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\begin{document}

\title{Severe glomerular C3 deposition indicated severe renal lesions and poor
prognosis in patients with Immunoglobulin A Nephropathy}



\author[1]{jianliang wu}%
\author[1]{Zhizhi  Hu}%
\author[1]{Yuxi  Wang }%
\author[1]{Danni Hu}%
\author[1]{Qian Yang}%
\author[1]{Yueqiang Li}%
\author[1]{Wei Dai}%
\author[1]{Fengming Zhu}%
\author[1]{Juan Yang}%
\author[1]{Meng Wang}%
\author[1]{Han Zhu}%
\author[1]{Liu Liu}%
\author[1]{Xiaofeng  He}%
\author[1]{Min Han}%
\author[1]{Ying Yao}%
\author[1]{Guangchang Pei}%
\author[1,2]{Rui Zeng}%
\author[1]{Gang Xu}%
\affil[1]{Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology}%
\affil[2]{Huazhong University of Science \& Technology}%


\vspace{-1em}



  
  \date{May 08, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
ABSTRACT Background and objectives Glomerular C3 deposition is often
observed in renal biopsies of patients with IgA nephropathy (IgAN),
however, the relationship between the level of C3 deposition and the
long-term prognosis of IgAN have rarely been reported. In this
observational cohort study, we aimed to evaluate the prognostic value of
glomerular C3 deposition in the progression of IgAN. Materials and
Methods From June 2009 to June 2010, a total of 136 adult patients with
IgAN were enrolled in the study. Glomerular deposition of the complement
protein C3, immune complexes, and inflammatory cells were detected in
renal biopsy tissue. The level of renal lesions, glomerular immune
complexes, and the density of interstitial inflammatory cells were
analyzed. Based on an average of 105 months of follow-up, the predictive
value of glomerular C3 deposition for IgAN progression was investigated.
Results Of the 136 patients, 102 patients were classified into the
glomerular C3low group and 34 patients were classified into the
glomerular C3high group. Patients in C3high group had more immune
complexes deposition than those in C3low group. In C3high group, the
degree of renal lesion and interstitial fibrosis were severer compared
to C3low group. Renal biopsy in C3high group presented with higher
density of interstitial inflammatory cells that in C3low group. The
density of glomerular C3 deposition was associated with poor renal
survival over a 105-month follow-up. Conclusions The high density of
glomerular C3 deposition was associated with severity of renal lesions
and predicted a long-term poor renal survival for IgAN patients.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

IgA nephropathy (IgAN), characterized by predominant IgA deposition in
the glomerular mesangium, is the most common form of primary
glomerulonephritis worldwide{[}1, 2{]}.The other histological features
of IgA nephropathy are mesangial cell proliferation with complement 3
(C3) and variable IgG and / or IgM co-deposits{[}3{]}. IgAN presented
with a wide range of histology and clinical features, among which about
one-third of patients develop into ESRD within 25 years{[}1, 4, 5{]}. As
no specific treatment is available for IgAN, it is particularly
important to find the potential risk factors for the long-term prognosis
of IgAN. It is well established that risk factors for the progression of
IgAN include the presence of proteinuria, high blood pressure, and
declined eGFR{[}6, 7{]}. The MEST scoring system including mesangium
hypercellularity (M), endocapillary hypercellularity (E), segmental
glomerulosclerosis (S), and tubular atrophy/interstitial fibrosis (T),
was also validated in a variety of studies for the prediction of
clinical outcomes{[}8, 9{]}. T cell subpopulations were also identified
to be associated with the severity of proteinuria and hematuria,
elevated serum creatinine levels and reduced GFR in IgAN{[}10{]}.

Glomerular co-deposition of C3 and IgA1 was observed in at least 90\% of
IgAN renal biopsies{[}3, 11{]}. Previous studies have shown that the
pathogenic co-deposition of C3 and IgA1 induces proliferation of
mesangial cells and secretion of cytokines and extracellular matrix,
which plays a key role in the pathogenesis of IgAN{[}12, 13{]}. However,
the role of complement activation on the progression and prognosis of
IgAN remains unclear. Although renal biopsy remains the gold standard
diagnosis, recent efforts have been made to find new biomarkers that
might predict progression and prognosis of IgAN.

In this observational cohort study, we analyzed clinical features
according to the pathologic findings and glomerular immune complex
deposition and then investigated the predictive value of glomerular C3
deposition in predicting the prognosis of patients with IgAN.

\textbf{MATERIALS AND METHODS}

\textbf{Patients}

The study was carried out in accordance with the Declaration of Helsinki
and approved by Committee on Research Ethics of Tongji Hospital,
Huazhong University of Science and Technology. Renal biopsy was
performed in 205 Chinese adult patients aged between 18 and 70 years
with IgAN between June 2009 to June 2010. All patients met the
diagnostic criteria for IgAN, which was published by the Oxford
classification working group {[}14{]}. Patients were excluded if they
had received glucocorticoids or immunosuppressants treatment before
renal biopsy; if they had HBV infection or liver~chirosis; if they had a
concomitant autoimmne disease ; or if they did not have complete
follow-up data. 136 patients were eventually enrolled into this study
(Figure 1).

\textbf{Clinical studies and laboratory data}

The following parameters were collected at the time of the renal biopsy,
including gender, age, blood pressure, hematuria, proteinuria, serum
uric acid, serum albumin, blood urea nitrogen, serum creatinine and
eGFR. To assess the presence of hematuria, 10 ml of clean fresh urine
that came from the middle piece was centrifuged for 5 minutes at 1500
rpm; 0.2 ml of sediment was taken and observed under microscopy. The
severity of erythrocyturia was characterized as follows:
\textgreater{}20 RBC/HPF as 3+. The estimated glomerular filtration rate
(eGFR) was calculated using the CKD-epidemiology collaboration (CKD-EPI)
formula: eGFR (ml/min per1.73 m2) =
186\selectlanguage{ngerman}×Scr\textsuperscript{-1.154}×age\textsuperscript{-0.203}×0.742 (if
female) × 1.227

\textbf{Histologic Evaluation}

The biopsy specimens were processed for light microscopy,
immunofluorescence and electron microscopy. Paraffin sections for light
microscopy were stained with hematoxylin and eosin, periodic
acid-Schiff, and Masson's trichrome stain for pathologic analysis.
Direct immunofluorescence for IgA, IgG, IgM, and C3 was performed in
frozen sections. Clinical renal pathologists performed qualitative
assessment of the degree of immunofluorescent staining. The degree of
glomerular C3 immunofluorescent stain intensity was reported on a scale
of 1+ to 3+, with 1+ representing low-intensity staining; 2+,
medium-intensity staining; or 3+, high-intensity staining. Glomerular
IgG and IgM deposition were graded by absent (score, 0), mild (score,
1), marked (score, 2), respectively. Glomerular IgA deposition were
graded by IgA=2+ and IgA\textgreater{}2+. Pathological features were
scored using the existing literature {[}14, 15{]}. In particular,
mesangial hypercellularity, segmental glomerulosclerosis, endocapillary
hypercellularity, tubular atrophy/interstitial fibrosis were graded by
Oxford classification. For each biopsy, we determined the fraction of
glomeruli with cellular or \selectlanguage{english}fibrocellular or fibrous crescents. A crescent
was de\selectlanguage{english}fined as extracapillary proliferation of more than two cell layers
of any size; this de\selectlanguage{english}finition was uniform in all studies. The severity of
global glomerulosclerosis and arterial wall thickening was graded in
three groups: absent (score, 0), mild (score, 0), and marked (score, 0).
Crescents and arterial hyalinosis were scored as either absent or
present.

\textbf{Immunohistochemistry and immunofluorescence}

Immunohistochemical staining was performed on 3-\selectlanguage{greek}μ\selectlanguage{english}m paraffinized sections
of renal tissue. Detection of CD68, CD4, CD8 and CD20 (Maxim-Bio),
tryptase and CD1c (Abcam) was performed on paraffin sections by an
immunohistochemical kit (DAKO, Santa Clara, USA) according to the
manufacturer's instructions. For immunofluorescence, the primary
antibody against C3, IgA, IgG, and IgM (Gene-Bio) and Alexa Flour
488-conjugated secondary antibody (Jackson ImmunoRearch, West Grove,
USA) were used. The numbers of each subset of interstitial inflammatory
cells were counted under five equivalent high-power cortical fields (HPFs)
(\selectlanguage{ngerman}×400) and were expressed as the average number of cells per square
millimeter {[}16{]}. The labeled cells were counted three times per high
power field (HDF) to reduce counting errors, and the average number was
recorded as the density of positive cells in this renal section.

\textbf{Evaluation of outcomes}

For the present analysis, we considered the creatinine doubling from
baseline as the primary endpoint; secondary endpoint was ESRD, which was
defined as initiation of renal replacement therapy including permanent
hemodialysis, peritoneal dialysis, or renal transplantation.

\textbf{Statistical Analyses}

Statistical analyses were performed using SPSS 13.0 software (SPSS Inc.,
Chicago, Illinois, USA). The Kolmogorov-Smirnov test was used to analyze
the normality of the distribution of parameters. Continuous variables
are expressed mean±SD, while categorical variables are expressed as a
number (percentage). Comparison between 2 groups using the t test or
chi-squared test. Nonparametric variables are described as medians and
quartile ranges, and the comparisons between groups were made using

the Mann-Whitney test or the Kruskal-Wallis test. Patients were
classified into C3\textsuperscript{low} and C3\textsuperscript{high}
groups by grading the density of glomerular C3 deposition. The
descriptive analysis of the time reaching the primary and secondary
endpoint was performed by computing survival curves according to the
Kaplan-Meier method, and between-group survival was compared by the
log-rank test. Univariate and multivariate Cox proportional hazards
models were used to determine the factors associated with the risk of
reaching the creatinine doubling from baseline (multifailure model) or
ESRD. Results were expressed as hazard-rate (HRs) with CI. Univariate
and multivariate linear regression analyses were used to determine the
associations between the density of glomerular C3 deposition and other
variables that correlate with renal outcome. The multivariate models
were built considering that the main interest was the identification of
prognostic factors, present at the enrollment and statistically
significant at univariate analysis. Two-sided P values \textless{}0.05
were considered statistically significant.

\textbf{Results}

\textbf{Demographic and clinical characteristics according to the degree
of glomerular C3deposition at the time of biopsy}

According to the scheme, 136 patients were enrolled and followed up 105
months after renal biopsy. The cohort of 136 patients with IgAN was
stratified according to C3 deposition on biopsy specimens as either
glomerular C3\textsuperscript{low} IgAN (C3 score of 1+ and 2+ on
immunofluorescent staining, n=102) or glomerular
C3\textsuperscript{high} IgAN (C3 score of 3+ on immunofluorescent
staining, n = 34) (Figure 1). We further discovered that patients in
C3\textsuperscript{high} group suffered from higher percentage of
glomerular IgA, IgM and IgG deposition (Figure 2).

The baseline characteristics of the study population was presented with
no significant differences between glomerular
C3\textsuperscript{low}group and glomerular C3\textsuperscript{high}
group in terms of sex, age, serum C3, blood pressure, erythrocyturia,
serum uric acid, serum albumin or blood urea nitrogen (Table 1). At time
of biopsy for the overall cohort (n = 136), the median degree of
proteinuria was 1.0 g/24h and the mean level of serum creatinine was
77.6 (\selectlanguage{greek}μ\selectlanguage{english}mol/L). Patients with C3\textsuperscript{high} IgAN compared to
C3\textsuperscript{low} IgAN had a higher serum creatinine
(C3\textsuperscript{high}: 89.4 vs. C3\textsuperscript{low}: 74.9
\selectlanguage{greek}μ\selectlanguage{english}mol/L, P = 0.008), and a higher degree of proteinuria
(C3\textsuperscript{high}: 1.6 vs. C3\textsuperscript{low}: 0.9 g/24h, P
\textless{}0.001). The estimated glomerular filtration rate (76.0 vs.
100.8 ml/min per1.73 m2, P=0.001) was lower in C3\textsuperscript{high}
group (Table 1).

\textbf{IgAN patients in C3\textsuperscript{high} group presented with
severe pathological lesions} \textbf{and} \textbf{suffered more
interstitial inflammatory cell infiltration}

In consistent with the higher proteinuria level and lower eGFR, IgAN
patients in C3\textsuperscript{high} group presented with a higher
percentage of mesangial hypercellularity (56.9\% versus 27.5\%;
P=0.003), segmental glomerulosclerosis (41.2\% versus 19.6\%; P=0.012),
severe tubular atrophy/interstitial fibrosis (T2, 44.1\% versus 17.6\%;
P=0. 002), crescents (52.9\% versus 33.3\%; P=0.042), severe arterial
wall thickening (29.4\% versus 12.7\%; P=0.034), severe arterial
hyalinosis (47.1\% versus 21.6\%; P=0.004) (Table 2). The two groups
showed no difference in endocapillary hypercellularity or global
glomerulosclerosis. Representative photographs of light microscopy (PAS
and Masson) and electron microscopy of the two groups were shown in
Figure 3.

To understand inflammatory cell infiltration in these patients, we
detected CD68+ macrophages, CD4+, CD8+ T lymphocytes, tryptase+ mast
cells, CD20+ B lymphocytes and CD1c+ myeloid dendritic cells in renal
biopsies. We found that patients in C3\textsuperscript{high} group
presented with intense interstitial macrophages and T lymphocytes
infiltration than that in C3\textsuperscript{low} group (Figure 4).
Renal tissues were revealed more interstitial tryptase+ mast cells
infiltration in the C3\textsuperscript{high} group in renal biopsies of
IgAN patients rather than CD20+ B lymphocytes and CD1c+ myeloid
dendritic cells (Supplementary figure).

\textbf{Prognostic value of glomerular C3 deposition for renal outcome
in patients with IgAN}

During a follow-up of 105 months, the primary endpoint of the creatinine
doubling from baseline occurred in 22.1\% (30/136) patients. Survival
curves were performed according to the Kaplan-Meier method. Proportion
of renal survival (absence of creatinine doubling) were 83.3\% (85/102)
v.s. 61.8\% (21/34) in C3\textsuperscript{low} and
C3\textsuperscript{high} group at the end of 105-month follow-up,
respectively (Figure 5A). Estimated overall survival time were 97.8
months for patients in C3\textsuperscript{low} group; 81.9 months for
patients in C3\textsuperscript{high} group, \emph{P} =0.025 (Figure 5A).
The secondary endpoint of ESRD occurred in 13.2\% (18/136) patients.
Proportion of renal survival (absence of ESRD) were 93.1 \% (95/102)
v.s. 67.6\% (23/34) in C3\textsuperscript{low} and
C3\textsuperscript{high} group, respectively. Estimated overall survival
time were 100.2 months for patients in C3\textsuperscript{low} group;
86.5 months for patients in C3\textsuperscript{high} group, P=0.002
(Figure 5B).

We then investigated whether the density of glomerular C3 deposition
could independently predict poor renal survival. In a multivariate Cox
regression model, renal outcome for doubling of Scr was significantly
associated with serum creatinine, proteinuria and density of glomerular
C3 deposition (Table 3, model 1). When the degree of Oxford-MEST lesion
classification was included in a multivariate model, the higher
intensity of glomerular C3 deposits remained as an independent predictor
of Scr doubling (model 2). Interestingly, the results of model 3 and
model 1 are exactly the same, even though there are many differences
between the two variables.

By using a multivariate Cox regression analysis, the incidence for ESRD
was significantly associated with serum creatinine, proteinuria and
glomerular C3 density at biopsy (Table 3, model 1). When the degree of
Oxford-MEST lesion classification was included in a multivariate model,
the higher intensity of glomerular C3 deposits remained as an
independent predictor for ESRD (model 2).

Different models depending on multivariate analyses revealed that
glomerular C3 deposits, when included with clinical variables, or
included with Oxford-MEST lesion classification, was an independent
predictor of Scr doubling and ESRD (Table 3, 4).

\textbf{DISCUSSION}

Although the risk factors affecting the poor prognosis of patients with
IgAN have been described{[}17{]}, the most influential factor in
endpoint outcomes of patients with IgAN remains unclear. In the present
study, we assessed 136 patients with IgAN, including 102 patients in
C3\textsuperscript{low} group and 34 patients in
C3\textsuperscript{high} group, to investigate whether glomerular C3
deposition has the value of evaluating clinical prognosis and predicting
kidney outcome according to an average of 105 months of follow-up. We
found that glomerular C3 deposition was associated with deterioration of
renal function and prognosis in patients with IgAN.

Complement regulatory proteins are expressed on the surface of almost
all resident kidney cells{[}18{]}. Of all the complement proteins
co-deposited with IgA1, C3 is the most abundant. Many studies have
previously showed that glomerular C3 deposition and complement
activation was involved in pathogenesis of patients with various kidney
disease including IgAN{[}19-21{]}, lupus nephritis{[}22{]}, C3
glomerulopathy{[}23{]}, and antineutrophil cytoplasmic antibody
(ANCA)-mediated crescentic glomerulonephritis{[}24{]}. The intensity of
glomerular C3 deposition has been negatively correlated with renal
survival in a cohort study of 111 kidney transplant recipients with
transplant glomerulopathy{[}25{]}. Interestingly, extraglomerular C3
deposits also affects clinical outcomes in IgAN patients{[}26{]}. The
classical, alternative and lectin pathways are three known pathways for
complement system activation. Each pathway has its own triggering
mechanism; however, once the C3 convertases is created, all pathways
will be unified. Thus, glomerular C3 deposition in IgAN highlights the
pathophysiological role of activation of complement fragments.

In this study, we found that with patients with heavy glomerular C3
deposition suffered higher proteinuria level and lower eGFR, higher
percentage of mesangial hypercellularity, segmental glomerulosclerosis,
severe tubular atrophy/interstitial fibrosis, crescents, severe arterial
wall thickening, severe arterial hyalinosis. According to the follow-up
data, patients in C3\textsuperscript{high} group had a significantly
higher risk of Scr doubling and ESRD than those in
C3\textsuperscript{low} group, which was consistent with the previous
studies. Nam et al. showed that the glomerular C3 and C4d (especially
C3) deposition was an independent risk factor for progression of IgAN
{[}27{]}. Kim et al. found decreased circulating C3 levels and mesangial
C3 deposition predicted renal outcome in patients with IgAN according to
53.7 months follow-up. They also showed a remarkable negative relevant
relation between serum C3 levels and mesangial C3 deposition {[}28{]}.
In our study, although we excluded patients who had received
glucocorticoids or immunosuppressants treatment before renal biopsy, we
did not find the negative relevant relation serum C3 levels and
mesangial C3 deposition in IgAN patients. Besides the histopathlogical
and clinical parameters, we further found C3\textsuperscript{high} group
contained more interstitial macrophages, T lymphocytes and mast cells
infiltration than the C3\textsuperscript{low} group. It suggested
glomerular C3 deposition might be related to the activation of local
immune response in the progression of IgAN.

There are several limitations of our study. First, the cohort was not
large enough. In the future, large prospective studies and repeat biopsy
after glucocorticoids therapy of IgAN patients are expected. Second, we
cannot dissect individual role of alternative and lectin pathways. Other
complement components were not available in our current research.

In conclusion, our study suggested the clinical significance of
glomerular C3 deposition in clinical practice and indicated that high
density C3 deposition in kidney were associated with severe renal
lesions and the activation of local immune response in the progression
of IgAN. Based on an average of 105 months of follow-up, glomerular C3
deposition were independently associated with poor renal outcome in
patients with IgAN. Thus, these findings suggest that glomerular C3
deposition are potentially served as a predictor factor of poor
prognosis in patients with IgAN.

\textbf{FUNDING}

This work was supported by the National Natural Science Foundation of
China for Young Scholar (Grant No.81600556,81700653,81700597,81800608);
Major Research plan of the National Natural Science Foundation of China
(Grant No. 91742204); International (regional) cooperation and exchange
projects, (NSFC-DFG, Grant No. 81761138041); National Natural Sciences
Foundation of China (Grants 81470948, 81670633,81570669, 81570615); the
National key research and development program (Grants 2016YFC0906103);
the National Key Technology R\&D Program (Grant
2013BAI09B06,2015BAI12B07); The third project for the young and
middle-aged excellent medical talents of Wuhan.

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\textbf{Figure and table legends}

\textbf{FIGURE 1. Study scheme.} The patients were selected into or
excluded from the study according to the scheme. Representative
photographs of C3 immunofluorescence staining. Bar=50\selectlanguage{greek}μ\selectlanguage{english}m.

\textbf{FIGURE 2. Glomerular immunodeposits from the patients in
C3\textsuperscript{low} and C3\textsuperscript{high} group. (A, B, D, E,
G} and \textbf{H)} Representative photographs of glomerular immune
complexes deposition (IgA, IgG and IgM) from C3\textsuperscript{low} and
C3\textsuperscript{high} group. Bar=50\selectlanguage{greek}μ\selectlanguage{english}m. \textbf{(C, F} and
\textbf{I)}The difference of glomerular immune complexes deposition
(IgA, IgG and IgM) in C3\textsuperscript{low} and
C3\textsuperscript{high} group. Glomerular IgA deposition was graded by
IgA=2+ and IgA\textgreater{}2+; Glomerular IgG, IgM deposition was
graded by absent (score, 0), mild (score, 1), severe (score, 2),
respectively. The difference of constituent~ratio was analyzed by Chi
square test.

\textbf{FIGURE 3. Morphological characteristics of the biopsies from the
patients in C3\textsuperscript{low} and C3\textsuperscript{high}
group.(A-F)} Representative photographs of PAS staining, Masson staining
and electron microscopy from C3\textsuperscript{low} and
C3\textsuperscript{high} group. Bar=50\selectlanguage{greek}μ\selectlanguage{english}m. The magnification by electron
microscopy was 2000 times.

\textbf{FIGURE 4. C3\textsuperscript{high} group contained more
lymphocytes in C3\textsuperscript{low} group in IgAN renal biopsies.A,
B, D, E, G, H} represent photographs of CD68\textsuperscript{+},
CD4\textsuperscript{+} and CD8\textsuperscript{+} cells in
C3\textsuperscript{low} and C3\textsuperscript{high} groups. \textbf{C,
F, I} showed renal tissues were revealed more CD68\textsuperscript{+},
CD4\textsuperscript{+} and CD8\textsuperscript{+} cells infiltration in
the C3\textsuperscript{high} group. Box plots indicated statistical
differences. Values greater than 95\% or less than 5\% is listed as a
dot while values less than 95\% or greater than 5\% were hidden in
positive and negative error line. The line in the center of each box
represents the median value, and the upper and lower ends of the box are
the upper and lower quartiles, Bar=50\selectlanguage{greek}μ\selectlanguage{english}m.

\textbf{FIGURE 5. Renal survival curve of creatinine doubling and ESRD.
(A)} Kaplan-Meier estimates of proportion of renal survival (absence of
creatinine doubling) in 83.3\% (85/102) v.s. 61.8\% (21/34) of the
patients in C3\textsuperscript{low} and C3\textsuperscript{high} group,
respectively. Estimated overall survival time were 97.8 (95\%
CI:93.4-102.2) months for patients in C3low group; 81.9 (95\% CI:
70.7--93.0) months for patients in C3\textsuperscript{high} group,
P=0.025 (log rank test). \textbf{(B)} Kaplan-Meier estimates of
proportion of renal survival (absence of ESRD) in 93.1 \% (95/102) v.s.
67.6\% (23/34) of the patients in C3\textsuperscript{low} and
C3\textsuperscript{high} group, respectively. Estimated survival time
were 100.2 (95\% CI: 96.4-104.1) months for patients in
C3\textsuperscript{low} group; 86.5 (95\% CI: 75.9--97.0) months for
patients C3\textsuperscript{high} group, P=0.002 (log rank test).

\textbf{Table 1. Demographic, clinical and biochemical characteristics
between patients with low or high levels of glomerular C3 deposition}

\textbf{SUPPLEMENTARY FIGURE. Renal tissues were revealed more
interstitial tryptase\textsuperscript{+} mast cells infiltration in the
C3\textsuperscript{high} group in renal biopsies of IgAN patients rather
than CD20\textsuperscript{+} B lymphocytes and
CD1c\textsuperscript{+}myeloid dendritic cells.} Box plots indicated
statistical differences. Values greater than 95\% or less than 5\% is
listed as a dot while values less than 95\% or greater than 5\% were
hidden in positive and negative error line. The line in the center of
each box represents the median value, and the upper and lower ends of
the box are the upper and lower quartiles.\selectlanguage{english}
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\verb`table.doc`  available at \url{https://authorea.com/users/340212/articles/467332-severe-glomerular-c3-deposition-indicated-severe-renal-lesions-and-poor-prognosis-in-patients-with-immunoglobulin-a-nephropathy}

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