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Tominaga K, Toda E, Takeuchi K, Takakuma S, Sakamoto E, Kuno H, Kajimoto Y, Terasaki Y, Kunugi S, Terasaki M, Goto H, Imakiire T, Oshima N, Shimizu A. Myeloperoxidase-Associated Membranous Nephropathy in Antineutrophil Cytoplasmic Antibody-Associated Glomerulonephritis. Kidney Int Rep 2024; 9:2240-2249. [PMID: 39081744 PMCID: PMC11284429 DOI: 10.1016/j.ekir.2024.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/08/2024] [Accepted: 04/17/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction Antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis (GN) is characterized by pauci-immune crescentic GN. Myeloperoxidase ANCA-associated GN (MPO-ANCA GN) with membranous nephropathy (MN), where bright granular capillary MPO and IgG staining along the glomerular basement membrane (GBM) is present, has been reported; however, its clinicopathological features remain unclear. Methods We investigated 7 MPO-ANCA GN with MN and 11 control cases (6 MPO-ANCA GN and 5 primary MN cases). Proteomics of laser microdissected glomeruli followed by immunohistochemical analysis was performed to identify causal antigens in MPO-ANCA GN with MN. We described the clinicopathological features of MPO-associated MN compared with those of MPO-ANCA GN and primary MN. Results We detected proteomic MPO and granular capillary MPO deposits in all MPO-ANCA GN with MN cases. Confocal microscopy revealed MPO and IgG colocalization along the GBM. MPO-associated MN clinicopathological features include greater proteinuria, a higher fibrous crescent rate, and a lower MPO-ANCA titer than MPO-ANCA GN. The estimated glomerular filtration rate (eGFR) and urinary protein excretion were lower in MPO-associated MN than in primary MN. Conclusion MPO-associated MN, a unique type of secondary MN where MPO serves as the causal antigen, is a subset of MPO-ANCA GN with MN. Prolonged periods of MPO-ANCA GN and a low MPO-ANCA titer might be related to MPO-associated MN development.
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Affiliation(s)
- Kenta Tominaga
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Etsuko Toda
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Kazuhiro Takeuchi
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Shoichiro Takakuma
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Emi Sakamoto
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Hideaki Kuno
- Division of Nephrology and Hypertension, The Jikei University School of Medicine, Tokyo, Japan
| | - Yusuke Kajimoto
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Yasuhiro Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
- Division of Pathology, Nippon Medical School Hospital, Tokyo, Japan
| | - Shinobu Kunugi
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Mika Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Hiroyasu Goto
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama, Japan
| | - Toshihiko Imakiire
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama, Japan
| | - Naoki Oshima
- Department of Nephrology and Endocrinology, National Defense Medical College, Saitama, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
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2
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Liu G, Feng X, Yu S, Sheng J, Liu C, Wang L. Diagnosis of membranous nephropathy with Anti-GBM glomerulonephritis: a case series report. BMC Nephrol 2024; 25:204. [PMID: 38907217 PMCID: PMC11193197 DOI: 10.1186/s12882-024-03637-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 06/12/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND The concomitant occurrence of membranous nephropathy and anti-glomerular basement (anti-GBM) disease has been previously described but is extremely rare. However, delayed recognition or misdiagnosis leads to delayed treatment, resulting in worse renal and patient outcomes. CASE PRESENTATION We present 3 patients with rapidly progressive glomerulonephritis (RPGN), anti-GBM and serum-positive M-type phospholipase A2 receptor (anti-PLA2R) antibody. Renal biopsies revealed PLA2R-associated membranous nephropathy with anti-GBM glomerulonephritis. We analyzed the clinical and pathological characteristics and discussed that the correct diagnosis of membranous nephropathy with anti-GBM should rely on a combination of renal biopsy findings and serological testing. Despite aggressive treatment, one patient received maintenance hemodialysis, one patient progressed to CKD 3 stage, and the other patient died of cerebral infarction. CONCLUSION The simultaneous occurrence of membranous nephropathy and anti-GBM disease is extremely rare. The correct diagnosis of membranous nephropathy with anti-GBM relies on a combination of renal biopsy findings and serological testing. Early diagnosis is needed to improve the renal dysfunction.
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Affiliation(s)
- Ge Liu
- Department of Nephrology, The Second Hospital, Dalian Medical University, 467 Zhongshan RoadLiao Ning, Dalian, 116000, China
| | - Xinyan Feng
- Department of Nephrology, The Second Hospital, Dalian Medical University, 467 Zhongshan RoadLiao Ning, Dalian, 116000, China
| | - Shuangyan Yu
- Department of Nephrology, The Second Hospital, Dalian Medical University, 467 Zhongshan RoadLiao Ning, Dalian, 116000, China
| | - Jie Sheng
- Department of Nephrology, The Second Hospital, Dalian Medical University, 467 Zhongshan RoadLiao Ning, Dalian, 116000, China
| | - Chunyan Liu
- Department of Nephrology, The Second Hospital, Dalian Medical University, 467 Zhongshan RoadLiao Ning, Dalian, 116000, China
| | - Lihua Wang
- Department of Nephrology, The Second Hospital, Dalian Medical University, 467 Zhongshan RoadLiao Ning, Dalian, 116000, China.
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Uchida T, Oda T. The Prevalence, Characteristics, and Putative Mechanisms of Dual Antigen-Positive Membranous Nephropathy: The Underestimated Condition. Int J Mol Sci 2024; 25:5931. [PMID: 38892120 PMCID: PMC11172907 DOI: 10.3390/ijms25115931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Following the discovery of podocyte phospholipase A2 receptor and thrombospondin type-1 domain-containing 7A, various potential target antigens for membranous nephropathy (MN) have been reported one after another. MN target antigens have now been identified in a significant proportion of patients, and a new classification framework classifies patients with MN based on the detected antigen and associated disease phenotype. A serology-based approach that does not require a histological diagnosis for patients suspected of having MN has also been proposed. However, there have been cases in which dual positivity for MN antigens and/or corresponding antibodies has been shown. Importantly, some of them showed a transition of the affected patient's immune responses to MN antigens, suggesting that serological diagnosis changes depending on the timing of the analysis. In this review, we provide detailed information on these cases and present an overview of our recent understanding of their putative mechanisms involved in these cases. Greater awareness is required to adequately recognize and develop appropriate therapeutic strategies for this condition.
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Affiliation(s)
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji 193-0998, Japan;
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Sharma P, Zonozi R, Geetha D. ANCA-Associated Vasculitis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:194-205. [PMID: 39004459 DOI: 10.1053/j.akdh.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 04/19/2024] [Accepted: 04/24/2024] [Indexed: 07/16/2024]
Abstract
ANCA-associated vasculitis (AAV) is a necrotizing, small-to-medium vessel vasculitis associated with significant morbidity and mortality. AAV is a systemic autoimmune disease affecting kidneys, eyes, sinuses, peripheral nerves, skin, and upper and lower respiratory tracts. AAV tends to present in characteristic phenotypes categorized clinically as granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic GPA (EGPA). Kidney involvement is a common feature of AAV, and has important implications on disease prognosis and management. Existing therapies have been refined and improvements in our understanding of the pathophysiology of AAV has led to approval of novel therapies. In this review, we provide an overview of epidemiology, disease mechanisms, clinical presentation and review therapeutic strategies for induction and maintenance of remission.
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Affiliation(s)
- Purva Sharma
- Division of Kidney Disease and Hypertension, Northwell Health, The Glomerular Disease Center at Northwell Health.
| | - Reza Zonozi
- Nephrology Associates of Northern Virginia, Fairfax, VA; Inova Fairfax Hospital, Falls Church, VA
| | - Duvuru Geetha
- Division of Nephrology, Johns Hopkins University School of Medicine
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5
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Kronbichler A, Bajema IM, Bruchfeld A, Mastroianni Kirsztajn G, Stone JH. Diagnosis and management of ANCA-associated vasculitis. Lancet 2024; 403:683-698. [PMID: 38368016 DOI: 10.1016/s0140-6736(23)01736-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/05/2023] [Accepted: 08/17/2023] [Indexed: 02/19/2024]
Abstract
Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis consists of two main diseases, granulomatosis with polyangiitis and microscopic polyangiitis, and remains among the most devastating and potentially lethal forms of autoimmune inflammatory disease. Granulomatosis with polyangiitis and microscopic polyangiitis are characterised by a necrotising vasculitis that can involve almost any organ, and have generally been studied together. The diseases commonly affect the kidneys, lungs, upper respiratory tract, skin, eyes, and peripheral nerves. Granulomatous inflammation and multinucleated giant cells are key pathological hallmarks of granulomatosis with polyangiitis, but are absent in microscopic polyangiitis. Many immune system events are essential to disease aetiopathogenesis, such as activation of the alternative complement pathway, neutrophil activation via complement receptors, and the influx of inflammatory cells, including monocytes and macrophages. These cells perpetuate inflammation and lead to organ damage. During the 21st century, the management of ANCA-associated vasculitis has moved away from reliance on cytotoxic medications and towards targeted biological medications for both the induction and maintenance of disease remission. Earlier diagnosis, partly the result of more reliable ANCA testing, has led to improved patient outcomes and better survival. Reductions in acute disease-related mortality have now shifted focus to long-term morbidities related to ANCA-associated vasculitis and their treatments, such as chronic kidney disease and cardiovascular disease. Therapeutic approaches in both clinical trials and clinical practice still remain too reliant on glucocorticoids, and continued efforts to reduce toxicity from glucocorticoids remain a priority in the development of new treatment strategies.
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Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria; Department of Medicine, University of Cambridge, Cambridge, UK.
| | - Ingeborg M Bajema
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, Netherlands
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | | | - John H Stone
- Division of Rheumatology, Allergy, and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Maifata S, Hod R, Ghani FA, Zakaria F. Prevalence and Pattern of Glomerulonephritis: An Experience of Two Tertiary Centers in Malaysia. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2023; 34:167-177. [PMID: 38146727 DOI: 10.4103/1319-2442.391896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
The prevalence of glomerulonephritis (GN), especially membranous GN (MGN), changes from time to time. This change may be due to genetic predisposition, environmental factors race, age, and indications for a renal biopsy. This study was conducted to evaluate the distribution and changing patterns of GN by further assessing the prevalence of MGN. A 1000, 123 biopsies were performed from January 2012 to October 2019 in Hospital Serdang and Hospital Kuala Lumpur. Electron microscopy, immunohistochemistry, and clinical presentations were used to differentiate primary and secondary MGN, from which 611 and 457 primary and secondary subjects were diagnosed with primary and secondary GN, respectively. Primary MGN accounts for 13% of all the primary GN, while lupus nephritis (LN) accounts for 44.2% of all secondary GN followed by diabetes mellitus (25.6%). The proportions of primary and secondary MGN were 64.8% and 35.2%, respectively, with a male-to-female ratio of 1:1.1 in favor of females. The renal biopsy obtained from the registry of two prominent hospitals in Malaysia provided valuable prevalence and demonstrated changes in the prevalence of GN in Malaysia. Notwithstanding, immunoglobulin A nephropathy and LN remain the most common causes of primary and secondary GN in Malaysia.
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Affiliation(s)
| | - Rafidah Hod
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Fauzah Abd Ghani
- Department of Pathology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Fadhlina Zakaria
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
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Crescentic Glomerulonephritis and Membranous Nephropathy: A Rare Overlap. Case Rep Nephrol 2022; 2022:8292458. [PMID: 35782521 PMCID: PMC9249512 DOI: 10.1155/2022/8292458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 05/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background Membranous nephropathy (MN) is a disease that affects the basement membrane of the glomeruli of the kidney resulting in proteinuria. The concurrent incidence of vasculitic glomerulonephritis and MN in the same patient is unusual. Herein, we report a case with this unusual combination. Case Our patient is a 53-year-old Hispanic male with a medical history of tobacco use, type 2 diabetes mellitus, and hypertension who presented with hematuria and was found to have nephrotic range proteinuria and renal impairment. Blood workup revealed positive ANCA serology, which led to a renal biopsy that showed crescentic vasculitis in addition to membranous nephropathy. The patient was started on intermittent hemodialysis (HD) and treated initially with intravenous (IV) pulse steroids; subsequently, oral prednisolone and IV cyclophosphamide were initiated. The patient remained HD dependent at the time of discharge with the resolution of hematuria. A follow-up with an outpatient nephrology clinic was arranged. Conclusion Membranous nephropathy complicated by crescentic glomerulonephritis has a more aggressive clinical course and decline in renal function compared to MN alone which can lead to initiating renal replacement therapy. However, immunosuppressive drugs can result in significant improvement of renal function if started early enough.
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8
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Caza TN, Al-Rabadi LF, Beck LH. How Times Have Changed! A Cornucopia of Antigens for Membranous Nephropathy. Front Immunol 2021; 12:800242. [PMID: 34899763 PMCID: PMC8662735 DOI: 10.3389/fimmu.2021.800242] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
The identification of the major target antigen phospholipase A2 receptor (PLA2R) in the majority of primary (idiopathic) cases of membranous nephropathy (MN) has been followed by the rapid identification of numerous minor antigens that appear to define phenotypically distinct forms of disease. This article serves to review all the known antigens that have been shown to localize to subepithelial deposits in MN, as well as the distinctive characteristics associated with each subtype of MN. We will also shed light on the novel proteomic approaches that have allowed identification of the most recent antigens. The paradigm of an antigen normally expressed on the podocyte cell surface leading to in-situ immune complex formation, complement activation, and subsequent podocyte injury will be discussed and challenged in light of the current repertoire of multiple MN antigens. Since disease phenotypes associated with each individual target antigens can often blur the distinction between primary and secondary disease, we encourage the use of antigen-based classification of membranous nephropathy.
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Affiliation(s)
| | - Laith F. Al-Rabadi
- Department of Internal Medicine (Nephrology & Hypertension), University of Utah, Salt Lake City, UT, United States
| | - Laurence H. Beck
- Department of Medicine (Nephrology), Boston University School of Medicine and Boston Medical Center, Boston, MA, United States
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9
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Zuo Y, Cavalcante LB, Smelser JM, Sanghani N, Dwyer JP, Lewis JB, Fogo AB. Anti-Phospholipase A2 Receptor in Nonlupus Patients with Membranous Nephropathy and Crescents. GLOMERULAR DISEASES 2021; 2:75-82. [PMID: 36751533 PMCID: PMC9670025 DOI: 10.1159/000520641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/29/2021] [Indexed: 12/29/2022]
Abstract
Introduction Anti-phospholipase A2 receptor (PLA2R) is detected in approximately 70% of biopsies of "primary" membranous nephropathy (MN). Crescents in MN in nonlupus patients suggest additional injury, such as antineutrophil cytoplasmic antibody (ANCA) or anti-glomerular basement membrane (anti-GBM)-associated glomerulonephritis and are postulated to reflect injury by a mechanism that unmasks cryptic epitopes leading to the second autoantibody. Methods We studied PLA2R staining in nonlupus patients with MN and crescents. Native renal biopsies in 16 nonlupus patients with MN and crescents were stained for PLA2R. Results The patients included 5 women and 11 men, with mean age 61 years and elevated serum creatinine (mean 4.68 mg/dL). Hematuria and proteinuria (mean 4.97 g/day) were documented in 13 patients. Two patients had positive serum anti-GBM antibody. Nine of 11 patients tested for ANCA were positive, with p-ANCA (n = 4), c-ANCA (n = 2), or both (n = 1), with 2 not specified. On average, 27% of glomeruli had crescents. One patient had an initial biopsy with MN, 4 years later had MN with crescent, and 7 years later had rebiopsy with persistent MN with crescents. One patient had ANCA-associated vasculitis, and 5 years later had MN and crescent. The remaining 14 patients had concurrent diagnoses of MN and crescents. PLA2R was positive in 5 cases, 3 with ANCA positivity, 2 with unknown ANCA status, and none with anti-GBM disease. The patient with initial MN preceding crescent was PLA2R positive; the patient with initial ANCA-associated vasculitis preceding MN was PLA2R negative. Conclusions Most patients (64%) presented with concomitant MN and crescents, with rare occurrence of an initial disease process followed later by the second injury. PLA2R was positive in 31% of patients, suggesting most are secondary MN. Further study to determine the cryptic epitopes may shed light on the triggering mechanisms for these rare but unlikely coincidental glomerular injuries.
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Affiliation(s)
- Yiqin Zuo
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA,Department of Pathology and Laboratory Medicine, University of Miami, Miami, Florida, USA
| | | | | | - Neil Sanghani
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jamie P. Dwyer
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Julia Breyer Lewis
- Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Agnes B. Fogo
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA,Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA,Division of Pediatric Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee, USA,*Agnes B. Fogo,
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10
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Suchanek O, Jayne DRW, Jones RB. Therapeutic dilemmas in relapsing renal ANCA-associated vasculitis. Rheumatology (Oxford) 2021; 60:iii60-iii62. [PMID: 34137872 DOI: 10.1093/rheumatology/keab178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 02/17/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ondrej Suchanek
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis and Lupus Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis and Lupus Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Rachel B Jones
- Department of Medicine, University of Cambridge, Cambridge, UK.,Vasculitis and Lupus Unit, Cambridge University Hospitals NHS Trust, Cambridge, UK
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11
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Segmental membranous nephropathy. Clin Exp Nephrol 2021; 25:700-707. [PMID: 33755821 DOI: 10.1007/s10157-021-02056-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
Most cases of membranous nephropathy (MGN) present with global and diffuse distribution of subepithelial deposits. However, segmental MGN, in which there is focal or diffuse segmental subepithelial deposits, are occasionally encountered. The clinical and pathologic significance of segmental MGN is not well understood and thought to be more likely due to either early or resolving phase of the global form of MGN. Several case reports and literature available suggest that it may be a manifestation of secondary causes based on pathologic features such as presence of C1q and mesangial deposits, extra-glomerular deposits involving tubular basement membranes, absence of PLA2R and THSD7A, IgG1 and IgG3 subclass dominance, and the presence of other co-existing renal disease. Other reports, however, suggest that some of these cases may be a variant of the primary form of MGN. In this review, we integrate what is known about segmental MGN in order to better direct interpretation of renal biopsies in which it is identified.
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12
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Ahmad SB, Santoriello D, Canetta P, Bomback AS, D'Agati VD, Markowitz G, Ahn W, Radhakrishnan J, Appel GB. Concurrent Anti-Glomerular Basement Membrane Antibody Disease and Membranous Nephropathy: A Case Series. Am J Kidney Dis 2021; 78:219-225.e1. [PMID: 33421452 DOI: 10.1053/j.ajkd.2020.11.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/29/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Anti-glomerular basement membrane (GBM) disease is a rapidly progressive glomerulonephritis which, in some instances, occurs concurrently with other diseases such as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Rarely, it also occurs with membranous nephropathy (MN). We report a series of such patients, characterizing their long-term follow up. STUDY DESIGN Case series. SETTING & PARTICIPANTS Twelve patients referred to 1 medical center between 2001 and 2019 with anti-GBM disease and MN whose clinical characteristics and course were described. RESULTS Patients' ages ranged from 20 to 81 years old, and all presented with severe acute kidney injury requiring dialysis on presentation or shortly thereafter. Only 1 patient had pulmonary findings on presentation. The predominant pathology was crescentic and necrotizing glomerulonephritis with linear staining for immunoglobulin G along the GBM associated with epimembranous electron-dense immune-type deposits. All 11 patients who were tested had significant titers of anti-GBM antibodies, but only 1 of the 5 tested for phospholipase A2 receptor (PLA2R) on biopsy was positive. Eight patients received therapy with cyclophosphamide, prednisone, and plasmapheresis; 2 patients with prednisone and plasmapheresis; and 2 with rituximab-based regimens. Progression to a requirement for kidney replacement therapy occurred in all 12 patients, but 2 patients later recovered kidney function. Recurrence of anti-GBM disease did not occur for any of the patients studied. LIMITATIONS Incomplete testing for PLA2R in biopsy and serum, limited sample size, and lack of uniform treatment regimen. CONCLUSIONS In this case series, the presentation of concurrent anti-GBM disease and MN was characterized by rapidly progressive glomerulonephritis and poor kidney outcomes. These findings suggest possible value from earlier diagnosis and the need for identification of more effective treatment regimens.
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Affiliation(s)
- Syeda B Ahmad
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Dominick Santoriello
- Department of Pathology, Columbia College of Physicians and Surgeons, New York, NY
| | - Pietro Canetta
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Vivette D D'Agati
- Department of Pathology, Columbia College of Physicians and Surgeons, New York, NY
| | - Glen Markowitz
- Department of Pathology, Columbia College of Physicians and Surgeons, New York, NY
| | - Wooin Ahn
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Jai Radhakrishnan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Gerald B Appel
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY.
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13
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Yoshida S, Hanai S, Nakagomi D, Kobayashi K, Takahashi K, Furuya F. Membranous Nephropathy with Proteinase 3-ANCA-associated Vasculitis Successfully Treated with Rituximab. Intern Med 2021; 60:145-150. [PMID: 32830174 PMCID: PMC7835465 DOI: 10.2169/internalmedicine.4752-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Membranous nephropathy (MN) with anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis (ANCA-GN) is seen infrequently. Previous reports of patients with ANCA-GN with MN showed that the most frequent ANCA subtype was myeloperoxidase-ANCA. We herein present a 73-year-old woman with scleritis, hematuria, proteinuria, and positive serum proteinase 3 (PR3)-ANCA. She underwent a renal biopsy and was diagnosed with MN and ANCA-GN. Immunofluorescence staining for PR3 colocalized with IgG along the glomerular basement membrane were observed. Oral prednisolone and intravenous rituximab therapy immediately improved her symptoms and urinalysis abnormalities. PR3-ANCA may be involved in the pathogenesis of MN via the formation of immune complexes.
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Affiliation(s)
- Shun Yoshida
- Third Department of Internal Medicine, University of Yamanashi, Japan
| | - Shunichiro Hanai
- Third Department of Internal Medicine, University of Yamanashi, Japan
| | - Daiki Nakagomi
- Third Department of Internal Medicine, University of Yamanashi, Japan
| | - Kei Kobayashi
- Third Department of Internal Medicine, University of Yamanashi, Japan
| | - Kazuya Takahashi
- Third Department of Internal Medicine, University of Yamanashi, Japan
| | - Fumihiko Furuya
- Third Department of Internal Medicine, University of Yamanashi, Japan
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Cavanaugh C, Okusa MD. The Evolving Role of Novel Biomarkers in Glomerular Disease: A Review. Am J Kidney Dis 2021; 77:122-131. [DOI: 10.1053/j.ajkd.2020.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/06/2020] [Indexed: 02/06/2023]
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15
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Golas VL, Lao KM, Misuraca MS, Li W, Marrone MG, Kanaan HD, Zhang PL. The clinical features of overlap syndrome (ANCA-associated crescentic glomerulonephritis [AACGN] and immune complex-mediated glomerulonephritis) are similar to those of AACGN alone. Int Urol Nephrol 2020; 53:515-521. [PMID: 33025405 DOI: 10.1007/s11255-020-02654-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 09/14/2020] [Indexed: 12/01/2022]
Abstract
The overlap syndromes of anti-neutrophil cytoplasmic antibodies (ANCA)-associated crescentic glomerulonephritis (AACGN) and variants of immune complex medicated glomerulopathy (ICMGN) have been reported. But very few have compared AACGN alone with the overlap syndromes (AACGN plus ICMGN). The aim of this retrospective study was to make that comparison, following serum creatinine (sCr) to determine whether the two groups (AACGN-only group versus overlap group) would behave differently over time. We identified 14 cases with dual diagnoses of AACGN and various ICMGN in the overlap group. Data were collected and compared with 15 randomly selected AACGN-only cases over the similar period of time. The overlap syndrome represented 0.35% of our overall biopsies (14/4049). All 14 patients were ANCA positive and had crescentic formation. The percentage of crescents in the biopsies ranged from 10 to 78%. ICMGN included the following: membranoproliferative glomerulonephritis, post-infectious glomerulonephritis, membranous glomerulopathies, idiopathic mesangial proliferative glomerulonephritis, lupus nephritis, and IgA nephropathy. With the exception one biopsy revealing lupus nephritis class III, most of the ICMGN were mild. When compared to the AACGN-only group, there were no significant differences in clinical and histologic indices including age, percent of crescents, and sCr (on biopsy days, and over the follow-up periods), although the numbers of follow-up cases were limited over time. Our findings suggest that AACGN was the dominant disease process in the majority of overlap syndromes between AACGN and ICMGN, similar to the clinical processes of AACGN-only disease, therefore, the AACGN in overlap syndrome cases should be the main target for clinical management.
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Affiliation(s)
- Victoria L Golas
- Department of Nephrology, Beaumont Health System, Farminton Hill Campus, Southfield, MI, USA
| | - Kriselle Maris Lao
- Department of Pathology, Royal Oak Campus, Beaumont Health System, Southfield, MI, USA
| | - Michael S Misuraca
- Department of Nephrology, Beaumont Health System, Farminton Hill Campus, Southfield, MI, USA
| | - Wei Li
- Department of Pathology, Royal Oak Campus, Beaumont Health System, Southfield, MI, USA
| | - Mark G Marrone
- Department of Nephrology, Beaumont Health System, Farminton Hill Campus, Southfield, MI, USA
| | - Hassan D Kanaan
- Department of Pathology, Royal Oak Campus, Beaumont Health System, Southfield, MI, USA
| | - Ping L Zhang
- Department of Pathology, Royal Oak Campus, Beaumont Health System, Southfield, MI, USA. .,Division of Anatomic Pathology, William Beaumont Hospital, Beaumont LaboratoryRoyal Oak, MI, 48073, USA.
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16
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The clinicopathologic spectrum of segmental membranous glomerulopathy. Kidney Int 2020; 99:247-255. [PMID: 32599086 DOI: 10.1016/j.kint.2020.06.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/05/2020] [Accepted: 06/04/2020] [Indexed: 01/12/2023]
Abstract
Membranous glomerulopathy (MGN) is characterized by global subepithelial immune deposits that stain most intensely by immunofluorescence for IgG. Here we describe the clinical and pathologic findings in a cohort of patients with MGN in which, by definition, only segmental immune deposits are present. This rare variant, termed segmental MGN (sMGN), is poorly characterized. We retrospectively identified all patients with sMGN diagnosed at Columbia University from January 2010 to October 2018, excluding those with systemic lupus erythematosus. Data on presenting features, pathologic findings, and outcomes were collected. Fifty cases of sMGN were identified, representing 2.5% of MGN. In 21 of 50 biopsies, there was an alternative, predominant disease process. The remaining 29 patients with isolated sMGN had a median creatinine of 0.97 mg/dl, median 24-hour urine protein 3.1 g/day, and 32% had nephrotic syndrome. Staining for NELL-1 (a protein kinase C binding protein) was positive in five of 17 cases. Staining for PLA2R, THSD7A, and exostosin 1 (autoantigens in primary MGN) was negative in all biopsies evaluated. Ultrastructural evaluation revealed predominantly early stage sMGN (stage 1 or 1-2 in 14/29). Follow-up was available for 21 of the 29 patients with isolated sMGN (median 12 months), including seven who received immunosuppression (primarily glucocorticoids). During follow-up, 86% had stable/improved kidney function and 45% achieved complete while 15% achieved partial remission. Among the 15 patients with isolated sMGN without full nephrotic syndrome, only two received immunosuppression; nonetheless, 50% achieved complete while 21% achieved partial remission. Thus, sMGN is a rare PLA2R-negative variant of MGN with 29% NELL-1 positivity and favorable prognosis, even in the absence of immunosuppressive treatment.
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17
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Alawieh R, Brodsky SV, Satoskar AA, Nadasdy T, Parikh SV, Rovin B, Cassol CA. Membranous Nephropathy With Crescents. Kidney Int Rep 2020; 5:537-541. [PMID: 32274459 PMCID: PMC7136355 DOI: 10.1016/j.ekir.2020.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 01/14/2020] [Accepted: 01/20/2020] [Indexed: 10/31/2022] Open
Affiliation(s)
- Rasha Alawieh
- Department of Internal Medicine, Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sergey V Brodsky
- Department of Pathology, Division of Renal Pathology, The Ohio State University Wexner Medical Center, -Columbus, Ohio, USA
| | - Anjali A Satoskar
- Department of Pathology, Division of Renal Pathology, The Ohio State University Wexner Medical Center, -Columbus, Ohio, USA
| | - Tibor Nadasdy
- Department of Pathology, Division of Renal Pathology, The Ohio State University Wexner Medical Center, -Columbus, Ohio, USA
| | - Samir V Parikh
- Department of Internal Medicine, Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Brad Rovin
- Department of Internal Medicine, Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Clarissa A Cassol
- Department of Pathology, Division of Renal Pathology, The Ohio State University Wexner Medical Center, -Columbus, Ohio, USA
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18
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Nikolopoulou A, Huang-Doran I, McAdoo SP, Griffith ME, Cook HT, Pusey CD. Membranous Glomerulonephritis With Crescents. Kidney Int Rep 2019; 4:1577-1584. [PMID: 31890999 PMCID: PMC6933443 DOI: 10.1016/j.ekir.2019.07.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/15/2019] [Accepted: 07/31/2019] [Indexed: 01/10/2023] Open
Abstract
Introduction Membranous glomerulonephritis (MGN) is rarely associated with necrotizing and crescentic glomerulonephritis (NCGN). Methods We report the clinical and pathologic findings in 15 patients with MGN and NCGN associated with anti-neutrophil cytoplasm antibodies (ANCAs), anti-glomerular basement membrane (GBM), or anti-phospholipase A2 receptor (PLA2R) antibodies. Results The cohort consisted of 15 patients: 7 males and 8 females with a median age of 63 years (range: 18-79). In 12 of 15 patients, MGN and NCGN were diagnosed at the time of the biopsy, and in 3 cases, MGN predated the NCGN. ANCA was positive in 7 cases (6 MPO myeloperoxidase (MPO)-ANCA and 1 PR3-ANCA), anti-GBM antibodies were detected in 5 cases, and anti-PLA2R antibodies were found in 2 cases. One case was negative for all antibodies. Microscopic hematuria was present in all but one patient who was anuric, and median urinary protein-to-creatinine ratio was 819.5 mg/mmol (range: 88-5600). Pathologic evaluation revealed MGN and NCGN with crescents involving 28% of glomeruli (median; range: 5%-100%). Follow-up was available for all 15 patients; all were treated with steroids; 10 with cyclophosphamide, and 6 also received rituximab. At a median follow-up of 72 months, 9 had stabilization or improvement of renal function, 6 had progressed to end-stage renal disease, and 4 died during the follow-up period. Conclusion MGN with crescents associated with ANCAs or anti-GBM antibodies is a rare dual glomerulopathy. Patients present with heavy proteinuria, microscopic hematuria, and acute kidney injury and should be treated for a rapidly progressive glomerulonephritis. Prognosis is variable, and 40% of patients progress to end-stage renal disease.
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Affiliation(s)
- Aikaterini Nikolopoulou
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Isabel Huang-Doran
- University of Cambridge, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Megan E Griffith
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - H Terence Cook
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Charles D Pusey
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
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19
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Lionaki S, Liapis G, Boletis JN. Pathogenesis and Management of Acute Kidney Injury in Patients with Nephrotic Syndrome Due to Primary Glomerulopathies. ACTA ACUST UNITED AC 2019; 55:medicina55070365. [PMID: 31336742 PMCID: PMC6681356 DOI: 10.3390/medicina55070365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 01/10/2023]
Abstract
Acute kidney injury in the context of nephrotic syndrome is a serious and alarming clinical problem. Largely, acute kidney injury is a relatively frequent complication among patients with comorbidities while it has been independently associated with an increased risk of adverse outcomes, including death and chronic kidney disease. Nephrotic syndrome, without hematuria or with minimal hematuria, includes a list of certain glomerulopathies; minimal change disease, focal segmental glomerulosclerosis and membranous nephropathy. In the light of primary nephrotic syndrome, pathophysiology of acute kidney injury is differentiated by the nature of the primary disease and the severity of the nephrotic state. This review aims to explore the clinical circumstances and pathogenetic mechanisms of acute kidney injury in patients with nephrotic syndrome due to primary glomerulopathies, focusing on newer perceptions regarding the pathogenesis and management of this complicated condition, for the prompt recognition and timely initiation of appropriate treatment in order to restore renal function to its baseline level. Prompt recognition of the precise cause of acute kidney injury is crucial for renal recovery. Clinical characteristics, laboratory and serological findings along with histopathological findings, if required, will reveal the implicated pathway leading to individualized approach and management.
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Affiliation(s)
- Sophia Lionaki
- Nephrology Department & Transplantation Unit, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece.
| | - George Liapis
- Department of Pathology, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - John N Boletis
- Nephrology Department & Transplantation Unit, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece
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20
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Cassol CA, Rao PK, Braga JR. Acute renal failure in a patient with PR3-ANCA and monoclonal immunoglobulin deposition disease: Case report. Medicine (Baltimore) 2018; 97:e13799. [PMID: 30593167 PMCID: PMC6314724 DOI: 10.1097/md.0000000000013799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Acute renal failure developing over a short period of time with evidence of glomerular disease by urine sediment microscopy characterizes the clinical syndrome of rapidly progressive glomerulonephritis (RPGN), of which the most common causes are ANCA-associated glomerulonephritis (GN), immune-complex mediated GN and anti-GBM disease. PATIENT CONCERNS This was a middle-aged gentleman who presented with acute renal failure and a positive PR3-ANCA. DIAGNOSIS Renal biopsy showed an unusual combination of PR3-ANCA GN with focal crescents, monoclonal immunoglobulin deposition disease (MIDD) and mesangial IgA deposition on renal biopsy. INTERVENTIONS Serum and urine protein electrophoresis (UPEP) and immunofixation showed no detectable monoclonal paraprotein; bone marrow biopsy was negative for plasma cell neoplasia. He received high dose steroids and rituximab. OUTCOMES The patient did not respond to treatment and progressed to end-stage renal failure within 2 months after presentation. LESSONS To our knowledge, the simultaneous occurrence of MIDD, PR3-ANCA and mesangial IgA has not been reported. This case highlights not only the diagnostic but also the therapeutic challenges that such a complex case presentation poses to clinicians, where the culprit may not always be what would seem most obvious (such as ANCA in a patient with RPGN) but may, in fact, be an underlying and unsuspected disease, or possibly a combination of both.
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Affiliation(s)
- Clarissa A. Cassol
- Department of Pathology, Renal Pathology Division, the Ohio State University Wexner Medical Center
| | - Pawan K. Rao
- Department of Internal Medicine, St. Joseph's Hospital Health Center, Syracuse, NY, USA
| | - Juarez R. Braga
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Canada
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21
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Zonozi R, Niles JL, Cortazar FB. Renal Involvement in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis. Rheum Dis Clin North Am 2018; 44:525-543. [PMID: 30274621 DOI: 10.1016/j.rdc.2018.06.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Antineutrophil cytoplasmic antibody-associated vasculitis (AAV) is the most common cause of rapidly progressive glomerulonephritis. ANCAs play an important role in the pathogenesis and diagnosis of AAV. The classic renal lesion in AAV is a pauci-immune necrotizing and crescentic glomerulonephritis. Treatment is divided into 2 phases: (1) induction of remission to eliminate disease activity and (2) maintenance of remission to prevent disease relapse. AAV patients with end-stage renal disease require modification of immunosuppressive strategies and consideration for kidney transplantation. An improved understanding of disease pathogenesis has led to new treatment strategies being tested in clinical trials.
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Affiliation(s)
- Reza Zonozi
- Division of Nephrology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02114, USA
| | - John L Niles
- Division of Nephrology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02114, USA
| | - Frank B Cortazar
- Division of Nephrology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02114, USA.
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22
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Tominaga K, Uchida T, Imakiire T, Itoh K, Shimazaki H, Nakanishi K, Kumagai H, Oshima N. Anti-neutrophil cytoplasmic antibody-associated glomerulonephritis with detection of myeloperoxidase and phospholipase A 2 receptor in membranous nephropathy-lesions: report of two patients with microscopic polyangiitis. BMC Nephrol 2018; 19:120. [PMID: 29792176 PMCID: PMC5966893 DOI: 10.1186/s12882-018-0922-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 05/16/2018] [Indexed: 11/23/2022] Open
Abstract
Background Podocyte phospholipase A2 receptor (PLA2R) is a major target antigen in idiopathic adult membranous nephropathy (MN). Histological PLA2R staining in the renal tissue has proven to be useful for the detection of idiopathic MN. However, glomerular PLA2R deposits have also been recently observed in several patients with secondary MN, such as hepatitis B virus-associated, hepatitis C virus-associated, and neoplasm-associated MN. Certain inflammatory environments have been suggested to lead to abnormal expression of PLA2R epitopes, with the resulting production of PLA2R autoantibodies. Case presentation We report two patients diagnosed with anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis with MN-lesions, in whom ANCA titers for myeloperoxidase (MPO) were persistently positive. The first patient was a 52-years-old man who presented with interstitial pneumonitis. Microscopic hematuria and proteinuria were found when the interstitial pneumonitis became more severe. Renal biopsy findings yielded a diagnosis of ANCA-associated glomerulonephritis (mixed class) with MN-lesions. The second patient was a 63-years-old woman who had been treated for relapsing polychondritis. Her renal tissue showed evidence of focal ANCA-associated glomerulonephritis with MN-lesions. Interestingly, both MPO and PLA2R were detected in the glomerular subepithelial deposits of both patients. Immunoglobulin G (IgG) 1 and IgG2 were positive in the glomeruli of patient 2, and all subclasses of IgGs were positive in patient 1. Conclusion The present cases suggest that ANCA-associated glomerulonephritis could expose PLA2R, leading to the development of MN-lesions.
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Affiliation(s)
- Kenta Tominaga
- Department of Nephrology and Endocrinology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan.
| | - Takahiro Uchida
- Department of Nephrology and Endocrinology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Toshihiko Imakiire
- Department of Nephrology and Endocrinology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Kenji Itoh
- Division of Hematology and Rheumatology, Department of Internal Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hideyuki Shimazaki
- Department of Laboratory Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kuniaki Nakanishi
- Department of Laboratory Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hiroo Kumagai
- Department of Nephrology and Endocrinology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Naoki Oshima
- Department of Nephrology and Endocrinology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
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Clinicopathological and long-term prognostic features of membranous nephropathy with crescents: a Japanese single-center experience. Clin Exp Nephrol 2017; 22:365-376. [DOI: 10.1007/s10157-017-1465-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 08/01/2017] [Indexed: 01/03/2023]
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24
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Manabe S, Hatano M, Nakano M, Fujii T, Nitta K, Nagata M. Myeloperoxidase-antineutrophil cytoplasmic antibody causes different renal diseases by immune-complex formation and pauci-immune mechanism: A case report. Pathol Int 2017; 67:419-424. [PMID: 28580649 DOI: 10.1111/pin.12545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 05/03/2017] [Indexed: 11/26/2022]
Abstract
Antineutrophil cytoplasmic antibody (ANCA) has been known to cause pauci-immune crescentic glomerulonephritis. In addition, several reports described membranous glomerulonephritis (MN) concurrent with ANCA-associated glomerulonephritis. Because the two glomerular diseases simultaneously appear in an ANCA-positive patient, the mechanisms whereby ANCA causes the two different glomerular diseases remain ambiguous. Herein, we report a case of 19-year-old man who presented with hematuria, pre-nephrotic proteinuria, and high titer of myeloperoxidase (MPO)-ANCA. The first renal biopsy revealed MN with chronic glomerular scar lesions of unknown etiology. Predominant immunoglobulin (Ig) G1 subclass and negative phospholipase-A2 receptor staining, together with granular-positive glomerular capillary co-localization of MPO and IgG staining, suggested secondary MN due to MPO-MPO-ANCA immune-complex. Five years later, the patient presented with fever, severe renal dysfunction, and alveolar hemorrhage with high titer of MPO-ANCA that indicated pulmonary renal syndrome due to ANCA-associated vasculitis. The second renal biopsy revealed pauci-immune crescentic glomerulonephritis without either apparent MN-lesion or glomerular IgG staining. This is the first reported case showing that MPO-ANCA caused two different glomerular diseases, MN and pauci-immune crescentic glomerulonephritis, in the same patient at the different time points. Our case indicated that common MPO-ANCA might cause different glomerular diseases by different immune mechanisms.
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Affiliation(s)
- Shun Manabe
- Kidney and Vascular Pathology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.,Department of Nephrology, Yokohama Rosai Hospital, Kanagawa, Japan.,Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Michiyasu Hatano
- Department of Nephrology, Yokohama Rosai Hospital, Kanagawa, Japan
| | - Marie Nakano
- Department of Nephrology, Yokohama Rosai Hospital, Kanagawa, Japan.,Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Teruhiro Fujii
- Department of Nephrology, Yokohama Rosai Hospital, Kanagawa, Japan.,Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Michio Nagata
- Kidney and Vascular Pathology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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25
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Fujigaki Y, Tamura Y, Shibata S, Kondo F, Iwakura T, Kojima K, Yamaguchi Y, Uchida S. A Rare Adult Case with Diffuse Segmental Membranous Glomerulonephritis. Intern Med 2017; 56:1691-1695. [PMID: 28674359 PMCID: PMC5519472 DOI: 10.2169/internalmedicine.56.8298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 71-year-old man with hypertension and diabetes mellitus presented with proteinuria. Laboratory data showed proteinuria of 3.1 g/g creatinine, serum albumin of 3.5 g/dL and serum creatinine of 1.03 mg/dL without autoantibodies. A renal biopsy revealed segmental granular IgG depositions on glomerular capillary walls. Electron microscopy showed segmentally subepithelial, intramembranous and mesangial deposits. Diffuse segmental membranous glomerulonephritis (MGN) was diagnosed with only IgG1 deposition and without M-type phospholipase A2 receptor or thrombospondin type-1 domain-containing 7A staining, suggesting secondary MGN with an unknown target antigen in immune deposits. Physicians should keep in mind the existence of segmental MGN to better understand the clinicopathological characteristics.
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Affiliation(s)
- Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
- Central Laboratory, Teikyo University School of Medicine, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Fukuo Kondo
- Department of Pathology, Teikyo University School of Medicine, Japan
| | - Takamasa Iwakura
- Internal Medicine I, Division of Nephrology, Hamamatsu University School of Medicine, Japan
| | | | - Yutaka Yamaguchi
- Department of Pathology, Teikyo University School of Medicine, Japan
| | - Shunya Uchida
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
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26
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P'ng CH, Dear L, Phoon R, Brown D. A rare case of concurrent myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA)-associated necrotising and crescentic glomerulonephritis and membranous glomerulonephritis. Pathology 2016; 49:100-103. [PMID: 27931720 DOI: 10.1016/j.pathol.2016.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/20/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Chow Heok P'ng
- Department of Tissue Pathology and Diagnostic Oncology, ICPMR, Westmead Hospital, Westmead, NSW, Australia.
| | - Levina Dear
- Department of Electron Microscopy, ICPMR, Westmead Hospital, Westmead, NSW, Australia
| | - Richard Phoon
- Department of Nephrology, Westmead Hospital, Westmead, NSW, Australia
| | - David Brown
- Department of Immunology, ICPMR, Westmead Hospital, Westmead, NSW, Australia
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27
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Antineutrophil cytoplasmic antibody-associated glomerulonephritis with immunoglobulin deposition. Clin Exp Nephrol 2016; 21:643-650. [PMID: 27830351 DOI: 10.1007/s10157-016-1341-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 10/02/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis is commonly classified as pauci-immune glomerulonephritis; however, some cases have granular immunoglobulin deposition along the glomerular capillary. The pathogenesis of immune deposits is poorly studied. METHODS Of 66 patients diagnosed with ANCA-associated glomerulonephritis on renal biopsy, cases with immunoglobulin deposition along the glomerular capillary were identified and their clinicopathological characteristics were analyzed. We also performed myeloperoxidase (MPO) and double immunofluorescence (IF) stainings to determine the presence of immune complex antigens. RESULTS Granular IgG deposition, IgG plus IgM deposition, and IgM deposition were observed in 15 (22.1%), 8 (11.2%), and 17 (25.0%) cases, respectively. In cases with granular IgG deposition, MPO-IgG double IF staining revealed co-localization of MPO and IgG. In cases with granular IgM deposition, MPO-IgM double IF staining did not co-localize. By electron microscopy, subepithelial deposition as well as intramembranous, subendothelial, and mesangial deposition was detected in the patients with IgG deposition. In addition, renal survival curves were not significantly different between the immunoglobulin deposition and non-deposition groups. CONCLUSIONS Granular IgG and/or IgM deposition was observed in 60.6% of patients with ANCA-associated glomerulonephritis. In cases with IgG deposition, electron-dense deposits (EDDs) were observed at various sites in the glomerulus, and MPO and IgG immunocomplex deposition was frequently observed along the glomerular capillary. With IgM deposition, EDDs were not obvious in the glomerular basement membrane, and MPO and IgM immunocomplex was not detected. These data suggest differential mechanism between IgG deposition and IgM deposition.
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Carrara C, Emili S, Lin M, Alpers CE. Necrotizing and crescentic glomerulonephritis with membranous nephropathy in a patient exposed to levamisole-adulterated cocaine. Clin Kidney J 2015; 9:234-8. [PMID: 26985374 PMCID: PMC4792616 DOI: 10.1093/ckj/sfv141] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/17/2015] [Indexed: 11/20/2022] Open
Abstract
Levamisole is an antihelminthic agent widely used as an adulterant of illicit cocaine recently implicated as a cause of antineutrophil cytoplasmic antibody (ANCA)–associated microscopic polyangiitis in cocaine abusers. An isolated case of membranous nephropathy (MN) associated with levamisole exposure has also been reported. We report the first case, to our knowledge, of a patient with both microscopic polyangiitis manifest as a pauci-immune necrotizing and crescentic glomerulonephritis and concurrent MN in the setting of chronic cocaine abuse and presumed levamisole exposure, raising the hypothesis that levamisole was the causative agent in the development of this rare dual glomerulopathy.
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Affiliation(s)
- Camillo Carrara
- Department of Medicine, Service of Nephrology , Azienda Ospedaliera Papa Giovanni XXIII , Bergamo , Italy
| | - Stefano Emili
- Department of Medicine, Service of Nephrology , Aurora Kidney , Anchorage, AK , USA
| | - Mercury Lin
- Department of Pathology , University of Washington Medical Center , Seattle, WA , USA
| | - Charles E Alpers
- Department of Pathology , University of Washington Medical Center , Seattle, WA , USA
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Wang J, Zhu P, Cui Z, Qu Z, Zhang YM, Wang F, Wang X, Wang JW, Zhu SN, Liu G, Zhou FD, Zhao MH. Clinical Features and Outcomes in Patients With Membranous Nephropathy and Crescent Formation. Medicine (Baltimore) 2015; 94:e2294. [PMID: 26683965 PMCID: PMC5058937 DOI: 10.1097/md.0000000000002294] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cases of membranous nephropathy (MN) with crescent formation, in the absence of lupus, hepatitis B virus infection, anti-glomerular basement membrane (GBM) nephritis, or antineutrophil cytoplasmic antibody (ANCA), are on record. Clinical presentation and treatment outcomes in these patients are unclear. All patients with biopsy-proven MN diagnosed between years 2008 and 2014 and followed up were enrolled retrospectively. Patients with ANCA, anti-GBM antibodies, lupus, hepatitis B virus infection, or malignance were excluded. Clinical features and outcomes were compared between MN patients with and without crescent. Out of 401 consecutive patients with idiopathic MN, 28 (6.9%) showed crescent formation in 4.9% (2.2%-16.7%) of glomeruli. Mean age of these patients was 50.1 ± 11.1 years, and they presented with heavy proteinuria (6.5 ± 4.8 g/24 h) and hematuria; 21.4% of these patients had declined estimated glomerular filtration rate (<60 mL/min/1.73 m2) on biopsy. Anti-phospholipase A2 receptor antibody was detectable in 79.7% of these patients. These clinical features were comparable to the MN patients without crescent (P > 0.05). Twelve (42.9%) patients received steroids plus immunosuppressive therapy similar to that in patients without crescent (41.3%). Fewer patients with crescents achieved remission (67.9% vs 86.7%, P = 0.029). Crescent formation was a risk factor for no response to the treatments (odds ratio [OR] = 3.1, P = 0.033). Higher percentage of crescents predicted more risk for no remission (OR = 1.2, P = 0.038). Patients with crescents presented more frequencies of abnormal serum creatinine during follow-up (10.7% vs 1.3%, P = 0.031). Crescent formation was also a risk factor for worse renal outcome (relative risk = 10.2, P = 0.046). MN patients with crescents showed unfavorable therapeutic response and tended to have worse renal outcomes. More aggressive treatments and renal protection might be considered to improve the outcomes.
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Affiliation(s)
- Jia Wang
- From the Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing (JW, PZ, ZC, ZQ, Y-mZ, FW, XW, J-wW, GL, F-DZ, M-hZ); Renal Division (PZ), Department of Medicine, The First College of Clinical Medical Science, China Three Gorges University, Yichang; Department of Biostatistics (S-nZ), Peking University First Hospital; and Peking-Tsinghua Center for Life Sciences (M-hZ), Beijing, China
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Pauci-Immune Necrotizing and Crescentic Glomerulonephritis with Membranous Lupus Nephritis, Fifteen Years after Initial Diagnosis of Secondary Membranous Nephropathy. Case Rep Nephrol 2015; 2015:120762. [PMID: 26558120 PMCID: PMC4617882 DOI: 10.1155/2015/120762] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 08/30/2015] [Indexed: 12/02/2022] Open
Abstract
Renal involvement in systemic lupus erythematosus (SLE) is usually immune complex mediated and may have multiple different presentations. Pauci-immune necrotizing and crescentic glomerulonephritis (NCGN) refers to extensive glomerular inflammation with few or no immune deposits that may result in rapid decline in renal function. We report a case of a 79-year-old Hispanic male with a history of secondary membranous nephropathy (diagnosed by renal biopsy 15 years previously) who was admitted with acute kidney injury and active urinary sediment. P-ANCA titers and anti-myeloperoxidase antibodies were positive. The renal biopsy was diagnostic for NCGN superimposed on a secondary membranous nephropathy. A previous diagnosis of SLE based on American College of Rheumatology criteria was discovered via Veteran's Administration records review after the completion of treatment for pauci-immune NCGN. ANCAs are detected in 20–31% of patients with SLE. There may be an association between SLE and ANCA seropositivity. In patients with lupus nephritis and biopsy findings of necrotizing and crescentic glomerulonephritis, without significant immune complex deposition, ANCA testing should be performed. In patients with secondary membranous nephropathy SLE should be excluded.
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Zou R, Liu G, Cui Z, Chen M, Zhao MH. Clinical and Immunologic Characteristics of Patients With ANCA-Associated Glomerulonephritis Combined With Membranous Nephropathy: A Retrospective Cohort Study in a Single Chinese Center. Medicine (Baltimore) 2015; 94:e1472. [PMID: 26376387 PMCID: PMC4635801 DOI: 10.1097/md.0000000000001472] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The concurrent antineutrophil cytoplasmic antibody-associated glomerulonephritis (ANCA-GN) and membranous nephropathy (MN) have been increasingly documented, mainly in case studies and case series; however, the differences of clinical and pathologic characteristics as well as outcomes between ANCA-GN patients with and without MN remain unclear. The current study investigated the clinical and immunologic features of patients with combined ANCA-GN and MN in a large cohort. Twenty-seven of 223 patients had combined ANCA-GN and MN; they had significantly higher levels of initial serum creatinine, higher Birmingham Vasculitis Activity Score and poorer renal outcome than ANCA-GN patients without MN (P < 0.05). ANCA-GN patients with MN could recognize the light chain of myeloperoxidase more frequently than those without MN (P < 0.05). The prevalence of circulating anti-PLA2R antibodies and glomerular PLA2R deposits was significantly lower in patients with combined ANCA-GN and MN than that in patients with idiopathic MN (P < 0.05). Compared with the idiopathic MN patients, the patients with combined ANCA-GN and MN had significantly higher recognition frequency of immunoglobulin (Ig) G2 and IgG3, and significantly lower recognition frequency of IgG4 (P < 0.05). Patients with combined ANCA-GN and MN had distinct clinical features and a different pathogenesis of MN.
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Affiliation(s)
- Rong Zou
- From the Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology (RZ, GL, ZC, MC, M-HZ); Key Laboratory of Renal Disease, Ministry of Health of China (RZ, GL, ZC, MC, M-HZ); Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Peking-Tsinghua Center for Life Sciences; Beijing, China (RZ, GL, ZC, MC, M-HZ); and Renal Division, Department of Medicine, Wuhan Integrated TCM and Western Medicine Hospital; Wuhan, China (RZ)
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Kim YH, Kim HR, Ham YR, Jeon JW, Chung S, Choi DE, Lee KW, Na KR. A Case of Membranous Glomerulonephritis with Superimposed Anti-Neutrophil Cytoplasmic Antibody-Associated Rapidly Progressive Crescentic Glomerulonephritis. Chonnam Med J 2015; 51:102-5. [PMID: 26306306 PMCID: PMC4543148 DOI: 10.4068/cmj.2015.51.2.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/08/2015] [Accepted: 06/15/2015] [Indexed: 11/06/2022] Open
Abstract
Idiopathic membranous glomerulonephritis (IMGN) is commonly diagnosed in adults with proteinuria. Rapid deterioration of renal function is a rare complication of IMGN, except when accompanied by renal vein thrombosis, malignant hypertension, or other underlying disease, including lupus nephritis. Here, we present a case of rapid deterioration of renal function in a patient with MGN superimposed with anti-neutrophil cytoplasmic antibody (ANCA)-associated rapidly progressive crescentic glomerulonephritis (RPGN). Overall, about 20 cases of MGN with ANCA-associated RPGN have been reported. This case of biopsy-proven MGN with ANCA-associated RPGN is the first to be reported in Korea.
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Affiliation(s)
- Yoo Hyung Kim
- Departments of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Hae Ri Kim
- Departments of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Young Rok Ham
- Departments of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Jae Woong Jeon
- Departments of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Sarah Chung
- Departments of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Dae Eun Choi
- Departments of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Kang Wook Lee
- Departments of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Ki Ryang Na
- Departments of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
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Balafa O, Kalaitzidis R, Liapis G, Xiromeriti S, Zarzoulas F, Baltatzis G, Elisaf M. Crescentic glomerulonephritis and membranous nephropathy: a rare coexistence. Int Urol Nephrol 2015; 47:1373-7. [DOI: 10.1007/s11255-015-1031-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 06/07/2015] [Indexed: 11/24/2022]
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Kanodia K, Vanikar A, Patel R, Suthar K, Nigam L, Kute V, Trivedi H. Membranous Nephropathy With MPO-ANCA-Associated Crescentic GN. Nephrourol Mon 2015; 6:e20701. [PMID: 25738112 PMCID: PMC4330666 DOI: 10.5812/numonthly.20701] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 06/16/2014] [Accepted: 06/26/2014] [Indexed: 11/16/2022] Open
Abstract
Introduction: Antineutrophil cytoplasmic antibodies (ANCA)-associated glomerulonephritis (GN) is characterized by necrotizing and crescentic GN with paucity of immunoglobulin (Ig) and complement deposition, which is also known as pauci-immune crescentic GN. Membranous nephropathy (MN) is characterized by the formation of subepithelial immune deposit with resultant changes in glomerular basement membrane (GBM), most notably spike formation. Case Presentation: A 48-year-old man presented with marked proteinuria, hypoalbuminemia, and renal dysfunction with positive results for myeloperoxidase (MPO) and ANCA. Renal biopsy revealed crescents and thick GBM with subepithelial spikes along with IgG deposition on immunofluorescent staining. The condition was diagnosed as MN with MPO-ANCA-associated crescentic GN. He was treated with intravenous methylprednisolone and cyclophosphamide. After one-month follow-up, antibody level and renal function did not improve. Conclusions: Coexistence of MN with MPO-ANCA crescentic GN is very rare and should be managed aggressively.
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Affiliation(s)
- Kamal Kanodia
- Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedaba, India
- Corresponding author: Kamal Kanodia, Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedabad, India. Tel: +91-7922687162; +91-7922687000, Fax: +91-7922685454, E-mail:
| | - Aruna Vanikar
- Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedaba, India
| | - Rashmi Patel
- Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedaba, India
| | - Kamlesh Suthar
- Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedaba, India
| | - Lovelesh Nigam
- Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, G.R. Doshi and K.M. Mehta Institute of Kidney Diseases and Research Centre and Dr. H.L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Ahmedaba, India
| | - Vivek Kute
- Department of Nephrology and Transplantation Medicine, Ahmedabad, India
| | - Hargovind Trivedi
- Department of Nephrology and Transplantation Medicine, Ahmedabad, India
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A Case of Concurrent MPO-/PR3-Negative ANCA-Associated Glomerulonephritis and Membranous Glomerulopathy. Case Rep Nephrol 2015; 2015:316863. [PMID: 25648906 PMCID: PMC4306403 DOI: 10.1155/2015/316863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 12/21/2014] [Indexed: 11/23/2022] Open
Abstract
We report a case in which antineutrophil cytoplasmic antibody- (ANCA-) associated glomerulonephritis and membranous glomerulopathy (MGN) were detected concurrently. The patient showed rapidly progressive renal deterioration. A renal biopsy showed crescentic glomerulonephritis, together with marked thickening and spike and bubbling formations in the glomerular basement membranes. Indirect immunofluorescence examination of the patient's neutrophils showed a perinuclear pattern. Enzyme-linked immunosorbent assays revealed that the ANCA in this case did not target myeloperoxidase (MPO) or proteinase 3 (PR3) but bactericidal-/permeability-increasing protein, elastase, and lysosome. The relationship between these two etiologically distinct entities, MPO-/PR3-negative ANCA-associated glomerulonephritis and MGN, remains unclear.
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36
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Clinical and Pathological Study on Patients With Primary Antineutrophil Cytoplasmic Autoantibody–Associated Vasculitis With Renal Immune Complex Deposition. J Clin Rheumatol 2015; 21:3-9. [DOI: 10.1097/rhu.0000000000000207] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Hu ZJ, Niu K, Liu B, Shi YN. A case of membranous nephropathy and myeloperoxidase anti-neutrophil cytoplasmic antibody-associated glomerulonephritis. Exp Ther Med 2014; 8:1170-1172. [PMID: 25187818 PMCID: PMC4151641 DOI: 10.3892/etm.2014.1852] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 07/04/2014] [Indexed: 11/06/2022] Open
Abstract
Membranous nephropathy (MN) may be a primary disease or secondary to autoimmune conditions such as systemic lupus erythematosus, infection (for example, with hepatitis B or C virus), cancer or drugs. In primary MN, crescents are rarely observed. Therefore, the presence of crescents suggests another underlying disease, for example lupus nephritis, anti-glomerular basement membrane disease or anti-neutrophil cytoplasmic antibody-associated glomerulonephritis (ANCA-GN). The coexistence of primary MN and ANCA-GN is rare. In the present case, a 51-year-old female with mild edema in the lower extremities for 1 year was admitted to hospital for renal biopsy. The serum test for myeloperoxidase (MPO)-ANCA was positive. The patient was diagnosed with stage 2 MN with crescentic glomerulonephritis type 3; however, no causal association was found between these two diseases in this case. Treatment was initiated with 500 mg methylprednisolone for 3 days followed by 40 mg of oral methylprednisolone together with 50 mg cyclophosphamide twice per day. One month following treatment, the biochemical data results of the patient had improved.
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Affiliation(s)
- Zhi-Juan Hu
- Department of Nephrology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Kai Niu
- Department of Nephrology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Bing Liu
- Department of Nephrology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
| | - Ya-Nan Shi
- Department of Nephrology, Hebei General Hospital, Shijiazhuang, Hebei 050051, P.R. China
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Thajudeen B, John SG, Ossai NO, Riaz IB, Bracamonte E, Sussman AN. Membranous nephropathy with crescents in a patient with Hashimoto's thyroiditis: a case report. Medicine (Baltimore) 2014; 93:e63. [PMID: 25121358 PMCID: PMC4602443 DOI: 10.1097/md.0000000000000063] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Membranous nephropathy is a common cause of nephrotic syndrome in adults. It usually occurs secondary to underlying disease processes such as autoimmune disorders, malignancy, infection, and drugs. The presentation of nephrotic syndrome with concomitant precipitous decline in renal function warrants investigation of a coexistent disorder.We report the case of a 30-year-old male who presented with symptoms and signs of hypothyroidism.A diagnosis of Hashimoto's thyroiditis was contemplated based on the presence of high serum levels of antithyroglobulin and antithyroid peroxidase antibodies. Upon initiation of treatment with levothyroxine, patient symptomatology improved; however, the laboratory studies demonstrated continued elevated creatinine, hematuria, and proteinuria, which had not been addressed. Two months following treatment initiation, he had progressive deterioration in renal function and proteinuria. A renal biopsy revealed coexistent necrotizing and crescentic glomerulonephritis and membranous nephropathy.The final diagnosis was necrotizing, crescentic glomerulonephritis with superimposed membranous nephropathy likely secondary to Hashimoto's thyrodiitis.Induction treatment with oral cyclophosphamide and prednisone was started.At the end of 6 months of treatment, there was improvement in renal function and proteinuria and maintenance treatment with azathioprine and low-dose prednisone was initiated. This case highlights the importance of precise and detailed evaluation of patients with autoimmune diseases such as Hashimoto's thyroiditis particularly in the presence of active urine sediment. Proper evaluation and diagnosis of such patients has implications on the prognosis and response to treatment.
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Affiliation(s)
- Bijin Thajudeen
- Department of Nephrology (BT, N-OO, ANS); Department of Medicine (SGJ, IBR); Department of Pathology (EB), University of Arizona Medical Center, Tucson, Arizona, USA
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Rodriguez EF, Nasr SH, Larsen CP, Sethi S, Fidler ME, Cornell LD. Membranous nephropathy with crescents: a series of 19 cases. Am J Kidney Dis 2014; 64:66-73. [PMID: 24709471 DOI: 10.1053/j.ajkd.2014.02.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 02/06/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Membranous nephropathy (MN) with crescents is rare and, in the absence of lupus, usually is associated with anti-glomerular basement membrane (anti-GBM) nephritis or antineutrophil cytoplasmic antibody (ANCA)-positive glomerulonephritis. Only rare cases of crescentic MN without ANCA or anti-GBM have been reported. STUDY DESIGN Case series. SETTING & PARTICIPANTS 19 patients with ANCA- and anti-GBM-negative crescentic MN and no clinical evidence of systemic lupus. OUTCOMES Clinical features, kidney biopsy findings, laboratory results, treatment, and follow-up of patients with crescentic MN. RESULTS Mean age was 55 (range, 5-86) years. All patients presented with proteinuria (mean protein excretion, 11.5 [range, 3.3-29] g/d) and nearly all had hematuria; 16 of 19 (84%) patients had decreased estimated glomerular filtration rates (eGFRs; mean serum creatinine, 2.9 [range, 0.4-10] mg/dL; mean eGFR, 39.7 [range, 4 to >100] mL/min/1.73 m2). Glomeruli showed on average 25% (range, 2%-73%) involvement by crescents. All showed a membranous pattern; 7 showed mesangial and 2 showed segmental endocapillary proliferation. By immunofluorescence, all cases showed granular subepithelial immunoglobulin G (IgG) and κ and λ light chains, and all but one showed C3; 5 showed C1q or IgA. Electron microscopy revealed stages I-III MN; 38% of cases were M-type phospholipase A2 receptor (PLA2R) associated, indicating that at least some were primary MN. Follow-up clinical data were available for all patients (mean, 22 [range, 1.5-138] months). 14 patients received immunosuppressive therapy, and 2, only angiotensin-converting enzyme inhibitor/angiotensin receptor blocker therapy. 4 patients (21%) progressed to end-stage renal disease, at 0-9 months postbiopsy. Mean serum creatinine level of those without end-stage renal disease at follow-up was 1.7 (range, 0.5-4.1) mg/dL; mean eGFR was 53.3 (range, 16-103) mL/min/1.73 m2. 67% of patients had proteinuria with protein excretion≥1 (mean, 3.2) g/d at follow-up. LIMITATIONS Retrospective study. CONCLUSIONS Crescentic MN is a rare variant of MN that usually presents with heavy proteinuria, hematuria, and decline in GFR. The prognosis is variable and the disease may respond to therapy, but most patients develop a long-term decline in GFR.
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Affiliation(s)
- Erika F Rodriguez
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Mary E Fidler
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
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Ram R, Rao CSS, Swarnalatha G, Sireesha K, Madhuri HR, Rajasekhar L, Dakshinamurty KV. Membranous nephropathy superimposed on Churg-Strauss syndrome. Indian J Nephrol 2014; 24:57-9. [PMID: 24574636 PMCID: PMC3927196 DOI: 10.4103/0971-4065.125132] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The association of membranous nephropathy with Churg-Strauss syndrome is not widely reported. We present a patient with myeloperioxidase–perinuclear antineutrophilic cytoplasmic antibody (MPO-pANCA)-positive necrotizing and crescentic glomerulonephritis who later developed membranous nephropathy.
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Affiliation(s)
- R Ram
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - C Shyam Sunder Rao
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - G Swarnalatha
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - K Sireesha
- Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - H R Madhuri
- Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - L Rajasekhar
- Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - K V Dakshinamurty
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, India
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41
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Barrett CMF, Troxell ML, Larsen CP, Houghton DC. Membranous glomerulonephritis with crescents. Int Urol Nephrol 2013; 46:963-71. [PMID: 24217802 DOI: 10.1007/s11255-013-0593-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 10/22/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE The coexistence of membranous glomerulonephritis (MGN) and necrotizing and crescentic glomerulonephritis (NCGN) is an unusual finding in a renal biopsy except in lupus nephritis. Little is known about whether these lesions are causally related in any clinical setting. METHODS We reviewed the pathology, presentation, and clinical course of 13 non-lupus patients with combined MGN and NCGN in native kidney biopsies (nine females, four males; median age 69 years), with particular attention to evidence of secondary MGN. Additional IgG subclass and phospholipase A2 receptor (PLA2R) immunofluorescence studies were conducted in seven cases. RESULTS Eight biopsies were pauci-immune other than the capillary wall deposits of MGN; one patient had a non-lupus immune complex disease, and four had mesangial deposits, including one with rare subendothelial deposits. None had anti-glomerular basement membrane disease. IgG4 was dominant or codominant in the capillary wall deposits in three cases and virtually absent in four; PLA2R was positive in two cases, and negative in five. Seven patients were judged to have secondary MGN, including five of eight ANCA+ patients. Twelve patients were treated with combinations of steroids, cyclophosphamide, rituximab, followed by durable response in seven and relentless progression to end stage renal disease in four. CONCLUSIONS Secondary MGN occurs with higher frequency in ANCA-positive NCGN than in the general MGN population. A causal relationship between MGN and NCGN was not established in any patient, but circumstances suggest a common cause in several, including immune complex disease, drug reaction and paraneoplastic syndrome.
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Affiliation(s)
- Caroline M F Barrett
- Department of Pathology, Oregon Health and Science University, L471, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
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Abstract
Membranous nephropathy is characterized by immune complex deposits on the outer side of the glomerular basement membrane. Activation of complement and of oxidation lead to basement membrane lesions. The most frequent form is idiopathic. At 5 and 10 years, renal survival is around 90 and 65% respectively. A prognostic model based on proteinuria, level and duration, progression of renal failure in a few months can refine prognosis. The urinary excretion of C5b-9, β2 and α1 microglobuline and IgG are strong predictors of outcome. Symptomatic treatment is based on anticoagulation in case of nephrotic syndrome, angiotensin conversion enzyme inhibitors, angiotensin II receptor blockers and statins. Immunosuppressive therapy should be discussed for patients having a high risk of progression. Corticoids alone has no indication. Treatment should include a simultaneous association or more often alternating corticoids and alkylant agent for a minimum of 6 months. Adrenocorticoid stimulating hormone and steroids plus mycophenolate mofetil may be equally effective. Steroids plus alkylant decrease the risk of end stage renal failure. Cyclosporine and tacrolimus decrease proteinuria but are associated with a high risk of recurrence at time of withdrawal and are nephrotoxic. Rituximab evaluated on open studies needs further evaluations to define its use.
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Affiliation(s)
- Lucile Mercadal
- Service de néphrologie, groupe hospitalier Pitié-Salpêtrière, 83, boulevard de l'Hôpital, 75013 Paris, France.
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43
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Antineutrophil cytoplasmic antibody-associated crescentic glomerulonephritis with membranous nephropathy treated using thiamazole. CEN Case Rep 2013; 2:165-169. [DOI: 10.1007/s13730-013-0060-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 01/07/2013] [Indexed: 10/27/2022] Open
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44
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Lee CJ, Suh KS, Kim KH, Chang YK, Na KR, Lee KW. The Clinicopathologic Significance of Endothelial Tubuloreticular Inclusions in Glomerular Diseases. Ultrastruct Pathol 2013; 37:386-94. [DOI: 10.3109/01913123.2013.814738] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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45
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A patient presenting with bilateral lung lesions, pleural effusion, and proteinuria. Case Rep Med 2013; 2013:489362. [PMID: 23762073 PMCID: PMC3665212 DOI: 10.1155/2013/489362] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 04/01/2013] [Accepted: 04/08/2013] [Indexed: 12/24/2022] Open
Abstract
Diagnosis and management of a systemic vasculitis are among the most demanding challenges in clinical medicine. A patient with a past history of cryptogenic organizing pneumonia presents with new bilateral lung lesions, unilateral pleural effusion, and significant proteinuria. The patient tested p-ANCA and anti-MPO positive but c-ANCA negative. A diagnosis of granulomatosis with polyangiitis GPA was reached after performing both renal and lung biopsies. Step-by-step differential diagnosis and management are discussed.
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46
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Combined membranous nephropathy and crescentic glomerulonephritis with concurrent anti-glomerular basement membrane antibody and myeloperoxidase-specific anti-neutrophil cytoplasmic antibody. CEN Case Rep 2013; 2:107-111. [PMID: 28509234 DOI: 10.1007/s13730-012-0054-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 11/25/2012] [Indexed: 10/27/2022] Open
Abstract
We report a case of a 71-year-old man with rapidly progressive nephritic syndrome and dual positivity for anti-glomerular basement membrane antibody and myeloperoxidase-specific anti-neutrophil cytoplasmic antibody. Renal biopsy revealed crescentic, mainly cellular, glomerulonephritis with granulomatous lesions, and advanced membranous changes. Membranous nephropathy had apparently existed for an extended period before the development of crescentic glomerulonephritis. In some studies reporting the simultaneous occurrence of both diseases, membranous nephropathy might be followed by crescentic glomerulonephritis, presumably from a histological point of view. Although we cannot prove a causal relationship between the two diseases, we caution that precise observations, especially histological, are necessary in similar cases.
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Uyama S, Ohashi N, Iwakura T, Ono M, Fujikura T, Sakao Y, Yasuda H, Kato A, Fujigaki Y. A case presenting with the possible relationship between myeloperoxidase-antineutrophil cytoplasmic antibody-associated glomerulonephritis and membranous changes of the glomerular basement membrane. CEN Case Rep 2013; 2:53-58. [PMID: 28509220 DOI: 10.1007/s13730-012-0039-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2012] [Accepted: 09/28/2012] [Indexed: 11/26/2022] Open
Abstract
A 72-year-old woman exhibited elevated serum myeloperoxidase-antineutrophil cytoplasmic antibody (MPO-ANCA) levels since 2006. Her serum creatinine (sCr) levels increased from 0.5 to 1.62 mg/dl in a stepwise pattern with proteinuria and hematuria up to January 2011. Renal biopsy indicated global sclerosis (14 %), fibrocellular crescents (28 %), and Swiss cheese-like appearance of the glomerular basement membrane (GBM) on light microscopy. IgG4 staining was negative. Immunofluorescent examination indicated granular staining with IgG and C3 along the GBM. MPO-ANCA-associated glomerulonephritis with membranous nephropathy (MN) was diagnosed. As chronic changes were relatively evident in the renal biopsy specimen without acute augmentation of renal function, immunosuppressive therapy was not administered. Thereafter, rapidly progressive renal dysfunction occurred (sCr, 3.67 mg/dl in May 2011) with proteinuria (~2 g/day), hematuria, and elevated serum MPO-ANCA levels. Therefore, a second renal biopsy was performed in May 2011, indicating global sclerosis (42 %) and cellular crescents (35 %) on light microscopy. Electron microscopy indicated electron-dense deposits in the GBM and mesangial lesions. Steroid therapy was subsequently initiated, and the patient's renal function partially improved. MPO-ANCA levels decreased to within normal limits and hematuria disappeared. MPO-ANCA-associated glomerulonephritis with MN is a rare dual glomerulopathy. However, complication should be considered when urinary protein appears in large amounts. Secondary MN was suspected due to the lack of IgG4 staining and distribution of electron-dense deposits to the mesangial lesion. Renal dysfunction occurring in a stepwise pattern may be attributed to intermittent augmentation in MPO-ANCA-associated glomerulonephritis.
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Affiliation(s)
- Satoko Uyama
- Internal Medicine 1, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Naro Ohashi
- Internal Medicine 1, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan.
| | - Takamasa Iwakura
- Internal Medicine 1, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Masafumi Ono
- Internal Medicine 1, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Tomoyuki Fujikura
- Internal Medicine 1, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yukitoshi Sakao
- Blood Purification Unit, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Hideo Yasuda
- Internal Medicine 1, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Akihiko Kato
- Blood Purification Unit, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
| | - Yoshihide Fujigaki
- Internal Medicine 1, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, 431-3192, Japan
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48
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Shimada M, Fujita T, Nakamura N, Narita I, Shimaya Y, Murakami R, Yamabe H, Osawa H, Okumura K. A case of myeloperoxidase anti-neutrophil cytoplasmic antibody (MPO-ANCA)-associated glomerulonephritis and concurrent membranous nephropathy. BMC Nephrol 2013; 14:73. [PMID: 23537120 PMCID: PMC3616833 DOI: 10.1186/1471-2369-14-73] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Accepted: 03/12/2013] [Indexed: 11/17/2022] Open
Abstract
Background Myeloperoxidase anti-neutrophil cytoplasmic antibody-associated glomerulonephritis (MPO-ANCA-GN) and concurrent membranous nephropathy (MN) are very rare combination. Their causal relationship has been suggested, but not determined. Case presentation A 73-years-old male with 5-year history of proteinuria underwent an operation for his sigmoid colon cancer. Seven months later, he was referred to a nephrology division due to an exacerbating renal function and hypoalbuminemia. Laboratory examination revealed positive MPO-ANCA in the serum. A renal biopsy revealed a necrotizing extracapillary proliferative glomerulonephritis with crescents, demonstrating MPO-ANCA-GN. Whereas, immunofluorescent staining documented granular deposition of immumoglobulin (Ig) G and C3 along the capillary wall and electron microscopy showed subepithelial deposits in the glomerular basement membrane demonstrating MN. Immunofluorescent staining of IgG subclass showed positive IgG1, IgG2, negative IgG3 and weak positive IgG4 suggested the possibility of malignancy-associated MN. Conclusion Combination of MPO-ANCA-GN and MN are rare. Although the causal relationship has been suggested in some cases, we should consider all the possibilities including idiopathic MN and secondary MN associated with malignancy, drug use or infection.
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Affiliation(s)
- Michiko Shimada
- Graduate School of Medicine, Division of Cardiology, Respiratory Medicine and Nephrology, Hirosaki University, 5 Zaifu-cho, Hirosaki, 036-8562, Japan.
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49
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Konstantinov KN, Emil SN, Barry M, Kellie S, Tzamaloukas AH. Glomerular disease in patients with infectious processes developing antineutrophil cytoplasmic antibodies. ISRN NEPHROLOGY 2013; 2013:324315. [PMID: 24959541 PMCID: PMC4045435 DOI: 10.5402/2013/324315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 11/06/2012] [Indexed: 12/21/2022]
Abstract
To identify differences in treatment and outcome of various types of glomerulonephritis developing in the course of infections triggering antineutrophil cytoplasmic antibody (ANCA) formation, we analyzed published reports of 50 patients. Immunosuppressives were added to antibiotics in 22 of 23 patients with pauci-immune glomerulonephritis. Improvement was noted in 85% of 20 patients with information on outcomes. Death rate was 13%. Corticosteroids were added to antibiotics in about 50% of 19 patients with postinfectious glomerulonephritis. Improvement rate was 74%, and death rate was 26%. Two patients with mixed histological features were analyzed under both pauci-immune and post-infectious glomerulonephritis categories. In 9 patients with other renal histology, treatment consisted of antibiotics alone (7 patients), antibiotics plus immunosuppressives (1 patient), or immunosuppressives alone (1 patient). Improvement rate was 67%, permanent renal failure rate was 22%, and death rate was 11%. One patient with antiglomerular basement disease glomerulonephritis required maintenance hemodialysis. Glomerulonephritis developing in patients who became ANCA-positive during the course of an infection is associated with significant mortality. The histological type of the glomerulonephritis guides the choice of treatment. Pauci-immune glomerulonephritis is usually treated with addition of immunosuppressives to antibiotics.
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Affiliation(s)
- Konstantin N. Konstantinov
- Division of Rheumatology, Department of Medicine, Raymond G. Murphy VA Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Suzanne N. Emil
- Division of Rheumatology, Department of Medicine, Raymond G. Murphy VA Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Marc Barry
- Department of Pathology, University of New Mexico School of Medicine, MSC08 4640, BMSB, Room 335, University of New Mexico, Albuquerque, NM 87131, USA
| | - Susan Kellie
- Division of Infectious Diseases, Department of Medicine, Raymond G. Murphy VA Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Antonios H. Tzamaloukas
- Division of Nephrology, Department of Medicine, Raymond G. Murphy VA Medical Center, University of New Mexico School of Medicine, VA Medical Center (111C), 1501 San Pedro, SE, Albuquerque, NM 87131, USA
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50
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Imtiaz S, Alswaida A, Rehman H, Faraz N, Afshan T, Alkafoury H, Qayyum S, Al Khoiter M. Transformation of membranous into anti-GBM nephritis. Indian J Nephrol 2013; 22:370-3. [PMID: 23326049 PMCID: PMC3544060 DOI: 10.4103/0971-4065.103924] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Membranous nephropathy is a common glomerular disease. We report a 50-year-old man with a history of membranous nephropathy in remission, who presented with acute kidney injury, proteinuria, hematuria, and hypertension. He also had a high anti-glomerular basement membrane (anti-GBM) antibody titer and crescent transformation of primary pathology. The kidney functions deteriorated rapidly despite aggressive therapy with cyclophosphamide, methylprednisolone, and plasmapheresis.
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Affiliation(s)
- S Imtiaz
- Department of Medicine, King Khalid University, Hospital Riyadh, Saudi Arabia
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