The pathogenesis of membranous glomerulonephritis: from morphology to molecules

Prakash. Nephrin a biomarker of early glomerular injury in newly diagnosed untreated hypertensive subjects

Introduction and Aim: Hypertension and proteinuria is known to cause renal and cardiovascular disease and mortality in patients irrespective of diabetes. It is beneficial to identify proteinuria and probable glomerular injury early to take preventive measures from cardiovascular event.  In our study, we aimed to evaluate whether a biomarker such as nephrin can detect early glomerular injury in treatment naïve hypertensive subjects.   Materials and Methods: Forty newly diagnosed, treatment naïve hypertensive subjects were recruited for the study along with 40 normotensive controls after obtaining informed consent and procuring approval from. Institutional Ethics Committee. The hypertensive group was classified as diabetic and non-diabetic hypertensives and compared with apparently healthy controls (normotensive). Urine sample was analyzed for microalbumin, creatinine and nephrin. Blood sample was analyzed for glycated hemoglobin, urea, creatinine, sodium, and potassium.  Statistical analysis was performed using ANOVA to compare the groups for various parameters. Odds ratio was calculated.   Results: Hypertensives were sub-grouped based on amount of microalbumin excreted. Urine nephrin excretion was significantly higher in hypertensive subjects than normotensive subjects (nephrin cut-off: 0.09 mg/g of creatinine). Urine nephrin (mg/g) was found to be elevated (median 0.15; interquartile range, 0.12 and 0.17) in hypertensives with normoalbuminuria and it was significantly higher than normotensive subjects (median 0.07; interquartile range, 0.04 and 0.09).     Conclusion: Urine nephrin may be used as a biomarker of early glomerular injury in hypertensive subjects even before microalbuminuria is detected.

Podocyte membrane vesicles in urine originate from tip vesiculation of podocyte microvilli

Podocyte injury is involved in both the onset and progression of glomerular diseases. Our previous studies revealed that apical cell membranes of podocyte are shed into urine sediment and that urinary podocalyxin is a useful biomarker of podocyte injury. In this study, we examined the origin of urinary podocalyxin. Urine samples and kidney specimens from healthy children (n = 126) and patients with glomerular diseases (n = 77) were analyzed by immunohistologic methods. Immunofluorescence studies demonstrated that urinary podocalyxin was shed as granular structures into both the urine sediment and supernatant. Large amounts of podocalyxin were shed into both the urine sediment (17.2 +/- 3.2 ng/mg creatinine) and the supernatant (172.6 +/- 24.6 ng/mg creatinine) of patients, compared with the small amounts of urinary podocalyxin in healthy controls (sediment, 0.5 +/- 0.1 ng/mg creatinine; supernatant, 24.3 +/- 3.5 ng/mg creatinine). Electron and immunoelectron microscopic examinations showed that podocalyxin-positive vesicles in the sediment (125.6 +/- 8.8 nm) and the supernatant (121.2 +/- 6.4 nm) were similar in size to podocyte microvilli in biopsy specimens (123.6 +/- 8.9 nm), differentiating them from the much smaller urine exosomes (30-80 nm in diameter). Urine podocalyxin-positive vesicles tested negative in immunofluorescence microscopy on both exosomal markers CD24 and CD63. Podocalyxin-positive vesicles also tested negative for cytoskeletal markers, and electron microscopic examination revealed tip vesiculation of microvilli. We conclude that human urinary apical cell membrane vesicles appear to originate not from podocyte exosomes but from tip vesiculation of glomerular podocyte microvilli.

A case of systemic lupus erythematosus showing invagination of the podocyte into the glomerular basement membrane: an electron microscopic observation of a repeated-renal biopsy

A case of systemic lupus erythematosus (SLE) showing invagination of glomerular epithelial cells into the glomerular basement membrane (GBM) has been reported. The patient was a 30-year-old woman who was diagnosed with SLE at the age of 25 and had been medicated with corticosteroid. At the age of 30, she was re-admitted into our hospital because of the relapse of lupus nephritis. Renal biopsy was performed twice: at the onset of SLE and the second admission. Morphologically, the results of the first and second renal biopsies were compatible with the classification of lupus nephritis class II. Immunofluorescent study revealed the mesangial deposition of IgG, IgA, C1q, C3 and membrane attack complex (MAC) in two renal biopsies. Especially, in the second renal biopsy, numerous vesicular structures composed of a unit membrane going into the epithelial site of the GBM were observed by electron microscopy (EM), but not in the first renal biopsy. Moreover, observations of serial sections of EM suggested that these vesicular structures were invaginated into the GBM and derived from a part of the podocytes.

Linking Receptor-mediated Endocytosis and Cell Signaling

Megalin, a member of the low density lipoprotein receptor gene family, is required for efficient protein absorption in the proximal tubule. Recent studies have shown that the low density lipoprotein receptor-related protein, another member of this gene family, is proteolytically processed by gamma-secretase implying a role for low density lipoprotein receptor-related protein in a Notchlike signaling pathway. This pathway has been shown to involve: 1) metalloprotease-mediated ectodomain shedding and gamma-secretase-mediated intramembrane proteolysis of some receptors. Experiments were performed to determine whether megalin undergoes similar processing. By immunocytochemistry, immunoblotting, and a fluorogenic enzyme assay presenilin-1 (required for gamma-secretase activity) and gamma-secretase activity were found in the brush border of proximal kidney tubules where megalin is localized. Using a fluorogenic peptide containing an amyloid precursor protein gamma-secretase cleavage site and Compound E, a specific gamma-secretase inhibitor, we found high levels of gamma-secretase activity in renal brush border membrane vesicles. Immunoblotting analysis of renal microsomes and opossum kidney proximal tubule (OKP) cells using antibodies directed to the cytosolic domain of megalin showed a 35-40-kDa, membrane-associated, carboxyl-terminal fragment of megalin (MCTF). When cells were incubated with 200 nm phorbol 12-myristate 13-acetate, the appearance of the MCTF increased 2.5-fold and was blocked by metalloprotease inhibitors. When the cells were incubated with gamma-secretase inhibitor Compound E, it caused a 2-fold increase in MCTF. Finally, incubating the cells with 1 microm vitamin D-binding protein resulted in a 25% increase in the appearance of the MCTF. In summary, the MCTF is produced by protein kinase C regulated, metalloprotease-mediated ectodomain shedding and is the substrate for gamma-secretase. We postulate that the enzymatic processing of megalin represents part of a novel ligand-dependent signaling pathway in the proximal tubule that links receptor-mediated endocytosis with cell signaling.

Urinary excretion of the vitronectin receptor (integrin alpha V beta 3) in patients with Fabry disease

A renal disorder is one of the important manifestations of Fabry disease, but the details of the pathogenesis have not been clarified yet. We examined the possibility that the vitronectin receptor (VNR, integrin alpha V beta 3), one of the integrins, is involved in the progression of the renal injury in Fabry disease. We measured the urinary excretion of beta 3 originating from VNR in Fabry patients by immunoblotting analysis and enzyme-linked immunosorbent assay (ELISA). Immunofluorescent microscopic analyses for VNR and globotriaosylceramide were performed on urinary sediments from Fabry patients. Furthermore, beta 3 and vitronectin in kidney tissues were analyzed immunohistochemically. Immunoblotting analysis and ELISA showed that the urinary excretion of beta 3 originating from VNR was significantly increased in the Fabry group compared with both the pathological and healthy control groups. Immunofluorescent microscopy revealed the expression of VNR and accumulation of globotriaosylceramide in urinary sediments from the Fabry patients. Increased expression of beta 3 was observed in glomerular epithelial cells, and in Bowman's capsular epithelial layer and tubular cells, and the amount of vitronectin was moderately increased in the kidney tissues from the Fabry patients. The urinary excretion of VNR was increased, and the expression of VNR was observed in Fabry kidney tissues. The expression of VNR may be involved in the progression of the renal injury in this disease.

Idiopathic membranous nephropathy in identical twins

Familial idiopathic membranous nephropathy is rarely reported, despite the striking immunogenetic association of the disease with certain HLA antigens. This report describes a pair of identical male twins who contemporaneously developed idiopathic membranous nephropathy. HLA typing was carried out in the twins and in almost all members of their family. Interestingly, HLA antigens that have been reported to be associated with idiopathic membranous nephropathy, especially DR3, were found not only in the twins, but in the other family members as well. Due to similarities between Heymann nephritis and human membranous nephropathy, we performed a search for anti-brush border and antipodocyte antibodies. The inability to detect these antibodies suggests that they were probably not involved in the pathogenesis of these cases.

Basic fibroblast growth factor augments podocyte injury and induces glomerulosclerosis in rats with experimental membranous nephropathy

Podocyte injury is believed to contribute to glomerulosclerosis in membranous nephropathy. To identify the factors involved, we investigated the effects of basic fibroblast growth factor (bFGF), a cytokine produced by podocytes, on rats with membranous nephropathy (passive Heymann nephritis [PHN]). All rats received a daily i.v. bolus of 10 microg bFGF or vehicle from days 3-8 after PHN induction. In proteinuric PHN rats on day 8, bFGF injections further increased proteinuria. Podocytes of bFGF-injected PHN rats showed dramatic increases in mitoses, pseudocyst formation, foot process retraction, focal detachment from the glomerular basement membrane, and desmin expression. bFGF injections in PHN rats did not alter antibody or complement deposition or glomerular leukocyte influx. bFGF-injected PHN rats developed increased glomerulosclerosis when compared with control PHN rats. Also, bFGF induced proteinuria and podocyte damage in rats injected with 10% of the regular PHN-serum dose. None of these changes occurred in bFGF-injected normal rats, complement-depleted PHN rats or rats injected with 5% of the regular PHN serum dose. These divergent bFGF effects were explained in part by upregulated glomerular bFGF receptor expression, induced by PHN serum. Thus, bFGF can augment podocyte damage, resulting in increased glomerular protein permeability and accelerated glomerulosclerosis. This bFGF action is confined to previously injured podocytes. Release of bFGF from glomerular sources (including podocytes themselves) during injury may represent an important mechanism by which podocyte damage is enhanced or becomes self sustained.

Structure and function of podocytes: an update

Glomerular visceral epithelial cells, also termed podocytes, are highly specialized epithelial cells that cover the outer aspect of the glomerular basement membrane. Recent studies point to an important role of podocytes in the physiology and pathophysiology of the glomerulus. This review summarizes the structure-function relationships of podocytes. Following a description of the general morphology of podocytes, the technical problems associated with studying these cells are discussed. A survey of podocyte function forms the center of this review. Finally, selected aspects of podocyte development and cell division are discussed.

Physiology and pathophysiology of complement: progress and trends

The complement system comprises a family of at least 20 plasma and membrane proteins that interact in a tightly regulated cascade system to destroy invading bacteria and prevent the deposition of immune complexes in the tissues. This brief review addresses the basic mechanisms of complement activation and control and describes the active fragments produced during complement activation. The biological importance of the complement system is amply illustrated in patients with complement deficiencies, who are susceptible to bacterial infections and immune complex diseases. The involvement of complement in other immunological diseases is an expanding area of clinical research, supported by the development of new assays for the identification of complement activation. This area is discussed here with particular reference to neurological diseases. A promising new prospect involves the use of complement inhibitory molecules in therapy of complement-mediated disease and this exciting area is also discussed. Novel physiological roles of complement also are being revealed and new evidence that complement and complement receptors play an important role in reproduction is summarized. It is hoped that this brief overview will convey some of the enthusiasm currently pervading research in this underappreciated area of immunology.

The glomerular basement membrane in lupus nephritis

Systemic lupus erythematosus is a disease that is particularly suited for studies of glomerular basement membrane pathology. Classification of the renal pathology of lupus nephritis is usually based on light microscopic features, combined with immunofluorescence findings and electron microscopic alterations. Study of renal biopsy helps to distinguish potentially reversible and irreversible disease, and to estimate prognosis of patients with lupus nephritis. Moreover, studies of human disease, as well as the availability of animal models and in vitro cell culture systems employing biochemical and molecular biological studies of extracellular matrix, have led to a considerable increase in knowledge of the pathogenetic events underlying derangements of the glomerular basement membrane in lupus nephritis.

Common acute lymphoblastic leukemia antigen expression on visceral epithelial cells in several types of glomerulonephritis

The distribution of a group of glomerular antigens and the composition of deposits was examined by immunoelectron microscopy in patients with idiopathic membranous nephropathy (MN), focal segmental glomerulosclerosis (FSG) and membranoproliferative glomerulonephritis (MPGN). The decrease in expression of common acute lymphoblastic leukemia antigen (CALLA) on glomerular visceral epithelial cells was found in MN and FSG. The loss of CALLA on visceral epithelial cells was typical for immature glomerulus and for this cell culture. On the strength of these results we can suppose that the dedifferentiation of visceral epithelial cells takes place in MN and FSG. It leads to changes in the synthesis of the glomerular basement membrane components.

Altered glomerular extracellular matrix synthesis in experimental membranous nephropathy

Chronic progressive membranous nephropathy (MN) in humans is characterized by thickening of the glomerular basement membrane (GBM) with formation of spikes which contain laminin and other extracellular matrix (ECM) proteins. We have utilized two models of MN in the rat (active and passive Heymann nephritis, AICN, PHN) to define the sequential changes in composition of GBM as they relate to changes in glomerular gene expression for ECM components, altered permeability and morphological changes. Renal biopsies obtained during the course of AICN and PHN were immunostained for various ECM proteins and total glomerular RNA was hybridized with cDNA probes specific for laminin B2-chain, s-laminin, and types I and IV collagen. In addition, the ability of anti-glomerular epithelial cell (GEC) antibody and complement on rat GEC in culture to induce laminin release or laminin and s-laminin mRNA expression was determined. The results demonstrate that at weeks 12, 16, and 20 of AICN, immunostaining for laminin, s-laminin, fibronectin, entactin, and heparan sulfate proteoglycan increased in the GBM in a spike-like pattern. Concomitantly, glomerular mRNA levels of laminin B2-chain and of s-laminin increased. Type IV collagen protein and gene expression remained unchanged or decreased. No glomerular immunostaining for type I collagen occurred during AICN despite increased expression of mRNA for this collagen type. In contrast to AICN, in PHN no pronounced changes of the glomerular ECM occurred, except for transient expression of type I collagen mRNA in whole glomerular RNA and type I collagen protein the GEC cytoplasm. Stimulation of GEC in culture with anti-GEC antibody and complement also failed to induce transcription of laminin or s-laminin mRNA or the release of laminin protein. These findings suggest that the polyantigenic expansion of GBM which occurs in chronic experimental MN may be stimulated by factors different from the C5b-9 mediated processes that cause the initial proteinuria.

Elevated urinary excretion of the C5b-9 complex in membranous nephropathy

In experimental membranous nephropathy, antibody binding to glomerular epithelial cell membrane antigens results in complement activation and formation of complement C5b-9 membrane attack complexes in glomeruli. During active disease, the C5b-9 complexes are shed into the urine. To test the hypothesis that a similar mechanism might be operative in human membranous nephropathy, we measured urinary excretion of C5b-9 and C5 in 146 proteinuric patients with biopsy-proven glomerular diseases or diabetes mellitus. Urinary excretion of C5b-9 relative to C5 excretion was higher in 40 patients with membranous nephropathy than in 106 patients with proteinuria due to non-membranous glomerulonephritis when analyzed by covariance analysis (P less than 0.0002). Urinary C5b-9 excretion was higher in membranous nephropathy than in membranoproliferative glomerulonephritis (N = 13, P less than 0.05), minimal change-focal sclerosis (N = 33, P less than 0.001), mesangial proliferative glomerulonephritis (N = 9, P less than 0.02) and IgA nephropathy (N = 7, P less than 0.025). Urinary C5b-9 excretion was also higher in patients with lupus nephritis (N = 18, P less than 0.02) compared to those with non-membranous glomerulonephritis. The lupus patients with the highest excretion had clinical or pathological features of membranous nephropathy. Nine patients with membranous nephropathy and elevated urinary C5b-9 excretion had a shorter duration of disease (P less than 0.05), lower serum creatinine levels (P less than 0.05) and more proteinuria (P less than 0.02) than the 31 membranous nephropathy patients with normal values.(ABSTRACT TRUNCATED AT 250 WORDS)