Nefropatía por IgA. Revisión y conducta terapéutica a propósito de un caso clínico

  • Bruno Lococo Servicio de Nefrología, Hospital General de Agudos Dr. Juan A. Fernández, Buenos Aires
  • Valeria Alberton Servicio de Anatomía Patológica, Hospital General de Agudos Dr. Juan A. Fernández, Buenos Aires
  • Bernarda Fazzini Servicio de Nefrología, Hospital General de Agudos Dr. Juan A. Fernández, Buenos Aires
  • Alejandra Smuclir Quevedo Servicio de Nefrología, Hospital General de Agudos Dr. Juan A. Fernández, Buenos Aires
  • Diego Morales Servicio de Nefrología, Hospital General de Agudos Dr. Juan A. Fernández, Buenos Aires
  • Ana Malvar Servicio de Nefrología, Hospital General de Agudos Dr. Juan A. Fernández, Buenos Aires

Resumen

La Nefropatía por Inmunoglobulina A (NIgA), también conocida como enfermedad de Berger, fue descrita por primera vez en 1968 por Berger e Hinglais. Se trata de una enfermedad heterogénea, tanto desde el punto de vista clínico, como histológico, caracterizada por la presencia de depósitos mesangiales de IgA. La clínica de presentación es extremadamente variable, pudiendo manifestarse desde microhematuria aislada hasta un deterioro agudo de la función renal por una glomerulonefritis extracapilar superpuesta. Inicialmente se la consideraba una entidad de buen pronóstico, pero con el paso del tiempo y a partir de un mayor conocimiento de la NIgA, se constató que la realidad era otra y que del 20 al 30% de los pacientes a los 20 años evolucionaban a la insuficiencia renal crónica (IRC) terminal y otro 20% mostraba una pérdida significativa de la función renal. En el presente artículo se describe un caso clínico de un paciente en el que se detectan casualmente marcadores de daño renal en la orina, y en quien los hallazgos histológicos observados en la biopsia renal modificaron su pronóstico y la conducta terapéutica. A partir de este caso clínico se realiza una actualización sobre la Nefropatía por IgA.

Citas

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(3):920-3.

Simon P, Ramee MP, Boulahrouz R, Stanescu C, Charasse C, Ang KS, et al. Epidemiologic data of primary glomerular diseases in western France. Kidney Int. 2004;66(3):905-8.

Crowley-Nowick PA, Julian BA, Wyatt RJ, Galla JH, Wall BM, Warnock DG, et al. IgA nephropathy in blacks: studies of IgA2 allotypes and clinical course. Kidney Int. 1991;39(6):1218-24.

Galla JH. IgA nephropathy. Kidney Int. 1995;47(2):377-87.

Donadio JV, Grande JP. IgA nephropathy. N Engl J Med. 2002;347(10):738-48.

Floege J. The pathogenesis of IgA nephropathy: what is new and how does it change therapeutic approaches? Am J Kidney Dis. 2011;58(6):992-1004.

Glassock RJ. The pathogenesis of IgA nephropathy. Curr Opin Nephrol Hypertens. 2011;20(2):153-60.

Oortwijn BD, Rastaldi MP, Roos A, Mattinzoli D, Daha MR, Van Kooten C. Demonstration of secretory IgA in kidneys of patients with IgA nephropathy. Nephrol Dial Transplant. 2007;22(11):3191-5.

Lee HS, Choi Y, Lee JS, Yu BH, Koh HI. Ultrastructural changes in IgA nephropathy in relation to histologic and clinical data. Kidney Int. 1989;35(3):880-6.

Barratt J, Feehally J, Smith AC. Pathogenesis of IgA nephropathy. Semin Nephrol. 2004;24(3):197-217.

Hiki Y, Odani H, Takahashi M, Yasuda Y, Nishimoto A, Iwase H, et al. Mass spectrometry proves underO-glycosylation of glomerular IgA1 in IgA nephropathy. Kidney Int. 2001;59(3):1077-85.

Allen AC, Bailey EM, Brenchley PE, Buck KS, Barratt J, Feehally J. Mesangial IgA1 in IgA nephropathy exhibits aberrant O-glycosylation: observations in three patients. Kidney Int. 2001;60(3):969-73.

Smith AC, Molyneux K, Feehally J, Barratt J.

O-glycosylation of serum IgA1 antibodies against mucosal and systemic antigens in IgA nephropathy. J Am Soc Nephrol. 2006;17(12):3520-8.

Berthoux F, Suzuki H, Thibaudin L, Yanagawa H, Maillard N, Mariat C, et al. Autoantibodies targeting galactose-deficient IgA1 associate with progression of IgA nephropathy. J Am Soc Nephrol. 2012;23(9):1579-87.

Herzenberg AM, Fogo AB, Reich HN, Troyanov S, Bavbek N, Massat AE, et al. Validation of the Oxford classification of IgA nephropathy. Kidney Int. 2011;80(3):310-7.

Hall CL, Bradley R, Kerr A, Attoti R, Peat D. Clinical value of renal biopsy in patients with asymptomatic microscopic hematuria with and without low-grade proteinuria. Clin Nephrol. 2004;62(4):267-72.

Topham PS, Harper SJ, Furness PN, Harris KP, Walls J, Feehally J. Glomerular disease as a cause of isolated microscopic haematuria. Q J Med. 1994;87(6):329-35.

Colvin RB. Enfermedades renales: diagnóstico, patología. Buenos Aires: Marbán, 2014. 994 p.

De Rosa GE, von Stecher F, Falcón MF, Robaina J, Marini A, Alberton V. Prevalencia y correlación clínico-patológica de lesiones vasculares renales en la nefropatía por IgA. Nefrol Argent. 2012;10(1):9-19.

Working Group of the International IgA Nephropathy Network and the Renal Pathology Society, Cattran DC, Coppo R, Cook HT, Feehally J, Roberts IS, et al. The Oxford classification of IgA nephropathy: rationale, clinicopathological correlations, and classification. Kidney Int. 2009;76(5):534-45.

Working Group of the International IgA Nephropathy Network and the Renal Pathology Society, Roberts IS, Cook HT, Troyanov S, Alpers CE, Amore A, et al. The Oxford classification of IgA nephropathy: pathology definitions, correlations, and reproducibility. Kidney Int. 2009;76(5):546-56.

Working Group of the International IgA Nephropathy Network and the Renal Pathology Society, Coppo R, Troyanov S, Camilla R, Hogg RJ, Cattran DC, et al. The Oxford IgA nephropathy clinicopathological classification is valid for children as well as adults. Kidney Int. 2010;77(10):921-7.

Shi SF, Wang SX, Jiang L, Lv JC, Liu LJ, Chen YQ, et al. Pathologic predictors of renal outcome and therapeutic efficacy in IgA nephropathy: validation of the oxford classification. Clin J Am Soc Nephrol. 2011;6(9):2175-84.

Tanaka S, Ninomiya T, Katafuchi R, Masutani K, Tsuchimoto A, Noguchi H, et al. Development and validation of a prediction rule using the Oxford classification in IgA nephropathy. Clin J Am Soc Nephrol. 2013;8(12):2082-90.

Wakai K, Kawamura T, Endoh M, Kojima M, Tomino Y, Tamakoshi A, et al. A scoring system to predict renal outcome in IgA nephropathy: from a nationwide prospective study. Nephrol Dial Transplant. 2006;21(10):2800-8.

Chacko B, John GT, Neelakantan N, Korula A, Balakrishnan N, Kirubakaran MG, et al. Presentation, prognosis and outcome of IgA nephropathy in Indian adults. Nephrology (Carlton). 2005;10(5):496-503.

Alamartine E, Sabatier JC, Berthoux FC. Comparison of pathological lesions on repeated renal biopsies in 73 patients with primary IgA glomerulonephritis: value of quantitative scoring and approach to final prognosis. Clin Nephrol. 1990;34(2):45-51.

Yoshikawa N, Yoshiara S, Yoshiya K, Matsuo T, Okada S. Lysis of the glomerular basement membrane in children with IgA nephropathy and Henoch-Shönlein nephritis. J Pathol. 1986;150(2):119-26.

Xia YF, Huang S, Li X, Yang N, Huang J, Xue C, et al. A family-based association study of megsin A23167G polymorphism with susceptibility and progression of IgA nephropathy in a Chinese population. Clin Nephrol. 2006;65(3):153-9.

Appel GB, Waldman M. The IgA nephropathy treatment dilemma. Kidney Int. 2006;69(11):1939-44.

D’Amico G. Influence of clinical and histological features on actuarial renal survival in adult patients with idiopathic IgA nephropathy, membranous nephropathy, and membranoproliferative glomerulonephritis: survey of the recent literature. Am J Kidney Dis. 1992;20(4):315-23.

Szeto CC, Lai FM, To KF, Wong TY, Chow KM, Choi PC, et al. The natural history of immunoglobulin a nephropathy among patients with hematuria and minimal proteinuria. Am J Med. 2001;110(6):434-7.

Vivante A, Afek A, Frenkel-Nir Y, Tzur D, Farfel A, Golan E, et al. Persistent asymptomatic isolated microscopic hematuria in Israeli adolescents and young adults and risk for end-stage renal disease. JAMA. 2011;306(7):729-36.

Remuzzi A, Perticucci E, Ruggenenti P, Mosconi L, Limonta M, Remuzzi G. Angiotensin converting enzyme inhibition improves glomerular size-selectivity in IgA nephropathy. Kidney Int. 1991;39(6):1267-73.

Kanno Y, Okada H, Saruta T, Suzuki H. Blood pressure reduction associated with preservation of renal function in hypertensive patients with IgA nephropathy: a 3-year follow-up. Clin Nephrol. 2000;54(5):360-5.

Russo D, Pisani A, Balletta MM, De Nicola L, Savino FA, Andreucci M, et al. Additive antiproteinuric effect of converting enzyme inhibitor and losartan in normotensive patients with IgA nephropathy. Am J Kidney Dis. 1999;33(5):851-6.

Russo D, Minutolo R, Pisani A, Esposito R, Signoriello G, Andreucci M, et al. Coadministration of losartan and enalapril exerts additive antiproteinuric effect in IgA nephropathy. Am J Kidney Dis. 2001;38(1):18-25.

Donadio JV, Grande JP. The role of fish oil/omega-3 fatty acids in the treatment of IgA nephropathy. Semin Nephrol. 2004;24(3):225-43.

Pozzi C, Bolasco PG, Fogazzi GB, Andrulli S, Altieri P, Ponticelli C, et al. Corticosteroids in IgA nephropathy: a randomised controlled trial. Lancet. 1999;353(9156):883-7.

Pozzi C, Andrulli S, Del Vecchio L, Melis P, Fogazzi GB, Altieri P, et al. Corticosteroid effectiveness in IgA nephropathy: long-term results of a randomized, controlled trial. J Am Soc Nephrol. 2004;15(1):157-63.

Manno C, Torres DD, Rossini M, Pesce F, Schena FP. Randomized controlled clinical trial of corticosteroids plus ACE-inhibitors with long-term follow-up in proteinuric IgA nephropathy. Nephrol Dial Transplant. 2009;24(12):3694-701.

Ballardie FW. IgA nephropathy treatment 25 years on: can we halt progression? The evidence base. Nephrol Dial Transplant. 2004;19(5):1041-6.

Ballardie FW, Roberts IS. Controlled prospective trial of prednisolone and cytotoxics in progressive IgA nephropathy. J Am Soc Nephrol. 2002;13(1):142-8.

Pozzi C, Andrulli S, Pani A, Scaini P, Del Vecchio L, Fogazzi G, et al. Addition of azathioprine to corticosteroids does not benefit patients with IgA nephropathy. J Am Soc Nephrol. 2010;21(10):1783-90.

Tumlin JA, Lohavichan V, Hennigar R. Crescentic, proliferative IgA nephropathy: clinical and histological response to methylprednisolone and intravenous cyclophosphamide. Nephrol Dial Transplant. 2003;18(7):1321-9.

Frisch G, Lin J, Rosenstock J, Markowitz G, D’Agati V, Radhakrishnan J, et al. Mycophenolate mofetil (MMF) vs placebo in patients with moderately advanced IgA nephropathy: a double-blind randomized controlled trial. Nephrol Dial Transplant. 2005;20(10):2139-45.

Maes BD, et al Mycophemolate mofetil in IgA nephropathy: results of a 3-year prospective placebo-controlled randomized study. Kidney Int 2004, 65:1842

Lai KN, Lai FM, Li PK, Vallance-Owen J. Cyclosporin treatment of IgA nephropathy: a short term controlled trial. Br Med J (Clin Res Ed). 1987;295(6607):1165- 8.

Kim YC, Chin HJ, Koo HS, Kim S. Tacrolimus decreases albuminuria in patients with IgA nephropathy and normal blood pressure: a double-blind randomized controlled trial of efficacy of tacrolimus on IgA nephropathy. PLoS One. 2013;8(8):e71545.

Abe S. Pregnancy in IgA nephropathy. Kidney Int. 1991;40(6):1098-102.

Abe S. The influence of pregnancy on the longterm renal prognosis of IgA nephropathy. Clin Nephrol. 1994;41(2):61-4.

Choy BY, Chan TM, Lo SK, Lo WK, Lai KN. Renal transplantation in patients with primary immunoglobulin A nephropathy. Nephrol Dial Transplant. 2003;18(11):2399-404.

Chandrakantan A, Ratanapanichkich P, Said M, Barker CV, Julian BA. Recurrent IgA nephropathy after renal transplantation despite immunosuppressive regimens with mycophenolate mofetil. Nephrol Dial Transplant. 2005;20(6):1214-21.

Clayton P, McDonald S, Chadban S. Steroids and recurrent IgA nephropathy after kidney transplantation. Am J Transplant. 2011;11(8):1645-9

Ivanyi B. A primer on recurrent and de novo glomerulonephritis in renal allografts. Nat Clin Pract Nephrol. 2008;4(8):446-57.

Ji S, Liu M, Chen J, Yin L, Sha G, Chen H, et al. The fate of glomerular mesangial IgA deposition in the donated kidney after allograft transplantation. Clin Transplant. 2004;18(5):536-40.

McDonald SP, Russ GR. Recurrence of IgA nephropathy among renal allograft recipients from living donors is greater among those with zero HLA mismatches. Transplantation. 2006;82(6):759-62.

Ponticelli C, Traversi L, Feliciani A, Cesana BM, Banfi G, Tarantino A. Kidney transplantation in patients with IgA mesangial glomerulonephritis. Kidney Int. 2001;60(5):1948-54.

Reid S, Cawthon PM, Craig JC, Samuels JA, Molony DA, Strippoli GF. Non-immunosuppressive treatment for IgA nephropathy. Cochrane Database Syst Rev. 2011;(3):CD003962.

Floege J, Eitner F. Present and future therapy options in IgA-nephropathy. J Nephrol. 2005;18(4):354-61. 61) Locatelli F, Del Vecchio L, Pozzi C. The patient with IgA glomerulonephritis--what is the role of steroid treatment? Nephrol Dial Transplant. 1999;14(5):1057-60.

Lai KN, Lai FM, Ho CP, Chan KW. Corticosteroid therapy in IgA nephropathy with nephrotic syndrome: a long-term controlled trial. Clin Nephrol. 1986;26(4):174-80.

Cheng IK, Chan KW, Chan MK. Mesangial IgA nephropathy with steroid-responsive nephrotic syndrome: disappearance of mesangial IgA deposits following steroid-induced remission. Am J Kidney Dis. 1989;14(5):361-4.

Woo KT, Lee GS, Lau YK, Chiang GS, Lim CH. Effects of triple therapy in IgA nephritis: a follow-up study 5 years later. Clin Nephrol. 1991;36(2):60-6.

Yoshikawa N, Ito H, Sakai T, Takekoshi Y, Honda M, Awazu M, et al. A controlled trial of combined therapy for newly diagnosed severe childhood IgA nephropathy. The Japanese Pediatric IgA Nephropathy Treatment Study Group. J Am Soc Nephrol. 1999;10(1):101-9.

Japanese Pediatric IgA Nephropathy Treatment Study Group, Kamei K, Nakanishi K, Ito S, Saito M, Sako M, et al. Long-term results of a randomized controlled trial in childhood IgA nephropathy. Clin J Am Soc Nephrol. 2011;6(6):1301-7.

Welch TR, McAdams AJ, Berry A. Rapidly progressive IgA nephropathy. Am J Dis Child. 1988;142(7):789-93.

El Karoui K, Hill GS, Karras A, Moulonguet L, Caudwell V, Loupy A, et al. Focal segmental glomerulosclerosis plays a major role in the progression of IgA nephropathy. II. Light microscopic and clinical studies. Kidney Int. 2011;79(6):643-54.

Kunz R, Friedrich C, Wolbers M, Mann JF. Meta-analysis: effect of monotherapy and combination therapy with inhibitors of the renin angiotensin system on proteinuria in renal disease. Ann Intern Med. 2008;148(1):30-48.

Publicado
2016-06-01
Cómo citar
1.
Lococo B, Alberton V, Fazzini B, Smuclir Quevedo A, Morales D, Malvar A. Nefropatía por IgA. Revisión y conducta terapéutica a propósito de un caso clínico. Rev Nefrol Dial Traspl. [Internet]. 1 de junio de 2016 [citado 29 de marzo de 2024];36(2):108-23. Disponible en: http://revistarenal.org.ar/index.php/rndt/article/view/66
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Artículo de Revisión