Histological Correlation between Tonsillar and Glomerular Lesions in Patients with IgA Nephropathy Justifying Tonsillectomy: A Retrospective Cohort Study

Tonsillectomy with steroid pulse therapy (SPT) has been established as an effective treatment for immunoglobulin A nephropathy (IgAN) in Japan. However, the underlying mechanisms supporting tonsillectomy remain unclear. This study assessed palatine tonsils from 77 patients with IgAN, including 14 and 63 who received SPT before and after tonsillectomy, respectively. Tonsils from 21 patients with chronic tonsillitis were analyzed as controls. Specific tonsillar lesions were confirmed in patients with IgAN, correlating with active or chronic renal glomerular lesions and SPT. T-nodule and involution of lymphoepithelial symbiosis scores in tonsils correlated with the incidence of active crescents and segmental sclerosis in the glomeruli, respectively. The study revealed an essential role of the tonsil-glomerular axis in early active and late chronic phases. Moreover, the SPT-preceding group demonstrated no changes in the T-nodule score, which correlated with active crescent formation, but exhibited a considerable shrinkage of lymphatic follicles that produced aberrant IgA1. The study underscores the involvement of innate and cellular immunity in IgAN and advocates for tonsillectomy as a necessary treatment alongside SPT for IgAN, based on a stepwise process.

Role of Palatine Tonsil and Epipharyngeal Lymphoid Tissue in the Development of Glomerular Active Lesions (Glomerular vasculitis) in Immunoglobulin A Nephropathy

Hematuria is an essential symptom of immunoglobulin A nephropathy (IgAN). Although the etiology of hematuria in IgAN has not been fully elucidated, it is thought that the rupture of the glomerular basement membranes caused by intra-capillary leukocyte influx, so-called glomerular vasculitis, is the pathological condition responsible for severe hematuria. Glomerular vasculitis are active lesions that exist in the glomeruli of acute phase IgAN and it is important because it is suspected to make the transition to segmental glomerular sclerosis (SGS) as a repair scar lesion in the chronic phase, and the progression of SGS would eventually lead to glomerular obsolescence. Worsening of hematuria concomitant with acute pharyngitis is common in patients with IgAN; therefore, elucidating the relationship between the immune system of Waldeyer's ring, including the palatine tonsil and epipharyngeal lymphoid tissue, and the glomerular vasculitis may lead to understanding the nature of IgAN. The epipharynx is an immunologically activated site even under normal conditions, and enhanced activation of innate immunity is likely to occur in response to airborne infection. Hyperactivation of innate immunity via upregulation of Toll-like receptors in the interfollicular area of the palatine tonsil and epipharyngeal lymphoid tissue, followed by enhanced fractalkine/CX3CR1 interactions, appears to play an important role in the development of glomerular vasculitis in IgAN. As latent but significant epipharyngitis is present in most patients with IgAN, it is plausible that acute upper respiratory infection may contribute as a trigger for the innate epipharyngeal immune system, which is already upregulated in a chronically inflamed environment. Given that epipharyngitis and its effects on IgAN are not fully understood, we propose that the so-called "epipharynx-kidney axis" may provide an important focus for future research.

A case of autosomal dominant polycystic kidney disease with amelioration of refractory cyst infections following prolonged hemodialysis time

Renal cyst infection is a frequent and serious problem in patients with autosomal dominant polycystic kidney disease (ADPKD). Cyst infection is often a refractory complication of treatment that leads to sepsis and death in patients with ADPKD. It was previously reported that a higher dose of dialysis demonstrated clearly better survival than shorten-time dialysis. The relationship between the frequency of cyst infection episodes in hemodialysis (HD) patients with ADPKD and the dialysis dose has not yet been fully elucidated. In this report, we describe a case of an HD patient with ADPKD that was provided elongation of HD time from 4-h twice weekly HD to 8-h thrice weekly nocturnal HD. As a result, the frequency of cyst infection episodes decreased from 10.0 to 1.5 days a month. Our findings suggest that prolonged HD time might contribute to amelioration of refractory cyst infections in patients with ADPKD.

Pre-treatment hematuria and crescents predict estimated glomerular filtration rate trajectory after methylprednisolone pulse therapy with tonsillectomy for IgA nephropathy

BACKGROUND

Glomerular hematuria and proteinuria are typical manifestations of IgA nephropathy (IgAN). However, hematuria severity is not considered a useful marker of the potential benefits of corticosteroid administration as proteinuria severity only is included in the current guidelines.

METHODS

In this retrospective cohort study, we enrolled 133 patients diagnosed with IgAN through biopsy. We calculated the 2-year estimated glomerular filtration rate (eGFR) slope (mL/min/1.73m²/year) and eGFR trajectory after methylprednisolone pulse therapy using mixed effects models stratified by the Oxford classification and three categories of pre-treatment hematuria: mild [urinary red blood cells (URBCs) < 10/high-power field (HPF)], moderate (URBCs 10-30/HPF), and severe (URBCs ≥ 30/HPF).

RESULTS

The severe pre-treatment hematuria group showed a significantly higher likelihood of having crescents (odds ratio (OR), 4.3; 95% confidence interval (CI), 1.7-10.9). In the longitudinal analysis of 103 patients, most of whom underwent tonsillectomy, the severe pre-treatment hematuria group had a significantly higher 2-year eGFR slope after methylprednisolone pulse therapy than the mild and moderate hematuria groups (mild, -0.52 ± 1.97; moderate, -0.32 ± 1.99; severe, 1.44 ± 3.20 mL/min/1.73m²/year). Patients with C2 scores showed a significantly higher 2-year eGFR slope after methylprednisolone pulse therapy than those with C0 and C1 scores (C0, -0.38 ± 1.74; C1, 0.81 ± 3.02; C2, 3.29 ± 3.68 mL/min/1.73m²/year). Analyses of eGFR trajectory after methylprednisolone pulse therapy revealed that the eGFR improved only in patients with severe pre-treatment hematuria or C2 score (P_interaction with time < 0.001).

CONCLUSIONS

The eGFR is likely to improve after methylprednisolone pulse therapy with tonsillectomy in IgAN patients with severe pre-treatment hematuria or a high percentage of crescents.

Dysbiosis in the Salivary Microbiome Associated with IgA Nephropathy-‍A‍ ‍Japanese Cohort Study

IgA nephropathy is one of the leading causes of chronic kidney disease in Japan. Since the origin and mechanisms by which IgA nephropathy develops currently remain unclear, a confirmed disease diagnosis is currently only possible by highly invasive renal biopsy. With the background of the salivary microbiome as a rich source of biomarkers for systemic diseases, we herein primarily aimed to investigate the salivary microbiome as a tool for the non-invasive diagnosis of IgA nephropathy. In a comparison of salivary microbiome profiles using 16S rRNA amplicon sequencing, significant differences were observed in microbial diversity and richness between IgA nephropathy patients and healthy controls. Furthermore, recent studies reported that patients with IgA nephropathy are more likely to develop inflammatory bowel diseases and that chronic inflammation of the tonsils triggered the recurrence of IgA nephropathy. Therefore, we compared the salivary microbiome of IgA nephropathy patients with chronic tonsillitis and ulcerative colitis patients. By combining the genera selected by the random forest algorithm, we were able to distinguish IgA nephropathy from healthy controls with an area under the curve (AUC) of 0.90, from the ulcerative colitis group with AUC of 0.88, and from the chronic tonsillitis group with AUC of 0.70. Additionally, the genus Neisseria was common among the selected genera that facilitated the separation of the IgA nephropathy group from healthy controls and the chronic tonsillitis group. The present results indicate the potential of the salivary microbiome as a biomarker for the non-invasive diagnosis of IgA nephropathy.

The epipharynx-kidney axis triggers glomerular vasculitis in immunoglobulin A nephropathy

Macroscopic hematuria concomitant with acute pharyngitis is a characteristic feature of immunoglobulin A nephropathy (IgAN). Although the underlying mechanism of worsening hematuria has not been fully elucidated, activation of the innate immune system of nasopharynx-associated lymphoid tissue is thought to play an important role. The epipharynx is an immunologically activated site even under normal conditions, and enhanced activation of innate immunity is likely to occur in response to airborne infection. As latent but significant epipharyngitis presents in most IgAN patients, it is plausible that acute pharyngitis due to airway infection may contribute as a trigger of the epipharyngeal innate immune system, which is already upregulated in the chronically inflamed environment. The aim of this review was to discuss the mechanism of epipharynx-kidney axis involvement in glomerular vasculitis responsible for the worsening of hematuria in IgAN.

Usefulness of Dialysate Fibrin Degradation Products and Lactic Dehydrogenase Isoenzyme Patterns in Assessing the Clinical Course of Peritonitis

Objective

To establish the usefulness of fibrin degradation products (FDP) and lactic dehydrogenase isoenzyme patterns (LDH isoenzyme) in assessing the clinical course of peritonitis.

Design

A retrospective study of patients with peritonitis who were divided into three groups according to their clinical course.

Setting

Single dialysis unit of a general hospital.

Interventions

Patients were treated by intraperitoneal and oral antibiotics.

Patients

Twenty-six patients with 34 episodes of peritonitis were studied. Group 1 consisted of 21 patients with 26 recoveries from peritonitis; Group 2 consisted of 5 patients with 5 relapsing episodes of peritonitis, and Group 3 consisted of 3 patients with 3 persistent episodes of peritonitis.

Main Outcome Measures

Concentrations of WBCs, FDP, LDH isoenzyme and microbiological culture of the dialysate were determined.

Results

In most of Group 1, WBCs, FDP, and LDH isoenzyme returned to normal within 2 weeks. In 4 patients of Group 1, who had complications (diverticulitis, cholecystitis, cystitis, and tunnel infection), WBCs, FDP, and LDH isoenzyme returned to normal gradually within 3 weeks. In Group 2, WBCs returned to normal, but FDP remained relatively high and LDH isoenzyme did not normalize. In Group 3, WBCs, FDP and LDH isoenzyme did not normalize.

Conclusions

Failure of normalization of FDP and LDH isoenzyme suggests an incomplete recovery from peritonitis. FDP and LDH isoenzyme are useful in assessing the course of peritonitis.

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.

Comparisons of amino acids, body constituents and antioxidative response between long-time HD and normal HD

Introduction Oxidative stress is one of the main mediators of progression of chronic kidney diseases (CKD). Nuclear factor E2-related factor 2 (Nrf2) is the transcription factor of antioxidant and detoxifying enzymes and related proteins which play an important role in cellular defense. Long-time hemodialysis (HD) therapy (8 hours) has been considered to be more beneficial compared to normal HD therapy (4 hours). We investigated oxidative response related to Nrf2 in peripheral blood mononuclear cells (PBMCs) of long-time HD and normal HD patients. Methods Eight adult long-time HD therapy patients (44.5 ± 3.0 years) and 10 normal HD therapy patients (68.1 ± 2.7 years) were enrolled. PBMCs were isolated and processed for expression of Nrf2 and its related genes by qRT-PCR. Plasma indoxyl sulfate, amino acids, and body constituents were measured. Findings Plasma indoxyl sulfate was significantly low after long-time HD therapy compare to that of normal HD therapy. Although, skeletal muscle mass, lean body mass, mineral and protein were significantly decreased 2 months in normal HD patients, those in long-time HD patients were significantly increased after 2 months. Almost of amino acids were significantly decreased after HD therapy in both HD therapies. Plasma amino acids were significantly low in long-time HD patients compared to normal HD patients. In PBMCs, the expression of Nrf2 was significantly decreased and hemooxygenase-1 expression was significantly increased in long-time HD compared to normal HD. Conclusion These observations indicate the beneficial effects of in long-time HD in improving oxidative stress in patients.

Immunosuppressive therapy for active IgA nephropathy is effective and safe, even in "elderly" patients

Proportions of elderly aged ≥65 and ≥75 within Japan will increase to 30 and 20 %, respectively, in 2025, when "Baby-Boom Generations" will reach the age of 75 years. Okabayashi and colleagues report that even in elderly patients with IgA nephropathy (IgAN), immunosuppressive treatment can reduce proteinuria, with no adverse events. Their findings remind us of recent finding from STOP-IgAN study; additional immunosuppressive therapy to intensive supportive care [specifically renin-angiotensin system (RAS) inhibitors (RASi)] did not improve the outcome. If STOP-IgAN makes doctors believe that immunosuppression is not necessary, many patients could lose opportunity to eliminate their kidney disease. Indeed, we have experienced patients with IgAN, who despite hematuria, could not undergo renal biopsy or immunosuppressive treatment at another facility because of low proteinuria, and exhibited advanced lesions in their renal biopsy at our institution. The discrepancy between Okabayashi's and STOP-IgAN study was derived not only from differences in population age (≥60 years vs. 18-70 years). STOP-IgAN excluded the crescentic IgAN, whereas Okabayashi et al. found active manifestations (hematuria, mesangial proliferation, and cellular/fibrocellular crescent). Therefore, immunosuppressive therapy is required even in elderly patients. In STOP-IgAN, RASi were used first, and then immunosuppressive agent was additionally used. RASi has important implications to reduce glomerular capillary pressure and to suppress the intrarenal RAS activity. However, immunosuppressant should be administered initially to cure hematuria. In fact, microscopic-hematuria was resolved in only 16 and 42 % of two-assigned groups in STOP-IgAN, respectively. Okabayashi et al. provided a timely message regarding the significance of immunosuppressive treatment of IgAN.

Five cases of tonsillectomy and steroid pulse therapy for recurrent immunoglobulin A nephropathy after kidney transplantation

Five cases of recurrent immunoglobulin A nephropathy (IgAN) after kidney transplantation were successfully treated by tonsillectomy and steroid pulse therapy (SPT). The clinical background and pathology in the five cases were different, but good results were obtained in all of them. In cases 1 and 2, mild recurrent IgAN developed and failed to remit after tonsillectomy alone, but a remission was achieved in both cases after SPT. In case 3, highly active recurrent IgAN with crescent lesions developed 13 years after kidney transplantation, and a remission was achieved after SPT. In case 4, renal biopsy specimens showed pathological findings of recurrent IgAN with tubulitis, and hematuria and proteinuria resolved after SPT. In case 5, the biopsy findings indicated recurrent IgAN with chronic rejection. Tonsillectomy was followed by resolution of the proteinuria, and a remission was achieved after SPT. In conclusion, SPT is effective in inducing a remission of recurrent IgAN when tonsillectomy alone fails.

Serum levels of galactose-deficient immunoglobulin (Ig) A1 and related immune complex are associated with disease activity of IgA nephropathy

Background

The primary abnormal manifestation in immunoglobulin A nephropathy (IgAN) is recurring bouts of hematuria with or without proteinuria. Although immunohistochemical analysis of renal biopsy tissue remains the gold standard not only for diagnosis but also for evaluating the activity of IgAN, new sensitive and reasonably specific noninvasive tests are emerging to guide therapeutic strategy applicable to all stages of IgAN. The present study examined serum levels of galactose-deficient IgA1 (Gd-IgA1) and its immune complex (IgA/IgG-IC) as noninvasive markers for the disease activity.

Methods

We enrolled 50 IgAN patients (male 40 %, median age 37 years) showing complete or partial clinical remission after steroid pulse therapy with tonsillectomy (TSP) whose clinical data and serum could be followed up for 3–5 years.

Results

Cross-sectional analysis revealed that the degree of hematuria and proteinuria were significantly associated with levels of Gd-IgA1 and levels of IgA/IgG-IC. Longitudinal analysis further showed that from the group of 44 patients with heavy hematuria before TSP, 31 patients showed complete disappearance of hematuria (group A), but the remaining patients did not (group B). Although the levels of Gd-IgA1 and IgA/IgG-IC in the two groups before TSP were similar, percentage decrease of Gd-IgA1 and IgA/IgG-IC levels in group A was significantly higher than in group B.

Conclusion

Disease activity of IgAN assessed by hematuria and proteinuria correlated with serum levels and changes of Gd-IgA1 and IgA/IgG-IC. These new noninvasive disease activity markers can be useful for future activity scoring system and guiding therapeutic approaches.

Clinical and immunological implications of increase in CD208+ dendritic cells in tonsils of patients with immunoglobulin A nephropathy

BACKGROUND

The therapeutic effect of tonsillectomy for immunoglobulin A nephropathy (IgAN) has been widely recognized, but the mechanism by which tonsillar immunity leads to glomerulonephritis has been unclear. We investigated subtypes and localization of dendritic cells (DCs) in tonsils and looked for relationships between the tonsillar DCs and the clinical features and renal histological changes of patients with IgAN.

METHODS

We examined tonsils from 33 IgAN patients, using as control tonsillar specimens from subjects without glomerulonephritis. Five distinct markers of DCs (CD303, CD1c, CD209, CD208 and CD1a) were analyzed by immunohistochemistry and flow cytometry. The mRNA levels of these DC markers were evaluated using real-time polymerase chain reaction. The clinical data and histological results obtained evaluating renal biopsy tissues were statistically compared with immunological data.

RESULTS

Of the five subtypes of DCs, CD208(+) DCs were significantly increased in the tonsils of IgAN patients compared with that of controls. Furthermore, the number of CD208(+) DCs in the tonsils was positively and linearly correlated with the proportion of crescentic glomeruli in renal biopsy tissues and with the urinary protein level. Only few CD208(+) cells, however, were found in the kidney biopsy specimens of IgAN patients.

CONCLUSIONS

These observations suggest that increased CD208(+) DCs in tonsils may play a directive role in the pathogenesis of IgAN. The present results support the therapeutic significance of tonsillectomy for IgAN patients.

Significance of the duration of nephropathy for achieving clinical remission in patients with IgA nephropathy treated by tonsillectomy and steroid pulse therapy

BACKGROUND

Because of the well-established annual urinalysis screening system in Japan, the duration of nephropathy (DN) can be estimated in more than half of all patients with IgA nephropathy (IgAN). Treatment using a combination of tonsillectomy and steroid pulse (TSP) therapy has been reported as an effective method for obtaining clinical remission (CR), defined as negative hematuria and proteinuria, in IgAN patients. The present study aims to identify the correlation between DN and CR rate in IgAN patients treated by TSP therapy.

METHODS

We retrospectively investigated 830 IgAN patients who were followed up for 81.6 months after TSP therapy. DN could be estimated in 495 of the 830 patients.

RESULTS

The CR rate among patients with DN ≤36 months was 87.3% (295/338 patients). The CR rate among patients with DN of 37-84 months was 73.3% (63/86 patients), while that among patients with DN ≥85 months was 42.3% (30/71 patients). The CR rate among the remaining 335 patients in whom DN could not be estimated because of missing annual urinalysis results was 43.6% (146/335 patients). A multivariate Cox regression model using data from the former group of 495 patients showed that DN ≤36 months was a significant predictor of CR (hazard ratio 1.839; 95% confidence interval 1.410-2.398; P < 0.001).

CONCLUSION

Shorter DN is associated with higher likelihood of clinical remission in IgAN patients treated by TSP therapy.

Dialysis staff encouragement and fluid control adherence in patients on hemodialysis

BACKGROUND

Fluid control in patients on dialysis is an important predictor of outcome but is a difficult restriction to achieve. The authors examined the association between dialysis staff encouragement and fluid control adherence in patients on hemodialysis.

METHODS

This cross-sectional study used the dialysis staff encouragement subscale (DSE). The outcome measure was intradialytic weight loss (IWL) of dry weight (DW), with nonadherence defined as IWL/DW greater than 5.7%. Predictors of nonadherence were identified using logistic regression. Odds ratio (OR) was for the occurrence of nonadherence as it correlated with a one standard deviation (SD) decrease in scale score.

RESULTS

Seventy-two patients on hemodialysis participated, 45 men (62.5%) and 27 women. The crude OR in DSE score was 1.75 (95% confidence interval [CI]: 1.02 to 3.0) and adjusted odds ratio was 2.51 (95% CI: 0.99 to 6.34).

CONCLUSION

Dialysis staff encouragement is important in improving fluid control adherence.

[Soluble fibrin is not excreted in urine and its plasma level is elevated in nephrotic syndrome]

Soluble fibrin (SF) is produced by activated blood coagulation reaction and is useful to diagnose thrombotic diseases. We measured plasma and urine SF levels in nephritic patients to assess the hypercoagulability state associated with the disease. Before they received anti-coagulation or anti-platelet therapies, 60 patients underwent measurement of plasma SF and D-dimer levels by Latex agglutination turbidimetric immnoassay (LA). Urinary SF levels were also measured by LA. Plasma and urinary thrombin antithrombin III complex (TAT) levels were measured by enzyme immunoassay (EIA). Plasma SF levels showed a good correlation with plasma TAT levels but only weak positive correlations were observed between plasma D-dimer and SF or TAT levels. Plasma SF and D-dimer levels were significantly higher in the Iatients with nephrotic-range hypoalbuminemia (< or =3 g/dL) than those without it. Contrarily there was no significant difference in plasma TAT levels between these two groups of patients. In almost all patients, urinary SF levels were under the detection limit. However, TAT was excreted into urine more frequently in patients showing the nephrotic range of hypoalbuminemia at 38.2% than in non-nephrotic patients at 8.0%. Thus, plasma SF levels more precisely indicate activated blood coagulation reaction than plasma TAT levels in nephrotic patients, probably because the plasma SF is not excreted into urine, while plasma TAT is.

[Clinical significance of urinary cholesterol/total protein ratio as a marker of selectivity of proteinuria: comparison with selectivity index]

Selectivity index (SI) has been reported to reflect the selectivity of proteinuria, and it has a relationship with tubulointerstitial damage. Moreover it has a predictive value on functional outcome. However, it is necessary to measure serum IgG, serum transferrin, urinary IgG, and urinary transferrin to calculate SI. We measured urinary micro-cholesterol (mCHO) levels in sixty-three patients with proteinuria (urinary total protein > or = g/gCr) and compared urinary mCHO/total protein(uTP) ratio and SI. The patients' diseases were minimal change nephrotic syndrome (MCNS, n = 12), focal and segmental glomerular sclerosis (FSGS, n = 12), membranous nephropathy (MN, n = 17), and diabetic nephropathy (DMN, n = 22). Urinary mCHO levels were measured by the ECC method using cholesterol ester hydrolase (CEH) and cholesterol dehydrogenase, and this method was performed conveniently by automatic analyzer. No correlation was observed between urinary mCHO/gCr and serum lipid levels. There was no difference of urinary protein levels among each disease group. We found urinary mCHO/uTP ratio has a good positive correlation with SI(R = 0.722, p < 0.001). Although the difference between ROC curves of SI and urinary mCHO/uTP ratio in distinguishing MCNS from other diseases (FSGS+MN+DMN) did not reach the statistical significance, the area under the curve was larger for mCHO/uTP ratio. These results suggest that measurement of urinary mCHO by ECC method can be a simple and useful tool for predicting selectivity of proteinuria and lipoprotein-loading tubulopathy.

Predictive factors of clinical outcome in patients with diffuse proliferative lupus nephritis treated early by intravenous methylprednisolone pulse therapy

BACKGROUND

Diffuse proliferative lupus nephritis (DPLN) is associated with significant morbidity and mortality unless aggressive immunosuppressive therapy is initiated early in the course of the disease. It has been observed that with steroid pulse therapy, some patients with DPLN enter clinical remission while others do not. The factors predictive of clinical remission with steroid pulse therapy in these patients has not yet been elucidated.

METHODS

The authors retrospectively reviewed the records of 52 consecutive patients of DPLN treated by steroid pulse therapy in order to compare the characteristics of patients in the clinical remission group and those in the non-remission group. Clinical remission was defined as a serum creatinine level of < or = 1.2 mg/dL, negative or trace proteinuria, and the observation of < or = 1-4 red blood cells/high-power field in a routine urine examination. The 52 patients were divided into the clinical remission group (n = 29) and the non-remission group (n = 23), and also into subcategories of DPLN, namely, the IV-G group (n = 28) and the IV-S (n = 24). The characteristics of the patients were then compared between the two respective groups to identify factors that might be significantly related to clinical remission using Mann-Whitney's U test and the Cox proportional hazards model.

RESULTS

In regard to the clinical and immunological characteristics of the patients, except for a significant difference in the serum albumin level, there were no significant differences in any of the parameters examined, including blood pressure, degree of proteinuria, and serum creatinine, between the remission group and non-remission group. Added to that, in the non-remission group, the pretreatment period was significantly longer than in the remission group. In relation to the histological characteristics, the Chronicity Index (CI) and severity of interstitial fibrosis were significantly higher (p = 0.021) in the non-remission group than in the remission group. The result of the Cox proportional hazards analysis revealed that the serum albumin, pretreatment period, CI, and severity of interstitial fibrosis were strongly related to the clinical outcome, whereas the results of the multivariate Cox proportional hazards analysis revealed only a weak correlation between the CI and the outcome.

CONCLUSION

It was concluded that the diagnosis should be performed early and the pretreatment period should be shortened before treatment. Also, an aggressive therapeutic intervention should be initiated early, before chronic renal injury becomes established, to increase the likelihood of remission in patients with DPLN.

A multicenter prospective cohort study of tonsillectomy and steroid therapy in Japanese patients with IgA nephropathy: a 5-year report

Tonsillectomy combined with corticosteroids has been performed for IgA nephropathy (IgAN) mainly in Japan. We, the Japanese Multicenter Study Group on the Treatment of IgA Nephropathy (JST-IgAN), have conducted a multicenter prospective cohort study including the combination therapy from 1999. A total of 101 patients (43 male, 58 female) were observed for 5 years. Their average age was 34.4 +/- 11.8 (15-55). Subjects were classified by daily proteinuria (UP) and serum creatinine (sCr); UP excreted below 0.5 g/day was defined as stage 1, 0.5-1.0 g/da y defined as stage 2, more than 1.0 g/da y and sCr < or =1.2 mg/dl in females or < or =1.4 mg/dl in males defined as stage 3, and sCr >1.2 mg/dl in females or >1.4 mg/dl in male defined as stage 4. Both tonsillectomy and high-dose corticosteroid were performed in 75 patients. Of these, 29 patients were stage 1, 26 were stage 2, 16 were stage 3, and 4 were stage 4. The number of subjects with steroid monotherapy were 1 (stage 1), 7 (stage 2), 9 (stage 3) and 1 (stage 4). The primary endpoint in this study was normalized urinalysis as clinical remission. The remission rate treated with combined therapy was 86.2% in stage 1, 73.1% in stage 2, and 43.8% in stage 3. On the other hand, it was 71.4% in stage 2, and 11.1% in stage 3 in steroid monotherapy subjects. Although the number in each treatment group varied because of the non-randomized study, tonsillectomy combined with 3 courses of high-dose corticosteroid therapy was more effective for clinical remission in the higher proteinuria group. We concluded that the goal should be cure and release from disease at an earlier stage of IgAN.

Impact of annual urine health check-up system to obtain clinical remission in patients with IgA nephropathy

PURPOSE

In Japan, the annual urine health check-up system is well developed. Recently we reported a significant impact of tonsillectomy and steroid pulse therapy on clinical remission in our IgA nephropathy (IgAN) patients and indicated that clinical remission might terminate the progressive deterioration in renal function. We surveyed whether early detection of urinary abnormalities by annual urine health check-ups contribute to clinical remission in IgAN patients treated with tonsillectomy and steroid pulse therapy.

METHODS

We investigated 380 IgAN patients in whom the onset year was identified by annual urine check-ups. Group A consisted of 264 patients in whom treatment intervention was initiated within 3 years after the first appearance of urinary abnormalities, and group B consisted of 116 patients who were diagnosed after more than 3 years duration of urinary abnormalities. We also classified our 380 patients by the degree of glomerular lesions; 233 patients with mild, 83 with moderate, and 64 with severe glomerular lesions. All patients were treated with tonsillectomy and steroid pulse therapy in our renal unit.

RESULTS

The clinical remission rate of group A was 87.1%, while that of group B was 54.3%. In the mild glomerular lesion group, group B had a significantly lower remission rate than group A. Even in the severe glomerular lesion group, the remission rate of group A was significantly higher than that of group B.

CONCLUSION

Our results indicate the annual health check-up system to be very useful for achieving clinical remission in IgAN patients, if they are treated with tonsillectomy and steroid pulse therapy.

Significance of glomerular cell apoptosis in the resolution of acute post-streptococcal glomerulonephritis

BACKGROUND

Glomerular hypercellularity due to resident glomerular cell proliferation and leucocyte infiltration has been described in acute post-streptococcal glomerulonephritis (APSGN). APSGN usually resolves without progression. However, the mechanism of resolution remains to be determined.

METHODS

Renal biopsy tissues from 15 patients with APSGN (obtained 1-31 days after disease onset) and five control patients with minor glomerular abnormality were evaluated with respect to glomerular resolution. Apoptotic cells were assessed by terminal deoxynucleotidyl transferase-mediated dUTP nick end-labelling (TUNEL) as well as by immunostaining of single-stranded DNA (ssDNA).

RESULTS

The number of glomerular cells was high in the early-phase of APSGN and decreased over time. No TUNEL+ glomerular cells were found in control subjects, whereas prominent glomerular TUNEL+ cells were observed in APSGN patients, particularly in the early phase of the disease. The number of glomerular TUNEL+ cells decreased exponentially but was still prominent in renal tissue biopsied at 31 days after disease onset. Double staining for ssDNA and glomerular cell markers showed that glomerular apoptotic cells were predominantly mesangium and endothelial cells, with some neutrophils and macrophages.

CONCLUSIONS

These results suggest that apoptosis exists in the glomerulus in patients with APSGN from the early to the late stages of the disease and contributes to the resolution of glomerular hypercellularity.

Improvements in Treatment Strategies for Patients With Antineutrophil Cytoplasmic Antibody-associated Rapidly Progressive Glomerulonephritis

The course of rapidly progressive glomerulonephritis (RPGN) caused by antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis is often life-threatening, especially in the elderly when pulmonary involvement and/or severely impaired renal function are present. Corticosteroids and cyclophosphamide are the first-line treatment, but ironically infection, not vascular events such as hemorrhage, caused by the vasculitis itself, is the most common cause of death of RPGN patients. Several new treatment strategies, such as leukocytapheresis (LCAP) and intravenous immunoglobulin (IVIg), have become available during the past decade and these treatments have made it possible to treat high-risk RPGN patients without inducing serious immunosuppressive states. In the present paper we review recent clinical trials of LCAP and IVIg therapy in patients with pauci-immune/ANCA-associated RPGN, and show improved clinical outcomes after using these new treatment strategies in our institution.

Deoxyspergualin, an immunosuppressant, in patients suffering from nephropathies with crescent formation: an open-label trial to evaluate safety and efficacy

BACKGROUND

Crescent formation in glomeruli means an acute active lesion that develops a rapidly progressive course. Therapies using pulse methylprednisolone, oral corticosteroids, and cyclophosphamide are recommended, but no agreement has been reached on the optimal therapy. There have been no controlled trials, because of the severity of this condition and because withholding treatment would become an ethical issue.

METHODS

We evaluated the safety and efficacy of deoxyspergualin (DSG), an immunosuppressant, in a multicenter, prospective trial of 44 patients with crescent formation in over 10% of glomeruli, who were randomly placed into groups that received daily doses of 0.1 mg/kg (n = 21) and 0.2 mg/kg (n = 23) of DSG, given by a 1-h infusion for 4 weeks, and who were then monitored for 3 months. All patients received DSG in this open-label prospective study. We evaluated the levels of urinary protein and hematuria, and examined renal function after the DSG treatment.

RESULTS

Urinary protein significantly decreased with each dose after starting the DSG administration and this efficacy was sustained for 2 months after the discontinuation of DSG. In the groups receiving 0.1 mg/kg and 0.2 mg/kg, mean urinary protein levels were 2.1 g/day and 2.3 g/day at the initiation of the DSG administration, 1.4 g/day and 1.6 g/day at week 4, and 1.5 g/day and 1.3 g/day at week 12, respectively. Hematuria was markedly improved by a dose of 0.2 mg/kg and was not exacerbated following the termination of DSG. Exacerbation of renal dysfunction, as measured by creatinine clearance, serum creatinine, and blood urea nitrogen was prevented by both doses of DSG. The most common adverse reaction was reversible neutropenia.

CONCLUSIONS

Short-term treatment with DSG may be effective and tolerated in patients suffering from nephropathies with crescent formation.

Characteristics of acute glomerulonephritis associated with human parvovirus B19 infection

BACKGROUND

Acute glomerulonephritis (AGN) is a rare complication of human parvovirus B19 (HPB19) infection. The clinical and pathological features of AGN associated with HPB19 (HPBAGN) have not yet been fully elucidated.

METHODS

We analyzed 10 HPBAGN cases, focusing on their clinical and serological features. We also performed histopathological examinations of renal biopsy specimens obtained from three of the 10 patients on day 15, 19 and 23, respectively, after the onset of symptoms. The phenotype of the glomerular infiltrating leukocytes in HPBAGN was determined by immunohistochemical staining and compared with that of glomerular infiltrating leukocytes in poststreptococcal AGN (PSAGN) and lupus nephritis.

RESULTS

The clinical course and laboratory data of the HPBAGN patients revealed female preponderance (male = 0, female = 10), erythema in 9 of the 10 patients, leukopenia in 3, positive antinuclear antibody titer in 4, hypocomplementemia with low levels of C3, C4, and CH50 in 9, and liver dysfunction in 7. Endocapillary hypercellularity of leukocytes was demonstrated in all three patients who underwent renal biopsy. In comparison with PSAGN and lupus nephritis with crescents there were less neutrophil in HPBAGN compared to marked macrophage infiltrates that were equally intense in both the control and the HPBAGN group.

CONCLUSIONS

Our findings indicate that HPBAGN is characterized by female preponderance, erythema, leukopenia, positive antinuclear antibody titer, and hypocomplementemia, and that minor neutrophil infiltration may be related to mild clinical manifestations despite the marked fixation of glomerular leukocytes in HPBAGN.

Role of mast cells in the development of renal fibrosis: use of mast cell-deficient rats

BACKGROUND

Recent clinical studies have shown that the number of interstitial mast cells increases in various types of renal disease and correlates well with the magnitude of interstitial fibrosis. The present study was conducted to assess the role of mast cells in renal fibrosis by examining an experimental glomerular disease.

METHODS

A rat model of chronic glomerular disease, puromycin aminonucleoside-nephrosis, was induced in mast cell-deficient (Ws/Ws) and normal (+/+) rats.

RESULTS

The area of interstitial fibrosis was widely distributed at 6 weeks in both groups of rats; however, unexpectedly, the area of interstitial fibrosis was greater in Ws/Ws rats than in +/+ littermates. Biochemical analysis of the hydroxyproline content confirmed the more severe fibrosis in the Ws/Ws rats. The number of mast cells increased in both Ws/Ws and +/+ rats, concomitant with the development of interstitial fibrosis, but was confirmed to be lower in Ws/Ws than in +/+ rats. There were no differences in the numbers of interstitial macrophages and T lymphocytes between the two groups. Reverse transcription-polymerase chain reaction analysis of cytokine expression revealed that the level of mRNA for transforming growth factor-beta (TGF-beta), a potent profibrotic cytokine, was higher in Ws/Ws rats. In addition, heparin, one of the major components of mast cells, inhibited the expression of TGF-beta mRNA in rat fibroblasts in culture.

CONCLUSION

These results suggest that mast cells do not play a major role in the pathogenesis of interstitial fibrosis in puromycin aminonucleoside nephrosis. Rather, they might be protective or ameliorative in this model through the inhibition of TGF-beta production by heparin, and possibly in other models and also in humans.

Clinical observation of palatine tonsils with IgA nephropathy

We have previously reported that clinical remission could be achieved by combination therapy consisting of steroid pulse therapy and tonsillectomy in patients with IgA nephropathy. However, there is no consensus as to the indications for tonsillectomy in IgA nephropathy (IgAN) patients. To clarify whether there is any correlation between characteristics of removed palatine tonsils and clinical remission rate, we evaluated the relationships between the remission rate of urinary abnormalities and characteristics of 186 IgAN patients (aged 11-65 years) with mild or moderate renal pathology and their tonsils. Remission of proteinuria was observed in 134 patients (72%) and remission of hematuria was observed in 111 patients (60%). There was no significant difference in remission rate of either proteinuria or hematuria in terms of the past history of recurrent tonsillitis, episodes of synpharyngitic gross hematuria, pus plugs in the tonsillar lacunae, size of tonsils, age and the results of tonsillar provocation tests. Our findings suggest that it is very difficult to predict the efficacy of tonsillectomy and steroid pulse therapy based on the gross appearance of tonsils, the tonsillar provocation test or clinical episodes of tonsillitis. Moreover, contraindication of tonsillectomy for aged IgAN patients is not always justified.

Predictive value of urinary micro-cholesterol (mCHO) levels in patients with progressive glomerular disease

BACKGROUND

Trace amounts of lipids are present in the urine of patients with glomerular disease, raising the possibility that the excess lipids reabsorbed by tubule cells may be toxic to these cells. In the present study, we assessed the prognostic value of micro-cholesterol (mCHO) levels in patients with chronic glomerular disease.

METHODS

The urinary mCHO levels of healthy subjects and patients with chronic kidney disease were measured by the enzymatic cholesterol cycling (ECC) method with a minimum detection level of 0.10 x 10(-3) mmol/L. First, the urinary mCHO levels of healthy subjects and 320 patients with various glomerular diseases with proteinuria >1000 mg/gCr were measured. Second, correlations of urinary mCHO levels with those of various other molecules, including albumin, IgG, IgM, transferrin, phospholipid, alpha1-microglobulin (alpha1MG), Apo A1, Apo A2, and Apo B, and urinary fatty body counts, were determined. Third, urinary mCHO, total protein (TP), albumin, and N-acetyl-beta-D-glucosaminidase (NAG) levels were measured longitudinally over 12 months (20.5 +/- 5.8 months) in 68 nondiabetic patients with impaired renal function [serum creatinine (Cr) > or = 1.5 mg/dL]. Correlations of the concentrations of urinary parameters in the initial 3-month period with the slopes of the reciprocal of creatinine versus time for the entire follow-up period were assessed by the ROC method and multiple regression analysis.

RESULTS

Urinary mCHO levels of the healthy subjects were 0.06 to 0.72 mg/gCr for males and 0.16 to 2.34 mg/gCr for females. Urinary mCHO levels in subjects with minimal change nephrotic syndrome were significantly lower than those in the patients with other glomerular diseases with massive proteinuria. Urinary mCHO levels correlated significantly with Apo A1 and Apo A2 levels, but not with urinary Apo B levels, in the latter subjects. The correlation coefficient of urinary fatty body counts (a marker of lipoprotein loading tubulopathy) with mCHO was higher than those with TP, albumin, IgG, IgM, and alpha1MG. The urinary mCHO elevation was significantly greater in patients who had a nonselective index of proteinuria than in those with a highly or moderately selective index. In nondiabetic patients with impaired renal function, the urinary mCHO level had a higher predictive value for rapid decline of renal function than TP, albumin, or NAG.

CONCLUSION

The urinary cholesterol level corresponds to the magnitude of urinary HDL excretion, and correlates with the degree of lipoprotein loading tubulopathy. Measurement of urinary mCHO by the ECC method is a simple and useful tool for predicting progression of chronic glomerular disease.

Tonsillectomy combined with steroid pulse therapy: a curative therapy for IgA nephropathy

As IgA nephropathy (IgAN) was originally regarded as a benign condition, the indication of corticosteroids has been highly restricted because of their side effects, and has been used for a specific subgroup of IgAN patients with consideration of the risk/benefit ratio. During the last decade, however, with the recognition that the overall long-term prognosis of IgAN is a non-benign condition, more aggressive treatments, including high dose corticosteroids and tonsillectomy, have been used for a wider subgroup of patients with IgAN. Since 1988, we have treated IgAN patients with steroid semi-pulse therapy combined with tonsillectomy. Over 500 patients with IgAN have been treated with this treatment protocol, and a high percentage of patients enter clinical remission, i.e. free from urinary abnormalities if the combination therapy was initiated in its early stage. Through these experiences we think the goal of treatment of IgAN patients should be changed from "slowing the progression of nephropathy" to "clinical remission".

Use of corticosteroids, other immunosuppressive therapies, and tonsillectomy in the treatment of IgA nephropathy

Because IgA nephropathy (IgAN) was originally regarded as a benign condition, the indication of corticosteroids or other immunosuppressive therapies have been highly restricted because of potential side effects, and such drugs have been used for a specific subgroup of patients with IgAN, taking the risk/benefit ratio into consideration. During the last decade, however, with the recognition that the overall long-term prognosis of IgAN is a nonbenign condition, more aggressive treatments, including high-dose corticosteroids, various immunosuppressive agents, and tonsillectomy, have been used for wider subgroups of patients with IgAN. Moreover, recent studies have suggested that clinical remission as well as histopathologic regression of the nephropathy could be obtained by such treatments if treatment is initiated in its relatively early stage. Thus, the possibility has now been raised that the goal of treatment for patients with IgAN will shift from "slowing the progression of nephropathy" to "remission of nephropathy."

Cohort study of advanced IgA nephropathy: efficacy and limitations of corticosteroids with tonsillectomy

BACKGROUND

Elevated serum creatinine is associated with poor outcome in IgA nephropathy (IgAN). The efficacy and limitations of corticosteroids in advanced IgAN (Cr >or=1.5 mg/dl), however, remains controversial.

METHODS

We retrospectively investigated 70 patients with advanced IgAN (Cr >or=1.5 mg/dl) classified into three groups according to their treatment regimens, that is, steroid pulse with tonsillectomy, conventional steroid, and supportive therapy. We evaluated the three groups to elucidate predictors for the endpoints ESRF and doubled serum creatinine from baseline.

RESULTS

Steroid pulse with tonsillectomy, conventional steroid and supportive therapy were performed in 30, 25 and 15 patients, respectively. During the mean follow-up period of 70.3 (12-137) months, 41.4% of patients reached ESRF (13.3 vs. 56.0 vs. 73.3%, p < 0.001) and 45.7% doubled serum creatinine from baseline (16.7 vs. 64.0 vs. 73.3%, p < 0.001). The incidence of ESRF in the patients treated by steroid pulse with tonsillectomy was significantly lower than the incidences in the patients treated by conventional steroid and supportive therapy at a baseline creatinine level of 1.5-2 mg/dl, but no statistical difference was observed at a level of >2 mg/dl. The Kaplan-Meier estimated probability of renal survival without ESRF was 89.2, 74.1 and 72.2% at 5 years and 82.8, 51.0 and 45.1% at 8 years, respectively (p = 0.017). The predictors for ESRF, identified in a Cox proportional hazards model, were baseline serum creatinine (p < 0.001) and interstitial infiltrate (p = 0.003). Steroid pulse with tonsillectomy also had a protective effect on the risk of reaching ESRF (p = 0.013). By target cross-stratification, the patients with baseline creatinine of 1.5-2 mg/dl who underwent steroid pulse with tonsillectomy showed a better renal survival rate than the others (p < 0.001).

CONCLUSION

Steroid pulse therapy combined with tonsillectomy may be more effective than conventional steroid therapy in patients with a baseline creatinine level of <or=2 mg/dl.

Analysis of an expanded width of albumin fraction by cellulose acetate membrane electrophoresis in IgA nephropathy urine before treatment

Cellulose acetate membrane electrophoresis with colloidal silver stain re-vealed that the width of the albumin fraction in IgA nephropathy (IgAN) urine before treatment was significantly expanded. This phenomenon was not shown in IgAN urine after treatment or in non-IgAN urine. There was a reverse correlation between the width of the albumin fraction and the albumin con-centration in IgAN urine. By immuno-fixation, Tamm-Horsfall protein (THP) was located in the same position as the albumin band in IgAN urine before treatment; however, in the urine of a healthy subject it was located in the same position as alpha(1)-globulin. By ELISA, the THP-albumin complex concentration in IgAN urine before treatment was significantly higher than in the other two diseases. The width of the albumin fraction and the sodium ion concentra-tion of the urine were significantly correlated. The THP/albumin ratio in IgAN urine before treatment was significantly higher than in the other two groups. This suggests that the characteristic expanded width of albumin found by immunofixation indicates a THP-albumin complex, and that the sodium concentration of urine is involved in the formation of this complex.

Cellulose acetate membrane electrophoresis in the analysis of urinary proteins in patients with tubulointerstitial nephritis

Urinary proteins from 14 patients with tubulointerstitial nephritis were analyzed by cellulose acetate membrane electrophoresis. Urinary total protein concentrations were measured, and urinary 15 proteins (prealbumin, albumin, alpha(1)-microglobulin, alpha(1)-antitrypsin, alpha(2)-macroglobulin, haptoglobin, retinol binding protein, transferrin, beta(2)-microglobulin, IgA, IgG, kappa- and lambda-light chains, cystatin C, and lysozyme) were identified by the use of a rapid and highly sensitive colloidal silver staining reagent suited for use with cellulose acetate membranes, as reported previously by Matsuda et al. (J Clin Lab Anal 15:171-174, 2001; Clin Chem47:763-766, 2001) and Hiratsuka et al. (J Clin Lab Anal 10:403-406, 1996). We also analyzed urinary total protein concentration and urinary protein fractions according to the presence of acute or nonacute interstitial nephritis. In addition, the relationship between urinary protein fraction and complications of interstitial nephritis was analyzed. The goal of this work was to find a useful index for the diagnosis of tubulointerstitial nephritis.

15-Deoxyspergualin in patients with refractory ANCA-associated systemic vasculitis: a six-month open-label trial to evaluate safety and efficacy

The combination of cyclophosphamide (CYC) and oral corticosteroids is effective in the majority of patients with antineutrophil cytoplasmic antibody-associated vasculitis (AASV), but it carries substantial risk of drug-related morbidity and mortality. New regimens are desired, especially in refractory cases. The immunosuppressant 15-deoxyspergualin (DSG) is effective in experimental autoimmune disease and transplantation as well as in acute kidney transplant rejection in humans. To assess the efficacy and safety of DSG, an open label multicenter trial was conducted in patients with AASV who were either unresponsive or had contraindications for standard immunosuppressants. Included were 19 cases of Wegener granulomatosis and one case of microscopic polyangiitis. Nine of them had received CYC shortly before study entry without apparent therapeutic success. DSG (0.5 mg/kg per d) was given for 2 to 3 wk until the WBC count dropped to 3000/ micro l followed by a rest until at least a WBC of 4000/ micro l was reached again. This was repeated up to six cycles. During the study, no other immunosuppressants besides steroids were allowed. Disease improvement during treatment with DSG was achieved in 70% of cases (six cases of complete remission; eight cases of partial remission). Leucopenia occurred in each patient in a regular pattern during the cycles and was transient without exception. No mortality or septicemia was observed. Mild to moderate infections mainly in the respiratory tract were observed but resolved under adequate treatment without sequel. It is concluded that treatment with DSG is successful in patients with refractory Wegener granulomatosis under careful monitoring of WBC count.

Resolution of typical lipoprotein glomerulopathy by intensive lipid-lowering therapy

Lipoprotein glomerulopathy (LPG), characterized by glomerular lipoprotein thrombi, presumably composed of abnormal apolipoprotein E (apoE), leads to a progressive decline in renal function and eventually results in end-stage renal failure. A successful treatment for LPG has not yet been established. The authors treated a 36-year-old woman with LPG and exhibiting a nephrotic syndrome using an intensive lipid-lowering therapy consisting of fenofibrate (300 mg), niceritrol (750 mg), ethyl-icosapentate (1,800 mg), and probucol (500 mg). After the start of treatment, a remarkable decrease in urinary protein excretion and improvement in the hyperlipidemia were obtained; proteinuria was no longer detected 11 months after the initiation of treatment. A second biopsy performed 11 months after the initiation of treatment showed the complete disappearance of the lipoprotein thrombi that had been observed in a diffuse and global manner in the first renal biopsy. These findings suggest that typical LPG could be regressed if the abnormal lipoproteinemia is controlled sufficiently.

A repeat biopsy study in spontaneous crescentic glomerulonephritis mice

BACKGROUND

Spontaneous crescentic glomerulonephritis (SCG)/Kj mice are a candidate for suitable animal model of human pauci-immune crescentic glomerulonephritis (GN). In the present study, we used renal biopsy technique and analyzed time sequence correlations among crescent formation and glomerular neutrophil infiltration in SCG/Kj mice.

METHODS

We observed the progress of GN in SCG/Kj mice according to the urinary abnormalities, and performed the serial renal biopsies. The kinetics of histopathology and glomerular neutrophil influx corresponding disease stage were examined by enzyme-histochemistry and immunohistochemistry.

RESULTS

We divided natural course of GN into three periods in view of urinalysis: a proteinuria-negative/hematuria-negative (P- H-) period, followed by a proteinuria-positive/hematuria-negative (P+ H-) period, and finally a proteinuria-positive/hematuria-positive (P+ H+) period. Endocapillary proliferation phase existed in P+ H- period, whereas crescent formation occurred and extended in P+ H+ period. In P+ H- period, prominent glomerular neutrophil infiltration was observed, while these numbers decreased with the progression of crescent formation.

CONCLUSION

These observations suggest that there is a good correlation between urinalysis and histopathological events of SCG/Kj mice, and that endocapillary proliferation, which contains neutrophil infiltration, may contribute to the subsequent crescent formation in these mice.

Decreased CD4 lymphocyte count as a marker predicting high mortality rate in managing ANCA related rapidly progressive glomerulonephritis

As antineutrophil cytoplasmic antibody positive rapidly progressive glomerulonephritis (ANCA-RPGN) has a high risk of end stage renal failure and is a potentially life threatening disease, early aggressive therapy is recommended. However, aggressive immunosuppressive therapy may lead to immunodeficiency and subsequent mortality in the patients with this disease. Therefore, we need the index of immunodeficiency to cure the disease. To evaluate any risk factors, including therapies, on mortality in ANCA-RPGN, we conducted a retrospective investigation on patient survival in 32 patients with ANCA-RPGN by Kaplan-Meier analysis and the Cox regression model. Fourteen patients were treated with leucocytapheresis (LAP group) and the 18 patients were treated by steroid pulse therapy (steroid pulse group) as initial treatment. The patients were chosen for the different therapies at random. Two patients in the LAP group, and eight patients in the steroid pulse group had died within 6 months. The lymphocyte counts and CD4 cell counts after complete course of therapy were lower in the patients who died than in those who survived in the steroid pulse group. Patient survival was higher in the LAP group than in the steroid pulse group, but did not reach statistical significance. Multivariate Cox regression analysis showed that the factors influencing patient survival were initial serum creatinine, LAP therapy, CD4 cell counts, and lymphocytes at the end of treatment. Age, titer of MPO-ANCA, and percent of glomerular crescents were not found to have an effect on the patient survival. We recommend: that early diagnosis should be established, and immunosuppressive therapy may be done with monitoring of the lymphocyte and CD4 cell count.

Resolution of nodular glomerular lesions in a patient with light-chain nephropathy

A 37-year-old man developed nephrotic syndrome and renal insufficiency in 1986. He had kappa-light-chain protein both in serum and urine. A renal biopsy showed nodular glomerulosclerosis with deposition of kappa-light-chains in the mesangial area, compatible with light-chain nephropathy. Thereafter, he was treated with steroids and melphalane and the light-chain protein disappeared from both the urine and serum. Although his moderately impaired renal function maintained stable levels for over 10 years, he was diagnosed as having renal cell carcinoma in 1998, and a right nephrectomy was performed. Histopathological examination of a portion of the removed kidney, unaffected by carcinoma, showed mild mesangial proliferation, and both the nodular lesions and light-chain deposits were no longer observed. These observations suggest that an established nodular glomerular lesion may be reversible.

Enhanced expression of C chemokine lymphotactin in IgA nephropathy

Leukocyte accumulation in the kidney is observed in patients with IgA nephropathy. Chemokines are a large family of cytokines chemotactic for leukocytes and have been shown to be upregulated in renal diseases. We previously reported that the gene expression of lymphotactin, a sole member of C chemokine subfamily, is enhanced in an animal model of crescentic glomerulonephritis, but its expression in human renal diseases is totally unknown. In the present study, we investigated the expression of mRNAs of lymphotactin and some other chemokines in IgA nephropathy. The expression of mRNAs for three chemokines, lymphotactin, MCP-1, and MIP-1beta, in renal cortex was increased and the levels of lymphotactin and MCP-1 mRNAs were statistically higher in patients with glomerular crescents than in those without crescents. These levels also correlated with tubulointerstitial changes and urinary protein excretion. Glomerular levels of mRNAs for lymphotactin and MCP-1, but not MIP-1beta, were higher in IgA nephropathy than controls. By immunohistochemical analysis, lymphotactin was detected in tryptase-positive cells (putative mast cells) in the interstitial space. These results suggest that lymphotactin, as well as MCP-1, may contribute to leukocyte infiltration and disease progression in IgA nephropathy.

Leukocyte accumulation and changes in extra-renal organs during renal ischemia reperfusion in mice

Multiorgan failure is a life threatening complication in patients with ischemic acute renal failure (ARF). However, little is known about the underlying multiorgan system cellular immunity in ischemic ARF. We therefore studied the dynamics of cells accumulating in the kidneys and other organs in mice and analyzed the characteristics of the accumulated cells. We prepared a unilateral renal ischemia/reperfusion injury (IRI) model in C57BL/6 or C3H/He mice. At 1 to 3 hours after renal ischemia, increased accumulations of neutrophils and intermediate T cells were observed in the clamped kidney, but the same phenomena were also observed in the nonclamped kidney, liver, and spleen. After 24 hours, these cell numbers had returned to preischemic levels, but remained elevated for a longer period in the clamped kidney. The intermediate T cells that accumulated in the kidney and liver in the IRI mice expressed higher Vbeta chains specific to forbidden clones than in the control mice. Moreover, the accumulated intermediate T cells in the IRI liver had cytotoxic activity against both tumor cells and syngeneic thymocytes. In the clamped kidney, the accumulated intermediate T cells had less cytotoxic activity against tumor cells; however, the expression of the Fas ligand (FasL) increased, indicating a cell-mediated tissue injury via the Fas/FasL system. Histopathologically, an influx of neutrophils and lymphocytes was observed not only in the clamped kidney but also in the hepatic sinusoids concomitantly with liver dysfunction. These findings indicate that a systemic cellular immune response, including intermediate T cells, affects multiple organs during ischemic ARF, which may play an important role in the development of multiorgan failure.

Glomerulo-tubular junction stenosis as a factor contributing to glomerular obsolescence in IgA nephropathy

Periglomerular fibrosis (PF) is an interstitial injury observed in various renal diseases. It is speculated that this lesion, by occluding the glomerulo-tubular junction (GTJ) and causing atubular glomeruli, may result functionally in a reduction of the glomerular filtration rate (GFR) and may be a factor contributing to the progression of renal disease. In the present study, 340 renal biopsy specimens were analysed to determine whether or not there was nephron injury derived from such a mechanism, as well as direct glomerular injury, in IgA nephropathy (IgAN). The patients were divided into five groups according to the degree of glomerular sclerosis. The average age was lower in groups with milder sclerosis and serum creatinine (Cr) was elevated in groups with more severe sclerosis. Because the GTJ was assumed to disappear when an atubular glomerulus was formed, the ratio of the number of glomeruli with discernible GTJ to the total number of glomeruli was evaluated. As glomerular sclerosis progressed, discernible GTJ reduced significantly (p <0.001) and the degree of PF increased significantly (p <0.05). By serial section study in cases with pronounced PF, transitions between the stages of stenosis of the GTJ and atubular glomeruli were observed. It is speculated that the occlusion of the GTJ eventually hyalinizes the glomerulus; in such cases, glomerular obsolescence of the collapse type might be formed. On the other hand, obsolescence of the mesangial proliferative type might be formed in the hyalinization derived from direct glomerular injury. In this context, glomerular obsolescence of the collapse type was observed more frequently and was accompanied by more increased PF than obsolescence of the mesangial proliferative type (p <0.001). These results suggest that in addition to direct glomerular injury, nephron injury derived from interstitial damage of this type plays an important contributory role in the progression of IgAN.

Regression of IgA nephropathy: a repeat biopsy study

Histological cure of immunoglobulin A (IgA) nephropathy has been reported only rarely in adults. To elucidate the reversibility of established IgA nephropathy, we performed a repeat biopsy study. A second biopsy was performed in 35 patients with IgA nephropathy in whom hematuria, an essential finding of IgA nephropathy, had disappeared (proteinuria also had disappeared in 23 patients) after a treatment protocol involving high doses of methylprednisolone and tonsillectomy. The interval between the first and second biopsy was 18 to 138 months (mean, 77.1 months). Mean serum creatinine level was 1.11 +/- 0.35 (SD) mg/dL (range, 0.6 to 1.9 mg/dL) at the time of the first biopsy and 0.96 +/- 0.24 mg/dL at the time of the second biopsy. Mesangial proliferation was significantly reduced in second-biopsy specimens (mesangial proliferation score: first-biopsy specimens, 2.49 +/- 0.74; second-biopsy specimens, 0.91 +/- 0.89; P < 0.001). Acute inflammatory glomerular lesions, such as endocapillary proliferations, glomerular tuft necrosis, and cellular crescents, were present in 32 patients in first-biopsy specimens, whereas these were no longer present in any of the second-biopsy specimens. Although no significant difference in percentage of globally sclerotic glomeruli was observed between the first and second biopsy specimens, the percentage of segmentally sclerotic glomeruli was significantly lower in second-biopsy specimens (P < 0.001). Interstitial mononuclear cell infiltration was markedly reduced in second-biopsy specimens (P < 0.001). The area of renal cortex affected by interstitial fibrosis and/or edema was significantly reduced in second-biopsy specimens (first-biopsy specimens, 21.4% +/- 20.3%; second-biopsy specimens, 9.6% +/- 11.7%; P < 0.01). The distribution of IgA mesangial deposits had diminished in most patients, and no IgA deposits were seen in second-biopsy specimens from 8 patients. These findings indicate that mesangial proliferation and interstitial changes in IgA nephropathy are reversible to a considerable extent. A histological cure may be obtainable in a considerable proportion of patients, especially if treatment is initiated at a relatively early stage.

Steroid pulse therapy combined with tonsillectomy in IgA nephropathy associated with diabetes mellitus

Ten patients with biopsy-confirmed IgA nephropathy associated with diabetes mellitus underwent dietary weight control and three courses of intravenous pulses of methylprenisolone followed by prednisolone for 6-12 months and tonsillectomy. The average length of the follow-up period was 47.8 (range 30-96) months. As compared with pretreatment values, hematuria, proteinuria, body mass index, and hemoglobin A(1c) were significantly improved after treatment. There were no significant differences with regard to blood pressure and glycemic blood glucose control. There was no worsening of diabetic retinopathy and nephropathy. During steroid pulse therapy, the patients who were treated with insulin needed a higher dosage of insulin; after steroid pulse therapy, the dosage returned to baseline. Even patients with IgA nephropathy and diabetes mellitus could be treated with combined therapy and showed beneficial responses, it they succeeded in reducing body mass index.