focal and diffuse mesangial proliferative glomerulonephritis reveal the most common histologic lesions observed on renal biopsies from patients with iga nephropathy ( igan ) .
however , histologic variability is also observed in this disease , which is the same as with lupus nephritis . in some cases ,
endocapillary hypercellularity is accompanied by segmental duplication of the glomerular basement membrane , and there is rarely diffuse endocapillary proliferation with lobular accentuation and multiple double contours , resembling type i membranoproliferative glomerulonephritis ( mpgn ) .
tanaka and waga   have reported a biopsied patient with acute igan following the formation of keloid scars due to a burn injury . however , further reports regarding the correlation between igan and burn injury are rare .
a 46-year - old male patient with scrotal and pedal edema was admitted to our department in august 2012 .
laboratory examination showed proteinuria ( 4 + ) and more than 775 red blood cells in the urine without casts .
this patient had been treated for his 2nd- to 3rd - degree burn injuries in a local burn center .
he had no inhalation injury or sepsis during the whole treatment process . at the admission time
, he had a body temperature of 36.6c , a pulse rate of 75 beats / min , a respiratory rate of 16/min , and a blood pressure of 118/80 mm hg . physical examination revealed cutaneous convalescence after full - thickness burns of both hands , the coronal plane of the body and both legs .
the skin showed fuscous , slight exudation , bleeding cracks , mild scaling and itch during the treatment process ( fig .
the laboratory test results of the urine and blood for this patient are listed in table 1 .
he was diagnosed as having nephrotic syndrome on the basis of a diminished serum albumin level of 23
g / l and an increased proteinuria excretion of 10.0 g/24 h. during the treatment course , microbiological examination of wound secretion was performed twice a week and no infection was observed .
a percutaneous renal biopsy was performed on september 11 , 2012 ( day 57 after burn injury ) to explore the cause of proteinuria .
the examination under light microscopy revealed a diffuse and moderate proliferation of mesangial cells and endothelial cells without observable crescents in 20 glomeruli .
arterioles presented as normal status . neither tubular atrophy nor interstitial fibrosis was found , as shown in figure 2a  c .
immunofluorescence revealed iga ( 3 + ) , trace igm , c3 ( 3 + ) , igg (  ) , c4 (  ) and c1q (  ) in a coarse granular pattern with mesangial and capillary distribution ( fig .
2d , e ) , and inconspicuous staining for igm along the glomerular capillary walls in a granular pattern . in addition , this patient showed negative staining of hbsag and hbcag .
the mesangial hypercellularity and increased mesangial matrix were present between the glomerular basement membrane and glomerular endothelium .
the thickened capillary wall was composed of basement membrane - like materials , interposed mesangial cells , and electron - dense immune - type deposits ( fig .
based on the proliferative properties of glomerular lesions , the patient was started on therapy with oral prednisone at a dose of 1 mg / kg / day .
after treatment , the excretion of urinary protein revealed a significant decrease from 10.0 to 5.20 g/24 h in 2 weeks .
the patient had been followed up to date and showed normal renal function and mild proteinuria .
the glomerular filtration rate is increased after burn injuries , which is accompanied by vascular dysfunction and increased cardiac output .
renal disease and acute kidney injury remains prevalent and is associated with the increased mortality of patients with severe burn injuries .
this case shows the pattern of diffuse proliferative type i mpgn - like symptoms with mesangial interposition and double contours of the glomerular basement membrane present on periodic acid - schiff and silver stains ( fig .
the following reasons are considered as a close correlation between burn injury and the onset of igan .
first , this patient did not have any urinary abnormalities or chronic kidney diseases before and at the early stage of burn injury .
second , nephrotic syndrome was observed at the 2nd week after the injury , and the patient did not have a history of infection such as inflammation of the respiratory tract although concurrent nephrotic syndrome in convalescence was observed .
in addition , the patient suffered from skin problems with slight exudation , bleeding cracks , mild scaling and itch during the treatment process ( fig .
although a causal relationship between igan and burn injury has not been established , an association of cutaneous lesions after burn injury with igan has been reported in a few patients [ 2 , 4 ] .
tanaka and waga   mentioned a biopsied patient with acute igan following the formation of keloid scars due to burn injury .
the patient revealed a rapid recovery after complete removal of the scars without any medication .
wang et al .   have reported that acute igan is closely related to high - voltage electrical burn injury . in this study ,
all those case reports revealed a close relationship between igan and burn injury . because of trauma , infection , tissue necrosis , allogeneic plasma transfusion , increased concentrations of circulating immune complexes were observed .
this situation is similar to the immune dysfunction of igan . both have inherent genetic predisposition and external infections , which may induce igan . if the pathogenesis of igan is not correlated with the concurrent burn injury , what is the cause of the nephrotic sydrome ?
we hypothesize that an autoimmune dysregulation due to a sequestered antigen induced by skin infection and pruritus after burn injury may have an important role in the pathogenesis of igan .
the persistent skin lesions with dry , itch and crusting properties can trigger iga deposition and promote the depositions in the mesangium and subendothelium of the patient .
after serious burns , the immune system is disordered , the immune complex is increased in the circulation , and macrophages are excessively activated .
numerous studies have provided evidence that burns upregulate inflammatory cytokines such as tnf- and il-1 .
those cytokines can interfere with the hemodynamics of intraglomerular microcirculation , the coagulation - fibrinolysis system and the infiltration of inflammatory cells after burns .
nephritis is a rare complication of burn injury , and once this happens , it will affect the recovery and prognosis of the patient .
regular urine analysis will contribute to the early detection and diagnosis of glomerular diseases while treating burn injury .
it is difficult to measure the blood pressure of burned patients , but blood pressure should be monitored as early as possible . because of wound exudation , infection and other reasons , the patients with large burned areas often have some degree of hypoalbuminemia . once persistent
hypoalbuminemia exist , the burned patients need further examination to diagnose whether they have chronic glomerulonephritis or nephrotic syndrome . if the burned patient has nephrotic syndrome , enough glucocorticoid should be administered in order to alleviate proteinuria effectively and for the recovery of burn wounds .
the casual relationship between the onset of igan and burn injury remains speculative and needs to be explored further .
 iga nephropathy ( igan ) is the most common primary glomerulonephritis worldwide , accounting for approximately 3040% of patients undergoing renal biopsy in asia . 
 the characteristic and diagnostic lesion of igan is the deposition of glomerular iga . 
 the morphological lesions observed by light microscopy are extremely variable . 
 a causal relationship between igan and burn injury has not been established , and the correlation between them is not clear if they appear at the same time . 
 we have explored the cause of severe proteinuria of a chinese patient with burns of 2nd or 3rd degree after a gas leakage accident 2 weeks ago . 
 the diffuse proliferative glomerulonephritis of this patient revealed type i membranoproliferative glomerulonephritis - like symptoms . 
 moreover , this patient showed a sensitive response to prednisone . 
 this case report demonstrates the intrinsic relationship between kidney disease and burn injury , which will facilitate a feasible treatment strategy for proteinuria after burn injury . 
Introduction
Case Report
Discussion
Disclosure Statement