Hepatitis C as a potential cause of IgA nephropathy
A 16-year-old boy presented with oliguria and gradually developing anasarca of 5 months duration. He did not have any symptoms to suggest a connective tissue disorder. He gave no history of frank hematuria or febrile illness prior to the onset of renal symptoms. He denied any history of prior blood transfusions or drug intake. On physical examination, he appeared relatively well with blood pressure (BP) 130/90 mm Hg and dependent pitting edema. Systemic examination was unremarkable.\nLaboratory findings included hemoglobin of 12.7 g/dl and white blood cell (WBC) count of 4700 with normal differential. Peripheral smear showed normocytic, normochromic anemia. Serum creatinine and blood urea were 0.66 and 15 mg/dl, respectively. Serum triglyceride level was 234 mg/dl and cholesterol level was 330 mg/dl. Serum sodium and potassium were 145 and 4.33 mmol/l, respectively. His liver function test revealed a bilirubin of 0.13 mg/dl, AST of 43 mg/dl, ALT of 61 mg/dl, ALP of 150 mg/dl, with a total protein of 3.7 mg/dl and albumin of 1.2 mg/dl. Urine analysis showed 3+ proteinuria with occasional WBC and no red blood cell (RBC). Subsequently, a 24-h urine examination revealed a proteinuria of 8 g/day. Immunologic tests including cryoglobulins, ANA, dsDNA, and ANCA were negative, and complement levels were normal. Ultrasonography of the whole abdomen showed normal sized kidney, which were mildly echogenic.\nSerologic testing revealed him to be hepatitis C positive. On further investigations, HCV-RNA PCR showed 2,478,600 copies. Genotyping showed it to be HCV type 6. Liver biopsy did not show any specific changes. No varices were present on upper gastrointestinal endoscopy.\nSubsequently, the patient underwent renal biopsy with immunofluorescence staining, which revealed mesangioproliferative glomerulonephritis with IgA deposits consistent with IgAN.\nHe was subsequently started on oral ribavirin 200 mg twice daily and pegylated IFN 80 mcgm subcutaneously once a week for a period of 6 months. He improved symptomatically. After 4 weeks of anti-HCV therapy, a dramatic decrease in the 24-h urine protein excretion was observed from the initial 5.2 g/day to 238 mg/day. This response was even better after 8 weeks of therapy and the proteinuria decreased to 39 mg/day. No evidence of drug-related side effects was documented during this period. He is now on regular follow-up with us and is compliant with his medication.