Modulating the Progression in IgA Nephropathy

Omega-3 Polyunsaturated Fatty Acids for the Treatment of IgA Nephropathy

IgA nephropathy is a common disease that causes end-stage renal failure and requires renal replacement therapy. The main purpose of therapeutic intervention in this disease is not limited to improvement of prognosis and prevention of transition to end-stage renal failure, but also prevention of the occurrence of cardiovascular lesions, which increases risk in patients with chronic kidney disease. Steroids and immunosuppressants have been widely used as remission induction therapies; however, the balance between their therapeutic benefits and detrimental side-effects are controversial. In this regard, it is critical to identify alternative therapies which would provide holistic life-long benefits. Currently, the potential of ω-3 fatty acids as anti-inflammatory and inflammation-convergent drugs—especially the remarkable progress of the multifunctional ω-3 polyunsaturated fatty acids (PUFAs)—has garnered attention. In this section, we outline the background and current status of ω-3 PUFA-based treatment in IgA nephropathy.

Outcome results in children with IgA nephropathy: a single center experience

Background

Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis. Patients manifest variable clinical symptoms (eg, microhematuria) with preserved or progressive deterioration of renal function resulting in end-stage renal disease. The aim of this study was to evaluate patients from a single center to describe the clinical features, treatments, and follow-up results of those with the disease.

Methods

This is a retrospective data study of all children with IgAN. Patients who had a histopathologically proven diagnosis of IgAN and were followed up for at least 5 years were included in the study. Renal biopsy, graded as Hass classification, was performed on all patients. A total of 39 patients were included in the study.

Results

The mean follow-up time (± standard deviation) was 10.4 ± 3.51 (range 5–16) years. Twenty-nine patients (74.4%) were male and ten (25.6%) were female. Nineteen (48.7%) patients presented with recurrent macroscopic hematuria, ten (25.6%) with microscopic hematuria ± proteinuria, six (15.4%) with nephritic syndrome, and four (10.3%) with nephrotic syndrome. All patients underwent a renal biopsy, which was graded according to the Hass classification. At the end of follow-up time, 18 (46.1%) patients were normal, 15 (38.5%) had minor urinary abnormalities, three (7.7%) had active renal disease, and three (7.7%) developed renal failure.

Conclusion

The results of the present study are better than those from most other series. The majority of children with IgAN in this study were admitted with recurrent macroscopic hematuria and found to have a good prognosis. We suggest that children with IgAN have a good prognosis in the first 5-year follow-up period.

Comparison of inhibitors of renin-angiotensin-aldosterone system (RAS) and combination therapy of steroids plus RAS inhibitors for patients with advanced immunoglobulin A nephropathy and impaired renal function

BACKGROUND

The adaptation of steroid therapy and the effect of renin-angiotensin-aldosterone system inhibitors (RASIs) for advanced immunoglobulin A nephropathy (IgAN) patients with impaired renal function are still controversial.

METHODS

We divided 63 IgAN patients with an estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m(2) and proteinuria ≥ 0.5 g/day into two groups: the RASI group (RASI, n = 33), treated with RASIs alone; and the combination group (COMBI, n = 30), treated with corticosteroids and RASIs. We analyzed the clinical and histological background, renal survival rate, and the risk factors for progression.

RESULTS

Renal function (mean eGFR: COMBI 46.4 vs. RASI 47.0 ml/min/1.73 m(2)), the amount of proteinuria (median: COMBI 1.39 vs. RASI 1.17 g/g creatinine) and histological backgrounds were not significantly different between the groups, but urinary red blood cells (U-RBCs) were significantly higher in the COMBI group than in the RASI group (median: COMBI 30.0 vs. RASI 10.0 counts/high-power field, P = 0.0171). The serial change in proteinuria did not differ until 5 years after treatment, but U-RBCs were significantly decreased in both groups (P < 0.0001), and eGFR was significantly decreased in the RASI group (P < 0.001) but not in the COMBI group. The results for each year after treatment did not differ significantly between both groups. The renal survival rate was not significantly different between the groups. There was no independent risk factor for progression by Cox regression analysis.

CONCLUSION

Combination therapy with steroids and RASIs was not superior to monotherapy with RASIs for advanced IgAN with impaired renal function.

Autoimmune dysfunction and subsequent renal insufficiency in a collegiate female athlete: a case report

OBJECTIVE

To present the case of a female collegiate basketball player who was diagnosed with Wegener granulomatosis of the eyes and immunoglobulin A (IgA) nephropathy.

BACKGROUND

A 19-year-old female collegiate basketball player presented to a rheumatologist, urologist, and nephrologist with severe eye pain and was diagnosed with Wegener granulomatosis and IgA nephropathy. At age 20, during routine follow-up testing, urine protein levels were found to be 3 times normal values (0-8 mg/dL), prompting the need for a kidney biopsy, which showed IgA nephropathy, another autoimmune disorder.

DIFFERENTIAL DIAGNOSIS

Sinus infection, scleritis, lymphomatoid granulomatosis, Churg-Strauss syndrome, lupus erythematosus, general granulomatosis.

TREATMENT

Initial assessment revealed signs and symptoms, particularly in the patient's eyes, consistent with a sinus infection and scleritis. Her corneas were examined by a specialist, who prescribed various medications, including prednisone, for the relief of symptoms. When the dosage of prednisone was reduced, symptoms returned. Further tests revealed the presence of anti-neutrophil cytoplasmic antibody, a protein associated with Wegener granulomatosis, which helped confirm the diagnosis. The following year, a routine urinalysis showed abnormal levels of protein in her urine. A kidney biopsy revealed that IgA nephropathy also was present. At the time of this case report, the athlete continues to be monitored by an ophthalmologist who specializes in Wegener granulomatosis, a rheumatologist, and a nephrologist.

UNIQUENESS

This athlete presented with 2 rare autoimmune disorders at an early stage of life. The medications used to treat the disorders left the athlete fatigued on a daily basis. Additionally, she was placed on 3 immunosuppressant drugs, which increased her risk for further health complications, yet she was able to successfully compete in athletics at the collegiate level. No family history of renal disease or other autoimmune disorders was discovered, further adding to the complexity and uniqueness of this case.

CONCLUSIONS

Autoimmune disorders, such as Wegener granulomatosis, can present with a variety of common signs and symptoms. As athletic trainers, we encounter a host of unusual signs and symptoms; however, in cases such as this, further investigation into the cause of the chief complaints can go a long way toward restoring or managing an athlete's health. Excellent communication among the sports medicine team helped this athlete manage her potentially life-threatening condition while allowing her to remain active in her sport.

Effects of cyclosporin A therapy combined with steroids and angiotensin converting enzyme inhibitors on childhood IgA nephropathy

To evaluate the effects of cyclosporin A (CyA) on clinical outcome and pathologic changes in children with IgA nephropathy (IgAN), we retrospectively evaluated 14 children (mean age 8.9+/-2.9 yr; eight males, six females) who were treated with CyA and steroids. The starting dose of CyA was 5 mg/kg per day, and the drug level was maintained at 100-200 ng/mL. The mean CyA level was 183.8+/-48.3 ng/mL (range 120.7-276.0 ng/mL) and the mean duration of CyA therapy was 10.9+/-1.9 months (range 8-12 months). After CyA therapy the mean 24 hr urinary protein excretion declined from 107.1+/-35.1 mg/m(2)/hr to 7.4+/-2.4 mg/m(2)/hr (P<0.001) and serum albumin increased from 3.3+/-0.6 g/dL to 4.3+/-0.3 g/dL (P<0.001). At a follow-up biopsy the histological grade of IgAN was improved in seven (50%) of the 14 patients, remained the same in three (21%), and was aggravated in four (29%). Serum creatinine, creatinine clearance, and blood pressure did not differ before and after CyA therapy. Two patients (14%) showed CyA-induced nephrotoxicity at the second biopsy. Our findings indicate that CyA therapy may be effective in reducing proteinuria and regressing renal pathology in a subset of children with IgAN.

n-3 polyunsaturated fatty acids and autoimmune-mediated glomerulonephritis

Consumption of n-3 polyunsaturated fatty acids (PUFAs) found in fish oil suppresses inflammatory processes making these fatty acids attractive candidates for both the prevention and amelioration of several organ-specific and systemic autoimmune diseases. Both pre-clinical and clinical studies have been conducted to determine whether fish oils containing the n-3 PUFAs docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) can be used in the prevention and treatment of immunoglobulin A nephropathy (IgAN) and lupus nephritis. In a toxin-induced mouse model that mimics the early stages of IgAN, n-3 PUFA consumption suppresses aberrant interleukin (IL)-6-driven IgA production and mesangial IgA immune complex deposition by impairing phosphorylation of upstream kinases and activation of transcription factors essential for IL-6 gene transcription. n-3 PUFAs can also suppress production of anti-double-stranded DNA IgG antibodies and the resultant development of lupus nephritis in the NZBW F1 mouse and related models. These effects have been linked in part to impaired expression of proinflammatory cytokines and adhesion molecules as well as increases in antioxidant enzymes in kidney and immune organs. Several recent clinical trials have provided compelling evidence that n-3 PUFA supplementation could be useful in treatment of human IgAN and lupus nephritis, although some other studies suggest such supplementation might be without benefit. Future investigations employing genomics/proteomics and novel genetically altered mice should provide further insight into how n-3 PUFAs modulate these diseases as well help to identify clinically relevant biomarkers. The latter could be employed in future well-designed, long-term clinical studies that will resolve current controversies on n-3 PUFA efficacy in autoimmune-mediated glomerulonephritis.

The non-invasive biopsy--will urinary proteomics make the renal tissue biopsy redundant?

Proteomics is a rapidly advancing technique which gives functional insight into gene expression in living organisms. Urine is an ideal medium for study as it is readily available, easily obtained and less complex than other bodily fluids. Considerable progress has been made over the last 5 years in the study of urinary proteomics as a diagnostic tool for renal disease. Advantages over the traditional renal biopsy include accessibility, safety, the possibility of serial sampling and the potential for non-invasive prognostic and diagnostic monitoring of disease and an individual's response to treatment. Urinary proteomics is now moving from a discovery phase in small studies to a validation phase in much larger numbers of patients with renal disease. Whilst there are still some limitations in methodology, which are assessed in this review, the possibility of urinary proteomics replacing the invasive tissue biopsy for diagnosis of renal disease is becoming an increasingly realistic option.

Paraneoplastic glomerular diseases and malignancies

Paraneoplastic glomerulopathies are rare manifestations of neoplastic disease to be distinguished from iatrogenic renal damage. Solid tumors are preferentially associated with membranous nephropathy, whereas Hodgkin's lymphomas are associated with minimal change disease. The most common neoplasia associated with paraneoplastic glomerular disease are carcinomas of the lung and of the gastrointestinal tract. Nephrotic syndrome is the most frequent presentation of paraneoplastic glomerulopathy and the most critical glomerular disease regarding prognosis and patient care. Renal biopsy is recommended in patients with glomerular proteinuria or nephrotic syndrome and cancer, depending on life expectancy and therapeutic options. The primary treatment must be directed at the cancer in all cases. Symptomatic treatment of the nephrotic syndrome with diuretics and ACE inhibitors is justified. Prevention of nephrotic syndrome complications, i.e. thromboses and infections, should also be addressed and systematic regular renal follow-up is warranted. All treatments should be regularly reviewed to avoid toxicity, associated renal function loss or low albumin levels for patients receiving albumin-binding drugs. Epidemiologic studies have low evidence-based value. There is no widely accepted experimental model of the association of glomerulopathy and cancer. Thus, epidemiologic and mechanistic studies are needed to determine the true prevalence of paraneoplastic glomerulopathies and investigate new pathophysiologic approaches.

Behçet's disease complicated by IgA nephropathy with nephrotic syndrome

A 65-year-old woman with a 48-year history of Behçet's disease associated with nephrotic syndrome is described. Immunofluorescence study revealed IgA nephropathy. Following treatment with an angiotensin II type-I receptor-blocker, an anti-platelet drug, and an HMG-CoA reductase inhibitor, accompanied by dietary restrictions of protein and sodium, proteinuria was markedly decreased. This report describes our experience with a rare entity of Behçet's disease complicated by nephrotic syndrome due to IgA nephropathy. Routine urine examination and renal biopsy are needed for the detection and diagnosis of renal problems with Behçet's disease.

MPO-ANCA-positive IgA nephropathy successfully treated with tonsillectomy

A 20-year-old Japanese woman was admitted to a hospital because of gross hematuria. She was diagnosed with IgA nephropathy with a poor prognosis, based on the formation of many crescents in the glomerulus and monocyte infiltration in the interstitium in a renal biopsy specimen in February 2003. Myeloperoxidase (MPO)-antineutrophil cytoplasmic antibody (ANCA) was not identified at that time. After treatment with high-dose steroid pulse therapy and heparin/warfarin, her urinary protein improved, to 0.5 g/day. However, 1 year after the steroid pulse therapy, urinary protein was increased to 1.2 g/day, associated with repeated episodes of tonsillitis. A second renal biopsy was performed, and showed an improving tendency, compared to the findings of the previous one, although some crescent formation and adhesions of Bowman's capsule remained. Interestingly, MPO-ANCA was positive in the serological examination done at this time. One month and a half after the second renal biopsy, she had a tonsillectomy, followed by a regimen of 5 mg oral prednisolone daily, in order to prevent the progression of IgA nephropathy. After the tonsillectomy, her urinary protein level was markedly improved, at 0.14 g/day. Her creatinine clearance was ameliorated, at 102 ml/min, and in addition, MPO-ANCA had disappeared. This case suggests that an inflammation such as tonsillitis may be associated not only with the activity of IgA nephropathy but also with the production of MPO-ANCA.