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  Table of Contents    
LETTER TO EDITOR  
Year : 2012  |  Volume : 55  |  Issue : 1  |  Page : 126-127
Immunoglobulin M nephropathy in adults and adolescents in India: A single center study of natural history


Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan

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Date of Web Publication11-Apr-2012
 

How to cite this article:
Mubarak M. Immunoglobulin M nephropathy in adults and adolescents in India: A single center study of natural history. Indian J Pathol Microbiol 2012;55:126-7

How to cite this URL:
Mubarak M. Immunoglobulin M nephropathy in adults and adolescents in India: A single center study of natural history. Indian J Pathol Microbiol [serial online] 2012 [cited 2019 Dec 7];55:126-7. Available from: http://www.ijpmonline.org/text.asp?2012/55/1/126/94889


Sir,

I have read with interest the article by Singhai et al., [1] published in your journal. It describes the demographic, clinical, laboratory, and morphological features of a fairly common, but still controversial entity of IgM nephropathy (IgMN) in a large cohort of adolescents and adults presenting with steroid dependant/steroid resistant nephrotic syndrome (SDNS/SRNS), or nephrotic-nephritic syndrome. The study is a timely contribution to the recent surge in the number of publications on this subject and indicates that the scientific interest in the entity has not faded. [2],[3],[4],[5] We have also published our experience in the largest ever study on this disease in children including adolescents. [3] Fortunately, many of the clinical and pathological features of our cohort are more or less similar to those reported in the subject study. But, there are some points in the subject study which need clarification for a better understanding of the disease, as described below.

  1. Although, the age group of the 25 excluded cases of IgMN is not given, it seems that they belonged to young children category. In that case, the relatively low prevalence of IgMN in children is difficult to understand. It is also not clear whether all 2928 renal biopsies were done on adults and adolescents or younger children were also included.
  2. There is no information on the indications of renal biopsies in general, and for adolescents and adults, in particular. Obviously, the biopsy indications must have been different in the two age groups. In this context, the presentation of all cases of IgMN with SDNS, SRNS, or nephrotic-nephritic syndrome is inexplicable. The biopsy indications vary a lot, but in most centers, biopsies are done prior to any steroid therapy in adults. Moreover, the definition of SRNS used in the study pertains to children and not to adults.
  3. One wonders if there were some cases of IgMN presenting with asymptomatic urinary abnormalities (AUAs) or non-nephrotic proteinuria. I understand that the study design precluded such cases, but for an accurate epidemiological perspective, it will be interesting to know if there were cases in the authors' center with this presentation. The AUAs, of course, form a minimal fraction of biopsy indications in our part of the world. [3]
  4. The mean values and the ranges of urinary protein leak per 24 h for various morphological patterns do not match with the definition and clinical indications of NS in minimal change or mesangial proliferative pattern. Moreover, the terms of minimal change disease (MCD) and mesangial proliferative glomerulonephritis (MesPGN) are better avoided as these connote specific disease entities; instead, the terms of minor changes and mesangial proliferative pattern should be used.
  5. The careful scrutiny of [Figure 1]a of the article by Singhai et al. [1] shows that both the overall, and particularly, the mesangial cellularity are within normal limits. None of the lobules shows ≥4 mesangial cell nuclei. In addition, hematoxylin and eosin (HandE) stain is not the ideal stain for assessing the degree of mesangial cellularity.
  6. In the IF results, IgM as the sole immunoglobulin (Ig) has been described in 88.7% (n=126) of all 142 cases of IgMN and not just those finally included in the analysis (n=117). The other immune reactants have also been calculated in all 142 cases. The first sentence of IF results which stated that "IgM was the predominant Ig deposited in 50-100% of mesangial regions" implies that segmental positivity of IgM was also included in IgMN category.
  7. There is also some confusion in the study regarding the outcome of disease. This is largely due to the fact that no clear definitions of renal failure, end-stage renal failure (ESRF), remission, and steroid dependence are provided. To quote just one example, in the abstract, it is stated that all FSGS progressed to renal failure in one year, in results, it is stated that three patients reached ESRF, and also that all FSGS patients were enrolled in maintenance dialysis.


 
   References Top

1.Singhai AM, Vanikar AV, Goplani KR, Kanodia KV, Patel RD, Suthar KS, et al. Immunoglobulin M nephropathy in adults and adolescents in India: A single center study of natural history. Indian J Pathol Microbiol 2011;54:3-6.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Mokhtar GA. IgM nephropathy: Clinical features and pathological findings in 36 patients. Saudi J Kidney Dis Transpl 2011;22:969-75.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Mubarak M, Kazi JI, Malik S, Lanewala A, Hashmi S. Clinicopathologic characteristics and steroid response of IgM nephropathy in children presenting with idiopathic nephrotic syndrome. APMIS 2011;119:180-6.  Back to cited text no. 3
    
4.Myllymaki J, Saha H, Mustonen J, Helin H, Pasternack A. IgM nephropathy: Clinical picture and long term prognosis. Am J Kidney Dis 2003;41:343-50.  Back to cited text no. 4
    
5.Hsu HC, Chen WY, Lin GJ, Chen L, Kao SL, Huang CC, et al. Clinical and immunopathologic study of mesangial IgM nephropathy: Report of 41 cases. Histopathology 1984;8:435-46.  Back to cited text no. 5
[PUBMED]    

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Correspondence Address:
Muhammed Mubarak
Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi - 74200
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.94889

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This article has been cited by
1 Immunoglobulin M nephropathy in adults a clinicopathological study
Mubarak, M., Naqvi, R., Kazi, J.I., Shakeel, S.
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2 IgM nephropathy
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