LAUSR

Immunoglobulin A nephropathy (IgAN) is a major cause of primary glomerulonephritis worldwide. The beneficial effects of corticosteroid therapy (CT) for IgAN were first described by Kobayashi et al. [1], and Pozzi et al. reported steroid pulse therapy (SP) as an effective treatment regimen [2]. Furthermore, Hotta et al. introduced tonsillectomy combined with SP therapy (TSP) [3], and many clinical trials have subsequently analyzed its benefits, especially in Japan [4]. In 2016, Okabayashi et al. reported that CT, including SP, can reduce proteinuria without adverse events even in elderly IgAN patients, which may improve renal outcomes [5]. In that report, IgAN patients ≥ 60 years at the diagnosis were retrospectively analyzed, and urinary protein (UP) levels 1 year after the diagnosis were identified as an independent predictor of subsequent renal function loss. However, no patients who underwent tonsillectomy were included. To our knowledge, the effects of TSP for elderly IgAN patients have not yet been reported in the English literature. The oldest age to perform tonsillectomy for IgAN patients is thus unclear. From April 1, 2014, to November 30, 2020, we experienced 19 elderly IgAN patients in our single hospital who were diagnosed at ≥ 60 years old using a renal biopsy. For all of them, we presented all treatment options and performed the treatment they wanted. As a result, 14 patients underwent TSP, 2 patients CT (1 patient SP), 1 patient tonsillectomy, whereas 2 patients wanted neither tonsillectomy nor CT. We evaluated 12 patients who underwent TSP except 2 patients who were followed for less than 1 year after the diagnosis. The characteristics at the diagnosis were as follows (mean value): age 66 (range 61–73) years; UP 2.73 (range 0.51–7.75) g/gCre; serum creatinine (sCr), 1.06 (range 0.54–1.63) mg/dL; and estimated glomerular filtration rate (eGFR), 53 (range 34–86) mL/ min/1.73 m2. Hematuria grades according to the number of red blood cells per high-power field in urinary sediment as 0 if 0–4, 1 if 5–9, 2 if 10–30, 3 if 30–50, and 4 if ≥ 50 were 0, 1, 2, 3, and 4 in zero, two, five, one, and four cases, respectively. There were six males. Histological grades were I, II, III, and IV (version 3 of the guidelines of the Special Society Group [IgAN] on Progressive Glomerular Disease in Japan) in seven, two, two, and one case, respectively. The MEST-C scores (Oxford Classification of IgAN in 2016) were M1, E1, S1, T1, T2, C1, and C2 in two, two, seven, five, one, two, and one case, respectively. In addition, the mean ratio of global glomerulosclerosis in all glomeruli was 18.2 (range 0–66.7) %. All patients received a modified version of the protocol proposed by Pozzi et al. (intravenous methylprednisolone 0.5 g/day for 3 consecutive days at the beginning of months 1, 3, and 5 plus oral prednisolone 0.5 mg/kg on alternate days for 6 months). Ten patients were being treated for hypertension, and all 12 patients were receiving angiotensin II receptor blockers. The mean follow-up duration was 43 (range 13–73) months. At 1 year after the diagnosis, the mean UP, sCr, and eGFR levels were 0.35 (range 0.05–1.86) g/gCre, 0.93 (range 0.52–1.36) mg/dL, and 58 (range 40–90) mL/ min/1.73 m2, respectively. Hematuria grade was 0 in all patients. The UP and hematuria levels were significantly decreased, while the eGFR was significantly increased between the diagnosis and 1 year later (Fig. 1). At the * Tsuyoshi Takashima [email protected]