Sawada Anri, Kawanishi Kunio, Horita Shigeru, Koike Junki, Honda Kazuho, Ochi Ayami, Komoda Mizuki, Tanaka Yoichiro, Unagami Kohei, Okumi Masayoshi, Shimizu Tomokazu, Ishida Hideki, Tanabe Kazunari, Nagashima Yoji, Nitta Kosaku
Department of Surgical Pathology, Tokyo, Japan.
Department of Medicine, Tokyo, Japan.
Nephrology (Carlton). 2016 Jul;21 Suppl 1:48-52. doi: 10.1111/nep.12775.
Immunoglobulin (Ig) A nephropathy (IgAN) is a known autoimmune disease due to abnormal glycosylation of IgA1, and occasionally, IgG co-deposition occurs. The prognosis of IgG co-deposition with IgAN is adverse, as shown in the previous studies. However, in the clinical setting, monoclonality of IgG co-deposition with IgAN has not been observed. We describe a case of proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) combined with IgAN in a renal allograft. A-21-year-old man developed end-stage renal failure with unknown aetiology and underwent living-donor kidney transplantation from his mother 2 years after being diagnosed. One year after kidney transplantation, proteinuria 2+ and haematuria 2+ were detected; allograft biopsy revealed mesangial IgA and C3 deposits, indicating a diagnosis of IgAN. After tonsillectomy and steroid pulse therapy, proteinuria and haematuria resolved. However, 4 years after transplantation, pedal oedema, proteinuria (6.89 g/day) and allograft dysfunction (serum creatinine (sCr) 203.3 µmol/L) appeared. A second allograft biopsy showed mesangial expansion and focal segmental proliferative endocapillary lesions with IgA1λ and monoclonal IgG1κ depositions. Electron microscopic analysis revealed a massive amount of deposits, located in the mesangial and subendothelial lesions. A diagnosis of PGNMID complicated with IgAN was made, and rituximab and plasmapheresis were added to steroid pulse therapy. With this treatment, proteinuria was alleviated to 0.5 g/day, and the allograft dysfunction recovered to sCr 132.6 µmol/L. This case suggests a necessity for investigation of PGNMID and IgA nephropathy in renal allografts to detect monoclonal Ig deposition disease.
免疫球蛋白A肾病(IgAN)是一种已知的自身免疫性疾病,病因是IgA1糖基化异常,偶尔还会出现IgG共沉积。如先前研究所示,IgG与IgAN共沉积的预后不良。然而,在临床环境中,尚未观察到IgG与IgAN共沉积的单克隆性。我们描述了一例肾移植中增殖性肾小球肾炎伴单克隆IgG沉积(PGNMID)合并IgAN的病例。一名21岁男性因不明病因发展为终末期肾衰竭,确诊2年后接受了来自其母亲的活体供肾移植。肾移植1年后,检测到蛋白尿2+和血尿2+;移植肾活检显示系膜区IgA和C3沉积,提示诊断为IgAN。扁桃体切除和类固醇冲击治疗后,蛋白尿和血尿消失。然而,移植4年后,出现足部水肿、蛋白尿(6.89g/天)和移植肾功能不全(血清肌酐[sCr]203.3µmol/L)。第二次移植肾活检显示系膜扩张和局灶节段性增殖性毛细血管内病变,伴有IgA1λ和单克隆IgG1κ沉积。电子显微镜分析显示大量沉积物,位于系膜区和内皮下病变处。诊断为PGNMID合并IgAN,并在类固醇冲击治疗的基础上加用利妥昔单抗和血浆置换。经过这种治疗,蛋白尿减轻至0.5g/天,移植肾功能不全恢复至sCr 132.6µmol/L。该病例表明有必要对肾移植中的PGNMID和IgA肾病进行调查,以检测单克隆Ig沉积病。