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Nakamura Y, Kato N, Tatematsu Y, Arai Y, Mori N, Shibata K, Yamazaki M, Yasui H, Fujiwara S, Yamakawa T, Maruyama S. Clinical characteristics of anti-GBM disease with thrombotic microangiopathy: a case report and literature review. CEN Case Rep 2024; 13:37-44. [PMID: 37213063 PMCID: PMC10201029 DOI: 10.1007/s13730-023-00797-4] [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: 12/22/2022] [Accepted: 05/12/2023] [Indexed: 05/23/2023] Open
Abstract
The coexistence of anti-glomerular basement membrane (anti-GBM) disease with thrombotic microangiopathy (TMA) is rarely encountered, and the clinical characteristics of this phenomenon are not well known.A 76-year-old Japanese woman with a history of idiopathic pulmonary disease was diagnosed with anti-GBM disease due to rapidly progressive glomerulonephritis and a positive anti-GBM antibody test result. We treated the patient with hemodialysis, glucocorticoids, and plasmapheresis. During treatment, the patient suddenly became comatose. TMA was then diagnosed because of thrombocytopenia and microangiopathic hemolytic anemia. The activity of a disintegrin-like and metalloproteinase with thrombospondin type 1 motif 13 (ADAMTS-13) was retained at 48%. Although we continued the treatment, the patient died of respiratory failure. An autopsy revealed the cause of respiratory failure to be an acute exacerbation of interstitial pneumonia. The clinical findings of the renal specimen indicated anti-GBM disease; however, there were no lesions suggestive of TMA. A genetic test did not reveal an apparent genetic mutation of the atypical hemolytic uremic syndrome.We conducted a literature review of past case reports of anti-GBM disease with TMA. The following clinical characteristics were obtained. First, 75% of the cases were reported in Asia. Second, TMA tended to appear during the treatment course for anti-GBM disease and usually resolved within 12 weeks. Third, ADAMTS-13 activity was retained above 10% in 90% of the cases. Fourth, central nervous system manifestations occurred in more than half of the patients. Fifth, the renal outcome was very poor. Further studies are required to understand the pathophysiology of this phenomenon.
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Affiliation(s)
- Yoshihiro Nakamura
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan.
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan.
| | - Noritoshi Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshitaka Tatematsu
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
| | - Yoshifumi Arai
- Department of Pathology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Nozomi Mori
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Katsuaki Shibata
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Michiko Yamazaki
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Hirotoshi Yasui
- Department of Respiratory Medicine, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Shinji Fujiwara
- Department of Hematology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Taishi Yamakawa
- Department of Nephrology, Toyohashi Municipal Hospital, 50 Hakkennishi, Aotake-Cho, Toyohashi, 441-8570, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya, 466-8550, Japan
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Yamashita M, Takayasu M, Maruyama H, Hirayama K. The Immunobiological Agents for Treatment of Antiglomerular Basement Membrane Disease. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2014. [PMID: 38004064 PMCID: PMC10673378 DOI: 10.3390/medicina59112014] [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: 10/04/2023] [Revised: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023]
Abstract
Combination therapy with glucocorticoids, cyclophosphamide, and plasmapheresis is recommended as the standard treatment for anti-glomerular basement membrane (anti-GBM) disease, but the prognosis of this disease remains poor. Several immunobiological agents have been administered or are expected to be useful for anti-GBM disease in light of refractory disease or the standard treatments' tolerability. Many data regarding the use of biologic agents for anti-GBM disease have accumulated, verifying the effectiveness and potential of biologic agents as a new treatment option for anti-GBM disease. Tumor necrosis factor (TNF) inhibitors were shown to be useful in animal studies, but these agents have no clinical use and were even shown to induce anti-GBM disease in several cases. Although the efficacy of the TNF-receptor antagonist has been observed in animal models, there are no published case reports of its clinical use. There are also no published reports of animal or clinical studies of anti-B-cell-activating factor, which is a member of the TNF family of agents. Anti-interleukin (IL)-6 antibodies have been demonstrated to have no effect on or to exacerbate nephritis in animal models. Anti-C5 inhibitor was observed to be useful in a few anti-GBM disease cases. Among the several immunobiological agents, only rituximab has been demonstrated to be useful in refractory or poor-tolerance patients or small uncontrolled studies. Rituximab is usually used in combination with steroids and plasma exchange and is used primarily as an alternative to cyclophosphamide, but there is insufficient evidence regarding the efficacy of rituximab for anti-GBM disease, and thus, randomized controlled studies are required.
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Affiliation(s)
| | | | | | - Kouichi Hirayama
- Department of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami 300-0395, Ibaraki, Japan; (M.Y.); (M.T.); (H.M.)
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Ponticelli C, Calatroni M, Moroni G. Anti-glomerular basement membrane vasculitis. Autoimmun Rev 2023; 22:103212. [PMID: 36252931 DOI: 10.1016/j.autrev.2022.103212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/11/2022] [Indexed: 12/27/2022]
Abstract
Antiglomerular basement membrane disease (anti-GBM) is a rare life-threatening autoimmune vasculitis that involves small vessels and it is characterized by circulating autoantibodies directed against type IV collagen antigens expressed in glomerular and alveolar basement membrane. The typical clinical manifestations are the rapidly progressive glomerulonephritis and the alveolar hemorrhage. The diagnosis is usually confirmed by the detection of anti-GBM circulating antibodies. If not rapidly recognized, anti-GBM disease can lead to end stage kidney disease (ESKD). An early diagnosis and prompt treatment with immunosuppressive therapies and plasmapheresis are crucial to prevent a poor outcome. In this review, we discuss the primary form of anti-GBM (the so called Goodpasture syndrome) but also cases associated with other autoimmune diseases such as antineutrophil-cytoplasmic-antibody (ANCA) vasculitis, membranous nephropathy, IgA nephritis and systemic lupus erythematosus (SLE), as well as the few cases of anti-GBM vasculitis complicating kidney transplantation in the Alport syndrome.
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Affiliation(s)
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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Honda N, Shigehara R, Furuhashi K, Nagai Y, Yokogawa N. Anti-glomerular basement membrane diseases and thrombotic microangiopathy treated with rituximab. Mod Rheumatol Case Rep 2022:rxac091. [PMID: 36420905 DOI: 10.1093/mrcr/rxac091] [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: 08/26/2022] [Revised: 11/10/2022] [Accepted: 11/23/2022] [Indexed: 06/16/2023]
Abstract
A 68-year-old, male patient presented with a two-week history of malaise and anuria. Renal replacement therapy with hemodialysis was begun for acute kidney injury. His anti-glomerular basement membrane (anti-GBM) antibody titer was 3060 U/mL. Based on this finding, anti-GBM diseases was diagnosed. Plasmapheresis and high-dose glucocorticoid therapy were begun, but his hemolytic anemia and thrombocytopenia progressed. ADAMTS-13 activity decreased to 33%, but no inhibitor was detected. Secondary thrombotic microangiopathy (TMA) was suspected, and rituximab therapy was begun. The addition of rituximab is thought to have further reduced the anti-GBM antibodies, prevented recurrence, stabilized the platelet count, and facilitated the patient's withdrawal from plasmapheresis and glucocorticoid therapy. Rituximab may be a viable therapeutic option for anti-GBM diseases complicated with TMA.
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Affiliation(s)
- Nanase Honda
- Department of Internal Medicine Hino Municipal Hospital, Tokyo, Japan
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Rihiro Shigehara
- Department of Internal Medicine Hino Municipal Hospital, Tokyo, Japan
| | - Kazunori Furuhashi
- Department of Internal Medicine Hino Municipal Hospital, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiki Nagai
- Department of Internal Medicine Hino Municipal Hospital, Tokyo, Japan
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Naoto Yokogawa
- Department of Internal Medicine Hino Municipal Hospital, Tokyo, Japan
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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Molecular Pathogenesis of Endotheliopathy and Endotheliopathic Syndromes, Leading to Inflammation and Microthrombosis, and Various Hemostatic Clinical Phenotypes Based on "Two-Activation Theory of the Endothelium" and "Two-Path Unifying Theory" of Hemostasis. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58091311. [PMID: 36143988 PMCID: PMC9504959 DOI: 10.3390/medicina58091311] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 09/05/2022] [Accepted: 09/14/2022] [Indexed: 12/21/2022]
Abstract
Endotheliopathy, according to the “two-activation theory of the endothelium”, can be triggered by the activated complement system in critical illnesses, such as sepsis and polytrauma, leading to two distinctly different molecular dysfunctions: (1) the activation of the inflammatory pathway due to the release of inflammatory cytokines, such as interleukin 6 and tumor necrosis factor-α, and (2) the activation of the microthrombotic pathway due to the exocytosis of hemostatic factors, such as ultra-large von Willebrand factor (ULVWF) multimers and FVIII. The former promotes inflammation, including inflammatory organ syndrome (e.g., myocarditis and encephalitis) and multisystem inflammatory syndrome (e.g., cytokine storm), and the latter provokes endotheliopathy-associated vascular microthrombotic disease (VMTD), orchestrating thrombotic thrombocytopenic purpura (TTP)-like syndrome in arterial endotheliopathy, and immune thrombocytopenic purpura (ITP)-like syndrome in venous endotheliopathy, as well as multiorgan dysfunction syndrome (MODS). Because the endothelium is widely distributed in the entire vascular system, the phenotype manifestations of endotheliopathy are variable depending on the extent and location of the endothelial injury, the cause of the underlying pathology, as well as the genetic factor of the individual. To date, because the terms of many human diseases have been defined based on pathological changes in the organ and/or physiological dysfunction, endotheliopathy has not been denoted as a disease entity. In addition to inflammation, endotheliopathy is characterized by the increased activity of FVIII, overexpressed ULVWF/VWF antigen, and insufficient ADAMTS13 activity, which activates the ULVWF path of hemostasis, leading to consumptive thrombocytopenia and microthrombosis. Endothelial molecular pathogenesis produces the complex syndromes of inflammation, VMTD, and autoimmunity, provoking various endotheliopathic syndromes. The novel conceptual discovery of in vivo hemostasis has opened the door to the understanding of the pathogeneses of many endotheliopathy-associated human diseases. Reviewed are the hemostatic mechanisms, pathogenesis, and diagnostic criteria of endotheliopathy, and identified are some of the endotheliopathic syndromes that are encountered in clinical medicine.
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A Case of Paediatric Anti-Glomerular Basement Membrane Disease Associated with Thrombotic Thrombocytopenic Purpura. Case Rep Nephrol 2022; 2022:2676696. [PMID: 36065409 PMCID: PMC9440844 DOI: 10.1155/2022/2676696] [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: 03/03/2022] [Revised: 07/01/2022] [Accepted: 07/14/2022] [Indexed: 11/20/2022] Open
Abstract
Anti-GBM disease is a rare vasculitis that causes rapid progressive glomerulonephritis and pulmonary haemorrhage. It is usually an adult diagnosis with isolated paediatric cases reported. Thrombotic thrombocytopenic purpura (TTP) is a rare thrombotic microangiopathy mainly affecting adults that causes multiorgan ischaemia, microangiopathic haemolytic anaemia, and thrombocytopenia. We present the first paediatric case of concurrent anti-GBM disease and TTP. A 14-year-old boy presented with acute kidney failure and severe pulmonary haemorrhage due to anti-GBM disease, confirmed on auto-antibody testing. There was thrombocytopenia and moderately low ADAMTS13 activity suggestive of TTP. The renal prognosis was poor with a need for dialysis. He was severely unwell with pulmonary haemorrhages requiring the use of extracorporeal membrane oxygenation (ECMO). His disease was treated with corticosteroids, plasma exchange (PEX), rituximab, and cyclophosphamide, resulting in remission. Anti-GBM disease is rare in children but should be considered in those presenting with acute kidney injury, particularly where there has been exposure to pulmonary irritants. An aggressive presentation warrants aggressive treatment with methylprednisolone, PEX, and cyclophosphamide. Rituximab may benefit patients that have concurrent TTP. TTP may exacerbate pulmonary disease, but complete respiratory recovery is possible. Disease relapse is rare in the paediatric age group, and these patients are candidates for kidney transplantation.
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Povey J, Rutherford E, Levy J, Muniraju T. Relapse of treated anti-GBM disease following hair dye use. BMJ Case Rep 2021; 14:14/4/e240543. [PMID: 33795274 DOI: 10.1136/bcr-2020-240543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
An 18-year-old woman was treated for acute kidney injury (AKI) secondary to antiglomerular basement membrane (GBM) disease with prednisolone, cyclophosphamide and plasma exchange. She also had epistaxis at initial presentation with no other organ involvement and achieved good recovery of her kidney function. Two weeks after completing induction treatment, she re-presented with further AKI and pulmonary haemorrhage. She was recommenced on plasma exchange and steroids and was given rituximab. She recovered from her illness with significant improvement to her kidney function. The cause of her relapse was thought to be possibly due to the use of hair dye. This case highlights the importance of acknowledging potential environmental exposures to prevent relapses of disease. We were also able to demonstrate a case of successful treatment of anti-GBM disease with rituximab.
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Affiliation(s)
- James Povey
- Department of Nephrology, NHS Dumfries and Galloway, Dumfries, UK
| | - Elaine Rutherford
- Department of Nephrology, NHS Dumfries and Galloway, Dumfries, UK.,Institute of Medical and Cardiovascular Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jeremy Levy
- Renal Department, Imperial College Healthcare NHS Trust, London, UK
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Uematsu-Uchida M, Ohira T, Tomita S, Satonaka H, Tojo A, Ishimitsu T. Rituximab in treatment of anti-GBM antibody glomerulonephritis: A case report and literature review. Medicine (Baltimore) 2019; 98:e17801. [PMID: 31689860 PMCID: PMC6946414 DOI: 10.1097/md.0000000000017801] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
RATIONALE Anti-glomerular basement membrane (GBM) disease is a T cell-mediated disease that has a poor prognosis with conventional therapy. We tested rituximab as a primary therapy to reduce anti-GBM antibody produced by B cells. PATIENT CONCERNS A 53-year old woman with complaints of a fever, headache and abdominal discomfort showed renal failure with elevated anti-GBM antibody, and renal biopsy revealed crescentic necrotizing glomerulonephritis with linear immunoglobulin G (IgG) 1 deposition along GBM. DIAGNOSES The patient's plasma contained autoantibodies against Goodpasture antigen, which is the NC domain of collagen IVα3, and CD4-positive helper T cells were found surrounding crescent glomeruli with the coexistence CD20-positive B cells. INTERVENTIONS Rituximab with steroid and plasma exchange. OUTCOMES The levels of autoantibody for Goodpasture antigen were reduced, and the patient was able to temporarily withdraw from hemodialysis. LESSONS B cell depletion with rituximab is effective as an initial therapy for anti-GBM disease.
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Affiliation(s)
- Mayu Uematsu-Uchida
- Department of Nephrology & Hypertension, Dokkyo Medical University, Mibu, Tochigi
| | - Takehiro Ohira
- Department of Nephrology & Hypertension, Dokkyo Medical University, Mibu, Tochigi
| | - Shigeki Tomita
- Department of Pathology, Juntendo University Urayasu Hospital, Urayasu, Chiba, Japan
| | - Hiroshi Satonaka
- Department of Nephrology & Hypertension, Dokkyo Medical University, Mibu, Tochigi
| | - Akihiro Tojo
- Department of Nephrology & Hypertension, Dokkyo Medical University, Mibu, Tochigi
| | - Toshihiko Ishimitsu
- Department of Nephrology & Hypertension, Dokkyo Medical University, Mibu, Tochigi
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Bourgault M, Sarret D, Isnard P, Rabant M, Labaye J. [Atypic hemolytic uremic syndrome taken for Goodpasture's syndrome: A case report]. Nephrol Ther 2015; 11:564-8. [PMID: 26475667 DOI: 10.1016/j.nephro.2015.05.002] [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: 02/09/2015] [Revised: 03/29/2015] [Accepted: 05/16/2015] [Indexed: 10/22/2022]
Abstract
We report the case of a patient suffering from atypical hemolytic uremic syndrome with inaugural intra-alveolar hemorrhage. Clinical features and detection of circulating anti-glomerular basal membrane antibodies first raise the possibility of a Goodpasture syndrome. Renal biopsy allows to correct the diagnosis. Partial remission is obtained thanks to specific care and eculizumab infusions.
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Affiliation(s)
- Marie Bourgault
- Service de néphrologie, hôpital d'instruction des armées du Val-de-Grâce, 74, boulevard Port-Royal, 75005 Paris, France.
| | - Damien Sarret
- Service de néphrologie, hôpital d'instruction des armées du Val-de-Grâce, 74, boulevard Port-Royal, 75005 Paris, France
| | - Pierre Isnard
- Service de néphrologie, hôpital d'instruction des armées du Val-de-Grâce, 74, boulevard Port-Royal, 75005 Paris, France
| | - Marion Rabant
- Service d'anatomopathologie, hôpital Necker, 149, rue de Sèvres, 75015 Paris, France
| | - Jacques Labaye
- Service de néphrologie, hôpital d'instruction des armées du Val-de-Grâce, 74, boulevard Port-Royal, 75005 Paris, France
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