[Long-term prognosis for tonsillectomy patients with IgA nephropathy]

Tonsillectomy plus steroid pulse therapy is the most effective treatment in adult patients with C-Grade I IgA nephropathy, and the weight of the extracted palatine tonsils and Yamamoto scale have no significant correlation with the effects of this treatment

OBJECTIVE

We studied patients who underwent tonsillectomy plus steroid pulse therapy (TSP) for immunoglobulin A nephropathy (IgAN), in order to investigate the clinical factors associated with a positive response to this treatment.

METHODS

We analyzed 118 IgAN patients who underwent TSP. We collected patients' data retrospectively, including age, sex, blood pressure, onset of IgAN, pathological findings of a renal biopsy, serum concentration of creatinine, estimated glomerular filtration rate, serum concentration of protein, urinary protein, hematuria, past history of tonsillitis, the Yamamoto scale, the weight and pathological findings of the extracted palatine tonsils, and the presence or absence of anti-platelet drugs and renin-angiotensin system inhibitors (RAS-I) usage. This study included participants who were over 18 years of age, had undergone tonsillectomy within three months of steroid pulse therapy administered thrice, in whom renal biopsy was performed within a year before treatment, and with follow-up period of over 3 years. Clinical remission (CR) of urinary abnormalities was defined as remission of both proteinuria and hematuria: three consecutive negative results over a 6-month period, with a urinary sediment red blood cell count of <5/HPF, and a proteinuria qualitative reaction of (-) to (±).

RESULTS

The CR rate of all cases was 56.8% and statistical significance was observed with respect to the C-Grade (P =  0.0003, P =  0.028) using both univariate and multivariate analysis. The CR rate of C-Grade І (73.4%) patients was significantly higher than that of C-Grade II patients (39.0%; P =  0.0004) and C-Grade III patients (30.8%; P =  0.003). We analyzed clinical factors in each C-Grade patient. No statistical significance was observed with respect to any of the factors using univariate analysis in C-Grade I patients. The weight of the extracted palatine tonsils and Yamamoto scale showed no statistical significance in every analysis. Fibrosis or hyalinization of the stroma of the palatine tonsils showed statistical significance (P =  0.026) only in the univariate analysis of C-Grade III patients. However, the patient number of C-Grade III was small.

CONCLUSION

Our results indicate that TSP is mostly effective in patients with of C-Grade I IgAN and that the C-Grade reflects the clinical indication for TSP. The weight of the extracted palatine tonsils and Yamamoto scale did not show obvious correlations with the clinical effect of TSP.

Steroid pulse therapy transiently destroys the discriminative histological structure of tonsils in IgA nephropathy: Tonsillectomy should be performed before or just after steroid pulse therapy

OBJECTIVE

Tonsillectomy combined with steroid-pulse therapy is a widely accepted method for the treatment of IgA nephropathy (IgAN) in Japan. However, the indication of tonsillectomy for IgAN is still controversial, and the timing of tonsillectomy is not clearly defined for the protocol of this therapy. Based on the results of a randomized control trial in Japan, the Evidence-Based Clinical Practice Guidelines for IgA nephropathy 2014 (edited in Japan) recommended tonsillectomy combined with steroid-pulse therapy for Grade C1. However, this is not widely accepted worldwide. To clarify the validity and timing of tonsillectomy, we evaluated how the three-consecutive steroid-pulse therapy method affects the tonsil tissues of IgAN patients.

METHODS

We examined tonsil specimens from 35 IgAN patients and 8 chronic tonsillitis patients. We compared the proportion of follicular area to total tonsillar area and the number of germinal centers between each group on hematoxylin and eosin stained pathological specimens to clarify the histopathological characteristics of tonsils from IgAN patients. Based on these findings, we examined the tonsils of patients after three-consecutive steroid-pulse therapy treatments (n=34) to determine the influence of this therapy on the tonsil tissues of IgAN patients. Moreover, we observed chronological changes in tonsil tissues after steroid-pulse therapy.

RESULTS

The extrafollicular area was enlarged in IgAN patients before steroid-pulse therapy compared with chronic tonsillitis patients. Just after steroid-pulse therapy, the follicles became very small with blurry outlines, and the number of germinal centers was remarkably decreased. With a gradual decrease in oral prednisolone, the tonsil tissue structure was gradually restored.

CONCLUSION

Tonsillectomy combined with steroid-pulse therapy is considered a reasonable treatment for IgAN. Steroid-pulse therapy-induced histological changes in tonsils were transient, indicating tonsillectomy should be performed before or just after steroid-pulse therapy.

The size of palatine tonsils cannot be used to decide the indication of tonsillectomy for IgA nephropathy

Background. Tonsillectomy is one of the treatment strategies for immunoglobulin A nephropathy (IgAN). The relationship between the indication of tonsillectomy and the size of palatine tonsils (PTs) in patients with IgAN remains controversial.

Methods. This retrospective cohort study investigated 57 patients with IgAN who underwent tonsillectomy combined with steroid pulse therapy (SPT). They were classified into two groups, the hypertrophy group and the nonhypertrophy group, according to the weight of their excised PTs. The effects of tonsillectomy combined with SPT on clinical remission (CR) and the histopathological findings of PTs were compared between the two groups.

Results. During the mean follow-up period of 45.5 (range 6–133) months, 78.9% of the patients achieved CR (79.3 versus 78.6%, P = 0.945) and the baseline serum creatinine doubled only in one patient in the nonhypertrophy group (0 versus 3.6%, P = 0.491). No significant difference was observed in the incidence of CR between the two groups by the Kaplan–Meier method (P = 0.839). The predictor for CR, identified in Cox proportional hazards models, was baseline proteinuria [hazard ratio 0.14 (95% CI 0.032–0.621) P = 0.010]. Although macroscopic pus plugs were observed on the surface of PTs in almost 60% of patients in each group, microscopic pus plugs in the crypt and the enlarged interfollicular area were observed in all patients.

Conclusions. The treatment effect of tonsillectomy combined with SPT and the pathological features of PTs in IgAN were equal, regardless of the size of the PTs. Therefore, the size of PTs should not be included as a factor when deciding the indication of tonsillectomy for IgAN.

[Prognostic factors of IgA nephropathy after tonsillectomy]

Tonsillectomy is one of the prevailing treatments for IgA nephropathy. This retrospective study aimed to elucidate prognostic factors for the postoperative kidney function of tonsillectomized patients with IgA nephropathy. Forty consecutive patients with IgA nephropathy who underwent tonsillectomy in our department between 1999 and 2008 were enrolled. They were 21 men and 19 women with ages ranging 14-52 years with an average age of 25.5 years. The patients were classified into remission and non-remission groups based on their kidney function assessed 1 year after surgery according to the clinical guidelines for IgA nephropathy of the Japanese Society of Nephrology. Patients' profiles and preoperative physical findings/laboratory data in the remission group were then compared with those in the non-remission group. The remission and non-remission groups included 13 and 27 patients, respectively. The remission group showed a significantly shorter interval between onset to surgery (2.3 +/- 2.1 vs. 5.0 +/- 6.7 years; p = 0.032), a lower diastolic blood pressure (66 +/- 13 vs. 75 +/- 17 mmHg; p = 0.040), a higher level of serum total protein (7.6 +/- 0.5 vs. 7.0 +/- 0.7 mg/dl; p = 0.015), and a higher degree of tonsillar hypertrophy (I degrees: II degrees: III degrees = 5 : 8: 0 vs. 21 : 6 : 0; p = 0.033) in comparison with the non-remission group. Multiple logistic regression analysis also revealed that patients with a higher level of serum total protein and those with a higher degree of tonsillar hypertrophy were more likely to recover. We should carefully consider these prognostic factors when indicating tonsillectomy for the treatment of IgA nephropathy.

[Therapeutic effects and prognostic factors in tonsillectomy patients with IgA nephropathy]

INTRODUCTION

Because upper respiratory tract infections, particularly tonsillitis, often precede IgA nephropathy (IgAN), IgAN is now recognized as a tonsil-related disease, and reports have shown that tonsillectomy is effective in preventing disease progression in IgAN patients. IgA may thus play an important role in IgAN pathogenesis and development. B cell activation factor belonging to the TNF family (BAFF) is expressed by monocytes, macrophages, and dendritic cells, and may be the mechanism by which macrophages and dendritic cells directly regulate human B-cell activation. BAFF acts as a potent B-cell growth factor and costimulator of immunoglobulin production, including IgA. We studied therapeutic effects and serum BAFF levels as prognostic factors.

PATIENTS AND METHODS

Subjects were 41 patients undergoing tonsillectomy and followed up for at least 1 year. Serum samples were obtained from 38 with IgAN and 29 with recurrent tonsillitis as a properative control groups. The remission group consisted of patients with normal renal function without hematuria and proteinuria. Serum BAFF levels were measured by ELISA kits at our laboratory.

RESULTS

Overall remission was 39.0%. The disappearance of hematuria increased for long-term follow-up groups, but proteinuria was unchanged. Serum BAFF levels among the two groups did not differ significantly. Among IgAN patients, higher BAFF levels were associated with higher serum IgA/C3 levels. The correlation was weak (p =0.026, r = 0.407). Using 3.2 ng / ml as a cut off point, we compared cumulative improvement in those with high pretreatment BAFF levels to those with low pretreatment levels. Those with high pretreatment BAFF levels had inferior cumulative improvement in hematuria.

CONCLUSION

Tonsillectomy was effective in improving hematuria. BAFF appears to be a key factor in tonsillectomy among [gAN patients.

Relationship between tonsils and IgA nephropathy as well as indications of tonsillectomy

Although there are many papers about IgA nephropathy (IgAN) and tonsils, respectively, reviews about the relationship between tonsils, tonsillitis, tonsillectomy, and IgAN are limited. In this review, we introduced the structure, development, and function of tonsils, difference of tonsils with and without IgAN, consistency of both tonsillar IgA and glomerular IgA, the effect of tonsil stimulation, tonsil infection, and tonsillectomy on IgAN showed some evidences in which tonsils were closely related to IgAN and polymeric IgA1 deposited in glomerular mesangium were at least in part of tonsillar origin. Tonsillectomy can improve the urinary findings, keep stable renal function, improve mesangial proliferation and IgA deposit, have a favorable effect on long-tern renal survival in some IgAN patients, and do not cause significant immune deficiency and do not increase incidence of the upper respiratory tract infections, and can be used as a potentially effective treatment. The indications of tonsillectomy in patients with IgAN include mainly the deterioration of urinary findings after tonsillar infection, mild or moderate renal damage. However, tonsillectomy may not be enough and may not change the prognosis in IgAN patients with marked renal damage.

The efficacy of tonsillectomy on long-term renal survival in patients with IgA nephropathy

BACKGROUND

Little information has been available until now about the clinical efficacy of tonsillectomy on long-term renal survival of patients with idiopathic immunoglobulin A nephropathy (IgAN).

METHODS

To investigate the effect of tonsillectomy on long-term renal survival, we reviewed the clinical course of 118 patients with idiopathic biopsy-diagnosed IgAN from 1973 to 1980. Of those, 48 patients received tonsillectomy and 70 patients did not. The starting point of observation was defined as the time of the diagnostic renal biopsy, and the end point as when requiring the first dialysis. Up to 2001, the mean observation time was 192.9 +/- 74.8 months (48-326 months). Renal survival and impact of covariates were evaluated by Kaplan-Meier analysis and Cox proportional hazards regression model.

RESULTS

Age, gender, amount of urinary protein excretion, serum creatinine, serum IgA, blood pressure, and histopathologic findings at the time of renal biopsy and treatments during the observation period were not significantly different between patients with and without tonsillectomy. Five (10.4%) of the patients with tonsillectomy and 18 (25.7%) of the patients without tonsillectomy finally required dialysis therapy (chi-square test, P = 0.0393). By Kaplan-Meier analysis, renal survival rates were 89.6% and 63.7% at 240 months in the patients with and without tonsillectomy, respectively, and were significantly different (log-rank test, P = 0.0329). In the multivariate Cox regression model, tonsillectomy (hazard ratio, 0.22; 95% CI, 0.06 to 0.76; P = 0.0164) had a significant effect on renal outcome.

CONCLUSION

These results indicate that tonsillectomy has a favorable effect on long-term renal survival in patients with IgAN.