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- Glomerulonephritis -
5/31/01 re: Immunotherapy in someone with an IgM nephropathy 
I have a patient who suffers from a moderate to severe SAR. She says she was diagnosed several years ago with "Glomerulonephritis, type IgM". She did not bring any report from the nephrologist but stated she is stable regarding her kidney diseases. The nephrologist told her that she should not received any type of medication or "vaccination." She wants to have IT or medications to control her SAR. Is she a candidate for either one?
As you may know, IgM nephropathy is a somewhat ill-defined type of glomerulonephritis characterized by predominant, if not exclusive, deposition of IgM in the glomerulus. Most patients with this diagnosis present with heavy proteinuria, including the nephrotic syndrome (see enclosed abstracts). The prognosis appears to vary among patients. I assume that the nephrologist cautioned the patient against receiving immunizations because of the concern that immune complexes may be formed and then deposit in the glomerulus. However, I know of no evidence that IgM nephropathy is immune complex-mediated and could find no evidence for this in a brief Medline search. There have been a few anectodal reports of renal complications following allergy immunotherapy (I.T.). In the 2 cases described in the enclosed abstract, the I.T. used was of the "rush" type. One report from Colorado many years ago suggested possible immune-complex mediated vasculitis as an occasional complication of I.T. However, a subsequent, more extensive prospective study in the Walter Reed Hospital in Washington could not find evidence of immune complex formation during I.T. therapy using a fairly sensitive technique. Thus, I feel that there is little hazard of immune complex-induced aggravation of the underlying renal disease. Also, since febrile systemic reactions should be rare in carefully administered I.T., cytokine release and subsequent non-specific aggravation of the renal disease is unlikely.
I cannot comment about the nephrologist's caution against "medication" without knowing which medications he/she had in mind. I suggest that you discuss these issues directly with the nephrologist.
Nephron 1996;72(1):37-43
Childhood IgM nephropathy: comparison with minimal change disease.
Al-Eisa A, Carter JE, Lirenman DS, Magil AB.
Department of Pediatrics, University of British Columbia, Vancouver, Canada.The distinctiveness of IgM nephropathy (IgMN) as a clinicopathologic entity is controversial. Twenty-seven children (16 males, 11 females) with IgMN as defined immunohistochemically by diffuse mesangial staining of glomeruli for IgM were compared to a group of 63 children (40 males, 23 females) with minimal change disease (MCD). While mesangial expansion was significantly greater in IgMN than in MCD (p = 0.0014), there were no significant differences between the two groups with respect to the other biopsy factors. IgMN showed a significantly higher incidence of hypertension at presentation. More than 90% of patients in both groups presented with the nephrotic syndrome which in most initially responded to prednisone. Frequently relapsing/steroid-dependent nephrotic syndrome was the most common indication for biopsy in both groups. Approximately 60% of patients from both groups received cytotoxic therapy. Eight percent of IgMN and 7% of MCD patients failed to respond to therapy. Relapse rates and mean dose of prednisone at relapse were very similar in both groups prior to biopsy. Relapse rates diminished significantly after treatment in the postbiopsy interval, but mean dose of prednisone at relapse did not change appreciably over time. None of the patients developed renal failure or hypertension in the follow-up period. At last visit 23% of IgMN and 27% of MCD had proteinuria. The results indicate that IgMN and MCD are indistinguishable clinically in children who are biopsied for the nephrotic syndrome.
Am J Nephrol 1989;9(2):124-8
Clinical follow-up of 54 patients with IgM-nephropathy.
Saha H, Mustonen J, Pasternack A, Helin H.
Department of Clinical Sciences, University of Tampere, Finland.The clinical course of mesangial glomerulopathy with IgM deposits (IgM-nephropathy) was studied in 54 patients. The initial manifestations of the disease were nephrotic syndrome in 18, proteinuria in 21, proteinuria together with hematuria in 4 and isolated hematuria in 11 patients. The nephrotic syndrome was steroid-responsive in 60% of cases and of these 80% were steroid-dependent. During a 5-year postbiopsy follow-up 3 patients went into terminal uremia and in 6 more patients a milder renal insufficiency was observed. Three patients were rebiopsied and in 2 of these the second biopsy specimen disclosed typical focal and segmental glomerulosclerosis. Hematuria was a favorable sign, as no patient with hematuria showed progressive impairment of renal function. The prevalence of hypertension in the whole material was 37%. At close of follow-up 35% of all patients were in clinical remission. It is suggested that IgM-nephropathy associated with abundant proteinuria or the nephrotic syndrome represents a distinct disorder from that associated with hematuria. While the nephrotic type often manifested itself with a morphologic change and a tendency to develop renal insufficiency, the hematuric type showed female predominance, a high tendency to spontaneous clinical remission and a favorable clinical course.
Allerg Immunol (Paris) 1986 Apr;18(4):17-9
[Renal complications due to desensitization].
Drouet M, Sabbah A, Bonneau JC, Le Sellin J.
Laboratorie d'Immuno-Allergologie, C.H.U. Angers, France.Two observations with induction of renal complications during immunotherapy are reported. For the first patient proteinuria and infections complications happened immediately after a rush immunotherapy with Yellow Jacket Venom Extract. For the second patient an "half-rush" immunotherapy with light doses of phleole extract (cumulative dose: 7 PNU) induced an immediate reaction with rhinitis, conjunctivitis and after 24 hours a macroscopic hematuria.
