. [PMID: 24520244 PMCID: PMC3919854 DOI: 10.3892/etm.2013.1467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 12/23/2013] [Indexed: 11/21/2022] Open
Abstract
The present study aimed to evaluate the effects of an individualized, low-dose multi-drug immunosuppressive regimen for the treatment of immunoglobulin A nephropathy (IgAN). A preliminary investigation of the course of IgAN following immunosuppressive treatment was conducted based on repeat renal biopsies. Clinical and pathological data of 17 patients with IgAN who received repeat renal biopsies were analyzed retrospectively. In addition to basic treatment, 16 patients regularly received an individualized low-dose immunosuppressive regimen according to their clinical manifestations and pathological patterns following the first biopsy. Clinical parameters, including 24-h urinary protein excretion and levels of serum albumin, uric acid and total cholesterol were collected. Glomerular deposits of IgA and C3, as well as the activity and chronicity indexes of renal lesions were evaluated by semi-quantitative methods. The 24-h urinary protein excretion of the patients decreased significantly from the first biopsy (2.53±2.17 g/day) to the repeated biopsy (0.26±0.55 g/day) (P<0.001). Deposits of IgA and C3 in the glomerulus were persistent, but were reduced in quantity at the second biopsy. Although active renal lesions were observed in the majority of patients, the activity index decreased significantly from 3.18±1.33 prior to therapy to 2.47±0.80 following therapy (P<0.05), while the chronicity index did not change significantly (2.59±2.00 versus 2.76±1.89, respectively). The individualized, low-dose multi-drug immunosuppressive regimen used in the present study significantly minimized proteinuria, stabilized renal function and alleviated histological lesions in patients with IgAN without causing overt adverse effects during the short-term follow-up. In addition to proteinuria, renal pathological changes should be appraised when considering the withdrawal of immunosuppressants from IgAN treatment.
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Affiliation(s)
- Mian-Na Luo
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Cui-Wei Yao
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Bi-Hua Xu
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Yong-Zhi Xu
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Wei Jing Liu
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Yong-Min Feng
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Jing-Li Tao
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Hua-Feng Liu
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
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9
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Wei M, Xiong P, Zhang L. Effect of Chinese herbs on immunoglobulin A nephropathy: a randomized controlled trial. J TRADIT CHIN MED 2013; 33:65-9. [PMID: 23596814 DOI: 10.1016/s0254-6272(13)60102-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The accumulation of extracellular matrix (ECM) is one of the main causes of renal fibrosis. Emerging evidence suggests that the metabolic enzyme of ECM is associated with renal fibrosis. In this study, we applied randomly controlled trial to check the curative effect of Chinese herbs on patients with immunoglobulin A nephropathy (IgAN). METHODS Twenty-six patients were randomly divided into group A (control group) treated with Western Medicine and group B (treatment group) treated with combination of Traditional Chinese Medicine (TCM) and Western Medicine. Blood and urine tests were done before treatment and after 8-week treatment. RESULTS The levels of the main composition of extracellular matrix (MC-ECM), the metabolic enzyme of ECM (ME-ECM) and some cytokines in group B decreased more obviously than those in group A after 8-week treatment. So did the level of 24-hour urine protein. However, Metal matrix protease (MMP)-2 and vascular endothelial growth factor in group B increased more obviously than those in group A after 8-week treatment. No effects on the renal function were found in both groups. CONCLUSION Our study provided important information on using the combination of TCM with Western Medicine to inhibit the progression of renal fibrosis in patients with IgAN.
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Affiliation(s)
- Minggang Wei
- The First Affiliated Hospital of Soochow University, Suzhou 215006, China.
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Kawamura T. [Progressive renal diseases: recent advances in diagnosis and treatments. Topics: II. Pathophysiology and treatments; 5. IgA nephropathy]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2013; 102:1136-44. [PMID: 23847978 DOI: 10.2169/naika.102.1136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Tetsuya Kawamura
- Department of Kidney and Hypertension, Clinical Training Center, Jikei University School of Medicine, Japan
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Shimizu A, Takei T, Moriyama T, Itabashi M, Uchida K, Nitta K. Clinical and pathological studies of IgA nephropathy presenting as a rapidly progressive form of glomerulonephritis. Intern Med 2013; 52:2489-94. [PMID: 24240786 DOI: 10.2169/internalmedicine.52.0420] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE IgA nephropathy (IgAN) is widely regarded as a slowly progressive disease. However, a minor population of patients present with a rapidly progressive form of glomerulonephritis (RPGN). METHODS We studied 25 cases of IgAN who presented with RPGN. The laboratory data, histology, and five-year prognosis after diagnostic renal biopsy were evaluated. We compared the data of these patients with those of 495 patients with the non-RPGN type. In addition, we divided the patients with the RPGN type of IgAN into a group with reduced renal function and a group with maintained renal function, and compared the data between the two groups. RESULTS In the 'RPGN type', the serum creatinine levels and a 24-hour urinary protein excretion were significantly higher than in the non-RPGN type. Histological examinations showed that the rates of endocapillary hypercellularity and tubular atrophy/interstitial fibrosis were significantly higher in the patients with the RPGN type. In the comparison between the groups with reduced and maintained renal functions, the former group exhibited higher levels of proteinuria, serum creatinine and crescent formation than the latter group. CONCLUSION The RPGN type of IgAN was significantly worse in terms of the renal survival rate at five years than the non-RPGN type. Intensive and active treatments are necessary for this minor population, according to the guideline for the management of RPGN.
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Affiliation(s)
- Ari Shimizu
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Japan
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Shima Y, Nakanishi K, Hama T, Mukaiyama H, Togawa H, Hashimura Y, Kaito H, Sako M, Iijima K, Yoshikawa N. Validity of the Oxford classification of IgA nephropathy in children. Pediatr Nephrol 2012; 27:783-92. [PMID: 22134880 DOI: 10.1007/s00467-011-2061-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2011] [Revised: 11/01/2011] [Accepted: 11/06/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND In 2009, the Oxford classification of IgA nephropathy was published. However, its validity has not been fully examined in children. This study aimed to assess this system in an independent large-scale cohort of children. METHODS We analyzed 161 consecutive children with newly diagnosed IgA nephropathy from 1977 to 1989 retrospectively. We examined the ability of each variable in the Oxford classification as a predictor of renal outcome defined as ≥ stage III chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2)) using Cox regression analysis. RESULTS The mean mesangial score, and ratios of segmental glomerulosclerosis, endocapillary hypercellularity, tubular atrophy, and crescents were 0.49, 0.8%, 13.1%, 3.3%, and 9.2% respectively. Seven cases reached ≥ stage III CKD. In univariate analyses, mesangial hypercellularity score, endocapillary hypercellularity, tubular atrophy, and crescents were significant predictors of renal outcome. In a multivariate analysis, only mesangial hypercellularity score, tubular atrophy, and crescents were significant though, depending on models. Segmental glomerulosclerosis was not a significant predictor of renal outcome. Although the significance of crescents was not addressed in the Oxford classification, crescents were important predictors of outcome. CONCLUSIONS The Oxford classification appears to be valid for predicting renal outcome in children.
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Affiliation(s)
- Yuko Shima
- Department of Pediatrics, Wakayama Medical University, 811-1, Kimiidera, Wakayama City, Wakayama 641-8509, Japan
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Stangou M, Ekonomidou D, Giamalis P, Liakou H, Tsiantoulas A, Pantzaki A, Papagianni A, Efstratiadis G, Alexopoulos E, Memmos D. Steroids and azathioprine in the treatment of IgA nephropathy. Clin Exp Nephrol 2011; 15:373-380. [PMID: 21301920 DOI: 10.1007/s10157-011-0415-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Accepted: 01/17/2011] [Indexed: 11/26/2022]
Abstract
AIM IgA nephropathy (IgAN) is a very common glomerulonephritis among young adults, but the best therapeutic approach has not been fully elucidated. This study evaluated the effect of two different treatment regimes in IgAN, steroids alone or in combination with azathioprine. METHODS Among 122 patients with primary IgA nephropathy diagnosed in the 2000-2007 period, 22 fulfilled the inclusion criteria for the study: estimated glomerular filtration rate (eGRF) ≥30 ml/min/1.73 m(2), urine protein (Upr) ≥1 g/24 h, blood pressure (BP) <130/80 mmHg, and previous treatment with renin-angiotensin system inhibitors (RAASi) and polyunsaturated fatty acids (PFA) for at least 6 months. Patients were randomized to receive either methylprednisolone alone (MP group) or MP in combination with azathioprine (MP + Aza group) for 12 months, while treatment with RAASi + PFA continued unchanged in both groups. RESULTS At the completion of the trial, renal function in the MP group remained stable, eGFR from 52 ± 26.7 to 53.6 ± 27.3 ml/min/1.73 m(2), p = NS, and Upr decreased from 2.4 ± 0.9 to 0.8 ± 0.5 g/24 h, p < 0.001. In the MP + Aza group, eGFR slightly increased from 57.4 ± 28.7 to 66 ± 31 ml/min/1.73 m(2), p = NS, and Upr decreased from 2.4 ± 1 to 0.7 ± 0.7 g/24 h, p < 0.001. Four patients from the MP group with partial remission at the end of the trial had a complete response when converted to Aza. Eleven patients (5 from the MP and 6 from the MP + Aza group) relapsed after stopping treatment and were restarted on lower doses. CONCLUSIONS Both, steroid treatment alone and steroids in combination with azathioprine seem to be effective in reducing the severity of proteinuria and stabilizing renal function in IgAN. Patients who do not respond to steroids may have a better response with the combination of steroids and azathioprine.
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Affiliation(s)
- Maria Stangou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece.
| | - Domniki Ekonomidou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Panagiotis Giamalis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Helen Liakou
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Apostolis Tsiantoulas
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Afroditi Pantzaki
- Department of Histopathology, Hippokration Hospital, Thessaloniki, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - George Efstratiadis
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Efstathios Alexopoulos
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
| | - Dimitrios Memmos
- Department of Nephrology, Aristotle University of Thessaloniki, Hippokration Hospital, Thessaloniki, Greece
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Shima Y, Nakanishi K, Kamei K, Togawa H, Nozu K, Tanaka R, Sasaki S, Iijima K, Yoshikawa N. Disappearance of glomerular IgA deposits in childhood IgA nephropathy showing diffuse mesangial proliferation after 2 years of combination/prednisolone therapy. Nephrol Dial Transplant 2011; 26:163-169. [DOI: 10.1093/ndt/gfq387] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Rodrigo Orozco B, Alberto Fierro C, Luis Contreras M, Alex Wash F. Caso clínico-anatomopatológico: Las diversas presentaciones de la nefropatía por IgA. REVISTA MÉDICA CLÍNICA LAS CONDES 2010. [DOI: 10.1016/s0716-8640(10)70584-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Proteinuria-reducing effects of tonsillectomy alone in IgA nephropathy recurring after kidney transplantation. Transplantation 2010; 88:935-41. [PMID: 19935466 DOI: 10.1097/tp.0b013e3181b75374] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few studies have been conducted to determine the efficacy of tonsillectomy in suppressing IgA nephropathy recurring after the kidney transplantation. MATERIALS AND METHODS Of the 405 kidney recipients who received allograft transplants at our institution between 1998 and 2005, 63 (63 of 405, 16%) were diagnosed as having recurrence of IgA nephropathy in the kidney graft. Among the 63 patients, our subjects in this study were 28 patients who were confirmed to have recurrence of IgA nephropathy by histopathological examination, and who had persistent urinary protein excretion levels of more than 300 mg/day despite medical treatments. Sixteen patients (group 1) underwent tonsillectomy alone, whereas the remaining 12 patients (group 2) did not receive tonsillectomy. The degree of proteinuria, kidney graft function, and blood pressure were analyzed retrospectively in the two patient groups. RESULTS The urinary protein excretion decreased dramatically after the tonsillectomy in all of the 16 patients of group 1 (880+/-630 mg/day to 280+/-220 mg/day, P<0.01) but none of group 2. The reduction in urinary protein excretion after tonsillectomy was especially marked in the patients with mild mesangial changes, such as minor glomerular abnormalities, when compared with that in patients with severe mesangial changes, such as diffuse proliferative glomerular abnormalities (mean percent decrease in the urinary protein excretion rate at 12 months after tonsillectomy; 31% minor glomerular abnormalities vs. 62% diffuse proliferative glomerular abnormalities, P<0.01). CONCLUSION These results suggest that in patients receiving oral immunosuppressive therapy for recurrence of IgA nephropathy after the kidney transplantation, reduction of the urinary protein excretion can be expected with tonsillectomy alone, without accompanying pulsed steroid therapy.
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STANGOU MARIA, ALEXOPOULOS EFSTATHIOS, PAPAGIANNI AIKATERINI, PANTZAKI AFRODITI, BANTIS CHRISTOS, DOVAS SPIROS, ECONOMIDOU DOMNIKI, LEONTSINI MARIA, MEMMOS DIMITRIOS. Urinary levels of epidermal growth factor, interleukin-6 and monocyte chemoattractant protein-1 may act as predictor markers of renal function outcome in immunoglobulin A nephropathy. Nephrology (Carlton) 2009; 14:613-20. [DOI: 10.1111/j.1440-1797.2008.01051.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bantis C, Heering P, Aker S, Kuhr N, Grabensee B, Ivens K. Influence of Cytokine Gene Polymorphisms on IgA Nephropathy. Ren Fail 2009; 30:135-40. [DOI: 10.1080/08860220701805182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Combination therapy with mizoribine for severe childhood IgA nephropathy: a pilot study. Pediatr Nephrol 2008; 23:757-63. [PMID: 18224343 DOI: 10.1007/s00467-007-0731-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2007] [Revised: 11/19/2007] [Accepted: 11/27/2007] [Indexed: 10/22/2022]
Abstract
In two previous randomized controlled trials we showed that treatment of severe childhood immunoglobulin A nephropathy (IgA-N) using prednisolone, azathioprine, heparin-warfarin, and dipyridamole prevented any increase of sclerosed glomeruli and that prednisolone alone did not prevent a further increase of sclerosed glomeruli. Accordingly, the immunosuppressant is considered to be important. Often, however, we were unable to complete azathioprine regimen due to toxicity. Therefore, a different but effective immunosuppressant may be worth trying. Mizoribine, like azathioprine, is an antimetabolite that exerts its immunosuppressant effect by inhibiting lymphocyte proliferation. In this pilot study, we administered mizoribine instead of azathioprine as part of the combination therapy for treating 23 children with severe IgA-N and evaluated the efficacy and safety. Eighteen patients reached the primary endpoint (urine protein/creatinine ratio <0.2) during the 2-year treatment period. The cumulative disappearance rate of proteinuria determined by Kaplan-Meier was 80.4%. Median protein excretion was reduced from 1.19 g/m(2)/day to 0.05 g/m(2)/day (p < 0.0001). After treatment, the median percentage of glomeruli showing sclerosis was unchanged in comparison with that before treatment. No patients required a change of treatment. In conclusion, the efficacy and safety of the mizoribine combination seems to be acceptable for treating children with severe IgA-N.
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Yata N, Nakanishi K, Shima Y, Togawa H, Obana M, Sako M, Nozu K, Tanaka R, Iijima K, Yoshikawa N. Improved renal survival in Japanese children with IgA nephropathy. Pediatr Nephrol 2008; 23:905-12. [PMID: 18224344 PMCID: PMC2335295 DOI: 10.1007/s00467-007-0726-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Revised: 11/15/2007] [Accepted: 11/30/2007] [Indexed: 12/23/2022]
Abstract
Since the beginning of the 1990s, Japanese medical practitioners have extensively prescribed angiotensin-converting enzyme (ACE) inhibitors for children with mild IgA nephropathy (IgA-N) and steriods for those with severe IgA-N. We have performed a retrospective cohort study to clarify whether the long-term outcome has improved in Japanese children with IgA-N. Renal survival was defined as the time from onset to end-stage renal disease (ESRD). We divided the study period into two time periods based on the occurrence of the initial renal biopsy:1976-1989 and 1990-2004. Actuarial survivals were calculated by Kaplan-Meier method, and comparisons were made with the logrank test. The Cox proportional hazard model was used for multivariate analysis. Between 1976 and 2004, 500 children were diagnosed as having IgA-N in our hospitals. The actuarial renal survival from the time of apparent disease onset was 96.4% at 10 years, 84.5% at 15 years and 73.9% at 20 years. Renal survival in the 1990-2004 period was significantly better than that in 1976-1989 (p=0.008), and a marked improvement in renal survival in patients with severe IgA-N was also observed (p=0.0003). Multivariate analysis indicated that diagnosis year was a significant factor for ESRD-free survival independently of baseline characteristics. The results of this study show that there has been an improvement in terms of renal survival in Japanese children with IgA-N.
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Affiliation(s)
- Nahoko Yata
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509 Japan
| | - Koichi Nakanishi
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509 Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509 Japan
| | - Hiroko Togawa
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509 Japan
| | - Mina Obana
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509 Japan
| | - Mayumi Sako
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509 Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Hyogo Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Hyogo Japan
| | - Kazumoto Iijima
- Department of Nephrology, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Norishige Yoshikawa
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509 Japan
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Alamartine É, Hurault de Ligny B. Controverse sur le traitement de la néphropathie à IgA. Nephrol Ther 2007. [DOI: 10.1016/s1769-7255(07)78747-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Li PKT, Leung CB, Chow KM, Cheng YL, Fung SKS, Mak SK, Tang AWC, Wong TYH, Yung CY, Yung JCU, Yu AWY, Szeto CC. Hong Kong study using valsartan in IgA nephropathy (HKVIN): a double-blind, randomized, placebo-controlled study. Am J Kidney Dis 2006; 47:751-60. [PMID: 16632013 DOI: 10.1053/j.ajkd.2006.01.017] [Citation(s) in RCA: 136] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Accepted: 01/04/2006] [Indexed: 01/13/2023]
Abstract
BACKGROUND Previous studies showed that angiotensin-receptor blocker (ARB) therapy decreased proteinuria and possibly slowed the rate of renal function decline in patients with chronic proteinuric nephropathies. We performed a double-blind, randomized, placebo-controlled, multicenter study on the ARB valsartan in the treatment of patients with immunoglobulin A (IgA) nephropathy. METHODS From 6 centers, we recruited 109 patients with IgA nephropathy who had either: (1) proteinuria with protein greater than 1 g/d and serum creatinine level less than 2.8 mg/dL (< 250 micromol/L), or (2) serum creatinine level of 1.4 to 2.8 mg/dL (120 to 250 micromol/L) regardless of degree of proteinuria. Patients were randomly assigned to administration of either valsartan, 80 mg/d (titrated up to 160 mg/d for blood pressure control), or placebo for 104 weeks. Additional antihypertensive therapy was allowed to achieve a target blood pressure of 140/90 mm Hg. The primary end point was doubling of serum creatinine level or dialysis-dependent renal failure. Secondary outcomes included change in proteinuria and decrease in glomerular filtration rate (GFR). RESULTS There were 54 patients in the treatment group and 55 patients in the placebo group. Baseline clinical characteristics were similar between groups, although the treatment group had a marginally greater baseline GFR (87 +/- 36 versus 78 +/- 38 mL/min/1.73 m2 [1.45 +/- 0.60 versus 1.30 +/- 0.63 mL/s/1.73 m2];P = 0.29) and less proteinuria (protein, 1.8 +/- 1.2 versus 2.3 +/- 1.7 g/d; P = 0.21) than the placebo group. Average blood pressures during the study were 92.7 +/- 10.6 mm Hg in the treatment group and 100.9 +/- 9.1 mm Hg in the placebo group (P < 0.001). During the study period, 4 patients in the placebo group and 1 patient in the treatment group reached the primary end point (log-rank test, P = 0.18). Proteinuria decreased significantly in the treatment group (protein, 1.8 +/- 1.2 to 1.2 +/- 1.2 g/d; P = 0.03), but did not change in the placebo group. With multiple linear regression models, valsartan treatment resulted in a 33.0% decrease in proteinuria (95% confidence interval, 10.9 to 55.1) after adjusting for other confounding factors. There was a significant decrease in mean rate of GFR decrease in the valsartan-treated group (-5.62 +/- 6.79 mL/min/y [-0.09 +/- 0.11 mL/s/y]) compared with the placebo group (-6.98 +/- 6.17 mL/min/y [-0.12 +/- 0.10 mL/s/y]) throughout the study period after adjustment for average blood pressure and proteinuria (P = 0.014). CONCLUSION Valsartan significantly decreases proteinuria and slows renal deterioration in patients with IgA nephropathy after adjustment for confounding factors, notably blood pressure. The long-term benefit of valsartan needs to be confirmed with additional studies.
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Affiliation(s)
- Philip Kam-Tao Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong.
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Abstract
IgA nephropathy affects almost 1% of the population and yet the diagnosis is often missed. This significant kidney disease is often progressive with 25% of the patients going on to end-stage kidney disease over the course of 25 years. This minireview describes the clinical presentations in children and young adults. Therapeutic options are discussed including angiotensin-converting enzyme blockade, steroids, cytotoxics, tonsillectomy, fish oil, vitamin E, singly or in combination, in order to modulate the rate of progression.
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Affiliation(s)
- James C M Chan
- University of Vermont and the Barbara Bush Children's Hospital, Maine Medical Center, Portland, Me 04102-3175, USA.
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Yoshikawa N, Honda M, Iijima K, Awazu M, Hattori S, Nakanishi K, Ito H. Steroid Treatment for Severe Childhood IgA Nephropathy: A Randomized, Controlled Trial. Clin J Am Soc Nephrol 2006; 1:511-7. [PMID: 17699253 DOI: 10.2215/cjn.01120905] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
A previous trial showed that treatment of children with severe IgA nephropathy (IgAN) using prednisolone, azathioprine, heparin-warfarin, and dipyridamole for 2 yr early in the course of disease reduced the severity of immunologic renal injury and prevented any increase in the percentage of sclerosed glomeruli. This study compared the effects of prednisolone, azathioprine, warfarin, and dipyridamole (combination) with those of prednisolone alone in 80 children with newly diagnosed IgAN that showed diffuse mesangial proliferation. Patients were randomly assigned to receive either the combination or prednisolone alone for 2 yr. The primary end point was the disappearance of proteinuria, defined as urinary protein excretion <0.1 g/m2 per d, and the secondary end points were urinary protein excretion at the end of treatment, the change in the percentage of sclerosed glomeruli during the trial, and adverse effects. The two study groups were similar in terms of baseline characteristics. Thirty-nine of the 40 patients who received the combination and 39 of the 40 who received prednisolone completed the trial. Thirty-six (92.3%) of the 39 patients who received the combination and 29 (74.4%) of the 39 who received prednisolone reached the primary end point by the 2-yr follow-up point (P = 0.007 log-rank). The percentage of sclerosed glomeruli was unchanged in the patients who received the combination but increased from 3.1 +/- 4.8 to 14.6 +/- 15.2% in the prednisolone group (P = 0.0003). The frequency of adverse effects was similar in the two groups. It is concluded that combination treatment may be better for severe IgAN than treatment with prednisolone alone.
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Affiliation(s)
- Norishige Yoshikawa
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8509, Japan.
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Zhong Q, Leung JCK, Chan LYY, Tsang AWL, Chen X, Lai KN. The study of Chinese medicinal herbal formula Shen San Fang in the treatment of experimental IgA nephropathy. THE AMERICAN JOURNAL OF CHINESE MEDICINE 2005; 33:613-26. [PMID: 16173535 DOI: 10.1142/s0192415x05003211] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
IgA nephropathy (IgAN) is the most common primary glomerulonephritis worldwide, yet there is no effective or specific therapy. Shen San Fang (S3F) is a traditional Chinese herbal medicinal formula that has been used in China for many years to treat patients with hematuria. The aim of this study is to test the therapeutic value of S3F in an experimental model of IgAN. IgAN was induced in Lewis rats by continuous oral immunization with bovine gamma-globulin (BGG) in the drinking water for 8 weeks, followed by intravenous injection of 1 mg BGG daily for 3 successive days. The rats were randomly divided into four groups (five rats/group): control, control receiving S3F, induction of IgAN, and IgAN receiving S3E S3F decoction was fed to rats beginning week 4 from the first day of oral sensitization with BGG. The S3F treatment was continued until the rats were sacrificed or for a 4-week period. Hematuria, renal immunohistochemistry for IgA and transforming growth factor-beta 1 (TGF-beta1), renal histopathology, and renal content of TGF-beta1 were measured. Rats developing IgAN had marked hematuria, profound mesangial proliferation and mesangial expansion, intense and diffuse glomerular IgA deposition, increased glomerular TGF-beta1 expression, and raised renal TGF-beta1 levels. S3F treatment resulted in a significant reduction of hematuria, decreased mesangial IgA deposition, weaker immunostaining of TGF-beta1 in glomerulus, and a lower renal TGF-beta1 concentration. Our animal data suggests a therapeutic value for the Chinese medicinal formula S3F in experimental IgAN. This beneficial effect was due to reduced glomerular IgA deposition and TGF-beta1 expression. Our preliminary findings hold promise for future human therapy.
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Affiliation(s)
- Qing Zhong
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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