Two Cases of IgAN in Healthy Adult Male Bodybuilders Using Testosterone Replacement Therapy

Introduction: We report two cases of healthy adult men using testosterone replacement therapy for recreational purposes who were referred to an outpatient nephrology clinic for proteinuria and worsening serum creatinine. A kidney biopsy revealed IgA nephropathy in both cases. Case Description: Patient A is a 45-year-old gentleman with a medical history of hypertension on valsartan and hypogonadism secondary to anabolic steroid use treated with topical testosterone for the last ten years evaluated for worsening creatinine and proteinuria. His creatinine rose from 1.3mg/dL to 1.6mg/dL over ten years with new microscopic hematuria and proteinuria detected on a recent urine dipstick. Urine protein to creatinine ratio on a 24-hour urine collection was 699mg/g creatinine. Other labs were notable for mild transaminitis (AST 82U/L, ALT 140U/L). Patient B is a 39-year-old gentleman with a medical history of hypertension on lisinopril and hypogonadism secondary to anabolic steroid use treated with testosterone injections for seven months evaluated for worsening serum creatinine. His creatinine had risen from 1.3mg/dL to 1.9mg/dL over seven years with new proteinuria detected at the time of initial nephrology evaluation. Notably, his creatinine rose from 1.5mg/dL to 1.9mg/dL after initiation of testosterone replacement therapy. Spot urine protein evaluation revealed urine protein to creatinine ratio of 1.72mg/mg creatinine. He did not have evidence of liver dysfunction and urine testing was negative for hematuria. Due to unexplained chronic kidney disease progression and proteinuria, a kidney biopsy was performed in both cases revealing IgA nephropathy. Interstitial fibrosis with tubular atrophy was evident in approximately 10% of the tissue in both biopsies. Discussion: IgA nephropathy is a disease characterized by deposition of abnormal IgA immune complexes in the kidney causing inflammation, hematuria, proteinuria and eventual tissue scarring. It is most associated with certain infections, liver disease and celiac disease. In these adult men, use of testosterone replacement therapy and anabolic androgenic steroids may have affected liver function impairing the clearance of these abnormal IgA immune complexes and leading to the development of IgA nephropathy. This underscores the importance of screening patients using testosterone replacement therapy for bodybuilding.