A case of rapidly progressive IgA nephropathy in a patient with exacerbation of Crohn’s disease

Abstract

BackgroundIgA nephropathy has been reported as a renal involvement in Crohn’s disease. Crescentic IgA nephropathy, which accounts for fewer than 5% of cases of IgA nephropathy, has a poorer prognosis than other forms of crescentic glomerulonephritis. We recently experienced a case of rapidly progressive IgA nephropathy concurrent with exacerbation of Crohn’s disease.Case presentationAn 18-year-old male diagnosed with Crohn’s disease underwent a hemicolectomy 2 years prior previously. He had maintained a state of Crohn’s disease remission with 5-aminosalicylic acid treatment. Four months prior to referral to the nephrology clinic, he experienced non-bloody diarrhea. He simultaneously developed proteinuria and microscopic hematuria with deterioration of renal function. Based on renal biopsy findings, the patient was diagnosed with crescentic IgA nephropathy. Immunostaining for interleukin-17 in renal tissue and previous exacerbated colonic ulcers was positive. Steroid pulse therapy was administered, followed by high-dose glucocorticoid and oral cyclophosphamide therapy. The patient’s renal function recovered and his gastrointestinal symptoms were alleviated.ConclusionsWe report a case of crescentic IgA nephropathy presenting with exacerbation of Crohn’s disease, and present a review of the literature focusing on the pathophysiologic relationship between these two conditions.

Adalimumab-induced IgA nephropathy

“…This is in contrast to case reports of adalimumab-induced IgAN where renal recovery was observed following withdrawal of adalimumab and commencement of an alternate immunosuppressive regimen 8 13 15. This finding would suggest that patients with adalimumab-induced IgAN may be a distinct subset of IgAN and these patients may have a markedly different response to immunosuppression compared with idiopathic IgAN 11 12…”

“…IgAN has been recognised as a rare complication of CD. However, this usually occurs among patients with poorly controlled CD 11 12. Thus, this was felt to be less likely in our patient, who had stable disease since commencing adalimumab.…”

Kidney Manifestations of Inflammatory Bowel Diseases

“…However, IL-17 was absent in renal tissue with primary IgAN. These findings suggest the simultaneous involvement of IL-17 in both worsening intestinal inflammation and enhancing rapidly progressive IgAN development in CD patients [24]. Interestingly, wang J et al have revealed in their experimental studies the etiology behind IgAN in IBD patients, highlighting the critical role of LIGHT, a TNF-α super family member and keystone mediator in the pathogenesis of CD [26] [27].…”

“…Patients with IgAN often develop proteinuria and hematuria with deterioration of renal function. Recent clinical studies have demonstrated that IgAN appears concurrently with the onset or exacerbation of IBD, mainly CD [23] [24]. However, the connection between the impaired mucosal immunity and the progression of IgAN is still unclear.…”

The Histopathologic Spectrum of Kidney Biopsies in Patients with Inflammatory Bowel Disease

“…They described both clinical and pathologic remission of kidney disease concomitant with the treatment of symptoms of intestinal disease. Nineteen subsequent case reports in the literature have described IgAN in IBD (9,22,(24)(25)(26)(27)(28)(29)(30)(31)(32)(33)(34). A majority of these patients had IgAN during onset or exacerbation of IBD, as well as clinical remission of kidney disease in conjunction with successful treatment of bowel inflammation.…”