Clinical characteristics and treatment of patients with IgA nephropathy and hepatitis B surface antigen

Rapidly Progressive Glomerulonephritis Associated With IgA Nephropathy and C3 Deposits in a Patient With Chronic Hepatitis B

Hepatitis B-associated glomerulonephritis (GN) has been recognized for decades. However, only a few cases of IgA nephropathy (IgAN) in a setting of rapidly progressive glomerulonephritis (RPGN) associated with chronic hepatitis B virus (HBV) have been described. Herein, we report the case of a 42-year-old Asian female with a past medical history significant for chronic HBV on entecavir, hypertension, chronic kidney disease, and newly diagnosed breast cancer, who underwent elective bilateral mastectomy and breast augmentation. Post-operatively, she developed non-oliguric acute kidney injury and proteinuria. Renal biopsy revealed active focal crescentic and necrotizing GN with IgA and C3 deposits. Systemic autoimmune-associated and other infection-related GN were ruled out. IgAN in a setting of RPGN associated with chronic HBV was suspected.

Hepatitis B Virus Status and Clinical Outcomes in IgA Nephropathy

Introduction

Immunoglobulin A nephropathy (IgAN) has been reported to coexist with hepatitis B virus (HBV) infection. Despite the clinical significance of this association, there is a lack of comprehensive research investigating the impact of various common conditions following HBV infection and the potential influence of anti-HBV therapy on the progression of IgAN.

Methods

We investigated 3 distinct states of HBV infection, including chronic HBV infection, resolved HBV infection, and the deposition of hepatitis B antigens in renal tissue, in a follow-up database of 1961 patients with IgAN. IgAN progression was defined as a loss of estimated glomerular filtration rate (eGFR) >40%. Multivariable cause-specific hazards models to analyze the relationship between HBV states and IgAN progression.

Results

Chronic HBV infection was identified as an independent risk factor for IgAN progression, supported by both prematching analysis (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.06-2.44; P = 0.024) and propensity-score matching analysis (HR, 1.74; 95% CI 1.28-2.37; P < 0.001). Conversely, resolved HBV infection showed no significant association with IgAN progression (HR, 1.01; 95% CI 0.67-1.52; P = 0.969). Moreover, the presence of HBV deposition in the kidneys and the utilization of anti-HBV therapy did not appear to be significant risk factors for renal outcomes (P > 0.05).

Conclusion

Chronic HBV infection is an independent risk factor for IgAN progression, whereas resolved HBV infection is not. In patients with IgAN, management of concurrent chronic HBV infection should be enhanced. The presence of HBV deposition in the kidneys and the use of anti-HBV medications do not impact the kidney disease progression in patients with IgAN with concurrent HBV infection.

Liver Disease-Associated Glomerulopathies

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infect a significant number of individuals globally and their extra-hepatic manifestations, including glomerular disease, are well established. Additionally, liver disease-associated IgA nephropathy is the leading cause of secondary IgA nephropathy with disease course varying from asymptomatic urinary abnormalities to progressive kidney injury. Herein we provide an updated review on the epidemiology, pathogenesis, clinical manifestations, and treatment of HBV- and HCV-related glomerulonephritis as well as IgA nephropathy in patients with liver disease. The most common HBV-related glomerulonephritis is membranous nephropathy, although membranoproliferative glomerulonephritis and podocytopathies have been described. The best described HCV-related glomerulonephritis is cryoglobulinemic glomerulonephritis occurring in about 30% of patients with mixed cryoglobulinemic vasculitis. The mainstay of treatment for HBV-GN and HCV-GN is antiviral therapy, with significant improvement in outcomes since the emergence of the direct-acting antivirals. However, cases with severe pathology and/or a more aggressive disease trajectory can be offered a course of immunosuppression, commonly anti-CD20 therapy, particularly in the case of cryoglobulinemic glomerulonephritis.

Virus-Associated Nephropathies: A Narrative Review

While most viral infections cause mild symptoms and a spontaneous favorable resolution, some can lead to severe or protracted manifestations, specifically in immunocompromised hosts. Kidney injuries related to viral infections may have multiple causes related to the infection severity, drug toxicity or direct or indirect viral-associated nephropathy. We review here the described virus-associated nephropathies in order to guide diagnosis strategies and treatments in cases of acute kidney injury (AKI) occurring concomitantly with a viral infection. The occurrence of virus-associated nephropathy depends on multiple factors: the local epidemiology of the virus, its ability to infect renal cells and the patient's underlying immune response, which varies with the state of immunosuppression. Clear comprehension of pathophysiological mechanisms associated with a summary of described direct and indirect injuries should help physicians to diagnose and treat viral associated nephropathies.

Hepatitis B–Associated Lupus-Like Glomerulonephritis Successfully Treated With Antiretroviral Drugs and Prednisone: A Case Report and Literature Review

Kidney involvement with hepatitis B virus is varied and mostly limited to nephrotic syndrome with membranous nephropathy and nephritic syndrome with membranous proliferative glomerulonephritis. Lupus nephritis is associated with nephritic or nephrotic range proteinuria with most common finding of sub-endothelial electron-dense deposits and immunological stain demonstrating full-house picture with all immunological marker staining. Our case discusses a young male patient presenting with rapidly worsening renal function along with proteinuria, found to be positive for both hepatitis B core antibody along with hepatitis B surface antibody plus positive anti-neutrophilic antibody but negative anti-double-stranded DNA. Kidney biopsy demonstrated hepatitis B–associated lupus-like glomerulonephritis. He responded successfully with antiretroviral therapy and high-dose prednisone. Patient did not need lupus-specific treatment and recovered with antiretroviral therapy only. Hepatitis B–associated lupus-like glomerulonephritis has rarely been reported and possess a diagnostic and therapeutic challenge to all nephrologists.

Clinicopathological features, risk factors, and outcomes of immunoglobulin A nephropathy associated with hepatitis B virus infection

BACKGROUND

Hepatitis B virus (HBV) infections are associated with an increased risk of kidney diseases. However, the effects of HBV infection on the prognosis of immunoglobulin A nephropathy (IgAN) are unclear.

METHODS

A total of 838 patients with biopsy-confirmed IgAN were enrolled in this retrospective cohort study. The patients were categorized into either affected by IgAN and HBV infection (HBsAg-IgAN) or by primary IgAN with no sign of HBV infection (P-IgAN). A 1:1 propensity-score matching was performed between the two groups, followed by a Kaplan-Meier survival analysis, to compare the prognoses, and a Cox regression analysis, to identify factors influencing the HBsAg-IgAN outcomes.

RESULTS

A total of 176 pairs of patients were successfully matched. A significant difference in the systolic blood pressure and urea, serum creatinine, uric acid, and 24-h urine protein levels was observed between the groups. A renal pathological analysis also revealed a significant difference in the mesangial hypercellularity between the groups. During a median follow-up period of 2.4 years, Kaplan-Meier analysis also revealed a significant difference in the renal survival between the groups. Furthermore, multivariate Cox analysis confirmed that HBV infection is an independent risk factor for IgAN progression (hazard ratio [HR] 2.096; 95% confidence interval [CI] 1.091-4.026). Finally, the HBsAg-IgAN patients who received treatment with renin-angiotensin-aldosterone system inhibitors had a better overall prognosis than those who received immunosuppressive therapy and antiviral treatment.

CONCLUSION

Our results indicate that the clinicopathological features and outcomes of patients with IgAN differ significantly between those with and without HBV infection, and that HBV is an independent risk factor for IgAN progression.

"Associated" or "Secondary" IgA nephropathy? An outcome analysis

BACKGROUND

Whether differences in outcome between primary (pIgAN) and secondary IgA nephropathy (sIgAN) exist is uncertain.

METHODS

We conducted a retrospective, observational study that included all histologically diagnosed IgAN patients between 2010-2017 (N = 306), 248 with pIgAN and 58 with sIgAN. To obtain samples with similar risk of progression, sIgAN patients were grouped as liver disease and autoimmune/viral disease and propensity score matched to corresponding pIgAN samples. Univariate (Kaplan Meier) and multivariate time-dependent (Cox modelling) analyses were performed to identify predictors of the composite end-point (doubling of serum creatinine, end-stage kidney disease or death).

RESULTS

Of the whole cohort, 20% had sIgAN (6% alcoholic cirrhosis, 6% autoimmune disease and 8% viral infections). sIgAN patients were older, had more comorbidities, lower proteinuria and higher haematuria, but similar distribution in MESTC lesions and eGFR as those with pIgAN. They reached the end-point in similar proportions with those with pIgAN (43 vs. 30%; p = 0.09) but their mortality was higher (19 vs. 3%; p<0.0001). Both in unmatched (HR 0.80, 95%CI 0.42-1.52; p = 0.5) and matched samples (log-rank test: liver disease-IgAN vs. pIgAN, p = 0.1; autoimmune/viral-IgAN vs. pIgAN, p = 0.3), sIgAN was not predictive for end-point. In analyses restricted only to sIgAN, those with viral infections (HR, 10.98; 95% CI, 1.12-107.41; p = 0.03) and lower eGFR (HR, 0.94; 95%CI, 0.89-0.98; p = 0.007) had a worse prognosis. Immunosuppression did not influence outcome.

CONCLUSIONS

The differences in MESTC score and outcome between pIgAN and sIgAN seems to be minimal, suggesting that "associated" describes better than "secondary" the relationship among the two. Immunosuppression did not to influence outcome of sIgAN.

Secondary IgA nephropathy

IgA nephropathy is the most common primary glomerulonephritis worldwide. Its frequent coexistence with inflammatory, infectious, or malignant processes raises the possibility of a pathologic rather than coincidental association. Major strides have been made to elucidate the underlying pathophysiologic events that culminate in the development of primary IgA nephropathy. Whether secondary forms of the disease share common pathways triggered by underlying disorders or different mechanisms leading to similar pathologic findings remains to be determined. In this article we describe the most frequent etiologies for secondary IgA nephropathy and review the available literature for the pathophysiology.

Viral-Associated GN: Hepatitis B and Other Viral Infections

By definition, viral-associated GN indicates the direct pathogenic relationship between active viral replication and the development of acute GN. This definition is in sharp contrast to the semantic label and pathophysiologic foundation behind postinfectious GN that uniquely develops only during a period of resolved and absent active infection. The primary example of postinfectious GN are the glomerular lesions described after a pharyngeal or cutaneous streptococcal infection and do not represent the clinical or immunologic pattern seen with viral-associated GN. Hepatitis B (HBV) is the most common chronic viral infection in the world affecting >400 million people which is more than double the prevalence of chronic HIV and hepatitis C carriers combined. In addition, 10%-20% of HBV patients may be coinfected with hepatitis C and 5%-10% will have coinfection with HIV. Being able to distinguish the different types of GN seen with each viral infection is essential for the practicing clinician as each virus requires its own specific antiviral therapy. HBV-induced immune complex disease with renal injury lies on one end of the spectrum of disorders that occurs after a prolonged chronic carrier state. On the opposite end of the spectrum are renal diseases that develop from acute or subacute viral infections. One important glomerular lesion in this category is the association of collapsing FSGS with acute active cytomegalovirus, Epstein-Barr virus, and parvovirus B19 infection. The data supporting or disproving this relationship for each of these viruses will be discussed. A second renal manifestation of acute viral infections often occurs with many different sporadic or epidemic infections such as dengue and hantavirus and can lead to a transient proliferative GN that resolves upon viral clearance. The complex interplay of HBV and all viruses with the immune system provides conceptual lessons on the pathophysiology of immune complex GN that can be applied to all infection-related renal disease and plays an integral role in developing an approach to therapeutic intervention.

Glomerular Diseases Associated With Hepatitis B and C

Infections with hepatitis B virus (HBV) and hepatitis C virus (HCV) are prevalent worldwide. In this review, we discuss the epidemiology, pathogenesis, clinical manifestations, and treatment of HBV- and HCV-related glomerulonephritis (GN). The most common histopathologic presentation of HBV-GN is HBV-associated membranous nephropathy, which usually manifests clinically with varying grades of proteinuria and microscopic hematuria. The pathogenesis is likely to be immune complex mediated; however, other host and viral factors have been implicated. The treatment of HBV-GN revolves around antiviral therapy. Various histologic types of glomerular diseases are reported in association with HCV infection, the most frequent being Type 1 membranoproliferative glomerulonephritis, usually in the context of Type 2 mixed cryoglobulinemia. The pathogenesis of HCV-GN can be attributed to glomerular deposition of cryoglobulins or noncryoglobulin-immune complexes. Cryoglobulins typically comprised immunoglobulin Mκ with rheumatoid factor activity. Clinically, patients may present with proteinuria, microscopic hematuria, hypertension, and acute nephritic and/or nephrotic syndrome. The treatment of HCV-GN, especially cryoglobulinemic membranoproliferative glomerulonephritis, encompasses various options including contemporary antiviral therapy with or without conventional and novel immunomodulatory agents.

Clinical usefulness of kidney biopsy in liver transplant recipients with renal impairment

Background

Chronic kidney disease is a common complication after liver transplantation. In this study, we analyzed the results of kidney biopsy in liver transplantation recipients with renal impairment.

Methods

Between 1999 and 2012, 544 liver transplants were performed at our hospital. We retrospectively analyzed the clinical and histological data of 10 liver transplantation recipients referred for kidney biopsy.

Results

The biopsies were performed at a median of 24.5 months (range, 3–73 months) after liver transplantation. The serum creatinine level was 1.81±0.5 mg/dL at the time of kidney biopsy. There were no immediate complications. The most common diagnosis was glomerulonephritis (GN), such as immunoglobulin A nephropathy (n=4), mesangial proliferative GN (n=1), focal proliferative GN (n=1), and membranous GN (n=1). Typical calcineurin inhibitor (CNI)-induced nephrotoxicity was detected in three cases (30%). Chronic tissue changes such as glomerulosclerosis, interstitial fibrosis, and tubular atrophy were present in 90%, 80%, and 80% of cases, respectively, and mesangial proliferation was detected in 40% of cases. We began treatment for renal impairment based on the result of kidney biopsy; for example, angiotensin-receptor blockers or steroids were prescribed for GN, and the CNI dose was reduced for CNI nephrotoxicity. As a result, eight of 10 patients showed improvement in glomerular filtration rate, but two progressed to end-stage renal disease.

Conclusion

Kidney biopsy is a safe and effective method for determining the cause of renal impairment after liver transplantation. Management of patients based on the result of kidney biopsy may improve renal outcomes.