Corticosteroids in IgA nephropathy: a randomised controlled trial

BACKGROUND

IgA nephropathy is progressive in most cases and has no established therapy. In this randomised trial, we assessed the efficacy and safety of a 6-month course of steroids in this disorder.

METHODS

Between July, 1987, and September, 1995, we enrolled 86 consecutive patients from seven renal units in Italy. Eligible patients had biopsy-proven IgA nephropathy, urine protein excretion of 1.0-3.5 g daily, and plasma creatinine concentrations of 133 micromol/L (1.5 mg/dL) or less. Patients were randomly assigned either supportive therapy alone or steroid treatment (intravenous methylprednisolone 1 g per day for 3 consecutive days at the beginning of months 1, 3, and 5, plus oral prednisone 0.5 mg/kg on alternate days for 6 months). The primary endpoint was deterioration in renal function defined as a 50% or 100% increase in plasma creatinine concentration from baseline. Analyses were by intention to treat.

FINDINGS

Nine of 43 patients in the steroid group and 14 of 43 in the control group reached the primary endpoint (a 50% increase in plasma creatinine) by year 5 of follow-up (p<0.048). Factors influencing renal survival were vascular sclerosis (relative risk for 1-point increase in score 1.53, p=0.0347), female sex (0.22, p=0.0163), and steroid therapy (0.41, p=0.0439). All 43 patients assigned steroids completed the treatment without experiencing any important side-effects.

INTERPRETATION

A 6-month course of steroid treatment protected against deterioration in renal function in IgA nephropathy with no notable adverse effects during follow-up. An increase in urinary protein excretion could be a marker indicating the need for a second course of steroid therapy.

Urinary microscopy as seen by nephrologists

Urinary microscopy is a diagnostic tool which is largely used by nephrologists. In the opinion of the authors the best results can be achieved when all the aspects concerning this test are properly taken into account. Thus, from the methodological point of view, proper patient guidance, proper urine collection and handling, adequate microscopic equipment, and knowledge of the factors which can influence the results are all necessary. All the elements of clinical importance have to be known, namely, erythrocytes (with their morphological subtypes), leukocytes, tubular cells, uroepithelial cells (both superficial and deep), lipids, casts, crystals, and microorganisms. Then, the urinary findings have to be interpreted and, whenever possible, also combined into urinary profiles (e.g., the nephritic sediment, the nephrotic sediment). This, combined with other laboratory tests, the pathologic findings, and the clinical data, allows for the definition and management of urinary tract diseases.

Glomerulonephritis associated with myasthenia gravis

In a follow-up study of 128 myasthenic patients from a neurological center in Northern Italy, three were found to have developed glomerulonephritis at variable intervals after the onset of myasthenia gravis, thymoma (two patients), and thymectomy. By renal biopsy, two patients (cases 1 and 3) were found to have membranous nephropathy; and one (case 2), pauciimmune extracapillary glomerulonephritis. At follow-up, patient 1 was persistingly nephrotic and developed renal failure, and patient 3 only had urinary abnormalities. Patient 2 developed end-stage renal disease. The review of the literature showed 10 other cases of glomerulonephritis associated with myasthenia gravis with or without thymoma and thymectomy. Therefore, it is likely that these conditions are pathogenetically linked. The role of autoantibodies, thymoma, and thymectomy in favoring glomerulonephritis in myasthenic patients is discussed.

Don't forget sickled cells in the urine when investigating a patient for haematuria

Haematuria is a well-known complication of sickle cell disease. A South African coloured patient with repeated episodes of gross haematuria is described in whom the diagnosis of sickle cell disease was suggested after the finding of sickled erythrocytes in the urine sediment. The diagnosis was then confirmed by haemoglobin electrophoresis, which revealed sickle cell trait (Hb-AS). It is concluded that sickle erythrocytes must be looked for when urine is microscopically scrutinized to determine the source of a haematuria.

IgA-associated renal diseases

IgA nephropathy and Schönlein-Henoch purpura nephritis are common renal diseases. Recent studies have provided new insights into the factors that contribute to the initiation and progression of renal injury. Approaches to therapy, although still limited and largely empirical, show some encouraging results.

Crystalluria: a neglected aspect of urinary sediment analysis

Crystalluria is a frequent finding in the routine examination of urine sediments. In most instances the precipitation of crystals of calcium oxalate, uric acid triple phosphate, calcium phosphate and amorphous phosphates or urates is caused by transient supersaturation of the urine, ingestion of foods, or by changes of urine temperature and/or pH which occur upon standing after micturition. In a minority of cases, however, crystalluria is associated with pathological conditions such as urolithiasis, acute uric acid nephropathy, ethylene glycol poisoning, hypereosinophilic syndrome. In addition, crystalluria can be due to drugs such as sulphadiazine, acyclovir, triamterene, piridoxylate, primidone, which under the influence of various factors can crystallize within the tubular lumina and cause renal damage. In all these instances the study of crystalluria is diagnostically useful and is also important to follow the course of the disease. However, a proper methodological approach is necessary. This includes the handling of freshly voided urine, the knowledge of the urinary pH, and the use of a contrast phase microscope equipped with polarizing filters.

Renal disease and patient survival in light chain deposition disease

We evaluated retrospectively the presenting clinical features, response to treatment and clinical course of 19 patients with LCDD, 11 of whom had multiple myeloma. At presentation, renal insufficiency was present in 18 patients and proteinuria in 16. Renal biopsy revealed typical LCDD in 16 patients, while in the remaining three LCDD was associated with other abnormal tissue deposits. Extrarenal signs were observed in 12 patients (63%), with the liver, heart and peripheral nerves being the most frequently involved organs. After diagnosis, 18 patients underwent therapy: 2 received steroids alone and 16 were treated with steroids and cytotoxic drugs; 7 patients also underwent plasma exchange. At the end of the first month of treatment renal function improved in 5 patients, worsened in 5 and remained unchanged in 8. All but 3 of the patients continued treatment beyond the first month: 7 patients developed end-stage renal disease, 5 an improvement and 4 a worsening in renal function. No effect on proteinuria was observed. Extrarenal symptoms developed in 4 previously unaffected patients and in 3 others they extended to more organs. Sixteen patients died: 12 during the first year of the follow-up, and 4 at 21st, 34th, 37th and 82nd month of observation. Five patients died from neoplastic cachexia, 4 from hypokinetic cardiopathy, 3 from hemorrhagic complications, 2 from pneumonia and one from unknown cause. Mean patient survival after presentation was 18.1 +/- 20.7 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Light chain deposition disease of the kidney. Morphological aspects in 24 patients

Renal biopsies and autopsy specimens of 23 patients with light chain deposition disease (LCDD) and one with only heavy chain deposits, were studied by light (LM) and electron microscopy (EM) as well as immunohistology (IH). Thirteen patients had multiple myeloma; 1 had lymphoma, and 1 chronic myeloid leukaemia with polycythaemia vera. In nine patients, no lymphoproliferative disease was identified. The LM lesions most suggestive of LCDD, nodular glomerulosclerosis (NS) and thickening and wrinkling of the tubular basement membranes (TBM), were present in only ten and 13 patients, respectively. In five of seven specimens without NS or TBM thickening by LM, EM was negative, indicating a limited value of EM in confirming the diagnosis. Renal amyloidosis was not identified, but in one patient amyloid in the heart and tongue was seen at autopsy. One patient had both granular and extensive glomerular non-amyloid fibrillary deposits. In two patients myeloma casts were identified. Twenty-one patients showed renal LC immune reactivity, 1 had both alpha heavy and lambda LC, 1 had only detectable gamma heavy chain. One biopsy was negative by IH, but had characteristic electron dense deposits. In six patients with immune reactivity to LC, no electron dense deposits could be identified by EM. This study emphasizes the spectrum of renal changes by LM and EM in LCDD, the frequent lack of consistency between deposits detected by IH and EM and the difficulty in coming to a definite diagnosis without LM, EM and IH. The results of this study and examination of the literature indicates that extensive morphological changes are more often present in kappa than in lambda LCDD.