Glomerulonephritis Associated with Liver Disease

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Postgraduate Course 2011: The Liver and Other Organs

Glomerulonephritis associated with liver disease

경희대학교 의과대학 신장내과

임 천 규

Chun Gyoo Ihm

Department of Nephrology, Kyung Hee University School of Medicine, Seoul, Korea

Hepatitis B-associated glomerulonephritis

Membranous nephropathy (most) Membranoproliferative glomerulonephritis (type 1) Polyarteritis nodosa

Pathogenesis: immune complex-mediated HB antigen-antibody complexes, HBsAg, HBcAg, and HBeAg (membranous nephropathy) have all been demon- strated in glomerular lesions. HBV DNA and RNA have been localized to glomerular and tubular cells.

Clinical Features: Some affected patients have a history of active hepatitis. Liver biopsies: chronic active hepatitis. Many are asymptomatic; no or mild elevations in serum aminotransferases. Most patients present with proteinuria or the nephrotic syndrome and normal renal function at time of presentation. Resolution is relatively uncommon in adults

Treatment: Interferon has been used In patients with progressive renal dysfunction. Nucleoside analogs including lamivudine, adefovir, and lobucavir; Lamivudine was shown to reduce proteinuria and lead to a lesser incidence of ESRD. Immunosuppressive therapy may increase viral replication and possibly lead to exacerbation of chronic hepatitis.

83 Postgraduate Course 2011

Hepatitis C-associated glomerulonephritis

Membranoproliferative glomerulonephritis (type 1) with or without associated mixed cryoglobulinemia (most) Membranous glomerulopathy Diffuse proliferative glomerulonephritis, fibrillary GN (rare)

Pathogenesis: immune complex-mediated HCV-specific proteins have been isolated from glomerular lesions.

Clinical Features: Most patients have evidence of liver disease; elevated transaminase levels Essential mixed cryoglobulinemia: HCV (+) ~95% and a systemic vasculitis Hematuria, proteinuria (often nephrotic range), and renal insufficiency. * All patients with mixed cryoglobulinemia and type I MPGN should be evaluated serologically for possible under- lying HCV infection. HCV RNA should also be looked for in the serum and in the cryoprecipitate.

Treatment: α-interferon therapy: Vasculitic symptoms, viral titers, proteinuria, and plasma creatinine improved in 50% to 60% of patients. The disappearance of viremia in response to interferon is associated with a diminution of proteinuria. Cessation of interferon therapy was associated with recurrence of viremia and cryoglobulinemia in a majority of patients. Combination therapy with ribavirin and interferon: better response rates. Cyclophosphamide treatment has been used successfully in HCV-GN. Reports of rituximab-induced remissions of proteinuria in HCV-GN. * KDIGO guidelines suggest that patients with HCV-associated glomerular disease be considered for treatment with antiviral therapy. The suggested regimen depends upon the estimated glomerular filtration rate.

Glomerulonephritis associated with liver cirrhosis

rare Glomerular morphologic abnormalities with IgA deposition: > 50%. increase in mesangial matrix with little proliferation Mesangial proliferative glomerulonephritis with mesangial IgA deposits Membranoproliferative glomerulonephritis

84 임천규 ❚ Glomerulonephritis associated with liver disease

Pathogenesis: defective hepatic clearance of IgA as well as altered processing or portacaval shunting of circulating immune complexes.

Clinically silent disease: proteinuria, or abnormalities of the urine sediment.

Autoimmune Chronic Active Hepatitis

Membranous or membranoproliferative GN, interstitial nephritis.