Specific eye fundus lesions in type II membranoproliferative glomerulonephritis

Small Hard Macular Drusen and Associations in 11- to 12-Year-Old Children in the Copenhagen Child Cohort 2000 Eye Study

Purpose

To assess the prevalence and associations of small hard drusen in a child cohort.

Methods

Cross-sectional study of 11- to 12-year-old Danish children from the population-based Copenhagen Child Cohort 2000 Eye Study. Fovea-centered, 45° color images of both eyes were graded for macular drusen (within one optic-disc-rim-to-fovea distance of the foveal center) and for extramacular drusen. Analyses tested for associations between drusen and anthropometric measures including choroidal thickness.

Results

Gradable fundus images from both eyes were available for 1333 children (640 boys, 693 girls) with a mean (SD) age of 11.7 (0.40) years. One or more small hard macular drusen (diameter <63 μm) were present in 82 (6.2%) right eyes and 82 (6.2%) left eyes and in 147 (11.0%) subjects. Four children (0.30%) had 20 or more small hard macular drusen in one or both eyes. Extramacular small hard drusen were present in 10.7% of children, and 19% of children had such drusen anywhere. The odds for having one or more small hard macular drusen increased with subfoveal choroidal thickness with an odds ratio of 1.15 (95% confidence interval, 1.03-1.28; P = 0.013) per 50-μm thicker choroid, adjusted for age and sex. The association with choroidal thickness was also present for extramacular drusen.

Conclusions

Having one or more small hard macular drusen was common in 11- to 12-year old children and it was associated with a thicker subfoveal choroid. Few children had many small hard drusen. There is no apparent clinical impact of small hard drusen in childhood.

Multimodal imaging of retinal pigment epithelial detachments in patients with C3 glomerulopathy: case report and review of the literature

Background

To describe the optical coherence tomography angiograhy (OCTA) of drusenoid pigment epithelial detachments (PEDs) in a woman affected by Complement 3 (C3) glomerulopathy, which represents a spectrum of glomerular diseases characterized on fluorescent microscopy by C3 accumulation with absent, or scanty, immunoglobulin deposits. It is due to acquired or genetically defective alternative pathway control and is generally associated with drusen-like deposits in Bruch’s membrane, as well as choriocapillaris. These retinal lesions can be associated with choroidal neovascularization and central serous chorioretinopathy (CSCR). OCTA is useful to detect neovascularization without injecting a contrast product, particularly in these patients who may have renal insufficiency.

Case presentation

A 28-year-old woman affected by C3 glomerulpathy was diagnosed with asymptomatic multiple bilateral PEDs during a routine ophthalmologic consultation. To better characterize the lesions, multimodal imaging was performed and included: optic coherence tomography (OCT), en-face OCT, OCTA, fluorescence and indocyanine angiography. The OCTA clearly identified vascular network rarefaction with decreased choriocapillary vascularization. It confirmed that PEDs associated with C3 glomerulonephritis are not vascularized, but rather of serous type.

Conclusions

Patients affected by C3 glomerulopathy can develop neovascular membranes as retinal complications of pigment epithelial detachments. Optical coherence angiography may be indicated to identify this complication, without injecting any contrast product that could produce further kidney damage.

THE ASSOCIATION BETWEEN CUTICULAR DRUSEN AND KIDNEY FUNCTION: A Population-Based Case-Control Study

PURPOSE

To determine the association between cuticular drusen (CD) and kidney function.

DESIGN

observational case-control study.

METHODS

SETTING

Population-based. Patients or Study Population: 53 participants with (CD) and 53 age- and sex-matched controls, selected from the Danish Rural Eye Study. Cuticular drusen participants were diagnosed using fluorescein angiography and controls were excluded if the patients were suspected of having CD on fundus photography or did not have an available estimated glomerular filtration rate.

MAIN OUTCOME MEASURES

creatinine and estimated glomerular filtration rate.

RESULTS

The mean estimated glomerular filtration rate of those with CD was 73.3 mL·min·1.73 m (95% confidence interval [CI]: 70.0-76.6) and 73.4 mL·minute·1.73 m (95% CI: 69.5-77.3) in controls. The difference was not significant (P: 0.970). The mean creatinine among those with CD was 72.8 μmol/L (69.3-76.4) and 73.5 μmol/L (95% CI: 69.3-77.6) among controls. The difference was not significant (P = 0.820).

CONCLUSION

The authors did not find an association between a (CD) diagnosis and decreased kidney function at a population level.

Manifestations of Complement-Mediated and Immune Complex-Mediated Membranoproliferative Glomerulonephritis: A Comparative Consecutive Series

PURPOSE

Membranoproliferative glomerulonephritis (MPGN) recently was reclassified to reflect the underlying cause as a complement-mediated and immune complex-mediated disease. This classification is based on renal biopsy immunofluorescence examination, making the former electron-microscopy classification obsolete. In this report, we describe related eye findings in patients with MPGN based on the new classification.

DESIGN

Retrospective case series.

PARTICIPANTS

All Mayo Clinic Rochester patients with pathology-confirmed complement- and immune complex-mediated MPGN who had available ophthalmology records from 1997 through 2014 were included in this study.

METHODS

The medical and pathologic records of patients with MPGN and eye examination results were reviewed from years 1997 through 2014.

MAIN OUTCOME MEASURES

The number of patients and the number of eyes with MPGN-related pathologic features were examined. Visual acuity also was considered.

RESULTS

There were 23 patients with complement-mediated MPGN and available eye examination results. Of these, 9 patients (39%) and 17 eyes (37%) had retinal pathologic features that likely were related to the same underlying pathophysiologic process as their renal disease. Five patients (22%) and 6 eyes (13%) had significant vision loss. There were 23 patients with immune complex-mediated MPGN and available eye examination results. Only 2 (9%) of these patients (4 eyes) had retinal pathologic features that potentially could be related to the same underlying pathophysiologic process as their renal disease, and neither had vision loss.

CONCLUSIONS

Retinal abnormalities are more prominent among patients with complement-mediated MPGN when compared with patients with immune complex-mediated MPGN. It is critical for ophthalmologists to recognize the updated MPGN classification system, and all patients with complement-mediated MPGN require screening eye examinations.

Basal laminar drusen caused by compound heterozygous variants in the CFH gene

Age-related macular degeneration (AMD) is a multifactorial disease that is strongly associated with the Tyr402His variant in the complement factor H (CFH) gene. Drusen are hallmark lesions of AMD and consist of focal-inflammatory and/or immune-mediated depositions of extracellular material at the interface of the retinal pigment epithelium (RPE) and the Bruch membrane. We evaluated the role of CFH in 30 probands with early-onset drusen and identified heterozygous nonsense, missense, and splice variants in five families. The affected individuals all carried the Tyr402His AMD risk variant on the other allele. This supports an autosomal-recessive disease model in which individuals who carry a CFH mutation on one allele and the Tyr402His variant on the other allele develop drusen. Our findings strongly suggest that monogenic inheritance of CFH variants can result in basal laminar drusen in young adults, and this can progress to maculopathy and severe vision loss later in life.

Retinal changes associated with type 2 glomerulonephritis

AIMS

The aims of this study were to: Investigate retinal changes associated with type 2 membranoproliferative glomerulonephritis (type 2 MPGN). Assess whether there was a relationship between the severity of the kidney disease and ophthalmoscopically visible fundal changes. Find out if renal transplantation was linked with visual deterioration. Decide if patients with type 2 MPGN need to be referred for ophthalmological assessment.

METHODS

The patients were identified from pathology department records as having renal biopsy proven type 2 MPGN from January 1981 to October 2003. Patients were invited to attend for ophthalmic assessment.

RESULTS

A total of 26 biopsy proven cases of type 2 MPGN were identified. One patient lost vision from a possible occult choroidal neovascular membrane. The extent of ocular involvement did not consistently appear to be related to the severity of the renal involvement, although there was a relationship between the presence of ocular lesions and the duration of the disease. The longer the disease was present the more likely the patients were to have ophthalmoscopically visible fundal changes. Renal transplantation did not appear to have a detrimental effect on vision with the possible exception of one patient.

CONCLUSION

Referral of type 2 MPGN patients by the renal physician for an initial ophthalmological assessment may be beneficial so that symptoms of choroidal neovascularization can be explained and patients advised to seek urgent help if distortion of central vision occurs. Renal transplantation does not appear to be a risk factor for the development of choroidal neovascular membranes.

Complement and diseases: Defective alternative pathway control results in kidney and eye diseases

The complement system is a central part of innate immunity and in its normal setting aimed to recognize and eliminate microbes. For elimination toxic activation products are generated locally and are reported directly of the surface of the invading microbe. A deregulation of the alternative pathway results in defective recognition and toxic activation products can be formed on the surface of host tissues and structures. Recent studies have shown that mutated or defective regulators of the alternative pathway of complement are associated with auto immune diseases of the kidney, including the atypical form of hemolytic uremic syndrome (HUS), membranoproliferative glomerulonephritis (MPGN) and also of the eye, such as age-related macular degeneration (ARMD). Current research provides clues how mutations occurring in genes coding for single complement components or the inactivation of single regulators lead to defective alternative pathway amplification, via the convertase C3bBb. These scenarios explain how defects of a single regulator lead to local, organ specific damage.

Visual impairment caused by retinal abnormalities in mesangiocapillary (membranoproliferative) glomerulonephritis type II ("dense deposit disease")

Patients with mesangiocapillary glomerulonephritis (MCGN) type II usually present by early adulthood with hematuria, proteinuria, and renal impairment, and these features often are accompanied by a partial lipodystrophy and an autoantibody for the alternative complement pathway convertase (C3NeF). The diagnosis of MCGN type II depends on the demonstration of "dense deposits" in the glomerular basement membrane (GBM). Most patients also have multiple subretinal white spots or drusen that are histopathologically identical with the GBM deposits and evident ophthalmoscopically by the time renal failure develops. Initially visual acuity and visual fields are preserved, but fluorescein angiography and specialized tests of retinal function, such as dark adaptation, electroretinography, and electrooculography, may be abnormal and will worsen progressively. Over the next 20 years, vision often deteriorates because of retinal atrophy, and sometimes because of subretinal neovascular membranes, macular detachment, and central serous retinopathy. The authors describe a patient with MCGN type II who presented with renal failure and impaired vision at the age of 59. He already had widespread retinal atrophy, and subsequently a subretinal membrane developed. The drusen seen in MCGN type II, like the partial lipodystrophy, are a helpful clinical pointer to the diagnosis of this condition. All patients with MCGN type II should be warned of the risk of retinal complications and reviewed by an ophthalmologist at presentation and regularly after about 10 years to minimize the loss of visual acuity from complications of the retinopathy.

Retinal function abnormalities in membranoproliferative glomerulonephritis type II

PURPOSE

To characterize retinal electrophysiologic and psychophysical abnormalities associated with membranoproliferative glomerulonephritis type II.

METHODS

Three adults with membranoproliferative glomerulonephritis type II were studied. Retinal function was measured psychophysically (automated perimetry, Farnsworth D-15 color vision testing, and dark adaptometry) and electrophysiologically (full-field flash electroretinography and electro-oculography).

RESULTS

Two symptomatic individuals had prominent drusenlike deposits and retinal pigment epithelial disturbances, findings characteristic of membranoproliferative glomerulonephritis type II retinopathy. These individuals had mild visual field and color vision abnormalities, prolonged dark adaptation, and delayed electroretinographic dark-adapted dim and bright flash responses of normal amplitude. The electro-oculogram of the most severely affected individual was abnormal. The third individual who was asymptomatic had the mildest fundus abnormalities and exhibited normal psychophysical and electrophysiologic responses.

CONCLUSIONS

Membranoproliferative glomerulonephritis type II retinopathy may be associated with symptomatic and measurable psychophysical and electrophysiologic abnormalities of retinal function.

Chronic glomerulonephritis in childhood. Membranoproliferative glomerulonephritis, Henoch-Schönlein purpura nephritis, and IgA nephropathy

The chronic glomerulonephritides that lead to permanent loss of renal function may present with an acute nephritic syndrome, nephrotic syndrome, or asymptomatic hematuria and proteinuria. Membranoproliferative glomerulonephritis, Henoch-Schönlein purpura nephritis, and IgA nephropathy are common childhood glomerulonephritides that may lead to chronic renal failure. Their clinical manifestations, natural history, and long-term prognosis are distinct. This article reviews various presentations of these common childhood glomerulonephritides and an approach to management and potential therapy.

Membranoproliferative glomerulonephritis type II associated with central serous retinopathy

Membranoproliferative glomerulonephritis type II is specifically associated with the presence of dense deposits in the basement membrane of Bruch's membrane, which result in lesions similar to basal laminar drusen, exudative drusen, and retinal pigment epithelial detachments. In advanced stages of this dense-deposit retinopathy, choroidal neovascularization may occur. We observed a 36-year-old patient with membranoproliferative glomerulonephritis type II who developed central serous retinopathy in the presence of specific dense-deposit-associated fundus lesions. The diffuse drusenlike dense deposits (at the level of Bruch's membrane) and associated retinal pigment epithelial detachments appear to contribute to the pathogenesis of central serous retinopathy. Thus changes in Bruch's membrane may be involved in the development of central serous retinopathy.

Posterior segment changes in membranoproliferative glomerulonephritis

Membranoproliferative glomerulonephritis is a renal disorder characterized by proliferation of cells and changes in the basement membrane of the glomerulus. The disease is divided into three subtypes: type I, characterized by the presence of subendothelial electrondense deposits; type II, characterized by deposition of electrondense material of unknown origin in the lamina densa of the glomerular basement membrane; and type III, characterized by lesions having both type I and type II qualities. Specific posterior segment changes have been reported with membranoproliferative glomerulonephritis type II. We examined three patients with membranoproliferative glomerulonephritis type II and two patients with type III disease. All three patients with type II disease had Bruch's membrane and retinal pigment epithelial changes, whereas both patients with type III disease had normal posterior segments.

Idiopathic membranoproliferative glomerulonephritis in childhood

Membranoproliferative glomerulonephritis (MPGN), recognized since 1965, is now known to have three forms, designated types I, II, and III. The types are similar in the frequency of hypocomplementemia and clinical course but are dissimilar in glomerular ultrastructure, pathogenesis, mechanisms of complement activation, predisposition to recur in the renal transplant, and, to some extent, in clinical presentation. Although glomerular proliferation is usually diffuse, it may be focal and segmental particularly in mild cases of MPGN I. Hypocomplementemia, present in about 80% of patients, is the result of hypercatabolism of C3 by three mechanisms as well as of diminished C3 synthesis. The hypocomplementemia is unrelated to clinical course or prognosis. Although MPGN I and III both have a high frequency of an extended haplotype on chromosome 6, which has known associations with autoimmune phenomena, and both have a high frequency of inherited complement defects, they are nevertheless dissimilar in glomerular ultrastructure, complement profile, and immunohistology in ways which suggest a wide difference in pathogenesis. Abnormalities in humoral immunity appear not to be involved in MPGN III. Treatment with anticoagulant, antiplatelet and cytotoxic drugs have, in controlled trials, been either ineffective or marginally effective. Long-term use of alternate-day prednisone in high dosage appears to be the most efficacious regimen in both controlled and uncontrolled studies.