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DISEASEOF THE MONTH

Immunoglobulin A Nephropathy: A Clinical Perspective

JAMES V. DONADIO, JR.* and JOSEPH P. GRANDEt *Dit,isio,t of Nephrology and Internal and t/te tDepartment of Laboraton’ Medicine and , Mayo and Mayo Foundation, Rochester, Minnesota.

First described in 1968 by Berger and Hinglais (1), idiopathic patient selection bias, but also by a conservative approach immunoglobulin A nephropathy (IgAN) is now recognized as taken by nephrologists in our country in recommending renal the most common primary in the world in patients who have only an asymptomatic, abnormal (2,3). Also, we now appreciate as did Berger that renal failure urine sediment. It is common practice for patients presenting can develop in a substantial number of patients with IgAN with isolated or mild not to receive a (initially thought to be a totally benign process) over variable renal tissue diagnosis, the being reserved for those periods of time (4-9). IgAN is an immune complex-mediated people who develop increasing amounts of urine protein or a glomerulonephritis defined morphologically by the constant rising serum concentration, or both. This practice presence of predominant or codominant mesangial deposits of has bearing on comparative outcome studies and recommen- IgA accompanied by a variety of histopathologic lesions (9- dations for treatment to be discussed later.

1 1 ). The etiology is unknown in that no consistent environ- mental or infectious agent has been shown to be antigenic with Clinical Features an IgA antibody response. Since the original description of the IgAN occurs at all ages, with the usual age of clinical onset glomerulopathy, idiopathic IgAN has received the bulk of in the second and third decade of life (2,7,8, 1 1 ). There is a attention in the medical literature, but many diseases have been usual male sex predilection ranging from less than 2: 1 in reported that are sporadically associated with mesangial IgA Japanese patients to as high as 6: 1 in Caucasian patients in deposition (Table 1). Sch#{246}nlein-Henoch purpura, a multisys- northern Europe and the United States. IgAN has a predilection temic disease, is the most common and arguably considered a for whites and Asians and is less common in blacks. part of the spectrum of idiopathic IgAN. The association of IgAN must be highly suspected in any patient in whom there many of the secondary disorders may be coincidental because may be one of two common presentations: (1) episodic, mac- of the high prevalence of IgAN that is usually a long-term and roscopic hematuria, often coincident with an upper respiratory chronic disease. This review offers a perspective on the epi- tract , less often a gastroentenitis; or (2) asymptomatic demiology, clinical features, and diagnosis, pathology, out- with findings on urinalysis of an abnormal urine sediment come, and management of patients with idiopathic IgAN. containing erythrocytes (RBC) and RBC casts and proteinuria in patients in whom the urinalysis was performed as part of an Epidemiology examination for other purposes. Loin pain will accompany Population epidemiologic studies concerning the incidence macroscopic hematuria in approximately one-third of the of IgAN are meager; most reports relate prevalence rates cases. The presenting illness of episodic, grossly visible hema- expressed as a percentage of primary glomerulonephritis or of turia is more common in younger people, whereas that of an a total biopsy series originating in referral-based cohort studies abnormal urine sediment is more frequent in older individuals. (2,7, 1 1). For example, IgAN accounts for 7 to 52% of patients For example, in a recently completed, randomized clinical trial with glomerulonephnitis, which ranges from 4 to 44% of total of fish oil involving 106 proteinuric patients, a history of biopsy series, as reported in a recent comprehensive review by macroscopic hematuria was obtained only in patients under 34 Ibels and Gyory (7). The high-end prevalence rates are found yr old, the median age of the study cohort (12). in Singapore, Japan, Australia, Hong Kong, Finland, and Unfortunately, abnormalities found on urinalysis may be southern Europe, and the lower prevalence rates are reported overlooked or purposely not acted on by further testing until from the United Kingdom, Canada, and the United States, with renal function impairment becomes evident. It is imperative to the exception of Native Americans living in New Mexico (2,7). pursue urine sediment changes when first detected so as not to The low prevalence rate reported from the United States is delay making an accurate diagnosis. By definition, a diagnosis influenced not only by the fact that all published series from of IgAN requires renal biopsy, including immunofluorescence the United States are from referral centers in which there is a microscopy. This again raises the controversial issue among nephrolo- gists of performing a renal biopsy under the circumstances of Correspondence to Dr. James V. Donadio. Jr., Division of Nephrology, , 200 First Street, SW, Rochester. MN 55905. the above-cited presentations without renal function impair- ment or nephrotic-range proteinuria because of the perception l()46-6673/0808- I 324$03.00/0 Journal of the American Society of Nephrology that specific treatment is not available. The approach of pro- Copyright 0 1997 by the American Society of Nephrology spectively evaluating an asymptomatic patient was an accept- IgA Nephropathy I 325

Table 1. Classification of diseases associated with casts and dysmorphic RBC accompanying either macroscopic predominant mesangial IgA deposition or microscopic hematuria clearly indicate to the clinician that bleeding in the urinary tract is glomerular in origin, and this Idiopathic IgA nephropathy (Berger disease) should spare the patient from having to undergo urologic Secondary procedures such as cystoscopy and retrograde pyelography. Sch#{246}nlein-Henoch purpura-most common; a distinct Qualitative proteinuria can be assessed further by measuring entity or a multisystemic extension of IgA nephropathy 24-h total urine protein or by semiquantitative protein/osmo- Diseases of the lality or protein/creatinine ratios on first morning, voided urine liver: alcoholic, cryptogenic and primary biliary samples (16). Also, adults over 50 yr old who are first discov- cirrhosis; (endemic areas); chronic ered to have proteinuria in the nephrotic range (protein excre- schistosomiasis tion of 3.5 g or more per 24 h) should be screened for Bence intestine: celiac disease; chronic ulcerative colitis; Jones proteinuria by the sulfosalicylic precipitation method and Crohn’s disease examination by immunofixation electrophoresis to detect skin: dermatitis herpetiformis; psoriasis monoclonal light chains and immunoglobulins even in very bronchus/lung : idiopathic pulmonary hemosiderosis; low concentrations. cystic fibrosis, sarcoidosis The presence of an abnormal urine sediment and proteinuria Neoplasia: carcinoma of lung, larynx, and pancreas; require measurement of renal function, preferably by a clear- mycosis fungoides; IgA monoclonal gammopathy ance technique, to estimate GFR. Serial measurement of renal Infection: human immunodeficiency virus; leprosy; function is essential in the long-term follow-up of patients with toxoplasmosis IgAN. Other systemic/immunologic disorders: systemic lupus A small group of patients with IgAN will present with severe erythematosus; cryoglobulinemia; rheumatoid arthritis; , some even requiring , obviously representing psoriatic arthritis; ; Sjogren’s the most aggressive form of the disease. The late referral of a syndrome; antineutrophil cytoplasmic antibody- previously undiagnosed patient is also not unusual. associated ; familial immune Likewise, on immunofluorescence there may be the rarely reported, coexistent and IgAN marked by IgA mesangial deposits associated with focal and segmental mesangial expansion and minimal or no cellular proliferation. able practice until recently, in that rational therapeutic inter- There is no consensus about whether this clinicopathologic ventions can now be offered to patients who are at risk for combination represents a variant of one or other of the two developing progressive renal disease based on recently re- conditions, or of two different coexisting disorders. Prompt ported treatment studies (12-15). remission of the nephrotic syndrome after steroid treatment, or It is the rule for microscopic hematuria and proteinuria to spontaneously, suggests the phenotypic expression of minimal persist in variable amounts throughout the course of the dis- change disease (17). ease, even in those patients whose presenting illness is mac- There are other laboratory variables, including elevated se- roscopic hematuria. Complete and prolonged remission of all rum IgA levels, C3 fragments, IgA-fibronectin aggregates, and clinical signs is uncommon (approximately 4%). To illustrate the presence of circulating IgA-containing immune complexes, the importance of direct urine sediment examination, Ibels and which are found in patients with IgAN, but none can replace Gyory (7) showed a positive correlation between the quantity the renal biopsy for the firm establishment of a diagnosis (1 1). of RBC per milliliter of urine and the number of hyaline casts and progressive renal disease in a cohort of 121 Australian Pathology patients with IgAN. The typical light microscopic, immunofluorescence, and electron microscopic alterations observed in IgAN are illus-

Diagnosis trated in Figure 1 . The most common light microscopic lesion Having determined that a patient has a clinical renal presen- associated with IgAN is focal or diffuse mesangial hypercel- tatioh fitting the above descriptions, a definitive diagnosis of lularity, with expansion of the extracellular matrix. This non- IgAN can be made only by renal biopsy. The first clue in specific finding can be observed in a number of other glomer- making a proper diagnosis is by careful urinalysis performed ular disorders, including focal-segmental , on a first morning, freshly voided urine sample. In addition to , and other glomerular lesion-associated physicochemical testing for proteinuria, direct examination of systemic diseases. In addition, patients with IgAN may present the urine sediment, using unstained, bright-field microscopy, is with a wide variety of light microscopic glomerular lesions, required to identify RBC, leukocytes, and casts, and, in par- including segmental necrotizing lesions with crescent forma- ticular, RBC casts, all indicative of glomerular injury. Glomer- tion, segmental or global sclerosing lesions with hyalinosis, ular injury can also be suspected by finding dysmorphic or membranoproliferative lesions, or diffuse proliferative lesions. glomerular RBC, using an automatic microscopic technique Because the light microscopic features of IgAN are variable along the lines of a Coulter counter that distributes cells to be and nonspecific, immunofluorescence or immunoperoxidase examined according to size. The findings of renal (urinary) studies demonstrating a predominant or codominant deposition I 326 Journal of the American Society of Nephrology

Figure 1. Characteristic morphologic alterations in immunoglobulin A nephropathy (IgAN). (A) Light microscopy demonstrating mild ex- pansion of mesangial regions. both with cells and matrix (periodic acid-Schiff stain). Original magnification. X200. (B) Immunofluones- cence microscopy demonstrating brightly staining deposits of IgA. predominantly within mesangial regions. Original magnification. X200. (C) Electron micrograph demonstrating electron-dense depos- its within the mesangial region. The peripheral capillary loop base- ment membranes (right) are normal. Original magnification, X7l25. IgA Nephropathy 1327

Table 2. Renal survival in large cohorts of patients with IgAN relates to prevalence of renal progression risk factors at the time of renal biopsy’

Patients with Indicated Risk Factor (%) Renal Increased . Geographic Area n Survivalb Serum . Proteinuna (%) Creatinine (>3 g/24 h) Concentration

TUbingen, Germany (21) 239 81 34 19 NA Saint-Etienne, France (22) 282 94C 2 9 3 United Kingdom (23) 220 83 28 26 32 Fukuoka, Japan (24) 225 74 36 22 16 New South Wales, Australia (7) 121 86 36 31 16 Upper Midwestern U.S. (9) 148 67 59 47 30

a IgAN, immunoglobulin A nephropathy; NA, not available; U.S., United States. 1 10 yr after renal biopsy.

C After clinical onset of disease.

of IgA are essential in establishing a diagnosis of IgAN. The stitial fibrosis, tubular atrophy, interstitial , and deposits are predominantly within mesangial regions with focal both glomerular and interstitial proliferative activity as as- paramesangial/subendothelial extension. Other immune reac- sessed by Mib- 1 immunostaining, the total glomerular score tants frequently codistnibute with IgA, including IgG, 1gM, C3, was the only pathologic marker that provided independent lambda light chain, and kappa light chain ( 1 ,1 8). The findings information regarding outcome in a multivariate analysis (9). by electron microscopy parallel those observed by light mi- Although generally accepted that tubulointerstitial changes are croscopy and immunofluorescence studies and include mesan- major determinants in the progression of renal damage. the gial hypercellularity and an increase in mesangial matrix, with primacy of this relationship in patients with IgAN has been deposition of electron-dense deposits within mesangial areas. questioned. In a series of 39 patients with serial renal A number of tubulointerstitial and vascular changes may be reported by Bennett et al. (25), the change in creatinine clear- seen in patients with IgAN, including interstitial fibrosis, tu- ance rates between the initial and final biopsies did not corre- bular atrophy, interstitial cellular infiltrates, RBC or protein late with the change in interstitial volume (an index of inter- casts, or vascular sclerosis. Identification of these alterations stitial fibrosis). This finding raises the possibility that, at least may provide important prognostic information in patients with in IgAN, interstitial changes may be secondary to the glomer- IgAN. ular alterations. In addition, although we found that total gb- merular score was the best independent histopathologic pre- Outcome dictor of adverse outcome, mesangial hypercellularity did not IgAN is characterized by a highly variable clinical course, correlate with renal failure in either the univariate or the ranging from a totally benign condition and well-maintained multivariate models. renal function for decades to rapidly progressive renal failure. In our recent analysis, overall patient survival was 97 ± 1% Many patients have a chronic, slowly progressive decline in (estimate ± SEM) at 5 yr and 89 ± 4% at 10 yr (9). Ultimately, renal function over 10 to 20 yr (2-9). The wide variability in 39 of 148 patients developed end-stage renal failure, the pri- clinical course has been addressed in a number of reviews from mary end-point of our study. with survival free of renal failure around the world on the clinical, laboratory, and histologic estimated to be 79 ± 4% at 5 yr and 67 ± 5% at 10 yr. The characteristics that predict development of renal failure in overall 10-yr renal survival of 67% in our study group was IgAN (2,4-9, 19-24). Clinical and laboratory features found to below the percentage survivals reported in five recent large be independently associated with progressive renal disease cohort studies from Europe. Australia, and Japan (Table 2). In include the presence of hypertension, the degree of proteinuria, comparing the three most consistent risks for progression (i.e., decreased renal function, and persistent microscopic hematu- hypertension, elevated serum creatinine concentration, and in- na. Histologic features identified as independent predictors of creased protein excretion, as reported in these large cohort renal failure were glomerulosclerosis, interstitial fibrosis, and studies), the percentage of all three risks in our study group mesangial hypercellulanity. (Upper Midwestern United States) was much greater than that We recently reported the largest study of the clinical course observed in the other populations. Many of our patients carried of patients with IgAN in North America and the first in I 3 yr all of these risks, emphasizing that, in general, more advanced (9). We identified a number of the previously reported clinical cases are seen in referral renal centers in the United States and and histopathologic features associated with progressive dis- patients are coming to renal biopsy late in their disease course. ease. Although a large number of histopathologic features were Recent studies have shown that the angiotensin-converting univariately associated with adverse outcome, including inter- enzyme (ACE)IDD genotype was associated with an increased 1328 Journal of the American Society of Nephrology

Table 3. Nonrandomized controlled long-term studies of corticosteroid treatment of proteinuric patients with IgAN

No. of Patients Effect of t reatment on Group Steroid-Treated Control Renal Proteinunia Subjects Subjects Function

Children and adolescents (13) 13 l5 Stabilized 0

Adults (1 4) 20 26b Stabilized 0

a Historically derived from other centers.

h Allocated to treatment according to the order of the renal biopsy, and all were given dipyridamole 300 mg/d.

rate of progressive renal disease in Caucasian (26,27) and renal function more than in nonsteroid-treated patients in Japanese (28) cohorts of patients with IgAN. Furthermore, in whom initial renal function was normal or only mildly im- the Japanese patients 1 yr after ACE inhibitor , urinary paired (Table 3). The duration of steroid treatment was long protein excretion significantly decreased in those with the DD term ( I yr and longer), and there were few serious adverse side genotype but not in other patients with ACE/ID or ACE/I! effects reported either in the child or adult study groups genotypes (28). These findings suggest that the ACE/DD ge- (13,14). However, results from three recently published control notype may be a marker for an upregulated renin-angiotensin trials of steroids have shown no benefit (3 1-33). Each of these system, resulting in hemodynamic- and growth factor-related trials included small numbers of patients who were followed microvascular injury that is thought to play an important role in for 12 mo or less. progressive IgAN. In addition, interference with the renin- The efficacy of dietary fish oil has been tested in patients angiotensin system may improve renal function in patients who with IgAN in four randomized studies with varying results possess the ACEIDD polymorphism (26-28). (12,34-36). The rationale for using fish oil in IgAN is based on In summary, from these outcome studies it has been shown the premise that n-3 polyunsaturated fatty acids alter the pro- that a composite of clinicopathobogic determinants at the time duction or action of cytokines and eicosanoids evoked by the of diagnosis can be used to profile a patient with IgAN who is initial or by repeated immunological renal injury, thereby placed at an increased risk for developing progressive renal influencing mediators involved in ongoing renal damage (37). disease. Therapeutic strategies can now be offered to patients In the four published randomized clinical trials, two studies who carry this high-risk profile. showed that fish oil stabilized renal function and two trials reported a decline in renal function (Table 4). The largest study Treatment of 106 patients in a double-blind, placebo-controlled trial con- Until recently, no therapeutic agent has been shown to ducted by our collaborative group provided strong evidence of favorably influence renal function in spite of multiple inter- protection from 2 yr of treatment with a daily dose of fish oil ventions reported over the past 17 yr (29). However, in four (12 g/d of a 30% concentrate of eicosapentanoic acid and recently published studies, treatment with corticosteroids docosahexanoic acid) given to patients with persistent protein- ( I 3. 14), fish oil ( 12), and ACE inhibitors (ACEi) ( I 5) slowed uria greater than 1 g/24 h and deteriorating renal function renal progression in patients who had the more common (serum creatinine <3 mg/dl at study entry) (12). In the study chronic, persistently proteinuric form of the disease. In another from Japan, renal function did not deteriorate in 9 patients who uncontrolled study, treatment with high-dose immunoglobulins were treated with fish oil for 1 yr but did decline in 1 1 who was shown to stabilize renal function in 1 1 adults with severe were untreated (34). The study from Sweden might have failed IgAN (30). to show a benefit because of the short, 6-mo follow-up period; The use of alternate-day in children (1 3) and the changes in renal function were small but statistically sig- daily prednisolone in adults (14) has been shown to stabilize nificant, yet of little clinical significance (35). In the Australian

Table 4. Controlled clinical trials of fish oil treatment of IgAN

Trial Effect of Group Treatment Treatment on No. of EPAIDHA Duration Renal Function Patients (g/d) (yr)

Japanese (34) 20 1.6/1.0 1 Stabilized Australian (36) 37 1.8/1.2 2 Declined Swedish (35) 32 3.3/1.8 0.5 Declined U.S. American (12) 106 1.8/1.2 2 Stabilized

a EPA, eicosapentanoic acid; DHA, docosahexanoic acid. IgA Nephropathy I 329

trial, the failure to show any benefit from fish oil in a study sive renal disease and suggesting a more effective therapy than design similar to ours included only 37 patients and did not that provided by ACE1 inhibitors. mention the number of hypertensive subjects or how they were However, with the discrepancy of results in the four clinical managed (36). Hypertension is an important risk associated trials testing fish oil and in an effort to resolve the issue of with progressive renal failure. which is the better treatment for patients at risk of developing In a retrospective study from the Toronto Glomerulonephri- progressive renal disease-corticosteroids or n-3 fatty acids- tis Registry, Cattran and associates reported that treatment with two randomized clinical trials are currently under way in the ACE1 attenuated the decline in GFR based on a comparison of United States (39; and Donadio JV Jr. Bergstralh EJ, Offord treatment of one group of hypertensive patients with ACE1 KP, Spencer DC, Grande JP, for the Mayo Nephrology Col- drugs, another group treated with antihypertensive agents other laborative Group: A prospective comparative study of two than ACE1, and a third group of untreated normotensive pa- doses of OmacorTM in the treatment of patients with IgA tients (15). There were similar but lower rates of decline in nephropathy, in progress). The first trial tests the hypothesis creatinine clearance between ACE1-treated hypertensive and that alternate-day prednisone or daily fish oil will retard the normotensive individuals compared with the hypertensive pa- decline in renal function in children and young adults with tients treated with other agents, suggesting a renal protective moderate IgAN (39). The study design is a randomized, pla- effect from the ACE1 in hypertensive patients with IgAN. Yet cebo-controlled multicenter trial conducted by the North the observed annual decline in estimated GFR in the ACE1- American IgA Nephropathy Study Group comprised of both treated patients was similar not only to the normotensive Ca- pediatric and nephrologists. The second trial nadian group, but also to the high-risk patients reported from tests the hypothesis that an increased amount of n-3 fatty acids Sweden (38) and the placebo-treated group in our fish oil trial will influence clearly progressive IgAN (Donadio et al., study (12) in whom serial estimates of GFR were determined (Table in progress). The design is an open-label, comparative dose study 5). Moreover, decreases in GFR found in the ACE1-treated using a highly concentrated form of n-3 polyunsaturated fatty hypertensive and normotensive Canadian patients, the high- acids (Omacor’) and is being conducted by our collaborative risk Swedish patients, and the placebo-treated patients were group. In both of these trials, the ACEi enalapril is being used to significantly greater than the fish oil-treated group, providing treat hypertensive patients. Both of these prospective studies in- further evidence for the efficacy of fish oil in slowing progres- volve 2 yr of treatment, and because patients were entered in the study in late 1995, results are not yet available. It is evident, of course, that not every patient who was Table 5. Annualized changes in estimated GFR in different treated with any of these regimens-corticosteroids, fish oil, or ACE1- had a stabilization of renal function. There was relent- patient groups with IgANa less progressive loss of renal function in a subset of patients in . No. of GFR Change” Patient Group these study cohorts for which there seems to be no effective Patients (mb/mm per yr) treatment. Hence, our rudimentary understanding of progres- sive renal disease is the reason for a lack of effective Stockholm, Sweden (38) to curtail this disease in all patients. all patients 153 - 1.4 males 106 -2.5 advanced histology 48 -3.4 Renal Transplantation proteinuria Because IgAN is more common in young adults, those who >1 g/24h 72 -3.6 develop renal failure are generally in good health, except for >3.5 g/24 h 1 1 -8.8 renal failure, and at an ideal age for renal transplantation. In a hypertension 68 -4.0 review of renal transplantation at the Mayo Clinic from 1963 to 1988, Frohnert and Stenoff reported that IgAN accounted for Toronto Glomerulonephritis Registry (15) 10% of renal transplants done in patients with primary glomer- normotensive 33 -6.0 ulonephritis (41). hypertensive After renal transplantation, IgAN has been shown to recur in ACEi-treated’ 27 -8.4>

(9) (6) (2) 1 00 - ------------

90- I Lb - 80 ( 11) - - - - .

% ---- -- -- lI (9) (7) (2) > 70 -

No. at time 0 C,, 60-

. m CAD 12

LRD-0 3

--- LAD-I 29 ‘I, --- LRD-2 9 I I I I I I 0 2 4 6 8 10 Years

Figure 2. Actuarial renal allograft survival according to donor source. There was 5-yr graft survival of 100% in HLA-2 haplotype- matched living related donor (LRD)-2, 88% in HLA-l haplotype-matched LRD-l, and 74% in cadavenic donor (CAD) kidneys. All three

HLA-mismatched (LRD-0) kidneys were functioning for up to I .6 yr (longest follow-up) (,t = number of recipients at risk at a given time). Reprinted with permission from Frohnert PP. Donadio IV In, Vebosa IA, Holley KE, Sterioff 5: The fate of renal transplants in patients with IgAN. C/in Transplant 1997, in press.

Table 6. Recurrence of IgAN in renal albografts according to based on statistically nonsignificant data (50,5 1) and then reap- graft source in several patien t group? peared in a nephrology text as an unreferenced opinion (52). If the number of shared HLA antigens between donor and recipient Graft Source should increase the risk of IgAN recurrence, then HLA-identical Study Group and No. of CAD LRD-1 LRD-2 kidneys should suffer the highest rate. All studies with sufficient Year Transplants (Recurrence/Total data to determine rates of recurrence in LRD- 1 and in LRD-2 Transplants) grafts (2.5) are listed with our own results in Table 6. A total of 75 transplants were available for analysis, representing 23 CAD France, 1975 (42) 12 1/4 1/1 5/7 grafts, 34 LRD-1 kidneys, and 18 LRD-2 kidneys. There was no San Francisco, CA, 13 1/7 4/4 1/2 statistical difference in the incidence of IgAN between these 1986 (50) patient categories. Thus, LRD transplantation should not be dis- Rochester, MN, 50b 4/1 2 9/29 1/9 couraged for fear of disease recurrence. In addition to a recurrence 1994 (48, 49) rate of 26% in our patients. there was a 7 1% incidence of declin- Total 75 6/23 14/34 7/18 ing glomerular filtration in 14 grafts with recurrent IgAN, which

x2 = 1.43 (NS) far exceeds that seen in patients without recurrence (14%) (49). The interval of 2 yr between transplantation and development of a CAD, cadaver; LRD-l, one haplotype HLA-matched kidney; recurrence of IgAN and 3 yr to significant loss of albograft LRD-2. two haplotype HLA-matched kidney.

h There were three additional patients transplanted with HLA- function coincides with the Australian study (45). Finally, in our mismatched LRD kidneys. and none had a recurrence after a series, there was no relationship between the aggressiveness of the maximum follow-up of I .6 yr. primary disease and the rate of IgAN recurrence, which supports a previous observation by Berger et al. (42). of recurrent disease (45). In our experience with 53 renal It appears that D’Amico’s observation concerning primary transplants given to 51 patients (41 men, 10 women) with IgAN that the most frequent clinical course is an indolent, biopsy-proven IgAN, there was excellent graft survival (Figure 2). slowly progressing chronic disease (2) also applies to recurrent However, IgAN recurred in 14 (26%) allografts with equal fre- IgAN in the renal albograft. quency in cadaveric donor (CAD) and living related donor (LRD) grafts (48,49). Our experience with an equal frequency of IgAN References recurrence in CAD kidneys and in the different LRD groups does 1. Bergen I. Hinglais N: Les D#{233}p#{244}tsintracapillaires d’IgA-IgG. not support warnings against the use of LRD kidneys, which were J Urol 73: 694-695, 1968 IgA Nephropathy 1331

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