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Dear Editor,
We read the interesting Educational Review article entitled ‘Liver involvement in kidney disease and vice versa’ in which the authors describe numerous pathogenic mechanisms leading to dysfunction or malformations of the liver and kidneys in children [1]. In this context, we would like to bring to your attention the association between chronic liver disease and immunoglobulin A nephropathy (IgAN).
Working at a centre that has a busy Pediatric Hepatology Service, we have had the opportunity to manage a child with autoimmune hepatic disease who presented with hematuria and proteinuria and renal biopsy revealed IgA deposits in the mesangium. The child has now progressed to chronic kidney disease (CKD) stage III.
Immunoglobulin A nephropathy secondary to chronic liver disease is more often reported in adults with liver cirrhosis and portal hypertension. Sinniah reported mesangial deposits of IgA in 36% of adult autopsy cases with liver cirrhosis [2]. However, case reports of a similar illness in children have also been described [3].
Though the pathogenesis is not clearly understood, portosystemic antigen overload and intrinsic abnormalities of the IgA immune system along with impaired hepatic clearance of circulating IgA immune complexes and subsequent deposition in renal glomeruli have been postulated as mechanisms for this form of IgAN.
IgAN associated with chronic liver disease is usually asymptomatic; however, it may manifest as microscopic hematuria and proteinuria. Rarely, patients can present with nephrotic syndrome. Correlation between urine abnormalities and degree of mesangial proliferation has been shown.
In conclusion, though IgAN secondary to chronic liver disease is uncommon in children, it should be considered as a differential diagnosis in the appropriate clinical situation.
References
Hoeve KV, Mekahli D, Morava E, Levtchenko E, Witters P (2018) Liver involvement in kidney disease and vice versa. Pediatr Nephrol 33:957–971
Sinniah R (1983) Occurrence of mesangial IgA and IgM deposits in a control necropsy population. J Clin Pathol 36:276–279
Alghamdi SA, Saadah OI, Almatury N, Al-Maghrabi J (2012) Hepatic-associated immunoglobulin-A nephropathy in a child with liver cirrhosis and portal hypertension. Saudi J Gastroenterol 18:214–216
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Singhal, J., Sharma, J. IgA nephropathy secondary to liver disease. Pediatr Nephrol 33, 2393 (2018). https://doi.org/10.1007/s00467-018-4051-y
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DOI: https://doi.org/10.1007/s00467-018-4051-y