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Mizushima I, Saeki T, Kobayashi D, Sawa N, Hayashi H, Taniguchi Y, Nakata H, Yamada K, Matsui S, Yasuno T, Masutani K, Nagasawa T, Takahashi H, Ubara Y, Yanagita M, Kawano M. Improved Renal Function in Initial Treatment Improves Patient Survival, Renal Outcomes, and Glucocorticoid-Related Complications in IgG4-Related Kidney Disease in Japan. Kidney Int Rep 2024; 9:52-63. [PMID: 38312790 PMCID: PMC10831353 DOI: 10.1016/j.ekir.2023.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/26/2023] [Accepted: 10/16/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction We aimed to clarify long-term renal prognosis, complications of malignancy, glucocorticoid (GC) toxicity, and mortality in immunoglobulin G4 (IgG4)-related kidney disease (IgG4-RKD). Methods Reviewing the medical records of 95 patients with IgG4-RKD, we investigated clinical and pathologic features at baseline, the course of renal function, complications of malignancy, GC toxicity, and mortality during follow-up (median 71 months). The standardized incidence ratio (SIR) of malignancy and standardized mortality ratio were calculated using national statistics. Factors related to outcomes were assessed by Cox regression analyses. Results At diagnosis, the median estimated glomerular infiltration rate (eGFR) was 46 ml/min per 1.73 m2. GC achieved initial improvement. Additional renal function recovery within 3-months of initial treatment occurred in patients with highly elevated serum IgG and IgG4 levels and hypocomplementemia. During follow-up, 68%, 17%, and 3% of the patients had chronic kidney disease (CKD), >30% eGFR decline, and end-stage renal disease (ESRD), respectively. Age-adjusted and sex-adjusted Cox regression analyses indicated that eGFR (hazard ratio [HR], 0.71) and extensive fibrosis (HR, 2.58) at treatment initiation had a significant impact on the time to CKD. Ten patients died, and the standardized mortality ratio was 0.94. The SIR of malignancy was 1.52. The incidence rate (IR) of severe infection was 1.80/100 person-years. Cox regression analyses showed that the best eGFR within 3 months after treatment initiation were associated with lower mortality (HR 0.67) and fewer severe infections (HR 0.63). Conclusion This study suggests that more renal function recovery through early treatment initiation may improve patient survival, renal outcomes, and some GC-related complications in IgG4-RKD.
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Affiliation(s)
- Ichiro Mizushima
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata City, Japan
| | - Naoki Sawa
- Department of Nephrology Center, Toranomon Hospital, Kawasaki, Japan
| | - Hiroki Hayashi
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoshinori Taniguchi
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi University, Nankoku-shi, Japan
| | - Hirosuke Nakata
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto City, Japan
| | - Kazunori Yamada
- Department of Hematology and Immunology, Kanazawa Medical University, Kahoku-gun, Japan
| | - Shoko Matsui
- Health Administration Center, University of Toyama, Toyama City, Japan
| | - Tetsuhiko Yasuno
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Jonan-Ku, Japan
| | - Kosuke Masutani
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Jonan-Ku, Japan
| | - Tasuku Nagasawa
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Hiroki Takahashi
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yoshifumi Ubara
- Department of Nephrology Center, Toranomon Hospital, Kawasaki, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, Kyoto City, Japan
| | - Mitsuhiro Kawano
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
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McArthur M, Patel M. A pictorial review of genitourinary infections and inflammations. Clin Imaging 2023; 104:110013. [PMID: 37918136 DOI: 10.1016/j.clinimag.2023.110013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/03/2023] [Accepted: 10/23/2023] [Indexed: 11/04/2023]
Abstract
Various infectious and inflammatory diseases affect the genitourinary system. This paper provides a review of multiple common and uncommon infectious and inflammatory conditions affecting the genitourinary system and some associated complications. These include acute infectious cystitis, emphysematous cystitis, acute pyelonephritis, emphysematous pyelonephritis, renal and perinephric abscesses, pyonephrosis, xanthogranulomatous pyelonephritis, epididymo-orchitis, vasitis, prostatitis, pelvic inflammatory disease, renal hydatid infection, renal tuberculosis, actinomycosis, Erdheim-Chester Disease, IgG4-Related Kidney Disease, urethritis and urethral strictures, ureteritis cystica, and genitourinary fistulas. Radiologists should be aware of these diseases' complications and management. Uncommon conditions must be considered when evaluating the genitourinary system.
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Affiliation(s)
- Mark McArthur
- University of California, Los Angeles, United States.
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Mima A, Lee R, Murakami A, Gotoda H, Akai R, Lee S. Case Report: IgG4-related kidney disease complicated by interstitial pneumonia. F1000Res 2023; 12:1045. [PMID: 37744768 PMCID: PMC10511842 DOI: 10.12688/f1000research.131818.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 09/26/2023] Open
Abstract
Immunoglobulin G4 (IgG4)-related disease is a systemic inflammatory disorder characterized by tubulointerstitial nephritis with IgG4-positive plasma cell infiltration. We report the case of an 84-year-old male who presented with a history of dyspnea on exertion and cough. The lymph nodes were palpated in the axilla. Urinalysis revealed mild proteinuria and increased levels of NAG and β2-microglobulin. Blood tests showed hyperglobulinemia with a marked elevation of serum IgG4 levels. Chest computed tomography showed bilateral ground-glass and reticular opacities in the lower and peripheral portions of the lungs. Ga-67 scintigraphy showed kidney uptake. The patient was diagnosed with IgG4-related kidney disease based on the renal pathology indicative of typical tubulointerstitial nephritis with extensive IgG4-positive plasma cell infiltration. The patient was treated with prednisolone and showed a prompt response in his clinical condition. The patient achieved normalization of serum IgG4 levels 6 months after the initiation of treatment. Although IgG4-related disease is thought to be potentially associated with organ fibrosis, there are few reports on combination of interstitial pneumonia and IgG4-related kidney disease. Our case report presents a possible pattern of IgG4-related disease.
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Affiliation(s)
- Akira Mima
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Rina Lee
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Ami Murakami
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Hidemasa Gotoda
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Ryosuke Akai
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Shinji Lee
- Department of Nephrology, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
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Suenaga A, Sawa N, Ikuma D, Oba Y, Sekine A, Yamanouchi M, Hasegawa E, Mizuno H, Suwabe T, Kono K, Shintani-Domoto Y, Kinowaki K, Ohashi K, Suzuki Y, Miyazono M, Takemura T, Yamaguchi Y, Ubara Y. Immunoglobulin G4-related Tubulointerstitial Nephritis with Simultaneous Resolution of Plasma Cell Infiltration and Fibrosis after Steroid Treatment. Intern Med 2023; 62:2699-2706. [PMID: 36725037 PMCID: PMC10569928 DOI: 10.2169/internalmedicine.1121-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/11/2022] [Indexed: 02/03/2023] Open
Abstract
We performed 3 kidney biopsies in a 71-year-old man. At the first biopsy, we made the diagnosis of immunoglobulin G4 (IgG4)-related interstitial nephritis characterized by the simultaneous presence of IgG4-positive plasma cells and characteristic fibrosis with a bird's-eye pattern. At the second biopsy, rather than finding fibrosis as a post-inflammatory scar, we noted that steroid treatment had caused the simultaneous disappearance of IgG4-positive plasma cells and fibrosis and had restored the normal tubular structure. The third biopsy showed the recurrence of the disease with inflammatory cells accompanied by fibrosis. These findings suggest that IgG4-positive plasma cells and fibrosis occur simultaneously.
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Affiliation(s)
- Atsuhiko Suenaga
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Japan
- Department of Nephrology, Saga University School of Medicine, Japan
| | - Naoki Sawa
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Daisuke Ikuma
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Japan
| | - Yuki Oba
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Japan
| | - Akinari Sekine
- Department of Nephrology and Rheumatology, Toranomon Hospital, Japan
| | - Masayuki Yamanouchi
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Japan
| | - Eiko Hasegawa
- Department of Nephrology, Saga University School of Medicine, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
| | - Hiroki Mizuno
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Japan
| | - Tatsuya Suwabe
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Japan
| | - Kei Kono
- Department of Pathology, Toranomon Hospital, Japan
| | | | | | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Japan
- Department of Human Pathology, Tokyo Medical and Dental University, Japan
| | | | - Motoaki Miyazono
- Department of Nephrology, Saga University School of Medicine, Japan
| | - Tamiko Takemura
- Department of Pathology, Kanagawa Cardiovascular and Respiratory Center, Japan
| | | | - Yoshifumi Ubara
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Japan
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He PH, Liu LC, Zhou XF, Xu JJ, Hong WH, Wang LC, Liu SJ, Zeng JH. IgG4-related kidney disease complicated with retroperitoneal fibrosis: A case report. World J Clin Cases 2023; 11:1656-1665. [PMID: 36926395 PMCID: PMC10011980 DOI: 10.12998/wjcc.v11.i7.1656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/11/2023] [Accepted: 02/15/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND IgG4-related disease (IgG4-RD) is a chronic fibrotic disease mediated by immunity recognized by clinicians in recent years. When the kidney is involved, it is called IgG4-related kidney disease (IgG4-RKD). IgG4-related tubulointerstitial nephritis (IgG4-TIN) is a representative manifestation of IgG4-RKD. IgG4-TIN can cause obstructive nephropathy complicated by retroperitoneal fibrosis (RPF). Cases of IgG4-TIN complicated with RPF are rare. Glucocorticoids are the first-line therapeutic medication for IgG4-RD and can significantly improve renal function.
CASE SUMMARY Herein, we report the case of a 56-year-old man with IgG4-RKD complicated with RPF. The patient presented to the hospital with complaints of elevated serum creatinine (Cr), nausea, and vomiting. During hospitalization, Cr was 1448.6 µmol/L, and serum IgG4 was increased. A total abdominal computed tomography (CT) scan and enhanced CT scan obviously indicated RPF. Although this patient had a long course and renal insufficiency, we performed a kidney biopsy. Renal biopsy showed that the renal tubulointerstitium had focal plasma cell infiltration and increased lymphocyte infiltration accompanied by fibrosis. After combining the biopsy results with immunohistochemistry, it was found that the absolute number of positive IgG4+ cells per high power field exceeded 10, and the ratio of IgG4/IgG was over 40%. Finally, the patient was diagnosed with IgG4-TIN complicated with RPF and given glucocorticoids as long-term maintenance therapy, helping him keep out of dialysis. After a follow-up of 19 mo, the patient had recovered well. Previous literature on IgG4-RKD and RPF was retrieved from PubMed to characterize the clinical and pathological features and to identify the diagnosis and treatment of IgG4-RKD.
CONCLUSION Our case report demonstrates the clinical characteristics of IgG4-RKD complicated with RPF. Serum IgG4 is a favorable indicator for screening. Performing renal biopsy actively plays a vital role in diagnosis and treatment, even if the patient has a long course and manifests with renal insufficiency. It is remarkable to treat IgG4-RKD with glucocorticoids. Hence, early diagnosis and targeted therapy are essential for reversing renal function and improving extrarenal manifestations in patients with IgG4-RKD.
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Affiliation(s)
- Pei-Hua He
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510006, Guangdong Province, China
| | - Li-Chang Liu
- Department of Nephrology, Zhuhai Hospital of Guangdong Provincial Hospital of Chinese Medicine, Zhuhai 519015, Guangdong Province, China
| | - Xing-Fu Zhou
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510006, Guangdong Province, China
| | - Jun-Jie Xu
- The Second Clinical Medical College, Guangzhou University of Chinese Medicine, Guangzhou 510006, Guangdong Province, China
| | - Wei-Hong Hong
- Department of Nephrology, Zhuhai Hospital of Guangdong Provincial Hospital of Chinese Medicine, Zhuhai 519015, Guangdong Province, China
| | - Li-Chun Wang
- Department of Nephrology, Zhuhai Hospital of Guangdong Provincial Hospital of Chinese Medicine, Zhuhai 519015, Guangdong Province, China
| | - Su-Jun Liu
- Department of Nephrology, Zhuhai Hospital of Guangdong Provincial Hospital of Chinese Medicine, Zhuhai 519015, Guangdong Province, China
| | - Jia-Hao Zeng
- Department of Nephrology, Zhuhai Hospital of Guangdong Provincial Hospital of Chinese Medicine, Zhuhai 519015, Guangdong Province, China
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Kawano M, Saeki T, Ubara Y, Matsui S. Recent advances in IgG4-related kidney disease. Mod Rheumatol 2023; 33:242-251. [PMID: 35788361 DOI: 10.1093/mr/roac065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/01/2022] [Accepted: 06/21/2022] [Indexed: 11/14/2022]
Abstract
Recent advances in the management and understanding of immunoglobulin (Ig)G4-related kidney disease (RKD) have emphasized the importance of urgent treatment in IgG4-related tubulointerstitial nephritis. On the other hand, to avoid long-term glucocorticoid toxicity, strategies for early withdrawal of steroids or combination of immunosuppressants, such as rituximab, and the minimum dose of steroids have been pursued. However, disease recurrence after reducing or stopping steroid therapy hampers early withdrawal of glucocorticoid maintenance therapy. In addition, knowledge has accumulated in diagnostic approaches including differential diagnosis of anti-neutrophil cytoplasmic antibodies-associated vasculitis, idiopathic multicentric Castleman's disease, and Rosai-Dorfman disease with kidney lesion, which leads to earlier and precise diagnosis of IgG4-RKD. This review summarizes recent progress in the differential diagnosis of IgG4-RKD and related treatment strategies and recent topics of hypocomplementaemia, membranous glomerulonephritis, and IgG4-related pyelitis and periureteral lesion.
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Affiliation(s)
- Mitsuhiro Kawano
- Department of Rheumatology, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Nagaoka, Japan
| | - Yoshifumi Ubara
- Department of Nephrology and Rheumatology, Toranomon Hospital, Kawasaki, Japan
| | - Shoko Matsui
- Health Administration Center, University of Toyama, Toyama, Japan
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Singh S, Pokhariyal S, Nandwani A, Duggal R. Diagnostic Dilemma: Cardiorenal Syndrome As an Unusual Presentation of IgG4-Related Disease. Indian J Nephrol 2022; 32:512-515. [PMID: 36568604 PMCID: PMC9775612 DOI: 10.4103/ijn.ijn_143_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 08/05/2021] [Accepted: 09/14/2021] [Indexed: 12/27/2022] Open
Abstract
IgG4-related kidney disease (IgG4 RKD) is a rare clinical entity characterized by lymphoplasmacytic infiltration rich in IgG4-positive plasma cells along with fibrosis affecting several organs. Tubulointerstitial nephritis is commonly the predominant finding on kidney biopsy. Our patient was admitted with a provisional diagnosis of cardiorenal syndrome of unknown etiology. The patient was dialysis dependent for around 45 days following which kidney biopsy revealed features of acute tubulointerstitial nephritis (ATIN) with IgG4-positive plasma cells and no glomerular involvement. Positron emission tomography-computed tomography was supportive of findings of sialadenitis along with myocarditis. Our patient responded to treatment with steroids with definitive improvement in both renal and cardiac functions. This case highlights the importance of IgG4 RKD as an important differential in patients with ATIN presenting as a clinical syndrome.
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Affiliation(s)
- Shailendra Singh
- Department of Nephrology, Manipal Hospitals, Dwarka, Delhi, India,Address for correspondence: Dr. Shailendra Singh, Department of Nephrology, Associate Consultant, Manipal Hospitals, Dwarka, Delhi, India. E-mail:
| | | | - Ashish Nandwani
- Department of Nephrology, Manipal Hospitals, Dwarka, Delhi, India
| | - Rajan Duggal
- Department of Histopathology and Cytopathology, BLK Super Specialty Hospital, Delhi, India
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8
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Chow KVC, Hossain S. Concurrent IgG4-Related disease and clear cell renal cell carcinoma. Urol Case Rep 2021; 40:101856. [PMID: 34692417 PMCID: PMC8515402 DOI: 10.1016/j.eucr.2021.101856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/13/2021] [Accepted: 09/16/2021] [Indexed: 11/30/2022] Open
Abstract
We report a case of a 54-year-old man with a concurrent diagnosis of IgG4-related disease (IgG4-RD) and clear cell renal cell carcinoma (ccRCC) following asymptomatic submandibular lymphadenopathy with an incidental finding of a left renal mass. Partial nephrectomy revealed ccRCC with surrounding lymphoplasmacytic infiltrate, storiform fibrosis and a strong positivity for IgG4 on immunoperoxidase staining. The IgG4+:IgG + ratio was >40% and serum IgG4 levels were elevated at 159mg/dL. This case highlights the concurrent diagnosis of a unique dual pathology within the same organ and emphasises the importance of malignancy screening in patients with IgG4-RD and vice versa. Renal cell carcinoma (RCC) can rarely be associated with IgG4-related disease (IgG4-RD). The importance of a thorough work up to rule out malignancies after an initial diagnosis of IgG4-RD, as concurrent pathologies can occur. Ensuring long term follow up and high index of suspicion for malignancies in patients with IgG4-RD. A lower threshold for further investigation of suspicious lesions not responding to conventional IgG4-RD treatment is required. The underlying pathogenesis for the link between malignancies and IgG4-RD remains unclear and further studies are required in this area.
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Affiliation(s)
- Kar Ven Cavan Chow
- Bundaberg Base Hospital, 271 Bourbong Street Bundaberg Central, Queensland, 4670, Australia
| | - Shahadat Hossain
- Bundaberg Base Hospital, 271 Bourbong Street Bundaberg Central, Queensland, 4670, Australia
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Wu Z, Tang Y, Jiang GL, Li N, Jin ZY, Sun H. [Computed Tomography Imaging Features of IgG4-related Nephropathy]. Zhongguo Yi Xue Ke Xue Yuan Xue Bao 2021; 42:711-716. [PMID: 33423716 DOI: 10.3881/j.issn.1000-503x.12587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective To investigate the computed tomography(CT)imaging features of IgG4-related kidney disease(IgG4-RKD).Methods The clinicopathological and imaging data of 36 IgG4-RKD patients(including 26 cases of renal parenchyma,10 cases of renal pelvis,24 cases of double kidney or multiple lesions,and 12 cases of single focus)were retrospectively analyzed.Results IgG4-RKD had specific clinicopathological and imaging features.Although the kidney or renal pelvis was involved,there were no common clinical manifestations of malignant tumors such as hydronephrosis and hematuria.The boundary was clear and complete,and it had typical characteristics of continuous progressive enhancement.The peak value was mostly in the solid and excretory phase,and there were no imaging manifestations such as liquefaction,necrosis,cystic degeneration,and calcification.Even if the renal pelvis was obviously involved and the focus was large,there was no invasion of the peripheral renal parenchyma,the shape of the renal pelvis still existed,the wall was smooth,and there was no enlarged peripheral lymph nodes.Conclusions CT images of IgG4-RKD are similar to those of renal malignant tumors.Based on clinicopathological features,CT findings,and blood IgG4-related tests,a definite diagnosis can be made and unnecessary operation can be avoided.
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Affiliation(s)
- Zhe Wu
- Department of Radiology, Fushun Central Hospital, Fushun, Liaoning 113006,China.,Department of Radiology, PUMC Hospital, CAMS and PUMC, Beijing 100730,China
| | - Yi Tang
- Department of Radiology, Fushun Central Hospital, Fushun, Liaoning 113006,China
| | - Guo Lu Jiang
- Department of Radiology, Fushun Central Hospital, Fushun, Liaoning 113006,China
| | - Ning Li
- Department of Radiology, Fushun Central Hospital, Fushun, Liaoning 113006,China
| | - Zheng Yu Jin
- Department of Radiology, PUMC Hospital, CAMS and PUMC, Beijing 100730,China
| | - Hao Sun
- Department of Radiology, PUMC Hospital, CAMS and PUMC, Beijing 100730,China
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Miyanaga T, Mizuguchi K, Hara S, Zoshima T, Inoue D, Nishioka R, Mizushima I, Ito K, Fuji H, Yamada K, Sato Y, Yanagita M, Kawano M. Tertiary lymphoid tissue in early-stage IgG4-related tubulointerstitial nephritis incidentally detected with a tumor lesion of the ureteropelvic junction: a case report. BMC Nephrol 2021; 22:34. [PMID: 33468063 PMCID: PMC7816437 DOI: 10.1186/s12882-021-02240-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 01/12/2021] [Indexed: 12/24/2022] Open
Abstract
Background IgG4-related kidney disease causes renal impairment of unknown pathogenesis that may progress to kidney failure. Although ectopic germinal centers contribute to the pathogenesis of the head and neck lesions of IgG4-related disease, the presence of tertiary lymphoid tissue (TLT) containing germinal centers in IgG4-RKD has rarely been reported. Case presentation We report a 72-year-old Japanese man who had IgG4-related tubulointerstitial nephritis (TIN) with TLT formation incidentally detected in a resected kidney with mass lesion of IgG4-related ureteritis in the ureteropelvic junction. During follow-up for past surgical resection of a bladder tumor, renal dysfunction developed and a ureter mass was found in the right ureteropelvic junction, which was treated by nephroureterectomy after chemotherapy. Pathology revealed no malignancy but abundant IgG4-positive cell infiltration, obliterative phlebitis and storiform fibrosis, confirming the diagnosis of IgG4-related ureteritis. In the resected right kidney, lymphoplasmacytes infiltrated the interstitium with focal distribution in the renal subcapsule and around medium vessels without storiform fibrosis, suggesting the very early stage of IgG4-TIN. Lymphocyte aggregates were also detected at these sites and consisted of B, T, and follicular dendritic cells, indicating TLT formation. IgG4-positive cells infiltrated around TLTs. Conclusions Our case suggests that TLT formation is related with the development of IgG4-TIN and our analysis of distribution of TLT have possibility to elucidate IgG4-TIN pathophysiology.
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Affiliation(s)
- Tatsuhito Miyanaga
- Division of Rheumatology, Department of Internal Medicine, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan
| | - Keishi Mizuguchi
- Department of Diagnostic Pathology, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan
| | - Satoshi Hara
- Division of Rheumatology, Department of Internal Medicine, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan.
| | - Takeshi Zoshima
- Division of Rheumatology, Department of Internal Medicine, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medical Science, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan
| | - Ryo Nishioka
- Division of Rheumatology, Department of Internal Medicine, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan
| | - Ichiro Mizushima
- Division of Rheumatology, Department of Internal Medicine, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan
| | - Kiyoaki Ito
- Division of Rheumatology, Department of Internal Medicine, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan
| | - Hiroshi Fuji
- Division of Rheumatology, Department of Internal Medicine, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan
| | - Kazunori Yamada
- Department of Hematology and Immunology, Kanazawa Medical University, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, Japan
| | - Yuki Sato
- Department of Nephrology, Kyoto University Graduate School of Medicine, Yoshidakonoe-cho, Sakyo-ku, Kyoto, Japan.,Medical Innovation Center TMK Project, Graduate School of Medicine, Kyoto University, 53 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto, Japan
| | - Motoko Yanagita
- Medical Innovation Center TMK Project, Graduate School of Medicine, Kyoto University, 53 Shogoin, Kawahara-cho, Sakyo-ku, Kyoto, Japan.,Institute for the Advanced Study of Human Biology (ASHBi), Kyoto University, Yoshida-honmachi, Sakyo-ku, Kyoto, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, 13-1 Takaramachi, Kanazawa, Ishikawa, Japan
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11
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Saeki T, Kawano M, Nagasawa T, Ubara Y, Taniguchi Y, Yanagita M, Nishi S, Nagata M, Hisano S, Yamaguchi Y, Nomura H, Saito T, Nakashima H. Validation of the diagnostic criteria for IgG4-related kidney disease (IgG4-RKD) 2011, and proposal of a new 2020 version. Clin Exp Nephrol 2021; 25:99-109. [PMID: 33398598 DOI: 10.1007/s10157-020-01993-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 11/04/2020] [Indexed: 12/24/2022]
Abstract
Background In 2011, the IgG4-related kidney disease (IgG4-RKD) working group of the Japanese Society of Nephrology proposed diagnostic criteria for IgG4-RKD. The aim of the present study was to validate those criteria and develop a revised version. Methods Between April 2012 and May 2019, we retrospectively collected Japanese patients with kidney disease, for whom data on serum IgG4 values and/or immunohistological staining for IgG4 in renal biopsy samples were available. These patients were classified as IgG4-RKD or non-IgG4-RKD based on the diagnostic criteria for IgG4-RKD 2011, and the results were evaluated by expert opinion. Accordingly, we developed some revised versions of the criteria, and the version showing the best performance in the present cohort was proposed as the IgG4-RKD criteria for 2020. Results Of 105 included patients, the expert panel diagnosed 55 as having true IgG4-RKD and 50 as mimickers. The diagnostic criteria for IgG4-RKD 2011 had a sensitivity of 72.7% and a specificity of 90.0% in this cohort. Of the 15 patients with true IgG4-RKD who were classified as non-IgG4-RKD, all lacked biopsy-proven extra-renal lesions, although many had clinical findings highly suggestive of IgG4-RD. The revised version to which “bilateral lacrimal, submandibular or parotid swelling, imaging findings compatible with type 1 autoimmune pancreatitis or retroperitoneal fibrosis” was added as an item pertaining to extra-renal organ(s) improved the sensitivity to 90.9% while the specificity remained at 90.0%. Conclusion The revised version has considerably improved test performance after addition of the new extra-renal organ item (imaging and clinical findings).
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Abstract
IgG4-related disease (IgG4-RD) is an evolving entity characterized by immune mediated multisystem involvement in the form of fibro inflammatory lesions like sclerosing pancreatitis, dacryoadenitis, Reidel thyroiditis, or chronic sclerosing sialadenitis. Barely, the lesions are restricted to kidney (IgG4-RKD: IgG4-related kidney disease) involving either glomerular or extraglomerular compartment. It is challenging to identify and demands an awareness regarding the entity to reduce the number misdiagnosis and missed diagnosis. Here, we report a case of a 45-year-old woman with IgG4 tubulointerstitial nephritis (IgG4-TIN) who presented with unexplained renal dysfunction as her initial manifestation. This is the first case of IgG4-RKD reported from our tertiary care center among 1864 native renal biopsy in the last two years.
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Affiliation(s)
- Kavita Jain
- Department of Pathology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India
| | - Moumita Sengupta
- Department of Pathology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India
| | - Keya Basu
- Department of Pathology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India
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Kanda R, Kubo S, Nakano K, Kawabe A, Nawata A, Hanami K, Nakayamada S, Tanaka Y. A case of eosinophilic granulomatosis with polyangiitis as a mimicker of IgG4-related disease. Mod Rheumatol Case Rep 2020; 4:278-282. [PMID: 33087011 DOI: 10.1080/24725625.2020.1759200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A 62-year-old woman was admitted to our hospital because of fever, renal dysfunction, eosinophilia, and the presence of MPO-ANCA. Based on the renal pathological examination which showed granuloma lesion with eosinophils and crescentic glomerulonephritis, eosinophilic granulomatosis with polyangiitis (EGPA) was diagnosed. On the other hand, laboratory examination showed elevated serum IgG4 levels and renal pathological examination showed marked lymphoplasmacytic infiltration and fibrosis surrounding nest "Bird's eye pattern," which were characteristic of IgG4-related kidney disease (IgG4-RKD). Because there are cases when EGPA has clinical features of IgG4-RKD, we should be careful about diagnoses of IgG4-RKD in patients with EGPA.
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Affiliation(s)
- Ryuichiro Kanda
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Satoshi Kubo
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Kazuhisa Nakano
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Akio Kawabe
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Aya Nawata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Kentaro Hanami
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
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14
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Nishizawa Y, Honda K, Aoyama Y, Hosoda Y, Tamura T, Horimoto A, Omae K, Higuchi C, Sakura H, Nitta K, Ogawa T. Low-density lipoprotein apheresis for PLA2R-related membranous glomerulonephritis accompanied by IgG4-related tubulointerstitial nephritis. CEN Case Rep 2020; 9:395-403. [PMID: 32557252 DOI: 10.1007/s13730-020-00494-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 06/06/2020] [Indexed: 12/16/2022] Open
Abstract
IgG4-related disease preferentially involves the kidney by tubulointerstitial nephritis with IgG4-positive plasma cell filtration and/or membranous glomerulonephritis. We reported the case of a 68-year-old man with IgG4-related tubulointerstitial nephritis combined with antiphospholipase A2 receptor (PLA2R)-related membranous glomerulonephritis, in which distinguishing between idiopathic PLA2R-related and IgG4-related secondary membranous glomerulonephritis was difficult. We diagnosed him as having IgG4-related disease, based on a serum IgG4 level of 170 mg/dL and the presence of IgG4-related parotiditis. On renal biopsy, there was tubulointerstitial nephritis with IgG4-positive plasma cell filtration, which was compatible with IgG4-related disease and membranous glomerulonephritis, with concomitant positive staining for PLA2R on immunofluorescence microscopy. The renal function immediately recovered after steroid treatment, probably because of the improvement in the tubulointerstitial lesions, but his nephrotic syndrome was steroid-resistant. Low-density lipoprotein (LDL) apheresis therapy was effective for membranous glomerulonephritis and increased his serum albumin from 1.4 to 2.8 g/dL. Although IgG4-related kidney disease usually accompanies secondary membranous glomerulonephritis, the positive PLA2R staining suggested a concomitant primary membranous glomerulonephritis. The recent treatment strategy, including LDL apheresis, for primary and secondary membranous glomerulonephritis was discussed briefly in this report.
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Affiliation(s)
- Yoko Nishizawa
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan.
| | - Kazuho Honda
- Department of Anatomy, Showa University School of Medicine, 1-5-8, Hatanodai, Shinagawa, Tokyo, 142-8555, Japan
| | - Yumi Aoyama
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Yumi Hosoda
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Tomomi Tamura
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Ai Horimoto
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Kiyotsugu Omae
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Chieko Higuchi
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Hiroshi Sakura
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, 8-1, Kawadacho, Shinjyuku, Tokyo, 162-8666, Japan
| | - Tetsuya Ogawa
- Department of Medicine, Tokyo Women's Medical University Medical Center East, 2-1-10, Nishiogu, Arakawa, Tokyo, 116-8567, Japan
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Martín-Nares E, Hernandez-Molina G, Rodríguez-Ramírez S, Rivera-Fuentes L, Niño-Cruz JA, Núñez-Abreu A, Espinosa-González R, Uribe-Uribe NO. IgG4-related kidney disease: experience from a Mexican cohort. Clin Rheumatol 2020; 39:3401-3408. [PMID: 32488771 DOI: 10.1007/s10067-020-05135-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 04/22/2020] [Accepted: 05/01/2020] [Indexed: 12/15/2022]
Abstract
To evaluate the clinical/serological phenotype and outcomes of IgG4-related kidney disease. Case series of IgG4-related kidney disease from a cohort of 69 patients with IgG4-related disease. We defined kidney involvement as the presence of at least one of the following conditions: (A) laboratory parameters of kidney injury (proteinuria and/or elevated creatinine levels and/or hematuria); and/or (B) contrast-enhanced computed tomography features (multiple low-density lesions and/or nephromegaly and/or hypovascular solitary mass and/or renal pelvic lesion and/or perinephric lesions). We identified 17 patients with kidney involvement (24.6%), with a mean age of 53.6 ± 11.3 years; thirteen (76.5%) were male. Six patients fulfilled the laboratory criteria, six the imaging criteria, and five both. Five patients had a renal biopsy, the main histopathological diagnosis being IgG4 tubulointerstitial nephritis. Sixteen patients received glucocorticoids and 12 also immunosuppressors and/or biologics. Sixteen patients presented either total or partial renal remission at a median follow-up of 26 months, while one patient developed end-stage renal disease. Patients with kidney disease, as opposed to patients without kidney involvement, had a higher number of involved organs, higher IgG4-related disease responder index and IgG4 and IgG1 serum levels, higher prevalence of rheumatoid factor, and lower C3 and C4 levels. Our study emphasizes the systemic nature of IgG4-related disease, highlighting that renal involvement is usually present in a subset of patients with multisystemic disease, high IgG1 and IgG4 levels, and hypocomplementemia. Key Points • IgG4-RKD presents at a younger age in Mexican mestizo patients. • IgG4-RKD presents with proteinuria and kidney injury or as an asymptomatic imaging finding. • IgG4-RKD presents in the context of multisystemic disease, hypocomplementemia, and high IgG1 and IgG4 levels.
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Affiliation(s)
- Eduardo Martín-Nares
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, ZC 14080, Mexico City, Mexico
| | - Gabriela Hernandez-Molina
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, ZC 14080, Mexico City, Mexico
| | - Sonia Rodríguez-Ramírez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, ZC 14080, Mexico City, Mexico
| | - Lemuel Rivera-Fuentes
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, ZC 14080, Mexico City, Mexico
| | - José Antonio Niño-Cruz
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, ZC 14080, Mexico City, Mexico
| | - Alicia Núñez-Abreu
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, ZC 14080, Mexico City, Mexico
| | - Ricardo Espinosa-González
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, ZC 14080, Mexico City, Mexico
| | - Norma Ofelia Uribe-Uribe
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, ZC 14080, Mexico City, Mexico.
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16
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Fujisawa Y, Mizushima I, Yamada K, Yamamoto M, Saeki T, Matsui S, Tsuge S, Hara S, Ito K, Fujii H, Takahashi H, Nomura H, Kawa S, Kawano M. Hypocomplementemia is related to elevated serum levels of IgG subclasses other than IgG4 in IgG4-related kidney disease. Mod Rheumatol 2020; 31:241-248. [PMID: 31903809 DOI: 10.1080/14397595.2019.1709942] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES This study investigated the clinical features of IgG4-RKD patients with hypocomplementemia compared with those without it, so as to clarify the factors related to hypocomplementemia. METHODS In this single-center retrospective study, we analyzed the clinical features of 25 patients with IgG4-RKD according to the presence/absence of hypocomplementemia. Additionally, we validated the results of a single-center study in a separate large multicenter cohort of 328 patients with IgG4-RD, and searched for factors related to hypocomplementemia. RESULTS Serum IgG levels (p < .001), non-IgG4 IgG levels, calculated as the total IgG minus IgG4 (p < .001), serum IgG1 levels (p = .017), and the number of involved organs (p = .018) were significantly higher in the hypocomplementemia group. At relapse of renal lesions in four patients, all had serum IgG4 re-elevation, with the three with hypocomplementemia presenting worsening of hypocomplementemia and re-elevation of non-IgG4 IgG levels. In a validation cohort of 328 patients with IgG4-RD, multivariate logistic regression analysis indicated elevation of non-IgG4 IgG levels to be an independent factor related to hypocomplementemia in the patients with IgG4-RKD. CONCLUSION The present study suggests that hypocomplementemia is associated with elevation of IgG subclasses other than IgG4 including IgG1 in IgG4-RKD.
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Affiliation(s)
- Yuhei Fujisawa
- Department of Cardiovascular and Internal Medicine, Division of Rheumatology, Kanazawa University Graduates School of Medicine, Kanazawa, Japan.,Department of Internal Medicine, Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Ichiro Mizushima
- Department of Internal Medicine, Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kazunori Yamada
- Department of Internal Medicine, Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan.,Department of Advanced Research in Community Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Motohisa Yamamoto
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Niigata, Japan
| | - Shoko Matsui
- Health Administration Center, University of Toyama, Toyama, Japan
| | - Syunsuke Tsuge
- Department of Internal Medicine, Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Satoshi Hara
- Department of Internal Medicine, Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Kiyoaki Ito
- Department of Internal Medicine, Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroshi Fujii
- Department of Internal Medicine, Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
| | - Hiroki Takahashi
- Department of Rheumatology and Clinical Immunology, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hideki Nomura
- Department of General Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - Shigeyuki Kawa
- Department of Internal Medicine, Matsumoto Dental University, Shiojiri, Japan
| | - Mitsuhiro Kawano
- Department of Internal Medicine, Division of Rheumatology, Kanazawa University Hospital, Kanazawa, Japan
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Li ZY, Wang X, Xia X, Yu XJ, Wang SX, Chen W, Chen M, Zhao MH. An overlap of antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis and IgG4-related kidney disease. Clin Chim Acta 2019; 501:12-19. [PMID: 31805271 DOI: 10.1016/j.cca.2019.11.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND We investigated the characteristics of antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis (ANCA-GN) and immunoglobulin G4 (IgG4)-related kidney disease (IgG4-RKD) overlap syndrome. METHODS This is a 2-center study with 19 patients. RESULTS Fifteen patients were classified as microscopic polyangiitis (MPA). The initial serum creatinine levels were 320.9 ± 191.4 μmol/l and the BVAS was 19.7 ± 7.4 at diagnosis. Hematuria was absent or slight in 13 (68.4%) cases. Renal histology of these patients revealed concurrent ANCA-GN and IgG4-RKD. Regarding the histological classification of ANCA-GN, 9 (47.4%), 8 (42.1%), 1 (5.3%) and 1 (5.3%) patients were classified as focal, crescentic, mixed and sclerotic ANCA-GN, respectively. MPO-ANCA could be detected in 17/19 (89.5%) patients. IgG subclasses of MPO-ANCA were tested in 10 patients, and all were positive for IgG4-MPO-ANCA. In patients with combined ANCA-GN and IgG4-RKD, the percentage of positive IgG1-MPO-ANCA was significantly lower than the control group of 20 AAV patients without IgG4-RKD (P = 0.002), and the percentage of positive IgG4-MPO-ANCA was higher than the control group, but this difference was not statistically significant (P = 0.14). CONCLUSIONS ANCA-GN and IgG4-RKD overlap syndrome concerned mainly MPO-ANCA positive patients. The IgG subclass analysis of MPO-ANCA showed lower percentage of IgG1 subclass. The association between ANCA-GN and IgG4-RKD is possible and represents a special entity.
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Affiliation(s)
- Zhi-Ying Li
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, China
| | - Xu Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, China
| | - Xi Xia
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Key Laboratory of Nephrology, National Health Commission of China and Guangdong Province, Guangzhou 510080, China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, China; Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing 100034, China
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-sen University, Key Laboratory of Nephrology, National Health Commission of China and Guangdong Province, Guangzhou 510080, China
| | - Min Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing 100034, China; Peking-Tsinghua Center for Life Sciences, Beijing 100034, China
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Aljishi M, Thet Z, Han T, Madhan K. Acute Tubulointerstitial Nephritis as a Sole Manifestation of Immunoglobulin G4-Related Disease. J Med Cases 2019; 10:348-353. [PMID: 34434307 PMCID: PMC8383568 DOI: 10.14740/jmc3395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/10/2019] [Indexed: 11/23/2022] Open
Abstract
This is a case report of a patient who developed severe acute kidney disease with kidney biopsy showing interstitial nephritis, plasma cell infiltration and immunoglobulin G4 (IgG4) expression consistent with IgG4-related kidney disease. There were no other systemic features of IgG4-related disease. The patient was treated with corticosteroids and mycophenolate. This case highlights the need to consider IgG4-related kidney disease even in the absence of other systemic features. Isolated renal involvement is underrecognized and can lead to missed diagnosis. It also illustrates that mycophenolate can be used as a steroid sparing agent in this condition; an observation that adds to the limited literature in this field.
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Affiliation(s)
- Manaf Aljishi
- Renal Department, Rockhampton Hospital, Queensland, Australia.,University of Queensland, St Lucia QLD 4072, Australia
| | - Zaw Thet
- Renal Department, Rockhampton Hospital, Queensland, Australia
| | - Thin Han
- Medicine and Nephrology, Rockhampton Hospital, Rockhampton QLD 4700, Australia
| | - Krishan Madhan
- Renal Medicine Department, Hervey Bay Hospital, Queensland, Australia
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19
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Kuruma S, Kamisawa T, Kikuyama M, Chiba K, Shimizuguchi R, Koizumi S, Tabata T. Clinical characteristics of autoimmune pancreatitis with IgG4 related kidney disease. Adv Med Sci 2019; 64:246-251. [PMID: 30826634 DOI: 10.1016/j.advms.2018.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 09/29/2018] [Accepted: 12/10/2018] [Indexed: 12/28/2022]
Abstract
PURPOSE To clarify the clinical characteristics of autoimmune pancreatitis (AIP) in immunoglobulin (Ig)G4-related kidney disease (IgG4-RKD). PATIENTS AND METHODS A total of 92 patients with AIP were divided into an IgG4-RKD-positive group (RKD-P group, n = 13) and an IgG4-RKD-negative group (RKD-N group, n = 79) on the basis of the diagnostic criteria for IgG4-RKD. Clinical characteristics, including: age; sex; the presence of extrapancreatic lesions other than renal lesions, proteinuria, and hematuria; serum concentrations of IgG, IgG4, IgE, and creatinine; and urinary concentrations of liver-type fatty acid binding protein, α1-microglobulin, β2-microglobulin, and N-acetyl-β-d-glucosaminidase were compared between the RKD-P and RKD-N groups. The clinical course of the RKD-P group was also characterized. RESULTS The prevalence of extrapancreatic lesions other than renal lesions was significantly higher in the RKD-P group (84.6% vs 43.0%,p < 0.01). Serum creatinine (1.19 mg/dl versus 0.74 mg/dl, p < 0.05), urinary β2-microglobulin (6609.8 μg/l vs 265.8 μg/l, p < 0.05), and the prevalence of proteinuria (30.7% vs 7.6%, p < 0.05) were significantly higher in the RKD-P group. Nine out of thirteen patients in the RKD-P group had multiple low-density renal lesions on enhanced computed tomography, 3 patients had multiple high-intensity lesions on diffusion-weighted magnetic resonance images, and 1 patient had diffuse thickening of the renal wall, with a smooth intra-luminal surface. CONCLUSIONS Patients who had AIP with IgG4-RKD were more likely to have extrapancreatic lesions other than those in the kidney, and their serum creatinine and urinary β2-microglobulin concentrations were significantly higher than in those without IgG4-RKD.
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20
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Zhang NN, Wang YY, Kong LX, Zou WZ, Dong B. IgG4-related kidney disease (IgG4-RKD) with membranous nephropathy as its initial manifestation: report of one case and literature review. BMC Nephrol 2019; 20:263. [PMID: 31311519 PMCID: PMC6635993 DOI: 10.1186/s12882-019-1419-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 06/11/2019] [Indexed: 12/14/2022] Open
Abstract
Background IgG4-related disease (IgG4-RD) often affects multiple organs and tissues, especially the kidneys, and is characterized by interstitial nephritis, obstructive nephropathy, and in rare cases glomerulopathy (including membranous nephropathy). Case presentation In this article, we report a patient with nephrotic syndrome as the only initial manifestation. Membranous nephropathy was confirmed by renal biopsy, but without any renal interstitial lesions. The nephrotic syndrome completely resolved after treatment with immunosuppressants but recurred after drug withdrawal, which was accompanied by acute kidney injury. Ultimately, IgG4-related interstitial nephritis with membranous nephropathy was confirmed by a second renal biopsy. After routine administration of steroids and cyclophosphamide, renal function returned to normal after 2 months, and nephrotic syndrome was ameliorated after 5 months. Conclusion Special attention should be paid to this rare condition in the clinical setting. In patients with membranous nephropathy (MN) that is accompanied by multi-system damage, impaired renal function, elevated IgG4 levels (absolute or relative value), negative PLA2R, and/or renal interstitial plasma cell infiltration, the possibility of IgG4-related kidney disease (IgG4-RKD) should be carefully assessed.
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Affiliation(s)
- Nan-Nan Zhang
- Department of Nephrology, Fangshan Hospital of Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Yan-Yun Wang
- Department of Nephrology, Fangshan Hospital of Beijing University of Chinese Medicine, Beijing, 102400, China
| | - Ling-Xin Kong
- Department of Nephrology, Fangshan Hospital of Beijing University of Chinese Medicine, Beijing, 102400, China.
| | - Wan-Zhong Zou
- Department of Nephrology, People's Hospital of Peking University, Beijing, 110102, China
| | - Bao Dong
- Department of Nephrology, People's Hospital of Peking University, Beijing, 110102, China
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Wong ETY, Lahiri M, Teh M, Leo CCH. IgG4-Related Kidney Disease: A Curious Case of Interstitial Nephritis with Hypocomplementemia. Case Rep Nephrol Dial 2019; 9:49-54. [PMID: 31192228 PMCID: PMC6547283 DOI: 10.1159/000500296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 04/10/2019] [Indexed: 01/13/2023] Open
Abstract
IgG4-related kidney disease has been relatively newly recognized over the last two decades as a combination of an autoimmune and allergic disorder, with elevated serum IgG4 level and hypocomplementemia among its characteristic features. Here we report the case of a man with interstitial nephritis presenting with acute kidney injury and hypocomplementemia but normal serum IgG4 level and provide a literature review of IgG4-related kidney disease. This case highlights the importance of IgG4-related kidney disease as an important differential diagnosis in any patient presenting with a clinical syndrome mimicking acute interstitial nephritis with hypocomplementemia. A high index of suspicion with a low threshold for performing a native kidney biopsy would be paramount as patients do respond well to corticosteroid therapy.
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Affiliation(s)
- Emmett Tsz Yeung Wong
- Division of Nephrology, University Medicine Cluster, National University Hospital, Singapore, Singapore
| | - Manjari Lahiri
- Division of Rheumatology, University Medicine Cluster, National University Hospital, Singapore, Singapore
| | - Ming Teh
- Department of Pathology, National University Hospital, Singapore, Singapore
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22
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Wakabayashi K, Yanagawa H, Hayashi Y, Aoyama R, Shimizu Y, Tomino Y, Suzuki Y. Progressive Renal Dysfunction due to IgG4-Related Kidney Disease Refractory to Steroid Therapy: A Case Report. Case Rep Nephrol Dial 2019; 9:1-7. [PMID: 31616671 PMCID: PMC6787412 DOI: 10.1159/000496465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/09/2018] [Indexed: 12/24/2022] Open
Abstract
Recently, as the number of case reports of IgG4-related kidney disease (IgG4-RKD) has increased, the histopathological features and clinical approach have been clarified. IgG4-RKD generally has a benign prognosis due to the efficacy of steroid therapy and rarely requires dialysis. Herein, we report a case of IgG4-RKD that presented with a subacute onset, advanced to end-stage kidney disease, and finally required maintenance hemodialysis despite steroid therapy. A 75-year-old man was admitted to our hospital for further evaluation of subacute renal failure. Diffuse enlargement of the kidney on computed tomography and increased urinary N-acetyl-β-D-glucosaminidase and α1-microglobulin levels led us to suspect IgG4-RKD. Upon admission, the laboratory serological findings were as follows: creatinine 3.3 mg/dL, urea nitrogen 46.9 mg/dL, and IgG4 235 mg/dL. Urinalysis showed slight proteinuria without hematuria. Percutaneous renal needle biopsy showed diffuse infiltration of abundant lymphocytes and IgG4-positive plasma cells and storiform fibrosis, which is specific to IgG4-RKD, in the interstitium on light microscopy. Slight linear deposition of C3 was also observed in the tubules on immunofluorescence microscopy, with no electron-dense deposits. He was definitively diagnosed as having IgG4-RKD and started on prednisolone 0.6 mg/kg/day. However, the renal insufficiency continued to progress and hemodialysis was necessary. As the prednisolone was tapered, renal function did not improve and maintenance hemodialysis was started. In conclusion, this case indicates that the prognosis of IgG4-RKD is not necessarily benign and that further studies involving more patients are needed.
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Affiliation(s)
- Keiichi Wakabayashi
- Division of Nephrology, Department of Internal Medicine, Juntendo Shizuoka Hospital, Izunokuni, Japan
| | - Hiroyuki Yanagawa
- Division of Nephrology, Department of Internal Medicine, Juntendo Shizuoka Hospital, Izunokuni, Japan
| | - Yoko Hayashi
- Division of Nephrology, Department of Internal Medicine, Juntendo Shizuoka Hospital, Izunokuni, Japan
| | - Rumi Aoyama
- Division of Nephrology, Department of Internal Medicine, Juntendo Shizuoka Hospital, Izunokuni, Japan
| | - Yoshio Shimizu
- Division of Nephrology, Department of Internal Medicine, Juntendo Shizuoka Hospital, Izunokuni, Japan.,Shizuoka Medical Research Center for Disaster, Juntendo University, Izunokuni, Japan
| | - Yasuhiko Tomino
- Division of Nephrology, Department of Internal Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Yusuke Suzuki
- Division of Nephrology, Department of Internal Medicine, Juntendo University Faculty of Medicine, Tokyo, Japan
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23
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Arai H, Toda N, Kamimatsuse R, Nishioka K, Endo S, Akiyama S, Maruyama S, Matsubara T, Yokoi H, Yanagita M. A Refractory Case of Secondary Membranous Nephropathy Concurrent with IgG4-related Tubulointerstitial Nephritis. Intern Med 2018; 57:2873-2877. [PMID: 29709946 PMCID: PMC6207830 DOI: 10.2169/internalmedicine.0836-18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
A 58-year-old man with type 1 autoimmune pancreatitis was referred to nephrologists for severe proteinuria. Laboratory data revealed a high serum IgG4 level, hypoalbuminemia, and massive proteinuria, which were compatible with nephrotic syndrome. The renal pathological findings confirmed the diagnosis of secondary membranous nephropathy concurrent with IgG4-related tubulointerstitial nephritis. Despite the improvement of interstitial markers, the proteinuria was refractory to prednisolone, requiring cyclosporine to achieve complete remission. Membranous nephropathy is a rare manifestation of IgG4-related kidney disease. This case shows that the therapeutic response to prednisolone significantly differs between glomerular lesions and interstitial lesions of IgG4-related kidney disease.
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Affiliation(s)
- Hiroyuki Arai
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
| | - Naohiro Toda
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
| | - Ryo Kamimatsuse
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
- Department of Nephrology, Kyoto City Hospital, Japan
| | - Keisuke Nishioka
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
- Department of Nephrology, Osaka Red Cross Hospital, Japan
| | - Shuichiro Endo
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
| | - Shinichi Akiyama
- Division of Nephrology, Department of Internal Medicine, Nagoya University, Graduate School of Medicine, Japan
| | - Shoichi Maruyama
- Division of Nephrology, Department of Internal Medicine, Nagoya University, Graduate School of Medicine, Japan
| | - Takeshi Matsubara
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
| | - Hideki Yokoi
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University, Graduate School of Medicine, Japan
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24
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Takeji A, Yamada K, Inoue D, Mizushima I, Hara S, Ito K, Fujii H, Nakajima K, Mizutomi K, Yamagishi M, Kawano M. A case of IgG4-related kidney disease with predominantly unilateral renal atrophy. CEN Case Rep 2018; 8:8-13. [PMID: 30062635 PMCID: PMC6361077 DOI: 10.1007/s13730-018-0355-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 07/23/2018] [Indexed: 12/24/2022] Open
Abstract
A 73-year-old Japanese woman was diagnosed with type 1 autoimmune pancreatitis (AIP) without kidney lesions. She was treated with prednisolone (PSL) 30 mg/day, and her AIP symptoms promptly improved, after which the PSL dose was gradually tapered to 5 mg/day. Her renal function had remained normal (serum creatinine 0.7 mg/dL) until 1 year before the current admission without any imaging abnormalities in the kidney. However, during this past year her renal function gradually declined (serum creatinine 1.1 mg/dL). Follow-up computed tomography incidentally revealed unilateral renal atrophy, which rapidly progressed during the subsequent 10-month period without left kidney atrophy. A diagnosis of IgG4-RKD probably due to TIN was made, and we increased the dose of prednisolone to 30 mg/day. 1 month after administration, multiple low-density lesions on both kidneys were improved slightly but almost all lesions persisted as atrophic scars. Our case suggested that unilateral renal atrophy can develop in patients with IgG4-related tubulointerstitial nephritis without hydronephrosis caused by retroperitoneal fibrosis, and that monitoring the serum creatinine levels is not always sufficient, thereby highlighting the importance of regular imaging monitoring to detect newly developing kidney lesions.
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Affiliation(s)
- Akari Takeji
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Kazunori Yamada
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan.,Department of Advanced Research in Community Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medical Science, Kanazawa, Ishikawa, Japan
| | - Ichiro Mizushima
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Satoshi Hara
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Kiyoaki Ito
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hiroshi Fujii
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Kenichi Nakajima
- Department of Nuclear Medicine, Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | | | - Masakazu Yamagishi
- Division of Cardiology, Kanazawa University Graduate School of Medicine, Kanazawa, Ishikawa, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Kanazawa University Hospital, Kanazawa University Graduate School of Medicine, 13-1, Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan.
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25
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Cho YJ, Jung WY, Lee SY, Song JS, Park HJ. Perirenal capsule and scrotal involvement in immunoglobulin G4-related kidney disease: case-based review. Rheumatol Int 2018; 38:1941-1948. [PMID: 29959468 DOI: 10.1007/s00296-018-4089-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 06/18/2018] [Indexed: 12/20/2022]
Abstract
Immunoglobulin G4-related disease (IgG4-RD) is a chronic, immune-mediated-, systemic disease that is characterized by IgG4 plasma cell infiltration with fibrotic changes in various organs. The most affected organs are pancreas and salivary glands. Kidney can be rarely involved, and is usually represented as a renal mass and organomegaly. Usually, elevated levels of serum IgG4 more than 135 mg/dl with organ-specific features and biopsy results showing enriched infiltration of IgG4-positive plasma cells are needed to diagnose the disease. However, we experienced two unusual cases of IgG4-RD involving kidney. IgG4-related kidney disease (IgG4-RKD) was first reported as an extra pancreatic feature of autoimmune pancreatitis(AIP) in 2004. Herein, we describe two cases of such unique presentation of IgG4RKD and a literature review focusing on clinicopathologic features of IgG4RKD. Our cases are distinct in the fact that IgG4RD invades unusual organs such as perinephric capsule or scrotum. We reported the patient who showed extinct perirenal capsule invasion with multi-organ involvement including exocrine glands in comparison to previous IgG4RKD that often involved in renal parenchyma and renal pelvis lesions. And the other patient had scrotal invasion with multifocal renal parenchymes. Referring to the features observed in these two cases, we could propose that as every organ can be related to IgG4RD, we propose clinicians to confirm the disease using imaging, serologic, and pathologic studies. We also reviewed previous reports of IgG4-RKD and summarized diverse imaging findings and pathologic features.
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Affiliation(s)
- Yoon-Jin Cho
- Catholic Kwandong University College of Medicine, Incheon, Republic of Korea
| | - Wun-Yong Jung
- Department of Pathology, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, Republic of Korea
| | - Sang-Yoep Lee
- Department of Pathology, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, Republic of Korea
| | - Ji-Sun Song
- Department of Pathology, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, Republic of Korea
| | - Hee-Jin Park
- Division of Rheumatology, Department of Internal Medicine, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Simgok-dong 291, Seo-gu, Incheon, Republic of Korea.
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26
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Quattrocchio G, Barreca A, Demarchi A, Solfietti L, Beltrame G, Fenoglio R, Ferro M, Mesiano P, Murgia S, Del Vecchio G, Massara C, Rollino C, Roccatello D. IgG4-related kidney disease: the effects of a Rituximab-based immunosuppressive therapy. Oncotarget 2018; 9:21337-21347. [PMID: 29765543 PMCID: PMC5940417 DOI: 10.18632/oncotarget.25095] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 03/24/2018] [Indexed: 12/17/2022] Open
Abstract
IgG4-related disease (IgG4-RD) is a recently recognized disorder, characterized by elevated serum IgG4 concentrations, dense tissue infiltration of IgG4-positive plasma cells and storiform fibrosis. Treatment is usually based on steroids, however, relapses and long-term adverse effects are frequent. We prospectively studied 5 consecutive patients with histologically-proven IgG4-RD and renal involvement, treated with an extended Rituximab protocol combined with steroids. Two doses of intravenous cyclophosphamide were added in 4 patients. Five patients with IgG-RD were investigated: three had tubulointerstitial nephritis (TIN), while two had retroperitoneal fibrosis (RPF). In the patients with TIN, renal biospy was repeated after 1 year. In the patients with TIN, estimated glomerular filtration rate (eGFR) at 12 months increased from 9 to 24 ml/min per 1.73 m2; IgG/IgG4 decreased from 3,236/665 to 706/51 mg/dl; C3/C4 increased from 49/6 to 99/27 mg/dl; CD20+ B-cells decreased from 8.7% to 0.5%; Regulatory T-cells decreased from 7.2% to 2.5%. These functional and immunologic changes persisted at 24 months and in two patients at 36 months. A repeat renal biopsy in the patients with TIN showed a dramatic decrease in interstitial plasma cell infiltrate with normalization of IgG4/IgG positive plasma cells. The patients with RPF showed a huge regression of retroperitoneal tissue. In this sample of patients with aggressive IgG4-RD and renal involvement, treatment aimed at depleting B cells and decreasing antibody and cytokine production was associated with a substantial, persistent increase in eGFR, and a definite improvement in immunologic, radiologic and histological parameters.
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Affiliation(s)
- Giacomo Quattrocchio
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Andrea Demarchi
- Surgical Pathology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Laura Solfietti
- Center of Research of Immunopathology and Rare Diseases (CMID), San Giovanni Bosco Hospital, and University of Turin, Turin, Italy
| | - Giulietta Beltrame
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Roberta Fenoglio
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Michela Ferro
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Paola Mesiano
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Stefano Murgia
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Giulio Del Vecchio
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Carlo Massara
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Cristiana Rollino
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, and University of Turin, Italy.,Center of Research of Immunopathology and Rare Diseases (CMID), San Giovanni Bosco Hospital, and University of Turin, Turin, Italy
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27
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Singh N, Nada R, Rawat A, Sharma A, Sinha SK, Ramachandran R, Kumar V, Kohli HS, Gupta KL, Rathi M. Spectrum of IgG4-related Kidney Disease at a Tertiary Care Center. Indian J Nephrol 2018; 28:209-214. [PMID: 29962671 PMCID: PMC5998721 DOI: 10.4103/ijn.ijn_146_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
IgG4-related kidney disease (IgG4 RKD) is increasingly reported with varied manifestations. The present study was carried out to study the spectrum of IgG4 RKD. All patients with renal manifestation associated with conditions known to be associated with IgG4-related diseases (IgG4 RDs), or renal imaging or histology suggestive of IgG4 RKD were included and evaluated further. Patients with known extrarenal IgG4RD were also screened for renal involvement. Out of 40 patients screened over a period of 15 months, IgG4 RKD was diagnosed in 8. Majority were male (87.5%) with mean age being 56 years. Disease spectrum ranged from normal renal function in one to renal failure requiring dialysis in another two patients. Significant proteinuria was uncommon (12.5%) while hematuria was not seen in any patient. Tubulointerstitial nephritis was seen in all four patients who underwent kidney biopsy. Two patients had associated glomerular lesions in the form of immune complex crescentic glomerulonephritis. The most common imaging abnormality was hypodense renal lesions seen in 2 patients. Elevated IgG4 levels had 87.5% sensitivity and 78.3% specificity for IgG4 RKD and levels did not correlate with disease severity. Of 4 patients treated with steroids, 3 showed improvement in renal function. IgG4 RKD is an uncommon disease even at a referral tertiary care center. Elevated IgG4 levels alone are neither sensitive nor specific for the diagnosis of IgG4 RKD, and a combination of clinical, imaging, serological, and histological features are required for diagnosis.
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Affiliation(s)
- N Singh
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A Rawat
- Department of Paediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - A Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - S K Sinha
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - V Kumar
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - H S Kohli
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K L Gupta
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - M Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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28
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Tricard T, Addeo P, Sauvinet G, Mouracadé P, Lindner V, Le Van Quyen P, Roy C, Lang H, Bachellier P. [ IgG4-related kidney disease: Urologist trap?]. Prog Urol 2017; 28:135-136. [PMID: 29203156 DOI: 10.1016/j.purol.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 10/26/2017] [Accepted: 11/03/2017] [Indexed: 10/18/2022]
Affiliation(s)
- T Tricard
- Service de Chirurgie Urologique, Nouvel Hôpital Civil, 1, place de l'Hôpital, 67000 Strasbourg, France.
| | - P Addeo
- Service de Chirurgie Hépato-bilio-pancréatique et Transplantation, Hôpital de Hautepierre, 1, avenue Molière, 67100 Strasbourg, France
| | - G Sauvinet
- Service de Chirurgie Urologique, Nouvel Hôpital Civil, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - P Mouracadé
- Service de Chirurgie Urologique, Nouvel Hôpital Civil, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - V Lindner
- Service de Pathologie, Hôpital de Hautepierre, 1, avenue Molière, 67100 Strasbourg, France
| | - P Le Van Quyen
- Service de Pathologie, Hôpital de Hautepierre, 1, avenue Molière, 67100 Strasbourg, France
| | - C Roy
- Service de Radiologie et d'Échographie, Nouvel Hôpital Civil, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - H Lang
- Service de Chirurgie Urologique, Nouvel Hôpital Civil, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - P Bachellier
- Service de Chirurgie Hépato-bilio-pancréatique et Transplantation, Hôpital de Hautepierre, 1, avenue Molière, 67100 Strasbourg, France
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29
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Raber I, Ediriwickrema A, Higgins J, Kambham N, Pao AC. Crescentic Glomerulonephritis With Immunoglobulin G4-Related Disease. Am J Med Sci 2017; 354:236-239. [PMID: 28918828 DOI: 10.1016/j.amjms.2016.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/05/2016] [Accepted: 09/12/2016] [Indexed: 01/06/2023]
Abstract
Immunoglobulin G4 (IgG4)-related disease is an uncommon autoimmune disease that affects multiple organ systems. Renal involvement typically presents as tubulointerstitial nephritis and less commonly as membranous glomerulonephritis. In this case report, we discuss a 68-year-old patient who presented with rapidly progressive glomerulonephritis. His renal biopsy revealed a membranoproliferative pattern of injury with fibrocellular crescents and extensive infiltration of the tubulointerstitium with IgG4-positive plasma cells. We treated the patient with both corticosteroids and rituximab because of the aggressive nature of crescentic glomerulonephritis. The patient demonstrated a partial improvement in kidney function after 2 cycles of rituximab with a decrease in serum creatinine levels from 6.9-4.7mg/dL after 6 months from presentation. This case illustrates the importance of considering IgG4-related disease in cases of rapidly progressive glomerulonephritis and the need for effective treatments for more aggressive forms of this recently recognized disease entity.
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Affiliation(s)
- Inbar Raber
- Department of Medicine, Stanford University, Stanford, California
| | | | - John Higgins
- Department of Pathology, Stanford University, Stanford, California
| | - Neeraja Kambham
- Department of Pathology, Stanford University, Stanford, California
| | - Alan C Pao
- Department of Medicine, Stanford University, Stanford, California; Veterans Affairs Palo Alto Health Care System, Palo Alto, California.
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30
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Huart J, Grosch S, Bovy C, Moutschen M, Krzesinski JM. IgG4-related membranous glomerulonephritis and generalized lymphadenopathy without pancreatitis: a case report. BMC Nephrol 2017; 18:139. [PMID: 28446143 PMCID: PMC5405476 DOI: 10.1186/s12882-017-0561-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 04/20/2017] [Indexed: 12/24/2022] Open
Abstract
Background IgG4-related disease is a recently described pathologic entity. This is the case of a patient with nephrotic syndrome and lymphadenopathy due to IgG4-related disease. Such a kidney involvement is quite peculiar and has only been described a few times recently. Renal biopsy showed a glomerular involvement with membranous glomerulonephritis in association with a tubulo-interstitial nephropathy. Moreover, the patient was not suffering from pancreatitis. Case presentation The patient is a middle-aged man of Moroccan origin. He has developed recurrent episodes of diffuse lymphadenopathies, renal failure and nephrotic syndrome. Renal biopsies showed membranous glomerulonephritis. Discussion and conclusion The diagnostic approach of this atypical presentation is discussed in this case report as well as diagnostic criteria, therapeutic strategies, biomarkers and pathophysiology of IgG4-related disease. IgG4-related membranous glomerulonephritis is a well-established cause of membranous glomerulonephritis. It must be sought after in every patient with a previous diagnosis of IgG4-related disease and in every patient with this histological finding on renal biopsy. Corticoids are still the first-line treatment of IgG4-related disease. New therapeutic strategies are needed to avoid glucocorticoids long term side-effects. Interestingly, the patient was prescribed cyclophosphamide in addition to glucocorticoids for an immune thrombocytopenia. This treatment had a very good impact on his IgG4-related disease.
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Affiliation(s)
- Justine Huart
- Division of Nephrology, University of Liège Hospital (ULg CHU), Liège, Belgium.
| | - Stéphanie Grosch
- Division of Nephrology, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Christophe Bovy
- Division of Nephrology, University of Liège Hospital (ULg CHU), Liège, Belgium
| | - Michel Moutschen
- Division of Infectious diseases and General Internal Medecine, University of Liège Hospital (ULg CHU), Liège, Belgium
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31
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Hirabayashi Y, Ishikawa E, Ito M. Bilateral renal hilar tumors in IgG4-related disease. Clin Exp Nephrol 2017; 21:1131-2. [PMID: 28321597 DOI: 10.1007/s10157-017-1403-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 03/11/2017] [Indexed: 10/19/2022]
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Mizushima I, Yamamoto M, Inoue D, Nishi S, Taniguchi Y, Ubara Y, Matsui S, Yasuno T, Nakashima H, Takahashi H, Yamada K, Nomura H, Yamagishi M, Saito T, Kawano M. Factors related to renal cortical atrophy development after glucocorticoid therapy in IgG4-related kidney disease: a retrospective multicenter study. Arthritis Res Ther 2016; 18:273. [PMID: 27884179 PMCID: PMC5123425 DOI: 10.1186/s13075-016-1175-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 11/08/2016] [Indexed: 12/24/2022] Open
Abstract
Background In immunoglobulin G4-related kidney disease (IgG4-RKD), focal or diffuse renal cortical atrophy is often observed in the clinical course after glucocorticoid therapy. This study aimed to clarify the factors related to renal atrophy after glucocorticoid therapy in IgG4-RKD. Methods We retrospectively evaluated clinical features including laboratory data and computed tomography (CT) findings before and after glucocorticoid therapy in 23 patients diagnosed with IgG4-RKD, all of whom were followed up for more than 24 months. Results Seventeen patients were men, and six were women (average age 62.0 years). Average follow-up period was 54.9 months. The average estimated glomerular filtration rate (eGFR) at diagnosis was 81.7 mL/min/1.73 m2. All patients had had multiple low-density lesions on contrast-enhanced CT before glucocorticoid therapy, and showed disappearance or reduction of these lesions after it. Pre-treatment eGFR and serum IgE level in 11 patients in whom renal cortical atrophy developed 24 months after the start of glucocorticoid therapy were significantly different from those in 12 patients in whom no obvious atrophy was found at that time (68.9 ± 30.1 vs 93.5 ± 14.1 mL/min/1.73 m2, P = 0.036, and 587 ± 254 vs 284 ± 263 IU/mL, P = 0.008, respectively). Pre-treatment eGFR and serum IgE level were also significant risk factors for renal atrophy development 24 months after the start of therapy with an odds ratio of 0.520 (per 10 mL/min/1.73 m2, 95% confidence interval (CI) 0.273–0.993, P = 0.048) and 1.090 (per 10 IU/mL, 95% CI: 1.013–1.174, P = 0.022), respectively, in age-adjusted, sex-adjusted, serum IgG4 level-adjusted logistic regression analysis. Receiver operating characteristic curve analysis showed that eGFR of less than 71.0 mL/min/1.73 m2 and serum IgE of more than 436.5 IU/mL were the most appropriate cutoffs and yielded sensitivity of 63.6% and specificity of 100%, and sensitivity of 90.9% and specificity of 75.0%, respectively, in predicting renal atrophy development. Conclusions This study suggests that pre-treatment renal insufficiency and serum IgE elevation predict renal atrophy development after glucocorticoid therapy in IgG4-RKD. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-1175-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ichiro Mizushima
- Division of Rheumatology, Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, Takara-machi 13-1, Kanazawa, Ishikawa, 920-8640, Japan.,Division of Nephrology and Rheumatology, Department of Internal Medicine, Ishikawa Prefectural Central Hospital, Kanazawa, Japan
| | - Motohisa Yamamoto
- The First Department of Internal Medicine, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Dai Inoue
- Department of Radiology, Kanazawa University Graduate School of Medical Science, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yoshinori Taniguchi
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan
| | - Yoshifumi Ubara
- Nephrology Center and Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Toranomon 2-2-2, Minato-ku, Tokyo, 105-8470, Japan
| | - Shoko Matsui
- Health Administration Center, University of Toyama, 2630 Sugitani, Toyama-shi, Toyama, 930-0194, Japan
| | - Tetsuhiko Yasuno
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Hitoshi Nakashima
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Hiroki Takahashi
- The First Department of Internal Medicine, Sapporo Medical University, South 1, West 16, Chuo-ku, Sapporo, Hokkaido, 060-8543, Japan
| | - Kazunori Yamada
- Division of Rheumatology, Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, Takara-machi 13-1, Kanazawa, Ishikawa, 920-8640, Japan
| | - Hideki Nomura
- Department of General Medicine, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Masakazu Yamagishi
- Division of Cardiology, Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8640, Japan
| | - Takao Saito
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Fukuoka University, 7-45-1, Nanakuma, Jonan-ku, Fukuoka, 814-0180, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Department of Cardiovascular and Internal Medicine, Kanazawa University Graduate School of Medicine, Takara-machi 13-1, Kanazawa, Ishikawa, 920-8640, Japan.
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Lu Z, Yin J, Bao H, Jiao Q, Wu H, Wu R, Xue Q, Wang N, Zhang Z, Wang F. Coexistence of Acute Crescent Glomerulonephritis and IgG4-Related Kidney Disease. Case Rep Nephrol Dial 2016; 6:89-95. [PMID: 27504450 PMCID: PMC4965529 DOI: 10.1159/000448025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 06/28/2016] [Indexed: 12/24/2022] Open
Abstract
Introduction IgG4-related disease (IgG4-RD) is a fibroinflammatory disorder that may involve almost each organ or system. IgG4-related kidney disease (IgG4-RKD) refers to renal lesions associated with IgG4-RD. The most frequent morphological type of renal lesions is IgG4-related tubulointerstitial nephritis (IgG4-TIN) which is associated with increased IgG4-positive plasma cell infiltration and interstitial fibrosis. Case Report Herein, we present a rare case with coexisting IgG4-RKD and acute crescent glomerulonephritis with concomitant severe tubulointerstitial lesions instead of classic IgG4-TIN. Conclusion IgG4-RKD and acute crescent glomerulonephritis can occur in the same patient. This case may give us a clearer viewpoint of the disease.
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Affiliation(s)
- Zeyuan Lu
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jianyong Yin
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Hongda Bao
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qiong Jiao
- Department of Pathology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Huijuan Wu
- Department of Pathology, Fudan University School of Medicine, Shanghai, China
| | - Rui Wu
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qin Xue
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Niansong Wang
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Zhigang Zhang
- Department of Pathology, Fudan University School of Medicine, Shanghai, China
| | - Feng Wang
- Department of Nephrology and Rheumatology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Mann S, Seidman MA, Barbour SJ, Levin A, Carruthers M, Chen LYC. Recognizing IgG4-related tubulointerstitial nephritis. Can J Kidney Health Dis 2016; 3:34. [PMID: 27429760 PMCID: PMC4947514 DOI: 10.1186/s40697-016-0126-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 07/02/2016] [Indexed: 12/24/2022] Open
Abstract
PURPOSE OF THE REVIEW Immunoglobulin G4-related disease (IgG4-RD) is a systemic fibroinflammatory disorder affecting nearly all organs, including the kidney. Tubulointerstitial nephritis (IgG4-TIN) is the most common form of IgG4-related kidney disease (IgG4-RKD) and is the focus of this concise review. OBJECTIVE The study aims to describe when IgG4-TIN should be suspected and to summarize the diagnosis, treatment, and natural history of the disease. SOURCES OF INFORMATION Ovid MEDLINE, Google Scholar, and PubMed were searched for full-text English language articles up to January 2016. References included in the manuscript were chosen at the authors' discretion based on their relevance to the subject of the review. FINDINGS IgG4-TIN should be considered in patients presenting with abnormal urinalysis, abnormal kidney function, renal lesions on imaging, and elevated IgG, IgE, or hypocomplementemia. Diagnosis of IgG4-TIN requires a combination of histologic features (plasma cell-enriched TIN with >10 IgG4+ plasma cells/hpf, +/- TBM immune complex deposits in many cases) and at least one of the following:Characteristic radiologic findings (small peripheral low-attenuation cortical nodules, round or wedge-shaped lesions, or diffuse patchy involvement)Elevated serum IgG4 levelCharacteristic findings of IgG4-RD in other organs Other conditions such as lupus, vasculitis, diabetic nephropathy, and lymphoma must be excluded, as these can also present with IgG4+ plasma cells in the renal parenchyma. IgG4-TIN is generally responsive to steroids and B cell depletion with rituximab, but relapses are common and patients require close long-term follow-up. LIMITATIONS Available data on IgG4-TIN are from retrospective observational studies. IMPLICATIONS IgG4-TIN is a distinct and emerging subtype of interstitial nephritis. Nephrologists must be aware of this entity and how to definitively diagnose and treat it. Prospective studies and ideally multi-center clinical trials are needed to study the epidemiology, treatment, and natural history of this disease.
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Affiliation(s)
- Shawna Mann
- />Department of Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver,, BC V5Z 1M9 Canada
| | - Michael A. Seidman
- />Department of Pathology and Laboratory Medicine, Providence Health Care, 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Sean J. Barbour
- />Division of Nephrology, University of British Columbia, 2775 Laurel Street, 5th Floor, Vancouver, BC BC V5T 3A5 Canada
| | - Adeera Levin
- />Division of Nephrology, University of British Columbia, 1081 Burrard Street, Vancouver, BC V6Z 1Y6 Canada
| | - Mollie Carruthers
- />Division of Rheumatology, University of British Columbia, 839 West Broadway, Vancouver, BC V5Z 1J9 Canada
| | - Luke Y. C. Chen
- />Division of Hematology, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, BC V5Z 1M9 Canada
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Hara S, Kawano M, Mizushima I, Harada K, Takata T, Saeki T, Ubara Y, Sato Y, Nagata M. Distribution and components of interstitial inflammation and fibrosis in IgG4-related kidney disease: analysis of autopsy specimens. Hum Pathol 2016; 55:164-73. [PMID: 27246178 DOI: 10.1016/j.humpath.2016.05.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 03/30/2016] [Accepted: 05/19/2016] [Indexed: 12/24/2022]
Abstract
IgG4-related kidney disease (IgG4-RKD) occasionally progresses to chronic renal failure and is pathologically characterized by IgG4-positive lymphoplasmacyte-rich tubulointerstitial nephritis with storiform fibrosis (bird's-eye pattern fibrosis). Although radiology reveals a heterogeneous distribution of affected areas in this disease, their true distribution within the whole kidney is still unknown because of difficulty in estimating this from needle biopsy samples. Using 5 autopsy specimens, the present study histologically characterized the distribution and components of interstitial inflammation and fibrosis in IgG4-RKD. Interstitial lymphoplasmacytic infiltration or fibrosis was observed in a variety of anatomical locations such as intracapsular, subcapsular, cortical, perivascular, and perineural regions heterogeneously in a patchy distribution. They tended to be more markedly accumulated around medium- and small-sized vessels. Storiform fibrosis was limited to the cortex. Immunostaining revealed nonfibrillar collagens (collagen IV and VI) and fibronectin predominance in the cortical lesion, including storiform fibrosis. In contrast, fibril-forming collagens (collagen I and III), collagen VI, and fibronectin were the main components in the perivascular lesion. In addition, α-smooth muscle actin-positive myofibroblasts were prominently accumulated in the early lesion and decreased with progression, suggesting that myofibroblasts produce extracellular matrices forming a peculiar fibrosis. In conclusion, perivascular inflammation or fibrosis of medium- and small-sized vessels is a newly identified pathologic feature of IgG4-RKD. Because storiform fibrosis contains mainly nonfibrillar collagens, "interstitial fibrosclerosis" would be a suitable term to reflect this. The relation between the location and components of fibrosis determined in whole kidney samples provides new clues to the pathophysiology underlying IgG4-RKD.
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Affiliation(s)
- Satoshi Hara
- Department of Kidney and Vascular Pathology, University of Tsukuba, Tsukuba 305-8575, Japan; Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa 920-8641, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa 920-8641, Japan.
| | - Ichiro Mizushima
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa 920-8641, Japan
| | - Kenichi Harada
- Department of Human Pathology, Kanazawa University Graduate School of Medicine, Kanazawa 920-8640, Japan
| | - Takuma Takata
- Department of Internal Medicine, Nagaoka Chuo General Hospital, Nagaoka 940-8653, Japan
| | - Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, Nagaoka 940-2108, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital, Kajigaya 213-8587, Japan
| | - Yasuharu Sato
- Department of Pathology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama 700-8558, Japan
| | - Michio Nagata
- Department of Kidney and Vascular Pathology, University of Tsukuba, Tsukuba 305-8575, Japan
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Abstract
IgG4-related disease (IgG4-RD) is a recently recognized disorder, often with multiple organ involvement, characterized by dense tissue infiltration of IgG4-positive plasma cells, storiform fibrosis, obliterative phlebitis and frequently elevated serum IgG4 concentration. The kidney can be involved either directly or indirectly. The most frequent direct renal manifestations of IgG4-RD are IgG4-related tubulointerstitial nephritis (TIN) and membranous glomerulonephropathy. Retroperitoneal fibrosis (RPF) is another condition that is frequently IgG4-related and that can indirectly affect the kidney causing ureteral obstruction and hydronephrosis. Contrast-enhanced computerized tomography, magnetic resonance imaging and (18)F-fluorodeoxyglucose positron emission tomography/computed tomography show different imaging findings and are useful tools for monitoring therapeutic response. Steroid treatment is the first line of therapy, but relapsing or refractory forms of the disease are frequently observed and require more aggressive therapeutic approaches. At our centre, we treated three cases of aggressive IgG4-related TIN and two cases of IgG4-related RPF with an intensified, immune suppressive protocol, obtaining good results without severe adverse effects.
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Affiliation(s)
- Giacomo Quattrocchio
- Nephrology and Dialysis Unit, Giovanni Bosco Hospital, Turin, Italy. .,Second level Master in Practical Rheumatology, University of Turin, Turin, Italy.
| | - Dario Roccatello
- Nephrology and Dialysis Unit, Giovanni Bosco Hospital, Turin, Italy.,Department of Rare, Immunologic, Center of Research of Immunopathology and Rare Diseases (CMID), Hematologic and Immunohematologic Diseases, Giovanni Bosco Hospital, Turin, Italy.,University of Turin, Turin, Italy
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Zaarour M, Weerasinghe C, Eter A, El-Sayegh S, El-Charabaty E. An Overlapping Case of Lupus Nephritis and IgG4-Related Kidney Disease. J Clin Med Res 2015; 7:575-81. [PMID: 26015827 PMCID: PMC4432904 DOI: 10.14740/jocmr2189w] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2015] [Indexed: 12/24/2022] Open
Abstract
We report a case of a 71-year-old Filipino female who was admitted to the hospital for abdominal pain, vomiting and diarrhea of 8 days duration. The patient was found to have marked acute kidney injury (AKI), which required hemodialysis in the next 3 days. Extensive workup revealed hematuria, subnephrotic range proteinuria, elevated anti-nuclear antibody (ANA) and elevated total immunoglobulin G (IgG) levels, with normal IgG4 and anti-dsDNA levels. On kidney biopsy, mild membranous glomerulonephritis was found, along with autoimmune tubulointerstitial nephritis (TIN) with a “full-house” pattern of immune deposits. These findings were suggestive of lupus interstitial nephritis. However, IgG4+ plasma cells were detected in the interstitium by immunostaining, favoring a diagnosis of IgG4-related kidney disease (IgG4-RKD). Our case highlights the difficulty in differentiating lupus nephritis (LN) from IgG4-RKD in some patients, raising the suspicion that these two entities can co-exist.
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Affiliation(s)
- Mazen Zaarour
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Chanudi Weerasinghe
- Department of Medicine, Staten Island University Hospital, Staten Island, NY, USA
| | - Ahmad Eter
- Department of Medicine, Division of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
| | - Suzanne El-Sayegh
- Department of Medicine, Division of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
| | - Elie El-Charabaty
- Department of Medicine, Division of Nephrology, Staten Island University Hospital, Staten Island, NY, USA
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Watanabe R, Yasuno T, Hisano S, Sasatomi Y, Nakashima H. Distinct cytokine mRNA expression pattern in immunoglobulin G4-related kidney disease associated with renal cell carcinoma. Clin Kidney J 2015; 7:269-74. [PMID: 25852888 PMCID: PMC4377746 DOI: 10.1093/ckj/sfu024] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 02/21/2014] [Indexed: 12/24/2022] Open
Abstract
We treated a 61-year-old man with immunoglobulin (Ig)G4-related kidney disease (IgG4-RKD). He had a history of allergic diseases and an allergic reaction and had received a diagnosis of autoimmune pancreatitis (AIP). He had also received a diagnosis of renal cell carcinoma (RCC) and had undergone segmental resection of the left kidney at 59 years of age. His serum amylase level and number of peripheral eosinophils increased after RCC development. We hypothesized that the RCC may have induced AIP and IgG4-RKD and we therefore examined the excised RCC tissue; typical findings of IgG4-RKD associated with RCC were recognized. We next evaluated the mRNA expression of cytokines in the excised tissues of this case and ten other ordinary RCC cases. In all cases, notable levels of IL-10 mRNA and high levels of TGF-β mRNA were seen. Although prominent differences were not observed in the mRNA expression of Th1, Th17 and Treg cytokines in all cases, the present case alone showed increased production of the Th2 cytokines IL-4 and IL-5, which were not detected in ordinary RCC cases. Although the mechanism underlying IgG4-RKD development has not yet been determined, Th2 and Treg cells are thought to play a prominent role in the pathogenesis. It is therefore likely that in this case, the association of these two diseases was not coincidental, and a distinct immune response against RCC may trigger IgG4-RKD development.
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Affiliation(s)
- Renya Watanabe
- Division of Nephrology and Rheumatology, Department of Internal Medicine , Fukuoka University , Fukuoka , Japan
| | - Tetsuhiko Yasuno
- Division of Nephrology and Rheumatology, Department of Internal Medicine , Fukuoka University , Fukuoka , Japan
| | - Satoshi Hisano
- Department of Pathology, Faculty of Medicine , Fukuoka University , Fukuoka , Japan
| | - Yoshie Sasatomi
- Division of Nephrology and Rheumatology, Department of Internal Medicine , Fukuoka University , Fukuoka , Japan
| | - Hitoshi Nakashima
- Division of Nephrology and Rheumatology, Department of Internal Medicine , Fukuoka University , Fukuoka , Japan
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Kawamura E, Hisano S, Nakashima H, Takeshita M, Saito T. Immunohistological analysis for immunological response and mechanism of interstitial fibrosis in IgG4-related kidney disease. Mod Rheumatol 2015; 25:571-8. [PMID: 25547019 DOI: 10.3109/14397595.2014.1001474] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Our study aimed to clarify the immunological characteristics and the mechanism of interstitial fibrosis in immunoglobulin G4-related kidney disease (IgG4-RKD) by the immunohistological analysis. METHODS Immunohistological study was performed in the biopsied renal tissues of 16 IgG4-RKD, 16 Sjögren syndrome (SJS), and 17 idiopathic tubulointerstitial nephritis (ITIN) patients using antibodies against IgG; IgG1; IgG4; CD38; CD3; C-X-C chemokine receptor type 3 (CXCR3); chemokine (C-C motif) receptor 4 (CCR4); forkhead box 3 (Foxp3); Type I, Type III, Type IV, and Type VI collagens; and transforming growth factor (TGF)-β1. RESULTS Interstitial lymphoplasmacytic and eosinophilic infiltration and the severity of interstitial fibrosis were greater in IgG4-RKD than SJS and ITIN. The ratio of CXCR3+/CD3 + cells was greater in SJS as compared with that in IgG4-RKD and ITIN. The ratio of CCR4+/CD3 + cells was not different among the three diseases. The ratio of interstitial IgG4+/IgG+ plasma cells, Foxp3+/CD3 + cells, and TGF-β1 + cells/total infiltrating cells was higher in IgG4-RKD than SJS and ITIN. There was a positive correlation between the ratio of Foxp3+/CD3 + cells and that of IgG4+/IgG+ plasma cells in IgG4-RKD. Significant correlation was found between the ratio of Foxp3+/CD3 + cells and that of TGF-β1 + cells/total infiltrating cells in IgG4-RKD. Foxp3 + cells and TGF-β1 + cells were colocalized in the interstitium in IgG4-RKD. The significant correlation between the ratio of TGF-β1 + cells/total infiltrating cells and the severity of fibrosis was noticed in IgG4-RKD. The interstitial distribution of type III collagen and type IV collagen was higher in IgG4-RKD than in SJS. CONCLUSIONS Our results suggest that regulatory T-cells (Tregs) may play a central role in IgG4 production in the interstitium and TGF-β1 induced by Tregs may play a pivotal role in the interstitial fibrosis including type III and type IV collagens in IgG4-RKD.
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Affiliation(s)
- Eiichi Kawamura
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Fukuoka University , Fukuoka , Japan
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Nishikawa K, Takeda A, Masui S, Kanda H, Yamada Y, Arima K, Morozumi K, Sugimura Y. A case of IgG4-positive plasma cell-rich tubulointerstitial nephritis in a kidney allograft mimicking IgG4-related kidney disease. Nephrology (Carlton) 2015; 19 Suppl 3:52-6. [PMID: 24842825 DOI: 10.1111/nep.12250] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A 51-year-old woman received an ABO blood type-incompatible renal transplant. She was administered rituximab and basiliximab and underwent plasma exchanges for induction therapy, followed by administration of tacrolimus, mycophenolate mofetil and methylprednisolone as maintenance immunosupression therapy. A planned renal biopsy 2 years after transplantation revealed infiltration of plasma cells in the renal interstitium, although there was no 'storiform' fibrosis surrounding these cells. There were also no findings of rejection, BK virus nephropathy, or atypical plasma cells. Immunohistochemical stainings showed a large number of IgG4-positive plasma cells, most of which expressed kappa-type light chains. A CT scan showed a mass at the renal hilum. The serum IgG4 level was high. Based on these findings, the patient was suspected of having IgG4-related kidney disease. Nine months after the biopsy, her serum creatinine level increase to 1.56 mg/dL and the dose of methylprednisolone was therefore increased to 16 mg/day. Three months after this increase in steroid, a CT scan showed the hilum mass had disappeared. A follow-up biopsy 5 months later showed that infiltration of plasma cells in the renal interstitium had decreased markedly, although focal and segmental severely fibrotic lesions with IgG4-positive plasma cells were observed. Serum IgG4 levels decreased immediately after the increase in steroid dose and remained <100 mg/dL despite a reduction in methylprednisolone to 6 mg/day. Serum creatinine levels also remained stable at around 1.6 mg/dL. To our knowledge, this is the first report of IgG4-positive plasma cell-rich tubulointerstitial nephritis mimicking IgG4-related kidney disease after kidney transplantation.
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Affiliation(s)
- Kouhei Nishikawa
- Department of Nephro-Urologic Surgery and Andrology, Mie University Graduate School of Medicine, Tsu, Mie
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Adachi H, Okuyama H, Yamaya H, Kurose N, Kojima K, Toga H, Yokoyama H. A case of IgG4-related kidney disease complicated by eosinophilic lung disease. CEN Case Rep 2014; 4:162-168. [PMID: 28509093 DOI: 10.1007/s13730-014-0160-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 11/12/2014] [Indexed: 12/24/2022] Open
Abstract
IgG4-related disease is a systemic chronic inflammatory disorder characterized by a high blood level of IgG4 and the organ injuries by marked infiltration of IgG4-positive plasma cells and fibrosis. A 71-year-old male was hospitalized for a cough, malaise and anorexia. IgG4-related disease was suspected due to marked elevation of the serum IgG4 level. However, on lung biopsy, only eosinophil infiltration was demonstrated with no plasma cell infiltration. Otherwise abdominal contrast-enhanced CT showed mild enlargement of the bilateral kidneys and many differed contrasted areas and FDG PET-CT. Moreover, renal biopsy specimens showed typical tubulointerstitial nephritis with a large number of IgG4-positive plasma cells infiltration (the IgG4/IgG-positive cell rate, 89 %) and fibrosis. We diagnosed this patient as typical IgG4-related kidney disease. He was treated by the moderate dose of prednisolone (0.8 mg/kg/day) alone, and showed prompt response in the clinical condition, and both the lung and kidney lesions. In this case, it was useful for diagnosis of IgG4-related diseases to evaluate an image such as abdominal contrast-enhanced CT and FDG PET-CT. Our case might be one of the possible patterns of IgG4-related lung diseases. In addition, we thought that there might be an association between hypereosinophilia and IgG4-related kidney disease.
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Affiliation(s)
- Hiroki Adachi
- Department of Nephrology, Kanazawa Medical University School of Medicine, 1-1 Daigaku, Uchinada, Ishikawa, 920-0293, Japan.
| | - Hiroshi Okuyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, 1-1 Daigaku, Uchinada, Ishikawa, 920-0293, Japan
| | - Hideki Yamaya
- Department of Nephrology, Kanazawa Medical University School of Medicine, 1-1 Daigaku, Uchinada, Ishikawa, 920-0293, Japan
| | - Nozomu Kurose
- Department of Pathology and Laboratory Medicine, Kanazawa Medical University School of Medicine, Uchinada, Ishikawa, Japan
| | - Koji Kojima
- Department of Respiratory Medicine, Kanazawa Medical University School of Medicine, Uchinada, Ishikawa, Japan
| | - Hirohisa Toga
- Department of Respiratory Medicine, Kanazawa Medical University School of Medicine, Uchinada, Ishikawa, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, 1-1 Daigaku, Uchinada, Ishikawa, 920-0293, Japan
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Kim B, Kim JH, Byun JH, Kim HJ, Lee SS, Kim SY, Lee MG. IgG4-related kidney disease: MRI findings with emphasis on the usefulness of diffusion-weighted imaging. Eur J Radiol 2014; 83:1057-1062. [PMID: 24768583 DOI: 10.1016/j.ejrad.2014.03.033] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 03/25/2014] [Accepted: 03/27/2014] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To investigate the imaging findings of immunoglobulin G4 (IgG4)-related kidney disease (IgG4-KD) on magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI) and to evaluate the usefulness of DWI in lesion detection. METHODS This retrospective cohort study included 31 patients with IgG4-KD who underwent MRI covering both kidneys. Two radiologists reviewed in consensus the MR images to determine the distribution pattern (location, laterality, and multiplicity) and the visually assessed signal intensity (hypointense, isointense or hyperintense) of the renal lesions compared to the normal renal parenchyma on each sequence. Per-patient sensitivity for detecting IgG4-KD and the number of detectable lesions were compared in T2-weighted images, DWI, and dynamic contrast-enhanced images. RESULTS IgG4-KD typically manifested as bilateral (83.9%), multiple (93.5%), and renal parenchymal (87.1%) nodules appearing isointense (93.5%) on T1-weighted images, hypointense (77.4%) on T2-weighted images, hyperintense (100%) on DWI (b=1000), and hypointense (83.3%) in the arterial phase and with a progressive enhancement pattern on dynamic contrast-enhanced images. The sensitivity of DWI for detecting IgG4-KD was significantly higher than that of T2-weighted images (100% vs. 77.4%, P=0.034). The median number of detectable lesions was significantly greater in DWI (n=9) than in T2-weighted images (n=2) and dynamic contrast-enhanced images (n=5) (P≤0.008). CONCLUSIONS The characteristic MRI findings of IgG4-KD were bilateral, multiple, renal parenchymal nodules with T2 hypointensity, diffusion restriction, and a progressive enhancement pattern. As DWI was useful in the detection of IgG4-KD, adding DWI to conventional MRI for patients suspected of having IgG4-KD may enhance the diagnosis.
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Affiliation(s)
- Bohyun Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Asanbyeongwon-gil 86, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - Jin Hee Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Asanbyeongwon-gil 86, Songpa-Gu, Seoul 138-736, Republic of Korea.
| | - Jae Ho Byun
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Asanbyeongwon-gil 86, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - Hyoung Jung Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Asanbyeongwon-gil 86, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - Seung Soo Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Asanbyeongwon-gil 86, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - So Yeon Kim
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Asanbyeongwon-gil 86, Songpa-Gu, Seoul 138-736, Republic of Korea
| | - Moon-Gyu Lee
- Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Asanbyeongwon-gil 86, Songpa-Gu, Seoul 138-736, Republic of Korea
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