Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 6458 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 


 
Table of Contents   
CASE REPORT  
Year : 2019  |  Volume : 30  |  Issue : 2  |  Page : 531-536
Primary membranous nephropathy with concomitant IgA nephropathy


Department of Medicine, Division of Nephrology, David Geffen School of Medicine, Los Angeles, California, USA

Click here for correspondence address and email

Date of Submission06-Apr-2018
Date of Acceptance09-May-2019
Date of Web Publication23-Apr-2019
 

   Abstract 


Membranous nephropathy (MN), an autoimmune glomerulonephritis which can occur in primary and secondary forms, is one of the most common inflammatory glomerulopathies in elderly patients. The pathophysiology of the primary form is generally due to circulating immunoglobulin (IgG4) antibodies which often target phospholipase A2 receptors (anti-PLA2R) and Thrombospondin Type 1 Domain containing 7A (anti THSD7A). IgA nephropathy is one of the most common autoimmune glomerular diseases in the world and presents with a spectrum of disease ranging from asymptomatic mild hematuria and proteinuria to rapidly progressive crescentic glomerulonephritis. We present a rare case of concomitant IgA and primary MN in a single patient treated successfully with renin–angiotensin–aldosterone blockade, corticosteroids, and calcineurin inhibitors. The peak proteinuria was near 7.5–8 g protein/g creatinine by various measures. Serum creatinine remained normal, and anti-PLA2R was detectable and decreased with successful treatment. Clinicians should be aware of the possibility of two glomerular disorders in patients with glomerulonephritis and atypical presentations for any single disorder.

How to cite this article:
Khorsan R, Hanna RM, Ameen K, Arman F, Nobakht N, Hasnain H, Hyunh A, Rastogi A. Primary membranous nephropathy with concomitant IgA nephropathy. Saudi J Kidney Dis Transpl 2019;30:531-6

How to cite this URL:
Khorsan R, Hanna RM, Ameen K, Arman F, Nobakht N, Hasnain H, Hyunh A, Rastogi A. Primary membranous nephropathy with concomitant IgA nephropathy. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 May 20];30:531-6. Available from: http://www.sjkdt.org/text.asp?2019/30/2/531/256863



   Introduction Top


Membranous nephropathy (MN), an autoimmune glomerular disease, is one of the most common causes for nephrotic syndrome in older and is characterized by the formation of sub-epithelial immune deposits in the glomerular basement membrane. The disease is characterized by immunoglobulin G4 (IgG4) subtype and anti-phospholipase A2 receptor (PLA2R) antibodies in the majority (70%–80%) of cases of primary disease. The secondary form of the disease is associated with IgG1 and 2 and mesangial IgG deposits.[1],[2],[3] Of note, hypercoagulability is a notable feature of MN and the secondary form is associated with malignancy among diverse causes.[1],[2],[3]

IgA nephropathy (IgAN) is the most common primary glomerulonephritis in Caucasians,[4] Asians,[5],[6] and pediatric populations,[7] which is characterized by the presence of prominent IgA1 deposits in the glomerular mesangium.[8] It is the most common glomerulopathy world-wide and has a high prevalence in the populations of Asian nations.[5],[6]

There are other cases reported of concomitant IgAN and MN.[9],[10],[11] Here, we report a case of a 50-year-old female presented with proteinuria who was diagnosed with coexisting MN and IgAN on renal biopsy.


   Case Report Top


We present a 50-year-old female who presented with heavy proteinuria with no gross hematuria. She was hospitalized for deep venous thrombosis of her right lower extremity, multiple pulmonary emboli, and bilateral renal vein thrombosis (RVT) four months before her initial visit to our medical center. At presentation, she had a history of taking longterm oral contraceptive pills with no other significant past medical history. She is a lifetime nonsmoker with occasional alcohol use and no illicit drug use. When she was examined, only peripheral edema was found. She described no shortness of breath without any paroxysmal nocturnal dyspnea or orthopnea.

Initially, her proteinuria was thought to be due to her bilateral RVT. Renal biopsy was deferred until completion of anticoagulation therapy. Her renal function was normal; however, urine protein-to-creatinine ratio UPC was elevated at 7.5 mg/g. Repeat Doppler ultrasound study of her renal veins was performed to rule out continuous RVT, and the study revealed no evidence of RVT. Renal biopsy was performed and revealed the presence of primary MN with superimposed IgA nephropathy. The specific findings confirming concomitant IgAN and primary MN on renal biopsy is shown in [Figure 1].
Figure 1: Renal biopsy findings suggestive of IgAN and MN.
(a) Light microscopy showing glomerular basement membrane thickening and mesangial deposits consistent with MN and IgAN. (b) Immunofluorescence showing IgG in granular pattern consistent with MN. (c) Immunofluorescence showing IgA deposition in mesangium consistent with IgAN. (d) Electron micrograph showing subepithelial spike and ball deposits consistent with MN. (e) Positive anti-PLA2R stain. IgAN: Immunoglobulin A nephropathy, MN: Membranous nephropathy, PLA2R: Phospholipase A2 receptor.


Click here to view


The patient was started on cyclosporine 25 mg twice daily and prednisone 10 mg daily. She was also put on simvastatin for hyperlipidemia and lisinopril for the high blood pressure. In subsequent follow-up, cyclosporine was uptitrated up to 125 mg BID to control proteinuria. Renin angiotensin aldosterone blockade was accomplished with lisinopril, which was titrated up to 20 mg BD.

Four months after starting treatment, the patient was hospitalized for an episode of hypertensive emergency with systolic blood pressure >200 mm Hg. Cyclosporine was withheld, and she was started on metoprolol 25 mg twice daily, amlodipine 10 mg daily, and lisinopril 40 mg daily. A month later, when her blood pressure was stabilized, a retrial of cyclosporine 100 mg twice daily was started as the 24 h protein was 7.8 g/day at that time.

Seven months after starting treatment, the level of anti-PLA2R decreased, and her blood pressure improved, necessitating a decrease of diuretics and antihypertensive agents. Eight months later, on cyclosporine 100 mg twice daily, she felt well, proteinuria improved to nearly 1 g protein/24 h, and edema resolved. Her antihypertensive needs decreased, diuretics were not needed, and anti-PLA2R level decreased from 213.5 reference unit (RU)/mL to 1.9 RU/mL and became undetectable two months later at 10 months after presentation. Although proteinuria had greatly improved, some residual levels may persist due to segmental sclerosis from superimposed IgAN. The patient has developed a left-sided hearing loss possibly as a side effect due to cyclosporine. Laboratory findings of urine protein/ creatinine ratio, anti-PLA2R antibody levels, and serum creatinine versus date are shown in [Figure 2].
Figure 2: Plot of serum creatinine μmol/L, 24 h urine protein (g protein/24 h), and anti-PLA2R antibodies (RU/mL) versus date. Green arrows show start and restart of calcineurin therapy; red line shows the date of stopping calcineurin therapy due to hypertensive urgency.
PLA2R: Phospholipase A2 receptor.


Click here to view



   Discussion Top


MN and IgAN are common primary glomerular diseases, which are mediated by immune complex deposition. The concomitant presence of idiopathic MN (IMN) and IgAN is rare in adults and children, and limited cases of coexisting MN and IgAN have been previously reported.[9],[10],[11],[12],[13],[14] The etiology of overlapping MN and IgAN remains unclear. Genetic factors may contribute to the development of overlapping IgAN and MN, and familial overlapping of IgAN and MN has been reported.[15],[16],[17] There have been six reports of overlapping IgAN and MN reported in literature.[9],[10],[11],[15],[16],[17] All published reports of concomitant IgAN and MN in literature are show in [Table 1].
Table 1: Publications featuring cases of combined IgA and MGN nephropathies.

Click here to view


MN is characterized by the formation of subepithelial immune deposits that predominantly consist of IgG and C3 in the glomerular basement membrane.[13] The majority of cases of primary MN are associated with autoantibodies against the podocyte antigen M-type PLA2R.[18],[19] In IgAN, the distribution of IgA may include a presence in the mesangium, with or without capillary loop staining. IgG, IgM, and C3 may be present, but not in greater intensity than IgA, except that IgM may be prominent in sclerotic areas.[8]

IMN combined with IgAN comprises the clinical and pathological features of both diseases.[12] Histopathologic reports of previous studies in patients with overlapping MN and IgAN have shown that IgG deposits are mainly in the capillary walls, while IgA deposits are predominantly in the mesangial area in the renal pathology.[10],[11],[12]

A recent retrospective study, which included large patient cohort of overlapping MN and IgAN (73 cases) and MN alone (425 cases), has compared the renal pathological features of overlapping IMN and IgAN versus IMN only.[20] Result analysis showed that the renal histopathology of the overlapping MN and IgAN groups not only exhibited significantly increased mesangial cell proliferation and matrix expansion characteristic of the renal histopathology of IgAN but also showed an increase in the inflammatory cell infiltration and higher proportions of arteriolar hyalinosis.[20]

However, there was a lower proportion of segmental sclerosis in the overlapping IMN and IgAN group compared with the MN alone group.[20] The results of previous case series studies proposed that overlapping MN and IgAN appears to correlate with an increased incidence of disease remission and thus may not lead to a poorer prognosis compared with MN only.[9],[13],[14]

The primary means for diagnosing IgAN is renal biopsy.[21] Recently, progress has been made in using M-type PLA2R for diagnosing idiopathic MN.[1],[3],[18],[19],[22] It has been found the majority of patients with IMN to have anti-PLA2R autoantibodies in peripheral circulation, which is rarely detected in secondary MN.[23],[24] Another study has proposed that IFI27 may serve a useful noninvasive biomarker for diagnosing chronic GN using peripheral blood; nevertheless, more data are needed in this regard.[25]

The cases of coexisting MN and IgAN are rare, and they comprise the clinical and pathological features found in both diseases. Serum anti-PLA2R is considered an increasingly important biomarker that can support in the diagnosis of IMN associated with IgAN. We report this rare presentation of IgAN and MN as a rare presentation of concomitant glomerulopathies and to illustrate the usefulness of anti-PLA2R as a disease marker for MN, and the successful strategy of treating both underlying pathological findings that lead to successful clinical remission.


   Acknowledgments Top


We would like to acknowledge Dr. Mark Haas, MD, PhD, for his assistance in providing the biopsy slides for this report.

Conflict of interest: None declared.



 
   References Top

1.
Seitz-Polski B, Dolla G, Payré C, et al. Epitope spreading of autoantibody response to PLA2R associates with poor prognosis in membranous nephropathy. J Am Soc Nephrol 2016;27: 1517-33.  Back to cited text no. 1
    
2.
Hoxha E, Harendza S, Pinnschmidt HO, et al. Spontaneous remission of proteinuria is a frequent event in phospholipase A2 receptor antibody-negative patients with membranous nephropathy. Nephrol Dial Transplant 2015; 30:1862-9.  Back to cited text no. 2
    
3.
Radice A, Trezzi B, Maggiore U, et al. Clinical usefulness of autoantibodies to M-type phospholipase A2 receptor (PLA2R) for monitoring disease activity in idiopathic membranous nephropathy (IMN). Autoimmun Rev 2016;15: 146-54.  Back to cited text no. 3
    
4.
Nair R, Walker PD. Is IgA nephropathy the commonest primary glomerulopathy among young adults in the USA? Kidney Int 2006; 69:1455-8.  Back to cited text no. 4
    
5.
Zhou FD, Zhao MH, Zou WZ, Liu G, Wang H. The changing spectrum of primary glomerular diseases within 15 years: A survey of 3331 patients in a single Chinese centre. Nephrol Dial Transplant 2009;24:870-6.  Back to cited text no. 5
    
6.
Li LS, Liu ZH. Epidemiologic data of renal diseases from a single unit in china: Analysis based on 13,519 renal biopsies. Kidney Int 2004;66:920-3.  Back to cited text no. 6
    
7.
Avner E, Harmon W, Niaudet P, Yoshikawa N, editors. Pediatric Nephrology. Berlin, Heidelberg: Springer Berlin Heidelberg; 2009. Available from: http://www.link.springer.com/ 10.1007/978-3-540-76341-3. [Last accessed on 2017 Dec 20].  Back to cited text no. 7
    
8.
Working Group of the International IgA Nephropathy Network and the Renal Pathology Society, Roberts IS, Cook HT, et al. The oxford classification of IgA nephropathy: Pathology definitions, correlations, and repro-ducibility. Kidney Int 2009;76:546-56.  Back to cited text no. 8
    
9.
Stokes MB, Alpers CE. Combined membranous nephropathy and IgA nephropathy. Am J Kidney Dis 1998;32:649-56.  Back to cited text no. 9
    
10.
Koselj-Kajtna M, Rott T, Koselj M, et al. Recurrent immunoglobulin A nephropathy complicated with de novo membranous glome-rulonephritis in renal allografts. Transplant Proc 2002;34:3117-8.  Back to cited text no. 10
    
11.
Kfoury HK, Alghonaim M, AlSuwaida AK, Zaidi SN, Arafah M. Nasopharyngeal T-cell monomorphic posttransplant lymphoproliferative disorders and combined IgA nephropathy and membranous glomerulonephritis in a patient with renal transplantation: A case report with literature review. Transplant Proc 2010;42: 4653-7.  Back to cited text no. 11
    
12.
Hu R, Xing G, Wu H, Zhang Z. Clinico-pathological features of idiopathic membranous nephropathy combined with IgA nephropathy: A retrospective analysis of 9 cases. Diagn Pathol 2016;11:86.  Back to cited text no. 12
    
13.
Liang S, Le W, Xu F, et al. Concurrent membranous nephropathy and IgA nephropathy: A series of 55 cases. Int J Clin Exp Pathol 2016; 9:7528-36.  Back to cited text no. 13
    
14.
Nishida M, Kato R, Hamaoka K. Coexisting membranous nephropathy and IgA nephropathy. Fetal Pediatr Pathol 2015;34:351-4.  Back to cited text no. 14
    
15.
Miyazaki K, Miyazaki M, Tsurutani H, Sasaki O, Furusu A, Taguchi T, et al. Development of IgA nephropathy 14 years after diagnosis of membranous nephropathy. Nephrol Dial Transplant 2002;17:140-3.  Back to cited text no. 15
    
16.
Guella A, Akhtar M, Ronco P. Idiopathic membranous nephropathy in identical twins. Am J Kidney Dis 1997;29:115-8.  Back to cited text no. 16
    
17.
Jennette JC, Newman WJ, Diaz-Buxo JA. Overlapping IgA and membranous nephropathy. Am J Clin Pathol 1987;88:74-8.  Back to cited text no. 17
    
18.
VanBeek C, Haas M. Anti-PLA2R-associated membranous nephropathy: A review with emphasis on diagnostic testing methods. Clin Nephrol 2015;84:1-9.  Back to cited text no. 18
    
19.
Beck LH Jr., Bonegio RG, Lambeau G, et al. M-type phospholipase A2 receptor as target antigen in idiopathic membranous nephropathy. N Engl J Med 2009;361:11-21.  Back to cited text no. 19
    
20.
Chen X, Chen Y, Shi K, et al. Comparison of prognostic, clinical, and renal histopathological characteristics of overlapping idiopathic membranous nephropathy and IgA nephropathy versus idiopathic membranous nephropathy. Sci Rep 2017;7:11468.  Back to cited text no. 20
    
21.
Wyatt RJ, Julian BA, Bhathena DB, Mitchell BL, Holland NH, Malluche HH. Iga nephropathy: Presentation, clinical course, and prognosis in children and adults. Am J Kidney Dis 1984;4:192-200.  Back to cited text no. 21
    
22.
Debiec H, Guigonis V, Mougenot B, et al. Antenatal membranous glomerulonephritis due to anti-neutral endopeptidase antibodies. N Engl J Med 2002;346:2053-60.  Back to cited text no. 22
    
23.
Kanigicherla D, Gummadova J, McKenzie EA, et al. Anti-PLA2R antibodies measured by ELISA predict long-term outcome in a prevalent population of patients with idiopathic membranous nephropathy. Kidney Int 2013; 83:940-8.  Back to cited text no. 23
    
24.
Beck LH Jr., Salant DJ. Membranous nephropathy: From models to man. J Clin Invest 2014;124:2307-14.  Back to cited text no. 24
    
25.
Nagasawa Y, Okuzaki D, Muso E, et al. IFI27 is a useful genetic marker for diagnosis of immunoglobulin A nephropathy and membranous nephropathy using peripheral blood. PLoS One 2016;11:e0153252.  Back to cited text no. 25
    

Top
Correspondence Address:
Ramy M Hanna
Department of Medicine, Division of Nephrology, David Geffen School of Medicine, Los Angeles, California
USA
Login to access the Email id


DOI: 10.4103/1319-2442.256863

PMID: 31031392

Rights and Permissions


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]



 

Top
   
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
   Introduction
   Case Report
   Discussion
   Acknowledgments
    References
    Article Figures
    Article Tables
 

 Article Access Statistics
    Viewed135    
    Printed0    
    Emailed0    
    PDF Downloaded23    
    Comments [Add]    

Recommend this journal