Characteristics and outcomes of patients with Goodpasture's syndrome

BACKGROUND

Goodpasture's syndrome is a rare disorder characterized by pulmonary hemorrhage, glomerulonephritis, and antiglomerular basement membrane antibodies.

METHODS

Case reports of Goodpasture's syndrome between 1993 and 2000 were identified using MEDLINE. Each case was reviewed for clinical manifestations, laboratory features, pathophysiology, treatment options, and outcomes.

RESULTS

Eighty-five cases of Goodpasture's syndrome were reported in the English language literature. The mean age of patients in this review was 44 years. Most patients had multiple risk factors. Smoking was strongly associated with pulmonary hemorrhage. Most patients presented with hemoptysis and crackles. More than 90% had antiglomerular basement membrane antibodies, and 80% had crescenteric glomerulonephritis on renal biopsy.

CONCLUSION

Most patients were treated with immunosuppression and plasma exchange and were alive at follow-up. Patients with either pulmonary or renal signs and symptoms should be evaluated for Goodpasture's syndrome, since early diagnosis allows prompt treatment and improved outcome.

Goodpasture syndrome during the course of a Schönlein-Henoch purpura

Two months after surgical resection of a bronchogenic carcinoma, a 69-year-old patient presented with Schönlein-Henoch purpura with kidney involvement followed by pulmonary hemorrhage. The presence of an IgA linear pattern on the kidney biopsy specimen and circulating anti-glomerular basement membrane (GBM) IgA antibodies led to the diagnosis of Goodpasture syndrome, which implies the possibility that the well-known pulmonary involvement during the course of Schönlein-Henoch purpura could be caused by Goodpasture syndrome in certain cases. In cases of glomerulonephropathy with lung involvement, clinicians should not limit their investigations to anti-GBM IgG.

Glomerulonephritis induced by recombinant collagen IV alpha 3 chain noncollagen domain 1 is not associated with glomerular basement membrane antibody: a potential T cell-mediated mechanism

Glomerulonephritis is believed to result commonly from Ab-mediated glomerular injury. However, Ab-associated mechanisms alone cannot explain many cases of human glomerulonephritis. We developed a rat model of human anti-glomerular basement membrane (GBM) disease to investigate T cell and Ab response, and their associations with the disease. A single immunization of highly denatured recombinant mouse collagen IV alpha3 chain noncollagen domain 1 (rCol4alpha3NC1) induced severe glomerulonephritis in 100% of Wistar Kyoto rats, 33% of which died of this disease around day 35 postimmunization. The renal pathology demonstrated widespread glomerular damage and a mononuclear cell infiltration within the interstitial tissue. T cells from immunized rats responded not only to rCol4alpha3NC1, but also to isolated rat GBM. Sera Abs to rCol4alpha3NC1 were detectable in 100% of the rats, but only 20% of the rats had low levels of Ab to isolated rat GBM by Western blot, and none by immunofluorescence. Furthermore, IgG/M binding to or C3 deposition on endogenous GBM in immunized rats were not detected in most of the experimental rats, and showed no statistical correlation with disease severity. Additionally, no electronic dense deposition in the glomeruli was detected in all rats. Those data revealed a disassociation between the disease and anti-GBM Ab. T cell-mediated mechanisms, which are currently under our investigation, may be responsible for the glomerular disease.

IL-12-dependent, INF-gamma-independent experimental glomerulonephritis

There is evidence that crescentic glomerulonephritis initiated in rodents by heterologous antibodies against the glomerular basement membrane (anti-GBM glomerulonephritis) depends on a Th1-type immune reaction. Interleukin 12 (IL-12) is crucial for the development of Th1 helper cells, and interferon gamma (IFN-gamma) is a major proinflammatory product of these cells. In order to test the role of the two cytokines in anti-GBM glomerulonephritis we used mice lacking either the p40 chain of IL-12 (IL-12-/-) or the IFN-gamma receptor (IFN-gammaR-/-). Glomerulonephritis was induced by injecting a rabbit anti-GBM serum in mice preimmunized against rabbit IgG. Glomerulonephritis was assessed on the basis of proteinuria, immunofluorescence findings and histology. IL-12-/- mice were completely protected against glomerulonephritis. In contrast, IFN-gammaR-/- mice were more severely affected than wild-type mice. Similarly, cutaneous delayed-type hypersensitivity, a typical Th1 response, was abolished in the IL-12-/-, mice but increased in the IFN-gammaR-/- mice. The data obtained in IL-12-/- mice support the view that crescentic glomerulonephritis in this model represents a Th1 response. Since IFN-gamma is not required, other products of Th1 cells are likely to mediate glomerulonephritis.

Goodpasture syndrome: pathophysiology, diagnosis, and management

Goodpasture syndrome is an autoimmune disease characterized by glomerulonephritis, pulmonary hemorrhage, and autoantibodies to the glomerular and alveolar basement membranes. The cause is unknown, and if untreated, Goodpasture syndrome usually is fatal. Early diagnosis and prompt initiation of therapy can decrease disease progression and increase chances of survival. Treatment modalities remain controversial and vary among practitioners.

Matrix metalloproteinase 9 protects mice from anti-glomerular basement membrane nephritis through its fibrinolytic activity

Matrix metalloproteinase (MMP)9/gelatinase B is increased in various nephropathies. To investigate its role, we used a genetic approach. Adult MMP9-deficient (MMP9(-/)-) mice showed normal renal histology and function at 3 mo. We investigated the susceptibility of 3-mo-old mice to the accelerated model of anti-glomerular basement membrane nephritis, in which fibrin is an important mediator of glomerular injury and renal impairment. Unexpectedly, nephritis was more severe in MMP9(-/)- than in control mice, as attested by levels of serum creatinine and albuminuria, and the extent of crescents and fibrin deposits. Circulating or deposited immunoglobulin G, interleukin (IL)-1beta, or IL-10 were the same in MMP9(-/-) and MMP9(+/+) mice. However, we found that fibrin is a critical substrate for MMP9, and in its absence fibrin accumulated in the glomeruli. These data indicate that MMP9 is required for a novel protective effect on the development of fibrin-induced glomerular lesions.

[Lung involvement in rapidly progressive glomerulonephritis]

The purpose of this study is to evaluate pulmonary involvement in rapidly progressive glomerulonephritis (RPGN). Of 71 patients in whom RPGN was diagnosed, 32 (45.1%) had pulmonary involvement: 12, alveolar hemorrhage (AH) (16.9%); 10, interstitial pneumonia (IP) (14.1%); four, chronic bronchial lesions (5.6%); two, consolidation (2.8%), and four, old inflammatory lesions (5.6%). Investigation of which organ of the twelve AH patients, the kidney or the lung, was the first to be involved, showed that the lung preceded in one patient, the kidney was first in three, and the lung and kidney occurred at the same time in the other eight. Of the ten IP patients, the lung preceded in eight, the kidney was ahead in two, and lung and kidney were simultaneous in one. Three patients had a history of pneumoconiosis, and two had acute progressive IP. Seventeen (45.9%) of 37 patients who tested positive for antineutrophil cytoplasmic autoantibodies (MPO-ANCA) had lung involvement, and three (30.0%) of the ten patients who tested negative for MPO-ANCA, PR 3-ANCA and anti-GBM antibody also had lung involvement.

Oral administration of glomerular basement membrane prevents the development of experimental autoimmune glomerulonephritis in the WKY rat

Experimental autoimmune glomerulonephritis (EAG), an animal model of Goodpasture's disease, can be induced in Wistar Kyoto (WKY) rats by a single injection of collagenase-solubilized rat glomerular basement membrane (GBM) in adjuvant. EAG is characterized by circulating and deposited anti-GBM antibodies, accompanied by focal necrotizing glomerulonephritis with crescent formation. The inhibitory effect of orally administered antigens has been reported in various animal models of autoimmunity but not in EAG in the rat. The effects of feeding rat GBM by gavage, at total doses of 0.5, 2.5, or 5 mg, before immunization were examined. A dose-dependent effect was observed on the development of EAG. A dose of 0.5 mg of GBM had no effect on disease, 2.5 mg resulted in a moderate reduction in the severity of nephritis but no change in anti-GBM antibody production, and 5 mg resulted in a marked reduction in circulating and deposited anti-GBM antibodies, albuminuria, deposits of fibrin in the glomeruli, severity of glomerular abnormalities, and numbers of infiltrating T cells and macrophages. Animals that were fed 5 mg of GBM showed a significant reduction in IgG2a but not IgG1, anti-GBM antibody levels, suggesting downregulation of Th1 responses. There was also a dose-dependent reduction in the proliferative responses of splenic T cells from treated animals to GBM antigen in vitro. These results clearly demonstrate that mucosal tolerance can be induced by oral administration of GBM antigen and that this approach is effective in preventing EAG.

Anti-glomerular basement membrane nephritis after extracorporeal shock wave lithotripsy

Rapidly progressive glomerulonephritis was observed in a 37-year-old woman following the administration of extracorporeal shock wave lithotripsy (ESWL) for a single stone in her right kidney. The renal biopsy specimen showed diffuse cellular crescents in all glomeruli, with linear deposits of immunoglobulin G and complement component C3 along the glomerular basement membrane (GBM). Circulating anti-GBM antibodies were detected by enzyme-linked immunosorbent assay. Thus, the patient was diagnosed with anti-GBM nephritis. It is suggested that ESWL produced an alteration in the GBM leading to the production of anti-GBM antibodies.

[Anti glomerular basement membrane disease in a renal transplant patient with Alport syndrome]

We report a case of anti GBM disease that developed in the renal graft of a patient with Alport syndrome. After reaching abnormal values of creatinine, the patient presented with deteriorating renal function three months after a cadaver transplant and the biopsy showed crescent formation, and linear IF deposits. Circulating antibodies against alpha 5 chain of type IV collagen were found and plasmaphereses stabilized the condition for one year until a lung infection led to withdrawal of the immunosuppressive drugs and the patient returned to dialysis. We discuss the possible mechanisms underlying the specificity of the circulating antibodies in this case, which differs from the target characteristic of the idiopathic form of anti GBM disease, the alpha 3 (IV) chain.

The goodpasture autoantigen. Identification of multiple cryptic epitopes on the NC1 domain of the alpha3(IV) collagen chain

Goodpasture (GP) disease is an autoimmune disorder in which autoantibodies against the alpha3(IV) chain of type IV collagen bind to the glomerular and alveolar basement membranes, causing progressive glomerulonephritis and pulmonary hemorrhage. Two major conformational epitope regions have been identified on the noncollagenous domain of type IV collagen (NC1 domain) of the alpha3(IV) chain as residues 17-31 (E(A)) and 127-141 (E(B)) (Netzer, K.-O. et al. (1999) J. Biol. Chem. 274, 11267-11274). To determine whether these regions are two distinct epitopes or form a single epitope, three GP sera were fractionated by affinity chromatography on immobilized NC1 chimeras containing the E(A) and/or the E(B) region. Four subpopulations of GP antibodies with distinct epitope specificity for the alpha3(IV)NC1 domain were thus separated and characterized. They were designated GP(A), GP(B), GP(AB), and GP(X), to reflect their reactivity with E(A) only, E(B) only, both regions, and neither, respectively. Hence, regions E(A) and E(B) encompass critical amino acids that constitute three distinct epitopes for GP(A), GP(B), and GP(AB) antibodies, respectively, whereas the epitope for GP(X) antibodies is located in a different unknown region. The GP(A) antibodies were consistently immunodominant, accounting for 60-65% of the total immunoreactivity to alpha3(IV)NC1; thus, they probably play a major role in pathogenesis. Regions E(A) and E(B) are held in close proximity because they jointly form the epitope for Mab3, a monoclonal antibody that competes for binding with GP autoantibodies. All GP epitopes are sequestered in the hexamer configuration of the NC1 domain found in tissues and are inaccessible for antibody binding unless dissociation of the hexamer occurs, suggesting a possible mechanism for etiology of GP disease. GP antibodies have the capacity to extract alpha3(IV)NC1 monomers, but not dimers, from native human glomerular basement membrane hexamers, a property that may be of fundamental importance for the pathogenesis of the disease.

Idiotypic network dysregulation: a common etiopathogenesis of diverse autoimmune diseases

The pathogenesis of autoimmune disease is still an enigma. Whereas the diverse clinical manifestations of many autoimmune diseases cannot be explained by the existence of autoantibodies, idiotypic dysregulation may provide an alternative explanation. Experimental models, serum level changes of pathogenic idiotypes during exacerbation and remission, and the increased expression of pathogenic idiotypes following common infections all support this notion. In this article we review experimental models of autoimmune disease induction (systemic lupus erythematosus, antiphospholipid syndrome, Goodpasture's syndrome, autoimmune thyroiditis, and vasculitis) by manipulation of the idiotypic network, and discuss the utilization of idiotypes for the immunotherapy of autoimmune diseases and other conditions that involve the immune system (e.g., atherosclerosis).

Glomerular epithelial-myofibroblast transdifferentiation in the evolution of glomerular crescent formation

BACKGROUND

Glomerular cellular crescents consist of epithelial cells and macrophages, which can undergo an irreversible process of fibrous organization. However, the origin of the fibroblast-type cells that mediate this fibrous organization is unclear.

METHODS

This study examined glomerular epithelial- myofibroblast transdifferentiation (GEMT) in the formation and evolution of glomerular crescents in two distinct rat models of glomerulonephritis: 5/6 nephrectomy and antiglomerular basement membrane (GBM) disease.

RESULTS

Early in the course of both disease models, and prior to crescent formation, immunohistochemistry staining and in-situ hybridization demonstrated de novo expression of alpha-smooth-muscle actin (alpha-SMA), a marker of smooth muscle cells and myofibroblasts, by glomerular parietal epithelial cells (GPEC). The expression of alpha-SMA by GPEC was accompanied by a loss of E-cadherin staining, a marker of epithelial cells. At this early stage of GEMT, ultrastructural studies identified the presence of characteristic actin microfilaments and dense bodies within GPEC which retained a normal epithelial morphology with apical-basal polarity and microvilli. A late stage of transdifferentiation was seen in fibrocellular crescents. In this case, GPEC attached to intact segments of the capsular basement membrane contained large bundles of actin microfilaments throughout the cell, and this was accompanied by a loss of polarity, microvilli, and tight junctions. There was a significant correlation between the presence of alpha-SMA(+) GPEC and glomerular crescent formation. Cellular crescents contained small numbers of alpha-SMA(+) myofibroblasts. These cells become the dominant population in fibrocellular crescents, which was associated with marked local proliferation. Relatively few alpha-SMA(+) myofibroblasts remained in fibrotic/organizing crescents. Most cells within cellular and fibrocellular crescents expressed transforming growth factor-beta (TGF-beta) and basic fibroblast growth factor (FGF-2), suggesting that these growth factors may regulate this GEMT process during the evolution of glomerular crescents.

CONCLUSIONS

This study provides the first phenotypic and morphological evidence that glomerular epithelial-myofibroblast transdifferentiation participates in the formation and evolution of glomerular crescents.

Goodpasture's syndrome: a nursing challenge

Goodpasture's syndrome is an uncommon occurring disorder that causes hemorrhage in the basement membrane lining of the kidneys and the lungs. By recognizing early signs and symptoms of pulmonary-renal syndromes that may lead to a diagnosis of Goodpasture's syndrome, critical care and advanced practice nurses can play a key role in ensuring successful patient outcomes and preventing complications. Expert nursing care and emotional support is essential for the patient and family to cope with this usually fatal disease.