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      Remission of nephrotic syndrome after surgical intervention for bronchogenic carcinoma: the 10-year follow-up of a patient with membranous nephropathy

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          Abstract

          Nephrotic syndrome (NS) is a pivotal manifestation of glomerular injury associated with various types of neoplasms. It may either precede or act as the presenting feature of the disease, whereas membranous nephropathy (MN) is a major phenotype of paraneoplastic glomerulopathies. However, there is a lack of information regarding the remission from paraneoplastic NS due to MN in patients who achieve favorable long-term survival after the successful removal of malignant tissue. We, herein, describe a case of biopsy-proven MN in a 65-year-old male patient with bronchogenic carcinoma, which was found during the systemic workup for concurrent NS. He was successfully treated with thoracoscopic left lower lobectomy and achieved a complete remission from NS at approximately 10 months after radical surgery. In 10 years of follow-up, there has been no recurrence of the pulmonary cancer and the patient is doing well with no relapse of NS, despite having never received treatment with any type of immunomodulating agent. Several concerns, including diagnostic management and therapeutic strategies for paraneoplastic NS, are discussed.

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          Most cited references27

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          Membranous nephropathy and cancer: Epidemiologic evidence and determinants of high-risk cancer association.

          The association between membranous nephropathy (MN) and cancer is often mentioned in textbooks but poorly substantiated, and the characteristics of cancer-associated MN are unknown. To address these questions, we studied a cohort of 240 patients with MN, among them 24 had malignancy at the time of renal biopsy or within a year thereafter. The incidence of cancer was significantly higher in these patients than in the general population (standardized incidence ratio 9.8 [5.5-16.2] for men and 12.3 [4.5-26.9] for women). The frequency of malignancy increased with age. At the time of diagnosis, clinical presentation did not differ between the patients with cancer-associated MN and those with idiopathic MN, but smoking was more frequent among patients with cancer. Analysis of renal biopsies revealed that the number of inflammatory cells infiltrating the glomeruli was significantly higher in patients with cancer-associated MN (P = 0.001). The best cutoff value for distinguishing malignancy-related cases from controls was eight cells per glomerulus. Using this threshold led to a diagnosis of cancer-associated MN with a specificity of 75% and a sensitivity of 92%. In patients with cancer-associated MN, there was a strong relationship between reduction of proteinuria and clinical remission of cancer (P < 0.001). In conclusion, our study provides epidemiologic evidence of an excess of cancer risk in patients with MN. It also shows that age, smoking, and the presence of glomerular leukocytic infiltrates strongly increase the likelihood of malignancy in MN patients.
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            Paraneoplastic glomerulopathies: new insights into an old entity.

            P Ronco (1999)
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              Distribution of glomerular IgG subclass deposits in malignancy-associated membranous nephropathy.

              Several studies have shown a predominant glomerular deposition of IgG4 in patients with idiopathic membranous nephropathy (MN), whereas significant depositions of other IgG subclasses have been shown in patients with lupus-associated MN and bucillamine-induced MN. We examined the distribution patterns of glomerular IgG subclass deposits in 10 patients with malignancy-associated MN (M-MN) and in 15 patients with idiopathic MN by immunofluorescence (IF) microscopy. The glomerular IF intensities of IgG1 and IgG2 were significantly stronger in the malignancy group than in the idiopathic group (P<0.05). In contrast, there were no differences in glomerular IF intensities of IgG3 and IgG4 between the two groups. Our findings suggest that the distribution patterns of glomerular IgG subclass deposits are different in idiopathic MN and M-MN. The strong IF intensity of glomerular IgG1 and IgG2 in M-MN may provide a possible predictor for this condition.
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                Author and article information

                Journal
                Int Med Case Rep J
                Int Med Case Rep J
                International Medical Case Reports Journal
                International Medical Case Reports Journal
                Dove Medical Press
                1179-142X
                2018
                30 July 2018
                : 11
                : 167-171
                Affiliations
                [1 ]Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Tochigi, Japan, tetsu-a@ 123456jichi.ac.jp
                [2 ]Department of Chronic Kidney Disease Pathophysiology, Jichi Medical University, Shimotsuke, Tochigi, Japan, tetsu-a@ 123456jichi.ac.jp
                [3 ]Department of Pathology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Saitama, Japan
                Author notes
                Correspondence: Tetsu Akimoto, Division of Nephrology, Department of Internal Medicine, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi 329-0498, Japan, Tel +81 285 58 7346, Fax +81 285 44 4869, Email tetsu-a@ 123456jichi.ac.jp
                Article
                imcrj-11-167
                10.2147/IMCRJ.S170267
                6071629
                a0c3d9e3-3318-4372-9cd1-4c2efd03e55d
                © 2018 Nagayama et al. This work is published and licensed by Dove Medical Press Limited

                The full terms of this license are available at https://www.dovepress.com/terms.php and incorporate the Creative Commons Attribution – Non Commercial (unported, v3.0) License ( http://creativecommons.org/licenses/by-nc/3.0/). By accessing the work you hereby accept the Terms. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed.

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                Categories
                Case Report

                nephrotic syndrome,paraneoplastic kidney disease,membranous nephropathy,pulmonary cancer,remission

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