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

Efficacy and limitations of additional steroid pulse therapy in IgA nephropathy patients whose hematuria did not remit on tonsillectomy and protocol steroid pulse therapy

BACKGROUND

Hematuria is the essential symptom of IgA nephropathy that has been suggested to be associated with long-term renal prognosis, Tonsillectomy and steroid pulse therapy (TSP), which is widely practiced in Japan, is effective for achieving hematuria remission. However, some cases are refractory to TSP, and additional steroid pulse therapy (SP) administered to these cases to achieve remission of hematuria. Nonetheless, the clinical significance of additional SP is unknown.

METHODS

In this retrospective study, we enrolled 99 patients from Okubo Hospital whose hematuria persisted following TSP. Patients were divided into the hematuria remission and non-remission groups. A multivariate regression analysis was performed on the factors that contributed to hematuria remission.

RESULTS

Following TSP, 103 of 403 patients (32.3%) did not achieve hematuria remission. Additional SP were performed in 99 of these patients, and remission of hematuria was achieved in 57 (57.6%). Patients with a greater degree of improvement in hematuria with TSP were significantly more likely to have remission of hematuria with additional SP (p = 0.0084*). Even in the hematuria non-remission group, both hematuria and proteinuria improved after additional SP.

CONCLUSION

In IgA nephropathy, additional SP could induce hematuria remission and reduce proteinuria.

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.

Comparison of administration of single- and triple-course steroid pulse therapy combined with tonsillectomy for immunoglobulin A nephropathy

Immunoglobulin A nephropathy (IgAN) is a form of chronic glomerulonephritis that can cause end-stage renal disease. Recently, tonsillectomy combined with corticosteroid pulse (TSP) has been shown to be effective for achieving clinical remission and favorable renal outcome in patients with IgAN. However, the standard regimen of corticosteroid use in TSP has not been established. Herein, we compared the effect of single- or triple-course steroid pulse therapy combined with tonsillectomy in patients with IgAN.This retrospective, observational cohort study included 122 patients with IgAN enrolled from January 2004 to December 2018 at 2 independent institutions. We divided the patients into 2 groups; single-course (TSP1: n = 70) and triple-course (TSP3: n = 52) of corticosteroid pulse therapy (1 course comprised 3 consecutive days' infusion of 0.5 g methylprednisolone) combined with tonsillectomy. The primary outcome for renal survival was defined as the first occurrence of ≧30% decrease in estimated glomerular filtration rate from baseline. Secondary outcomes included the incidence of clinical remission and recurrence of the disease.Regarding clinical parameters and findings at baseline, there were no significant differences between the 2 groups. The 8-years renal survival in the 2 groups was not significantly different according to Kaplan-Meier curves (TSP1; 82.5% vs TSP3; 69.2%, log-rank test P = .39). The cumulative incidence rates of remission of hematuria (94.4% vs 85.4%, P = .56) and clinical remission (85.0% vs 64.8%, P = .07) were comparable in both groups, while those of proteinuria showed higher rates in TSP1 than TSP3 (88.4% vs 65.4%, P = .02). The cumulative incidence of relapse of hematuria (5.6% vs 2.3%, P = .42) and proteinuria (7.1% vs 3.3%, P = .41) showed no significant differences in the 2 groups. Cox regression analyses showed that the number of courses of corticosteroid pulse therapy was not significantly associated with renal outcome (TSP1 vs TSP3; Hazard ratios 0.69, 95% confidence intervals 0.29-1.64, P = .39).The effect of single-course corticosteroid pulse therapy is not statistically, significantly different from triple-course in TSP protocol for improving renal outcome and preventing relapse in patients with IgAN. Single-course corticosteroid pulse therapy may become a treatment option for patients with IgAN.

Utility of remission criteria for the renal prognosis of IgA nephropathy

Background

Novel criteria for the remission of Immunoglobulin A nephropathy (IgAN) based on an opinion survey of Japanese nephrologists and literature review were proposed in 2013. This single-center, longitudinal retrospective cohort study was conducted to validate this criteria.

Methods

Present study included the IgAN patients diagnosed between 2001 and 2005 in the Juntendo University Hospital. Remission of hematuria was defined as three consecutive dipstick test results of ( −) to ( ±) or a red blood cell count < 5 in urinary sediment per high-power field during at least 6 months. Remission of proteinuria was defined as three consecutive dipstick results of ( −) to ( ±) during at least 6 months. We categorized four groups according to the remission status which was assessed 2 years after the renal biopsy. The primary outcome was a 50% increase in the serum creatinine over the baseline. We evaluated the slope of eGFR decline (mL/min/1.73 m²/year) and a decrease in the eGFR of 30% from baseline eGFR as the secondary outcome, respectively.

Results

A total of 74 patients (male: 47.3%, median age: 30 years) were included and were followed for a median of 86.5 months. During the period, forty-one patients achieved neither remission of proteinuria nor hematuria (NR). Twelve patients met the primary study outcome. A survival analysis revealed that the NR had the worst prognosis and the steepest slope of eGFR decline.

Conclusion

Although further validation in a large cohort is necessary, these novel remission criteria for IgAN patients appear to predict the renal prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10157-021-02069-w.

Pathologic tonsillar findings similar to IgA nephropathy and the role of tonsillectomy in a patient with nephrotic syndrome

BACKGROUND

The pathological findings of tonsils in IgA nephropathy include the expansion of T-cell nodules around lymphoid follicles and abnormal reticulation of the crypt epithelium in contrast to chronic tonsillitis. Recently, several studies have reported that regulatory T cells play an important role in the maintenance of self-tolerance, an abnormality that is involved in the onset of nephrotic syndrome (NS). We encountered a patient of 28-year-old male with frequently relapsing nephrotic syndrome (FRNS) and chronic tonsillitis whose tonsils demonstrated pathological findings similar to those of IgA nephropathy.

CASE PRESENTATION

A patient had developed NS at the age of 5 years, and was pathologically diagnosed with minimal change disease (MCD), for which he received various immunosuppressive agents as treatment for recurrence. Because tonsillitis often triggers the recurrence of NS, a tonsillectomy was performed for chronic tonsillitis at the age of 25 years. Immunohistochemical staining of his tonsils showed the expansion of CD4 positive lymphocytes around the lymphoid follicles and abnormal reticulation of the crypt epithelium. The number of peripheral blood CD4+CD25+ regulatory T cells increased, and the frequency of relapses decreased after tonsillectomy.

CONCLUSION

A similar self-tolerance abnormality exists in NS and IgA nephropathy; therefore, tonsillectomy might become a novel therapeutic approach for FRNS to redress the unbalanced self-tolerance and to remove the tonsillar focal infection. Further studies are necessary to verify the clinical efficiency of tonsillectomy for FRNS with recurrent episodes triggered by tonsillitis.

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.

Comparison of oral steroids with tonsillectomy plus steroid pulse therapy in patients with IgA nephropathy

BACKGROUND

Treatment of IgA nephropathy (IgAN) in Japan has recently changed, from oral prednisolone (oPSL) to tonsillectomy plus steroid pulse (TSP) therapy. However, a few studies have compared their efficacy and safety.

METHODS

IgAN patients diagnosed in our institution between 1991 and 2013, treated with TSP or oPSL, aged ≥16 years, with ≥1 g/day proteinuria, and estimated glomerular filtration rate (eGFR) ≥30 ml/min/1.73 m², and no other renal disease were selected. Baseline clinical and histological findings, clinical outcomes, and adverse events were compared. Clinical remission (CR) was defined as <0.3 g/day proteinuria and <5 urinary red blood cells per high-powered field.

RESULTS

Sixty-six patients were identified; after propensity score adjustment, 26 patients were selected in each group. CR rates were significantly higher at 12 (30.8 % vs. 3.9 %), 36 (47.3 % vs. 7.9 %), and 72 (57.8 % vs. 20.1 %) months (p < 0.01), and the renal survival rate, defined as the development of a 25 % reduction from baseline eGFR, was significantly higher at 12 (96.2 % vs. 69.2 %), 36 (96.2 % vs. 61.5 %), and 72 (96.2 % vs. 41.0 %) months in the TSP than the oPSL group (p < 0.001). Multivariate analysis showed that TSP was the only independent factor associated with CR (hazard ratio, 3.58; 95 % confidence interval, 1.32-10.91, p = 0.01). The number of patients with adverse events was significant lower in TSP group than in oPSL group (11.5 % vs. 34.6 %, p = 0.04).

CONCLUSIONS

CR rates are higher; protection of renal function and prevention from adverse events were superior with TSP than with oPSL in patients with IgAN and moderate-to-severe proteinuria.

Comparison of methods of steroid administration combined with tonsillectomy for IgA nephropathy patients

BACKGROUND

IgA nephropathy (IgAN) is a chronic glomerular disease that causes end-stage renal disease in 20-40 % of patients within 20 years. The efficacy of tonsillectomy combined with steroid pulse (SP) administration (TSP) for clinical remission of IgAN has been reported. Particularly in Japan, TSP has been performed widely. However, the optimum method for steroid administration in TSP has not been established.

METHODS

We retrospectively compared clinical remission in IgAN patients treated with tonsillectomy combined with two different steroid administration methods: (1) three courses of SP therapy and oral prednisolone administered on alternate days (group 3A; n = 25); and (2) one course of SP therapy and oral prednisolone administered on consecutive days (group 1C; n = 22).

RESULTS

There was no significant difference in the clinical remission rates between the two groups at 12 (48.0 vs. 40.9 %, P = 0.77) and 24 months after starting treatment (68.0 vs. 72.7 %, P = 0.76) and at the final observation (76.0 vs. 81.8 %, P = 0.73). The mean period from starting treatment to remission of hematuria in group 3A was significantly shorter than that in group 1C (5.7 ± 4.4 vs. 9.9 ± 5.9 months, P = 0.03). Dyslipidemic patients treated for the first time with statin after the SP therapy were more present in group 3A at 24 months (P = 0.02).

CONCLUSIONS

In IgAN patients, treatment of group 3A may be effective for inducing rapid remission of hematuria. Further studies are needed to establish an appropriate protocol for TSP.

Significance of tonsillectomy combined with steroid pulse therapy for IgA nephropathy with mild proteinuria

Background

Medical intervention for patients with IgA nephropathy and mild proteinuria (<1.0 g/day) is controversial, and the effectiveness of tonsillectomy plus steroid pulse therapy (TSP) for such patients remains obscure.

Methods

Among 323 patients in our multicenter cohort study, 79 who had mild proteinuria (0.4–1.0 g/day) at diagnosis were eligible to participate in this study. We compared the clinicopathological findings at diagnosis, a decline in renal function defined as a 50 or 100 % increase in serum creatinine (sCr) and clinical remission (CR) defined as the disappearance of hematuria and proteinuria (<0.3 g/day) among groups given TSP (n = 46), steroid therapy (ST) (n = 9), and non-ST (n = 24). Factors contributing to CR were also evaluated using multivariate analysis.

Results

Background factors at diagnosis including age, ratio (%) of patients with hypertension, sCr, proteinuria, and histological severity did not significantly differ among the groups. Only two patients each in the TSP (4.3 %) and non-ST (8.3 %) groups achieved a 50 % increase in sCr during a mean follow–up period of 4.7 years. At the final observation, 71.7, 44.4, and 41.7 % of patients in the TSP, ST, and non-ST groups, respectively, achieved CR (p = 0.032). Cox proportional hazards models revealed that TSP led to CR more effectively than non-TSP by a factor of about threefold (hazard ratio, 2.74; p = 0.008).

Conclusion

TSP therapy has potential for inducing CR in patients with IgAN and mild proteinuria (<1.0 g/day).

Recurrent IgA nephropathy complicated with Crohn's disease after renal transplantation

A 27-year-old man was diagnosed with IgA nephropathy and Crohn's disease. He had been diagnosed with proteinuria and hematuria since he was 20 years old. Diarrhea had been a continuing problem during the past 5 months. Neither corticosteroid therapy nor tonsillectomy was performed. Hemodialysis was required at age of 30, while the symptoms of Crohn's disease were ameliorated by an elemental diet. He received a renal transplant from his mother 4 months after starting dialysis therapy. The initial immunosuppression therapy consisted of methylprednisolone, mycofenolate mofetil, cyclosporine, and basiliximab. Eight months after transplantation, proteinuria and hematuria appeared and serum creatinine was 1.4 mg/dL. Relapse of IgA nephropathy was confirmed by the one-year protocol biopsy. He had suffered from tonsillitis at 32 months after the transplantation. Urinary protein increased to 3 g/day and serum creatinine was elevated to 2.04 mg/dL. Renal biopsy was performed 2 weeks after the urinary findings were aggravated. The cellular crescents constituted 36 % of the glomeruli. The findings of rejection were not confirmed in both biopsies. Tonsillectomy was performed thereafter. No additional immunosuppressive therapy was added. Proteinuria and hematuria disappeared at 4 and 20 months, respectively, after tonsillectomy, even when the symptoms of Crohn's disease worsened 69 months and 89 months after transplantation. A renal biopsy was performed 101 months after transplantation. Although IgA in the mesangium area was confirmed by immunohistochemical staining, no active lesion was seen. Tonsillectomy along with immunosuppressants for the graft might be an effective treatment for some patients with active recurrent IgA nephropathy.

A multicenter randomized controlled trial of tonsillectomy combined with steroid pulse therapy in patients with immunoglobulin A nephropathy

Background

The study aim was, for the first time, to conduct a multicenter randomized controlled trial to evaluate the effect of tonsillectomy in patients with IgA nephropathy (IgAN).

Methods

Patients with biopsy-proven IgAN, proteinuria and low serum creatinine were randomly allocated to receive tonsillectomy combined with steroid pulses (Group A; n = 33) or steroid pulses alone (Group B; n = 39). The primary end points were urinary protein excretion and the disappearance of proteinuria and/or hematuria.

Results

During 12 months from baseline, the percentage decrease in urinary protein excretion was significantly larger in Group A than that in Group B (P < 0.05). However, the frequency of the disappearance of proteinuria, hematuria, or both (clinical remission) at 12 months was not statistically different between the groups. Logistic regression analyses revealed the assigned treatment was a significant, independent factor contributing to the disappearance of proteinuria (odds ratio 2.98, 95% CI 1.01–8.83, P = 0.049), but did not identify an independent factor in achieving the disappearance of hematuria or clinical remission.

Conclusions

The results indicate tonsillectomy combined with steroid pulse therapy has no beneficial effect over steroid pulses alone to attenuate hematuria and to increase the incidence of clinical remission. Although the antiproteinuric effect was significantly greater in combined therapy, the difference was marginal, and its impact on the renal functional outcome remains to be clarified.

Evaluation of tonsillectomy before kidney transplantation in patients with IgA nephropathy

The effectiveness of a tonsillectomy before kidney transplantation (KTx) in suppressing the recurrence of IgA nephropathy (IgAN) has never been studied. The aim of this study was to analyze the effectiveness of a preoperative tonsillectomy for preventing IgAN recurrence and to identify predictive risk factors for IgAN recurrence. Of the 462 recipients who underwent a KTx between 2006 and 2011, a total of 78 patients had biopsy-proven IgAN as their primary disease. Among these 78 patients, 28 patients (group 1) underwent a tonsillectomy and 50 patients (group 2) did not undergo a tonsillectomy before KTx. The time to recurrence was 15.5±8.7months, in group 1 and 20.2±18.6months in group 2. No significant difference was observed between the two groups (P=0.63). Using a multivariate Cox regression analysis, ABO incompatible KTx and acute rejection were associated with a lower incidence of recurrence (P=0.02 and 0.002 respectively). These results suggested that a preoperative tonsillectomy might not affect the recurrence of IgAN during a short-term follow-up period, whereas preoperative desensitization and the use of a higher steroid dose were effective for suppressing the recurrence of IgAN.

Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome and IgA nephropathy

BACKGROUND

A syndrome of periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA), as well as immunoglobulin A nephropathy (IgAN), may be caused by autoimmune reactivity nephropathy.

CASE-DIAGNOSIS/TREATMENT

A 10-year-old boy presented with periodic fever, exudative tonsillitis, oral aphthous ulcer, and cervical lymph node inflammation. These conditions had occurred at intervals of about 2-6 weeks since the age of 3 years. Microscopic hematuria, first detected at age 8 years, worsened during episodes of PFAPA-related fever; since 10 years of age, the hematuria was accompanied by sustained proteinuria. Examination of a kidney biopsy specimen led to a diagnosis of IgAN. In the kidney specimen, fractalkine immunoreactivity and heavy macrophage infiltration were prominent. Multi-drug cocktail therapy improved the urinalysis findings, and subsequent tonsillectomy succeeded in controlling recurrences of PFAPA and IgAN. In a post-treatment renal biopsy specimen, mesangial proliferation was decreased, and fractalkine immunoreactivity was absent.

CONCLUSION

Immunologic reactions against certain antigens in local mucosa, including tonsils, may be impaired in PFAPA and IgAN, as evidenced by the suppression of both diseases in our patient by tonsillectomy. Accordingly, the concurrence of PFAPA and IgAN in our patient appeared to be a consequence of shared autoimmune mechanisms and systemic and local increases in cytokine concentrations, rather than coincidence.

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.

Tonsillar TLR9 expression and efficacy of tonsillectomy with steroid pulse therapy in IgA nephropathy patients

BACKGROUND

Patients with IgA nephropathy (IgAN) often show aggravation of renal injury with macroscopic hematuria after mucosal infections, especially tonsillitis. We previously demonstrated the important role of mucosal Toll-like receptor 9 (TLR9) activation in the pathogenesis of murine IgAN. Moreover, a single nucleotide polymorphism (SNP) in TLR9 was significantly associated with pathological severity in human IgAN. In this study, we investigated correlations between tonsillar TLR9 messenger RNA expression, TLR9 SNP genotypes and clinical outcomes following tonsillectomy with steroid pulse therapy (SPT) in IgAN patients.

METHODS

Tonsillar TLR9 expression was examined in IgAN (n = 49) and control (n = 15) patients who had undergone tonsillectomy. The correlations between tonsillar TLR9 expression level, TLR9 SNP genotypes and clinical outcomes after tonsillectomy with SPT were examined.

RESULTS

High expression of tonsillar TLR9 was observed in ∼23% of IgAN patients. These patients showed stronger and earlier remission of hematuria and proteinuria than those with low TLR9 expression. Patients with the TT genotype of TLR9 SNP (rs352140) had more severe renal damage than those with other genotypes. Patients whose serum IgA level decreased more than average after tonsillectomy (large ΔIgA) showed higher cumulative remission rates of proteinuria than patients with a smaller decrease in these levels (small ΔIgA). CT/CC genotypes were more dominant and tonsillar TLR9 expressions significantly higher in large ΔIgA patients than in small ΔIgA patients.

CONCLUSION

In IgAN patients, expression levels of tonsillar TLR9 and TLR9 SNP were well correlated with the efficacy of tonsillectomy with SPT.

Long-term beneficial effects of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker therapy for patients with advanced immunoglobulin A nephropathy and impaired renal function

BACKGROUND

There are few reports analyzing the effects of angiotensin-converting enzyme inhibitors (ACEIs) and/or angiotensin receptor blockers (ARBs) on the long-term renal survival of advanced immunoglobulin A nephropathy (IgAN) patients.

PATIENTS AND METHODS

In this retrospective cohort analysis, we divided 66 IgAN patients with an estimated glomerular filtration rate (eGFR) <60 ml/min into three groups: ACEI group (n = 20, treated with ACEIs), ARB group (n = 23, treated with ARBs), and control group (n = 23, treated with antiplatelet agents), and analyzed the clinical and histological background, renal survival rate until the primary endpoint of 50% decrease of eGFR from baseline, and the secondary endpoint of progression to end-stage renal disease, and the risk factors for progression.

RESULTS

The clinical and histological background without serum IgA and C3 were not significantly different among the three groups. The renal survival rate until the primary and secondary endpoints was significantly higher in the ACEI and ARB groups than in the control group. The independent risk factors for progression were higher mean blood pressure (hazard ratio [HR] 1.76, P = 0.04), higher histological grade (HR 2.54, P = 0.0184) at baseline, and without ACEIs or ARBs (HR 7.09, P = 0.001), but decreased proteinuria and blood pressure. The risk factors with resistance to ACEIs or ARBs were higher blood pressure and lower eGFR at baseline. There was no difference regarding the survival rate and the risk for progression between ACEI s and ARBs.

CONCLUSION

ACEIs or ARBs were effective for long-term renal survival of advanced IgAN, although proteinuria and blood pressure did not decrease.

Effect of tonsillectomy plus steroid pulse therapy on clinical remission of IgA nephropathy: a controlled study

BACKGROUND AND OBJECTIVES

Few well-designed investigations have examined how tonsillectomy plus steroid pulse therapy affects IgA nephropathy. A prospective, controlled study therefore was performed to compare the effects of combined therapy with those of steroid pulse alone in patients with IgA nephropathy.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Fifty-five patients were followed up for 54.0 +/- 21.2 mo. Thirty-five of them underwent tonsillectomy and steroid pulse therapy (group C), and 20 received steroid pulse monotherapy (group M). Both groups received methylprednisolone intravenously, followed by oral prednisolone (initial dosage 0.5 mg/kg per d) for 12 to 18 mo. Primary evaluation items were a 100% increase in serum creatinine from baseline levels or the disappearance of urinary protein (UP) and/or occult blood (UOB) indicating clinical remission.

RESULTS

At 24 mo after the initial treatment, the ratios of the UP and UOB disappearance were higher in group C than in group M, and the therapeutic effect persisted until the final observation. None of group C achieved a 100% increase in serum creatinine from the baseline level, whereas one patient in group M developed ESRD during the observation period. The histologic findings of repeated biopsy specimens from 18 patients revealed that mesangial proliferation and IgA deposition were significantly more reduced in group C than in group M. The Cox regression model showed that the combined therapy was approximately six-fold more effective in causing the disappearance of UP than steroid pulse monotherapy.

CONCLUSION

Tonsillectomy combined with steroid pulse treatment can induce clinical remission in patients with 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.

Prevalence and Implications of Isolated Microscopic Hematuria in Asymptomatic Chinese Pregnant Women

BACKGROUND

IgA nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. However, the actual prevalence of microscopic hematuria and IgAN is unknown in the Chinese population.

METHODS

We screened 7,828 consecutive pregnant women for microscopic hematuria in the antenatal clinic of a tertiary referral center. Persistent microscopic hematuria was defined as urine Hemastix (Bayer Diagnostics, Hong Kong) of 1+ for red cells in two clinic visits. Subjects were referred to the renal clinic for specialist evaluation, including measurement of blood pressure, serum creatinine, urine bacterial culture, and quantification of proteinuria.

RESULT

There were 207 women (2.64%) with microscopic hematuria. Mean age was 31.8 +/- 5.0 years. In 101 patients (48.8%), there was proteinuria >0.1 g/day by quantitative assay. Hematuria was found to resolve before or shortly after delivery in 126 (60.9%) and 68 women (32.9%), respectively. Five patients (2.4%) had urinary tract infection proved by repeated urine culture, 1 had papillary necrosis, and 1 had duplex collecting system. Three patients were confirmed to have IgAN by renal biopsy; all had normal blood pressure and serum creatinine, but dysmorphic red cells in urine microscopy, and proteinuria of over 0.5 g/day that persisted after delivery. Renal biopsy on another woman showed no specific pathology. Two women were lost to follow-up, both with normal renal function and no detectable proteinuria. The overall prevalence of IgAN was 38 cases per 100,000 population (95% confidence interval: 8-112 cases).

CONCLUSION

Microscopic hematuria is not uncommon in pregnant women, and IgAN is present in a small proportion of these patients. Further study is needed to determine whether screening for microscopic hematuria would allow early diagnosis and improve the prognosis of these patients.