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Chen Z, Xu D, Cui F, Hou H, Mao Z, Gao X. Coexistence of anti-glomerular basement membrane disease and IgA nephropathy: an illustrative case and comprehensive literature review. Ren Fail 2024; 46:2323160. [PMID: 38466632 DOI: 10.1080/0886022x.2024.2323160] [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: 11/09/2023] [Accepted: 02/20/2024] [Indexed: 03/13/2024] Open
Abstract
Anti-glomerular basement membrane (GBM) disease is a rare autoimmune condition characterized by the presence of positive anti-GBM autoantibodies, linear deposition of immunoglobulin G (IgG) along the GBM and severe kidney injury. In a limited number of cases, the association of anti-GBM disease with other glomerulonephritis has been reported. Herein, we present the case of a 66-year-old female patient with progressive worsen kidney function and decreased urine output. A renal biopsy revealed crescent glomerulonephritis with lineal IgG deposition along the GBM and mesangial IgA deposition, which supported the diagnosis of concurrent anti-GBM disease and IgA nephropathy (IgAN). In an extensive literature review, we identified a total of thirty-nine patients were reported anti-GBM disease combined with IgAN. The clinical characteristics of these patients demonstrate that the anti-GBM disease combined with IgAN tends to be milder with a more indolent course and a better prognosis than the classic anti-GBM disease, and its potential pathogenesis deserves to be further explored.
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Affiliation(s)
- Zewei Chen
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Naval Military Medical University, Shanghai, China
- Department of Nephrology, The First Navy Hospital of Southern Theater Command, Zhanjiang, China
| | - Dechao Xu
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Fangzheng Cui
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Huihui Hou
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Zhiguo Mao
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Naval Military Medical University, Shanghai, China
| | - Xiang Gao
- Kidney Institute, Department of Nephrology, Shanghai Changzheng Hospital, Naval Military Medical University, Shanghai, China
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Monich A, Romani R, Carneiro J. Crescentic glomerulonephritis due to linear IgA anti-glomerular basement membrane disease: report of a rare case. Braz J Med Biol Res 2024; 57:e13466. [PMID: 38716984 PMCID: PMC11085031 DOI: 10.1590/1414-431x2024e13466] [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: 10/30/2023] [Accepted: 03/19/2024] [Indexed: 05/12/2024] Open
Abstract
Anti-glomerular basement membrane (GBM) disease is a rare and severe vasculitis that affects the glomerular and pulmonary capillaries and has an incidence of less than 2 cases per million individuals per year. Anti-GBM disease is mediated by autoantibodies against the α3 chain of type IV collagen. In the majority of cases, the autoantibodies are of the immunoglobulin G (IgG) class, with rare cases being mediated by immunoglobulin M (IgM) or immunoglobulin A (IgA); there are less than 15 IgA-mediated cases reported in the literature worldwide. The classic form of this disease manifests with rapidly progressive glomerulonephritis (RPGN), with or without pulmonary hemorrhage, and the diagnosis consists of identifying high titers of autoantibodies in the serum and/or deposited in the tissues. IgA antibodies are not identified in routine immunoassay tests, and renal biopsy with immunofluorescence is essential for diagnosis. We present a case of RPGN due to anti-GBM disease with linear IgA deposition, whose diagnosis was made exclusively by renal biopsy and with an unfavorable prognosis.
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Affiliation(s)
- A.G. Monich
- Serviço de Nefrologia, Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brasil
| | - R.F. Romani
- Serviço de Nefrologia, Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brasil
- Disciplina de Nefrologia, Faculdade Evangélica Mackenzie do Paraná, Curitiba, PR, Brasil
| | - J.L.S. Carneiro
- Serviço de Nefrologia, Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brasil
- Disciplina de Nefrologia, Faculdade Evangélica Mackenzie do Paraná, Curitiba, PR, Brasil
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3
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Tong R, Luo Z, Zhong X, Fan L, Lai H, Shen M, Huang Y. Atypical anti-glomerular basement membrane disease with membranous hyperplasia: diagnostic challenges and treatment variability. BMC Nephrol 2024; 25:132. [PMID: 38622525 PMCID: PMC11017607 DOI: 10.1186/s12882-024-03571-5] [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: 09/10/2023] [Accepted: 04/04/2024] [Indexed: 04/17/2024] Open
Abstract
This case report presents a detailed analysis of a 31-year-old male patient who presented with a complex array of clinical symptoms, including proteinuria, hematuria, edema, and kidney insufficiency. Despite undergoing multiple tests, the results for anti-glomerular basement membrane antibodies yielded negative findings. Subsequently, kidney biopsy pathology revealed a distinct diagnosis of atypical anti-glomerular basement membrane (anti-GBM) disease with membrane hyperplasia. Treatment was initiated with a comprehensive approach involving high doses of corticosteroids therapy and cyclophosphamide (CTX). However, contrary to expectations, the patient's kidney function exhibited rapid deterioration following this therapeutic regimen. The culmination of these complications necessitated a pivotal transition to maintenance hemodialysis. This case underscores the intricate challenges associated with diagnosing and managing rare and atypical presentations of kidney disorders. The negative anti-GBM antibody results and subsequent identification of atypical anti-GBM nephropathy highlight the need for tailored diagnostic strategies to discern subtle nuances within complex clinical scenarios. Additionally, the unexpected response to the treatment regimen emphasizes the potential variability in individual patient responses, underlining the necessity for vigilant monitoring and adaptable treatment strategies. This case report contributes to the evolving understanding of atypical kidney pathologies and the complexities involved in their management.
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Affiliation(s)
- Ruoyu Tong
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Zhengmao Luo
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Xianyang Zhong
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Liming Fan
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Huangwen Lai
- Pathology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Meng Shen
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China
| | - Yuanhang Huang
- Nephrology Department, Chinese PLA Southern Theater Command General Hospital, 510010, Guangzhou, China.
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Twomey Brenner C, Saha S, Bramham K, Vinen K, Horsfield C, Lioudaki E. An Unusual Presentation of Myeloperoxidase-Associated Glomerulonephritis and Suspected IgA-Mediated Anti-Glomerular Basement Membrane Disease: A Case Report. Case Rep Nephrol Dial 2024; 14:110-115. [PMID: 39015128 PMCID: PMC11249791 DOI: 10.1159/000538973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 04/04/2024] [Indexed: 07/18/2024] Open
Abstract
Introduction Anti-glomerular basement membrane (GBM) disease is a rare cause of glomerulonephritis usually mediated by IgG antibodies and is associated with ANCA-associated glomerulonephritis in up to 50% of cases. IgA-mediated anti-GBM disease is extremely rare and presents diagnostic difficulties as circulating IgA antibodies will not be detected by standard serological tests for anti-GBM disease. Case Presentation We present the case of a 67-year-old man with rapidly progressive glomerulonephritis requiring haemodialysis at presentation. Serological testing was positive for anti-myeloperoxidase and negative for IgG anti-GBM antibodies. Kidney biopsy revealed necrotizing crescentic glomerulonephritis with linear staining of IgA along the GBM. He was treated with a combination of immunosuppression and plasma exchange and was able to become dialysis-independent. Conclusion To our knowledge, this is the first documented "double-positive" IgA anti-GBM disease and ANCA-associated glomerulonephritis.
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Affiliation(s)
| | - Sujit Saha
- King’s College Hospital, NHS Foundation Trust, London, UK
| | - Kate Bramham
- King’s College Hospital, NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
| | - Katie Vinen
- King’s College Hospital, NHS Foundation Trust, London, UK
| | | | - Eirini Lioudaki
- King’s College Hospital, NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
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Uchida T, Sakai T, Hoshino T, Kojima A, Konno O, Yamada M, Iwamoto H, Oda T. Acute exacerbation of immunoglobulin A nephropathy complicated by alveolar hemorrhage after coronavirus disease 2019 vaccination: A case report. Medicine (Baltimore) 2023; 102:e36091. [PMID: 37986327 PMCID: PMC10659679 DOI: 10.1097/md.0000000000036091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023] Open
Abstract
RATIONALE Reports have suggested a relationship between coronavirus disease 2019 (COVID-19) vaccination and new-onset or recurring renal diseases, of which immunoglobulin A (IgA) nephropathy is a representative disease. Alveolar hemorrhage in patients with IgA nephropathy is rare but reportedly has a high mortality and morbidity. To our knowledge, there have been no reports regarding the development of IgA nephropathy with alveolar hemorrhage following COVID-19 vaccination. PATIENTS CONCERN A 23-year-old Japanese man presented with hemoptysis and peripheral edema a few days after receiving a second dose of a COVID-19 mRNA vaccine. Severe renal failure and alveolar hemorrhage were noted thereafter, and renal biopsy showed crescentic glomerulonephritis with mesangial proliferation accompanied by mesangial electron-dense deposits containing IgA. Renal biopsy tissue also showed chronic histological changes suggestive of acute exacerbation of preexisting IgA nephropathy. DIAGNOSIS The diagnosis of IgA nephropathy complicated by alveolar hemorrhage was made. INTERVENTIONS AND OUTCOMES Renal function did not recover despite treatment with high-dose steroids; the patient was maintained on hemodialysis and eventually underwent successful renal transplantation. LESSONS The present case suggested that although extremely rare, severe renal failure requiring renal replacement therapy could occur in patients with IgA nephropathy after COVID-19 vaccination. Future accumulation of similar cases is needed to predict the risk of renal injury following vaccination.
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Affiliation(s)
- Takahiro Uchida
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Takashi Sakai
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Takahiko Hoshino
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Aki Kojima
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Osamu Konno
- Department of Kidney Transplantation Surgery, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Muneharu Yamada
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Hitoshi Iwamoto
- Department of Kidney Transplantation Surgery, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
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Yang XF, Kuang H, Shen CR, Cui Z, Yu XJ, Ma YY, Zhao MH, Jia XY. The Prevalence and Characteristics of Circulating IgA Anti-Glomerular Basement Membrane Autoantibodies in Anti-Glomerular Basement Membrane Disease. Kidney Int Rep 2023; 8:2395-2402. [PMID: 38025241 PMCID: PMC10658233 DOI: 10.1016/j.ekir.2023.08.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 07/20/2023] [Accepted: 08/21/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction In some cases, immunoglobulin (IgA)-mediated antiglomerular basement membrane (anti-GBM) disease has been reported. Whether circulating IgA anti-GBM antibodies affect the clinico-pathologic characteristics and outcome of typical anti-GBM disease deserves further study. Methods Circulating IgA anti-α3(IV)NC1 antibodies were examined by enzyme-linked immunosorbent assay (ELISA) using recombinant human α3(IV)NC1 as solid phase antigens in 107 patients with anti-GBM disease and 115 controls. Clinical, pathological, and follow-up data of patients were retrospectively analyzed. Results Circulating IgA anti-α3(IV)NC1 antibodies were found in 18.7% (20/107) of patients with anti-GBM disease but were not detected in healthy controls or in patients with other glomerular diseases. The positivity of circulating IgA anti-α3(IV)NC1 antibodies was not associated with whether the patient was with combined IgA nephropathy or other glomerulonephritis. Kidney immunofluorescence showed no statistical difference in IgA deposition between patients with circulating IgA anti-α3(IV)NC1 antibodies and patients without (30.0% vs. 40.4%, P = 0.725). The titers of circulating immunoglobulin G (IgG) anti-α3(IV)NC1 antibodies in patients with circulating IgA anti-α3(IV)NC1 antibodies were significantly higher than those without (200 [183.3, 200] vs. 161 [85.5, 200] U/ml, P = 0.005). There were no significant differences in kidney outcome and mortality between the 2 groups. Conclusion Circulating IgA anti-α3(IV)NC1 antibodies occurred in 18.7% (20/107) of patients with anti-GBM in our center and were specific to anti-GBM disease. Patients with circulating IgA anti-α3(IV)NC1 antibodies showed a higher levels of serum IgG anti-α3(IV)NC1 antibodies than those without.
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Affiliation(s)
- Xue-fen Yang
- Renal Division, Peking University First Hospital, Beijing, China
- Renal Division, Second Hospital of Shanxi Medical University, Shanxi Kidney Disease Institute, Taiyuan, China
| | - Huang Kuang
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Cong-rong Shen
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-juan Yu
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi-yi Ma
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-hui Zhao
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
- Department of Urology, China-Japan Friendship Hospital, Beijing, China
| | - Xiao-yu Jia
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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Hishida E, Ono Y, Oe K, Imai T, Yoshizawa H, Nakaya T, Kawata H, Akimoto T, Saito O, Nagata D. Acute Interstitial Nephritis with Glomerular Capillary IgA Deposition Following SARS-CoV-2 mRNA Vaccination. Intern Med 2023; 62:2381-2387. [PMID: 37587055 PMCID: PMC10484757 DOI: 10.2169/internalmedicine.1631-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/20/2023] [Indexed: 08/18/2023] Open
Abstract
We herein report a case of acute kidney injury (AKI) presenting as acute interstitial nephritis (AIN) after the first dose of the BNT162b2 mRNA vaccine against coronavirus disease 2019 (COVID-19). A 69-year-old man with a history of diabetes and hypertension presented with AKI 4 days after receiving the vaccine. Despite the administration of methylprednisolone pulse treatment, his renal function worsened, which prompted us to initiate temporal hemodialysis. His renal function subsequently improved, and a renal biopsy confirmed AIN and glomerular capillary IgA deposition without apparent crescents. The clinical history and histological findings suggest a relationship between severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination and AIN as a rare side effect.
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Affiliation(s)
- Erika Hishida
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
| | - Yuko Ono
- Department of Diagnostic Pathology, Dokkyo Medical University, Japan
| | - Kazuho Oe
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
| | - Toshimi Imai
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
| | - Hiromichi Yoshizawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
| | - Takeo Nakaya
- Department of Pathology, Jichi Medical University, Japan
| | | | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
| | - Osamu Saito
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Japan
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Bharati J, Yang Y, Sharma P, Jhaveri KD. Atypical Anti-Glomerular Basement Membrane Disease. Kidney Int Rep 2023; 8:1151-1161. [PMID: 37284681 PMCID: PMC10239794 DOI: 10.1016/j.ekir.2023.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/09/2023] [Accepted: 03/15/2023] [Indexed: 06/08/2023] Open
Abstract
Atypical anti-glomerular basement membrane (anti-GBM) disease is characterized by linear immunoglobulin G (IgG) deposition along the GBM without circulating IgG anti-GBM antibodies. Compared to classic anti-GBM disease, atypical anti-GBM disease tends to be milder with a more indolent course in certain cases. Moreover, pathologic disease pattern is much more heterogenous in atypical anti-GBM disease than in the classic type, which is uniformly characterized by diffuse crescentic and necrotizing glomerulonephritis. Although there is no single well-established target antigen in atypical anti-GBM disease, the target antigen (within the GBM) and the autoantibody type are hypothesized to be different from the classic type. Some patients have the same antigen as the Goodpasture antigen that are detected only by a highly sensitive technique (biosensor analysis). Some cases of atypical anti-GBM disease have autoantibodies of a different subclass restriction like IgG4, or of monoclonal nature. Antibodies targeting antigen/epitope structure other than the Goodpasture antigen can be detected using modified assays in some cases. Patients with IgA- and IgM-mediated anti-GBM disease are known to have negative circulating antibodies because conventional assays do not detect these classes of antibodies. A significant proportion of cases with atypical anti-GBM disease do not have any identifiable antibodies despite extensive evaluation. Nevertheless, extensive evaluation of atypical autoantibodies using modified assays and sensitive techniques should be attempted, if feasible. This review summarizes the recent literature on atypical anti-GBM disease.
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Affiliation(s)
- Joyita Bharati
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Yihe Yang
- Department of Pathology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Purva Sharma
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
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Antonelou M, Horsley H, Heptinstall L, Harber M, Salama AD. Binding Truths: Seronegative Anti-Glomerular Basement Membrane Disease Mediated by IgM Anti-Glomerular Basement Membrane Antibodies. Kidney Int Rep 2023; 8:1117-1120. [PMID: 37180519 PMCID: PMC10166737 DOI: 10.1016/j.ekir.2023.02.1091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/22/2023] [Accepted: 02/27/2023] [Indexed: 03/08/2023] Open
Affiliation(s)
- Marilina Antonelou
- University College London Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Harry Horsley
- University College London Department of Renal Medicine, Royal Free Hospital, London, UK
| | | | - Mark Harber
- University College London Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Alan D. Salama
- University College London Department of Renal Medicine, Royal Free Hospital, London, UK
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10
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Kuang H, Liu J, Jia XY, Cui Z, Zhao MH. Autoimmunity in Anti-Glomerular Basement Membrane Disease: A Review of Mechanisms and Prospects for Immunotherapy. Am J Kidney Dis 2023; 81:90-99. [PMID: 36334986 DOI: 10.1053/j.ajkd.2022.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/10/2022] [Indexed: 11/06/2022]
Abstract
Anti-glomerular basement membrane (anti-GBM) disease is an organ-specific autoimmune disorder characterized by autoantibodies against the glomerular and alveolar basement membranes, leading to rapidly progressive glomerulonephritis and severe alveolar hemorrhage. The noncollagenous domain of the α3 chain of type IV collagen, α3(IV)NC1, contains the main target autoantigen in this disease. Epitope mapping studies of α3(IV)NC1 have identified several nephritogenic epitopes and critical residues that bind to autoantibodies and trigger anti-GBM disease. The discovery of novel target antigens has revealed the heterogeneous nature of this disease. In addition, both epitope spreading and mimicry have been implicated in the pathogenesis of anti-GBM disease. Epitope spreading refers to the development of autoimmunity to new autoepitopes, thus worsening disease progression, whereas epitope mimicry, which occurs via sharing of critical residues with microbial peptides, can initiate autoimmunity. An understanding of these autoimmune responses may open opportunities to explore potential new therapeutic approaches for this disease. We review how current advances in epitope mapping, identification of novel autoantigens, and the phenomena of epitope spreading and mimicry have heightened the understanding of autoimmunity in the pathogenesis of anti-GBM disease, and we discuss prospects for immunotherapy.
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Affiliation(s)
- Huang Kuang
- Renal Division, Peking University First Hospital, Beijing, People's Republic of China; Institute of Nephrology, Peking University, Beijing, People's Republic of China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Jing Liu
- Renal Division, Peking University First Hospital, Beijing, People's Republic of China; Institute of Nephrology, Peking University, Beijing, People's Republic of China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China; Peking-Tsinghua Center for Life Sciences, Beijing, People's Republic of China
| | - Xiao-Yu Jia
- Renal Division, Peking University First Hospital, Beijing, People's Republic of China; Institute of Nephrology, Peking University, Beijing, People's Republic of China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Beijing, People's Republic of China; Institute of Nephrology, Peking University, Beijing, People's Republic of China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Beijing, People's Republic of China; Institute of Nephrology, Peking University, Beijing, People's Republic of China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China; Peking-Tsinghua Center for Life Sciences, Beijing, People's Republic of China
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11
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Jamboti JS, Sinniah R, Dorsogna L, Holmes C. Recurrent, Atypical Anti-Glomerular Basement Membrane Disease. Indian J Nephrol 2021; 31:319-321. [PMID: 34376954 PMCID: PMC8330667 DOI: 10.4103/ijn.ijn_414_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 05/06/2020] [Accepted: 05/23/2020] [Indexed: 11/06/2022] Open
Abstract
Anti-glomerular basement membrane disease (GBM) (Goodpasture's disease) typically presents with acute manifestations of rapidly progressive glomerulonephritis often accompanied by lung haemorrhage. Anti-GBM disease is usually monophasic. However, atypical presentations with indolent renal involvement are being increasingly recognized. Herein we report a patient who presented with lung haemorrhage, minimal renal involvement, and negative result for serum anti-GBM antibody, while immunofluorescence examination of the renal biopsy provided the diagnosis leading to the institution right treatment with excellent response. Interestingly, he had presented 10 years earlier with lung hemorrhage, more significant renal involvement clinically and histologically, with positive serum anti-GBM antibody. The present case is intended to increase our awareness regarding the variable presentations of anti-GBM disease, such as with negative serology and recurrence of anti-GBM disease. The presentation of anti-GBM nephritis with non-proliferative, non-crescentic glomerulonephritis is also highlighted. The possible explanations for negative serum anti-GBM antibody are explored with a brief review of literature.
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Affiliation(s)
- Jagadish S Jamboti
- Department of Nephrology and Transplantation, Curtin University, Bentley, Western Australia.,Curtin University, Bentley, Crawley, Western Australia.,University of Western Australia, Crawley, Western Australia
| | - Rajalingam Sinniah
- University of Western Australia, Crawley, Western Australia.,Department of Anatomical Pathology, Bendigo, Monash University Rural School of Health, Bendigo, Victoria, Western Australia
| | - Lloyd Dorsogna
- University of Western Australia, Crawley, Western Australia.,Clinical Immunology, Fiona Stanley Hospital, Murdoch, Western Australia
| | - Christian Holmes
- Nephrology Service, Bendigo, Monash University Rural School of Health, Bendigo, Victoria, Western Australia
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Shen CR, Jia XY, Cui Z, Yu XJ, Zhao MH. Clinical-Pathological Features and Outcome of Atypical Anti-glomerular Basement Membrane Disease in a Large Single Cohort. Front Immunol 2020; 11:2035. [PMID: 33013861 PMCID: PMC7494752 DOI: 10.3389/fimmu.2020.02035] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Atypical cases of anti-glomerular basement membrane (GBM) disease had absent circulating antibodies but linear IgG deposits along GBM in the kidneys. Herein, we reported the clinical-pathological features and outcome of these rare cases. Methods: Linear IgG deposit along GBM were examined by immunofluorescence on renal specimens, with exclusion of diabetic kidney disease. Circulating anti-GBM antibodies were tested by commercial ELISA assay. Clinical, pathological and follow-up data were retrospectively analyzed. Results: From 2013 to 2018, a total of 60 patients were diagnosed as atypical anti-GBM disease. They had a male predominance, with an average age of 51.7 ± 15.6 years. Three (5.0%) patients had alveolar hemorrhage. Forty five percent of them presented with acute kidney disease. All patients had linear IgG deposit along GBM, some in addition on tubular basement membrane and/or Bowmans' capsules. C3 deposition was found in 65.0% of the patients. 41.7% (25/60) of the patients showed crescent formation and the percentage of crescent was (34.7 ± 23.5)% in those patients. They had higher prevalence of hematuria and C3 deposit, higher levels of serum creatinine, worse renal and patient survival than those without crescent (P < 0.05). During the follow-up of 35.7 ± 21.4 months, 14 (23.3%) patients progressed to ESRD. The serum creatinine on diagnosis [per 200 μmol/L increase, HR (95% CI): 2.663 (1.372, 5.172), P = 0.004], serum C3 [per 0.1 g/L increase, HR (95% CI): 0.689(0.483, 0.984), P = 0.040] and the intensity of kidney C3 staining [per 1+ increase, HR (95% CI): 2.770 (1.115, 6.877), P = 0.028] were independent predictive factors for kidney outcome. Nine (15.0%) patients died of all causes. Conclusions: Atypical anti-GBM disease manifested milder kidney injury and scarce pulmonary hemorrhage compared to the classical cases. Though heterogeneous, a substantial number of the patients had complement activation and crescent formation. Patients having crescents presented with more severe clinical course and worse outcomes. The poor kidney and patient prognosis emphasize prompt interventions from physicians. The immunosuppressive intervention was not associated with kidney or patient outcome. Further studies are needed to address the optimal therapeutic regimen.
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Affiliation(s)
- Cong-Rong Shen
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Yu Jia
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Juan Yu
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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Salama AD. IgA vasculitis and anti-GBM disease: two ends of a spectrum of immune complex vasculitis. Rheumatology (Oxford) 2020; 59:iii118-iii122. [PMID: 32348516 DOI: 10.1093/rheumatology/kez540] [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: 08/29/2019] [Revised: 09/30/2019] [Indexed: 11/12/2022] Open
Abstract
Two immune complex vasculitides, IgA vasculitis (IgAV) and anti-GBM disease, represent polar extremes with regard to our understanding of disease pathogenesis, standardized management protocols and outcomes. This report compares our current approach to these uncommon entities in adults. Both diseases demonstrate degrees of small vessel necrosis and glomerular crescent formation. IgAV has an antibody response directed against unknown antigens, is often treated conservatively and has poorly studied long term renal outcomes. By contrast, anti-GBM disease presents with rapidly progressive glomerulonephritis and often results in end stage renal failure, despite intensive immunosuppression. Rarely, some cases of anti-GBM disease may be IgA predominant and bind other α-chains present in the GBM, but their clinical course is as for other anti-GBM disease patients but not IgAV, suggesting that the antigenic target rather than the antibody subclass is the critical factor in determining disease outcome. However, both conditions are associated with increased mortality in adults and result in significant chronic kidney disease and hypertension.
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Affiliation(s)
- Alan D Salama
- UCL Department of Renal Medicine, Royal Free Hospital, London, UK
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