Concurrent IgA Nephropathy and Membranous Nephropathy, Is It an Overlap Syndrome?

Abstract

IgA nephropathy (IgAN) and membranous nephropathy (MN) are common glomerulonephritis, the presence of which in the same patient- concurrent of IgAN and MN (cIgAN/MN) has been described occasionally. This study aims to show clinical-pathological features of cIgAN/MN and attempts to suggest underlying pathogenesis using disease-specific biomarkers and a genomics approach. This retrospective cohort study described the clinical and pathological data from 137 patients with cIgAN/MN diagnosed in Peking University First Hospital from 2005 to 2019. One hundred primary IgAN and 100 MN cases were randomly selected as disease controls between the same time interval. Moreover, disease-specific biomarkers and polygenic risk score models were conducted to reveal the underlying pathogenesis. The median age of the cIgAN/MN cases was 45-year-old, and 46% were women. Compared to IgAN, patients with cIgAN/MN had a higher level of 24-hour proteinuria excretion but lower microscopic hematuria. They had a lower median level of galactose-deficient IgA1 (Gd-IgA1, 4.00 versus 5.45 μg/ml, P=0.002) as well as the standardized genetic risk scores of developing IgAN (GRSs: 0.05 versus 0.68, P<0.001). Compared to MN, patients with cIgAN/MN had a lower proportion of nephrotic syndrome and a lower level of albumin-to-creatinine ratio. However, the 24-hour proteinuria levels, serum lipid profiles, proportion of hypertension, and pathology classification were similar. Patients with cIgAN/MN had lower levels of plasma autoantibodies against the M-type transmembrane phospholipase A2 receptor (PLA2R) (11.23 versus 36.59 U/ml, P=0.005). Intriguingly, there were no statistical differences in standardized GRSs of developing MN between them (2.77 versus 3.02, P=0.326). Compared to IgAN, cIgAN/MN may lean towards MN more according to clinical-pathological features, disease-specific biomarker levels, and disease-specific genetic risk scores.

Keywords: IgA nephropathy; anti-phospholipase A2 receptor; galactose-deficient IgA1; polygenic risk score; primary membranous nephropathy.

Figure 1

Kidney biopsy from a case with concurrent IgAN and MN. PAS, Periodic Acid-Schiff; PASM, periodic acid-silver methenamine; EM, electron microscope.

Figure 2

Flowchart of the recruitment process.

Figure 3

Disease-specific biomarkers detection. The comparison of the level of Gd-IgA1 (A), anti-PLA2R antibodies (B), and the positive rates of anti-PLA2R antibodies (C) among patients with IgAN, cIgAN/MN and MN.

Figure 4

Genetic risk scores of developing IgAN or MN. The genetic risk scores of developing IgAN (A), genetic risk stratification of IgAN (B), and genetic risk scores of developing MN (C). ns, not significant.

Figure 5

(A) The comparison of the time-average proteinuria among patients with IgAN, cIgAN/MN and MN. (B) Proteinuria persisted means patients could not achieve complete or partial proteinuria remission during follow-up, which was were calculated according to the Kaplan-Meier method (log-rank test). ns, not significant.

Figure 6

The symbol “<“ or “>“ indicates that the specific item is lower or higher than the other group, respectively. Moreover, the symbol “⊙” means no statistical difference between the two groups.