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Mosquera-Sulbaran JA, Pedreañez A, Vargas R, Hernandez-Fonseca JP. Apoptosis in post-streptococcal glomerulonephritis and mechanisms for failed of inflammation resolution. Pediatr Nephrol 2024; 39:1709-1724. [PMID: 37775580 DOI: 10.1007/s00467-023-06162-y] [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: 07/18/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 10/01/2023]
Abstract
Post-streptococcal glomerulonephritis is a condition resulting from infection by group A beta-hemolytic streptococcus. The main mechanism involves the formation of immune complexes formed in the circulation or in situ on the glomerular basement membrane, which activates complement and causes various inflammatory processes. Cellular mechanisms have been reported in the induction of kidney damage represented by the infiltration of innate cells (neutrophils and monocyte/macrophages) and adaptive cells (CD4 + lymphocytes and CD8 + lymphocytes) of the immune system. These cells induce kidney damage through various mechanisms. It has been reported that nephritogenic antigens are capable of inducing inflammatory processes early, even before the formation of immune complexes. Usually, this disease progresses towards clinical and renal normalization; however, in a smaller number of patients, it evolves into chronicity and persistent kidney damage. Hypotheses have been proposed regarding the mechanisms underlying this progression to chronicity including failure to induce apoptosis and failure to phagocytose apoptotic cells, allowing these cells to undergo membrane permeabilization and release pro-inflammatory molecules into the environment, thereby perpetuating renal inflammation. Other mechanisms involved include persistent infection, genetic background of the host's complement system, tubulointerstitial changes, and pre-existing kidney damage due to old age and comorbidities.
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Affiliation(s)
- Jesús A Mosquera-Sulbaran
- Instituto de Investigaciones Clínicas "Dr. Américo Negrette," Facultad de Medicina, Universidad del Zulia, Apartado Postal: 23, Maracaibo, 4001-A, Zulia, Venezuela.
| | - Adriana Pedreañez
- Escuela de Bioanálisis, Facultad de Medicina, Universidad del Zulia, Maracaibo, Venezuela
| | - Renata Vargas
- Instituto de Investigaciones Clínicas "Dr. Américo Negrette," Facultad de Medicina, Universidad del Zulia, Apartado Postal: 23, Maracaibo, 4001-A, Zulia, Venezuela
| | - Juan Pablo Hernandez-Fonseca
- Instituto de Investigaciones Clínicas "Dr. Américo Negrette," Facultad de Medicina, Universidad del Zulia, Apartado Postal: 23, Maracaibo, 4001-A, Zulia, Venezuela
- Servicio de Microscopia Electrónica del Centro Nacional de Biotecnología (CNB-CSIC), Madrid, Spain
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Mosquera-Sulbaran JA, Pedreañez A, Carrero Y, Hernandez-Fonseca JP. Angiotensin II and post-streptococcal glomerulonephritis. Clin Exp Nephrol 2024; 28:359-374. [PMID: 38170299 DOI: 10.1007/s10157-023-02446-7] [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: 07/30/2023] [Accepted: 12/04/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Post-streptococcal glomerulonephritis (PSGN) is a consequence of the infection by group A beta-hemolytic streptococcus. During this infection, various immunological processes generated by streptococcal antigens are triggered, such as the induction of antibodies and immune complexes. This activation of the immune system involves both innate and acquired immunity. The immunological events that occur at the renal level lead to kidney damage with chronic renal failure as well as resolution of the pathological process (in most cases). Angiotensin II (Ang II) is a molecule with vasopressor and pro-inflammatory capacities, being an important factor in various inflammatory processes. During PSGN some events are defined that make Ang II conceivable as a molecule involved in the inflammatory processes during the disease. CONCLUSION This review is focused on defining which reported events would be related to the presence of this hormone in PSGN.
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Affiliation(s)
- Jesus A Mosquera-Sulbaran
- Facultad de Medicina, Instituto de Investigaciones Clínicas "Dr. Américo Negrette", Universidad del Zulia, Apartado Postal: 23, MaracaiboZulia, 4001-A, Venezuela.
| | - Adriana Pedreañez
- Facultad de Medicina, Cátedra de Inmunología, Escuela de Bioanálisis, Universidad del Zulia, Maracaibo, Venezuela
| | - Yenddy Carrero
- Facultad de Medicina, Instituto de Investigaciones Clínicas "Dr. Américo Negrette", Universidad del Zulia, Apartado Postal: 23, MaracaiboZulia, 4001-A, Venezuela
| | - Juan Pablo Hernandez-Fonseca
- Facultad de Medicina, Instituto de Investigaciones Clínicas "Dr. Américo Negrette", Universidad del Zulia, Apartado Postal: 23, MaracaiboZulia, 4001-A, Venezuela
- Servicio de Microscopia Electrónica del Centro Nacional de Biotecnología, CNB-CSIC, Madrid, Spain
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Oba Y, Mizuno H, Taneda S, Sawai T, Oda T, Ikuma D, Yamanouchi M, Suwabe T, Kono K, Kinowaki K, Ohashi K, Sawa N, Ubara Y. Anti-factor H antibody-positive C3 glomerulonephritis secondary to poststreptococcal acute glomerulonephritis with diabetic nephropathy. CEN Case Rep 2024; 13:110-116. [PMID: 37452997 PMCID: PMC10982226 DOI: 10.1007/s13730-023-00809-3] [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: 11/11/2022] [Accepted: 07/05/2023] [Indexed: 07/18/2023] Open
Abstract
Poststreptococcal acute kidney glomerulonephritis (PSAGN) has been seen in adults in recent years, especially in patients with type 2 diabetes mellitus, and the renal prognosis has not always been good. There have been cases of PSAGN in which complete remission was not achieved and hematuria and proteinuria persisted, leading to end-stage renal disease. Previous reports showed that the patients subjected to PSAGN have an underlying defect in regulating the alternative pathway of complement, and they identified that antibodies to the C3 convertase, C3 nephritic factors (C3NeF), are involved. C3NeF stabilizes C3 convertase, sustains C3 activation, and causes C3 glomerulonephritis (C3GN). On the other hand, factor H is a glycoprotein that suppresses the overactivation of the alternative pathway by decaying the C3 convertase. Anti-factor H (aFH) antibodies interfere with factor H and cause the same activation of the alternative pathway as C3NeF. However, a limited number of reports describe the clinical course of C3GN with aFH antibodies. We encountered a 49-year-old Japanese man with type 2 diabetes mellitus. He was referred to our hospital because of his elevated serum creatinine, proteinuria, hematuria, and developed edema on both legs. He was diagnosed as PSAGN at the first kidney biopsy, and his renal function improved and edema and hematuria disappeared, but proteinuria persisted after 5 months. He was diagnosed as C3GN at the second kidney biopsy. In our case, no C3NeF was detected. However, a high titer of aFH antibodies was detected in stored serum from the initial presentation, providing a unified diagnosis of aFH antibody-positive C3GN secondary to PSAGN. He progressed to end-stage renal disease (ESRD) and hemodialysis was started. The persistence of high levels of aFH autoantibodies may have caused C3GN secondary to PSAGN due to activating the alternative complement pathway, which eventually worsened the nephropathy and led to ESRD.
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Affiliation(s)
- Yuki Oba
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Kawasaki, Kanagawa, 213-8587, Japan.
| | - Hiroki Mizuno
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Kawasaki, Kanagawa, 213-8587, Japan
| | - Sekiko Taneda
- Department of Pathology, Tokyo Women's Medical University, 8-1 Kawada-Cho, Shinjuku-Ku, Tokyo, 162-8666, Japan
| | - Toshihiro Sawai
- Department of Pediatrics, Shiga University of Medical Science, Seta Tsukinowa-Cho, Otsu, Shiga, 520-2192, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Daisuke Ikuma
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Kawasaki, Kanagawa, 213-8587, Japan
| | - Masayuki Yamanouchi
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Kawasaki, Kanagawa, 213-8587, Japan
| | - Tatsuya Suwabe
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Kawasaki, Kanagawa, 213-8587, Japan
| | - Kei Kono
- Department of Pathology, Toranomon Hospital, 2-2-2 Toranomon, Minato-Ku, Tokyo, 105-8470, Japan
| | - Keiichi Kinowaki
- Department of Pathology, Toranomon Hospital, 2-2-2 Toranomon, Minato-Ku, Tokyo, 105-8470, Japan
| | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, 2-2-2 Toranomon, Minato-Ku, Tokyo, 105-8470, Japan
- Department of Human Pathology, Tokyo Medical Dental University, 1-5-45 Yushima, Bunkyo-Ku, Tokyo, 113-8510, Japan
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Kawasaki, Kanagawa, 213-8587, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital Kajigaya, 1-3-1 Kajigaya, Kawasaki, Kanagawa, 213-8587, Japan
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Casuscelli C, Longhitano E, Maressa V, Di Carlo S, Peritore L, Di Lorenzo S, Calabrese V, Cernaro V, Santoro D. Autoimmunity and Infection in Glomerular Disease. Microorganisms 2023; 11:2227. [PMID: 37764071 PMCID: PMC10538233 DOI: 10.3390/microorganisms11092227] [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: 07/26/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
The ongoing glomerular damage of infections is not limited to the most widely known form of post-streptococcal glomerulonephritis, which is today less common in the Western world; other forms of glomerulonephritis are associated with several bacterial, viral and parasitic pathogens. The mechanisms responsible range from the direct damage of glomerular cells to the formation and deposition of immunocomplexes to molecular mimicry to the secretion of superantigens. Similarly, in the course of glomerular disease, infections are more frequent than in the general population due to the loss of immunoglobulins in urine and the immunosuppressive agents used to treat the autoimmune disease that decrease the activity of the immune system. Recognizing this two-way link, understanding its pathogenetic mechanism, and identifying the most appropriate therapeutic choice are essential for the personalized management of patients. In this continuously developing field, this short review summarizes the current state of the art as support for physicians, who are increasingly involved in managing patients with glomerular disease and infections.
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Affiliation(s)
- Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. “G. Martino”, University of Messina, 98122 Messina, Italy; (E.L.); (V.M.); (S.D.C.); (L.P.); (S.D.L.); (V.C.); (V.C.)
| | | | | | | | | | | | | | | | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, A.O.U. “G. Martino”, University of Messina, 98122 Messina, Italy; (E.L.); (V.M.); (S.D.C.); (L.P.); (S.D.L.); (V.C.); (V.C.)
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Toishi T, Oda T, Hamano A, Sugihara S, Inoue T, Kawaji A, Nagaoka K, Matsunami M, Fukuda J, Ohara M, Suzuki T. Infection-Related Cryoglobulinemic Glomerulonephritis with Serum Anti-Factor B Antibodies Identified and Staining for NAPlr/Plasmin Activity Due to Infective Endocarditis. Int J Mol Sci 2023; 24:ijms24119369. [PMID: 37298319 DOI: 10.3390/ijms24119369] [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: 04/09/2023] [Revised: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 06/12/2023] Open
Abstract
In this rare case of infection-related cryoglobulinemic glomerulonephritis with infective endocarditis, a 78-year-old male presented with an acute onset of fever and rapidly progressive glomerulonephritis. His blood culture results were positive for Cutibacterium modestum, and transesophageal echocardiography showed vegetation. He was diagnosed with endocarditis. His serum immunoglobulin M, IgM-cryoglobulin, and proteinase-3-anti-neutrophil cytoplasmic antibody levels were elevated, and his serum complement 3 (C3) and C4 levels were decreased. Renal biopsy results showed endocapillary proliferation, mesangial cell proliferation, and no necrotizing lesions on light microscopy, with strong positive staining for IgM, C3, and C1q in the capillary wall. Electron microscopy showed deposits in the mesangial area in the form of fibrous structures without any humps. Histological examination confirmed a diagnosis of cryoglobulinemic glomerulonephritis. Further examination showed the presence of serum anti-factor B antibodies and positive staining for nephritis-associated plasmin receptor and plasmin activity in the glomeruli, suggesting infective endocarditis-induced cryoglobulinemic glomerulonephritis.
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Affiliation(s)
- Takumi Toishi
- Department of Nephrology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Tokyo Medical University Hachioji Medical Center, 1163, Tate-machi, Hachioji 193-0998, Tokyo, Japan
| | - Atsuro Hamano
- Department of Nephrology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba, Japan
| | - Shinnosuke Sugihara
- Department of Nephrology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba, Japan
| | - Tomohiko Inoue
- Department of Nephrology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba, Japan
| | - Atsuro Kawaji
- Department of Nephrology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba, Japan
| | - Kanako Nagaoka
- Department of Nephrology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba, Japan
| | - Masatoshi Matsunami
- Department of Nephrology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba, Japan
| | - Junko Fukuda
- Department of Nephrology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba, Japan
| | - Mamiko Ohara
- Department of Nephrology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba, Japan
| | - Tomo Suzuki
- Department of Nephrology, Kameda Medical Center, 929 Higashi-cho, Kamogawa 296-8602, Chiba, Japan
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Yoshizawa N, Yamada M, Fujino M, Oda T. Nephritis-Associated Plasmin Receptor (NAPlr): An Essential Inducer of C3-Dominant Glomerular Injury and a Potential Key Diagnostic Biomarker of Infection-Related Glomerulonephritis (IRGN). Int J Mol Sci 2022; 23:ijms23179974. [PMID: 36077377 PMCID: PMC9456382 DOI: 10.3390/ijms23179974] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 08/11/2022] [Accepted: 08/16/2022] [Indexed: 11/25/2022] Open
Abstract
Nephritis-associated plasmin receptor (NAPlr) was originally isolated from the cytoplasmic fraction of group A Streptococci, and was found to be the same molecule as streptococcal glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and plasmin receptor (Plr) on the basis of nucleotide and amino acid sequence homology. Its main functions include GAPDH activity, plasmin-binding capacity, and direct activation of the complement alternative pathway (A-P). Plasmin trapped by deposited NAPlr triggers the degradation of extracellular matrix proteins, such as glomerular basement membranes and mesangial matrix, and the accumulation of macrophages and neutrophils, leading to the induction of plasmin-related endocapillary glomerular inflammation. Deposited NAPlr at glomerular endocapillary site directly activates the complement A-P, and the endocapillary release of complement-related anaphylatoxins, C3a and C5a, amplify the in situ endocapillary glomerular inflammation. Subsequently, circulating and in situ-formed immune complexes participate in the glomerular injury resulting in NAPlr-mediated glomerulonephritis. The disease framework of infection-related glomerulonephritis (IRGN) has been further expanded. GAPDH of various bacteria other than Streptococci have been found to react with anti-NAPlr antibodies and to possess plasmin-binding activities, allowing glomerular NAPlr and plasmin activity to be utilized as key biomarkers of IRGN.
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Affiliation(s)
| | - Muneharu Yamada
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Tokyo 193-0998, Japan
| | - Masayuki Fujino
- National Institute of Infectious Disease, Tokyo 162-8640, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Tokyo 193-0998, Japan
- Correspondence: ; Tel.: +81-42-665-5611; Fax: +81-42-665-1796
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Kanazawa N, Iyoda M, Hayashi J, Honda K, Oda T, Honda H. A case of acute poststreptococcal glomerulonephritis complicated by interstitial nephritis related to streptococcal pyrogenic exotoxin B. Pathol Int 2022; 72:200-206. [PMID: 35147256 DOI: 10.1111/pin.13203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/29/2021] [Indexed: 01/26/2023]
Abstract
This paper presents the case of a patient who developed acute kidney injury and nephrotic syndrome following streptococcal cutaneous infection. He presented with microhematuria, severe proteinuria and systemic edema 5 days after infection. Blood examination showed elevated creatinine level, hypocomplementemia, and elevated anti-streptolysin O level. Renal biopsy revealed endocapillary proliferative glomerulonephritis with tubulointerstitial nephritis (TIN). Immunofluorescence revealed C3-dominant glomerular staining, while electron microscopy showed hump-shaped subepithelial deposits. The patient was therefore diagnosed with poststreptococcal glomerulonephritis. The unique histological feature was C3 deposition in the tubular basement membrane (TBM), in which we detected streptococcal pyrogenic exotoxin B (SpeB), a nephritogenic antigen produced by streptococci. No nephritis-associated plasmin receptor or plasmin activity was evident in the TBM. These nephritogenic antigens and upregulation of plasmin activity were observed in glomeruli. This case suggests that TIN after poststreptococcal infection might be partially attributable to SpeB toxicity.
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Affiliation(s)
- Nobuhiro Kanazawa
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Masayuki Iyoda
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan.,Department of Microbiology and Immunology, Showa University School of Medicine, Tokyo, Japan
| | - Junichi Hayashi
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Kazuho Honda
- Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
| | - Hirokazu Honda
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
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The influences of α-hemolytic Streptococcus on class switching and complement activation of human tonsillar cells in IgA nephropathy. Immunol Res 2021; 70:86-96. [PMID: 34642907 DOI: 10.1007/s12026-021-09223-2] [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: 01/21/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
While β-hemolytic streptococcus (β-HS) infections are known to predispose patients to acute poststreptococcal glomerulonephritis, there is evidence that implicates α-hemolytic streptococcus (α-HS) in IgA nephropathy (IgAN). The alternative pathway of the complement system has also been implicated in IgAN. We aimed to explore the association between α-HS and complement activation in human tonsillar mononuclear cells (TMCs) in IgAN. In our study, α-HS induced higher IgA levels than IgG levels, while β-HS increased higher IgG levels than IgA levels with more activation-induced cytidine deaminase, in TMCs in the IgAN group. Aberrant IgA1 O-glycosylation levels were higher in IgAN patients with α-HS. C3 and C3b expression was decreased in IgAN patients, but in chronic tonsillitis control patients, the expression decreased only after stimulation with β-HS. Complement factor B and H (CFH) mRNA increased, but the CFH concentration in culture supernatants decreased with α-HS. The percentage of CD19 + CD35 + cells/complement receptor 1 (CR1) decreased with α-HS more than with β-HS, while CD19 + CD21 + cells/complement receptor 2 (CR2) increased more with β-HS than with α-HS. The component nephritis-associated plasmin receptor (NAPlr) of α-HS was not detected on tonsillar or kidney tissues in IgAN patients and was positive on cultured TMCs and mesangial cells. We concluded that α-HS induced the secretion of aberrantly O-glycosylated IgA while decreasing the levels of the inhibitory factor CFH in culture supernatants and CR1 + B cells. These findings provide testable mechanisms that relate α-HS infection to abnormal mucosal responses involving the alternative complement pathway in IgAN.
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Mosquera J, Pedreañez A. Acute post-streptococcal glomerulonephritis: analysis of the pathogenesis. Int Rev Immunol 2020; 40:381-400. [PMID: 33030969 DOI: 10.1080/08830185.2020.1830083] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Increasing evidence supports a central role of the immune system in acute post streptococcal glomerulonephritis (APSGN), but the current view of how streptococcal biology affects immunity, and vice versa, remains to be clarified. Renal glomerular immune complex deposition is critical in the initiation of APSGN; however, mechanisms previous to immune complex formation could modulate the initiation and the progression of the disease. Initial and late renal events involved in the nephritis can also be related to host factors and streptococcal factors. In this review we describe the mechanisms reported for the APSGN pathogenesis, the interactions of streptococcal products with renal cells and leukocytes, the possible effects of different nephritogenic antigens in the renal environment and the possibility that APSGN is not just due to a single streptococcal antigen and its antibody; instead, kidney damage may be the result of different factors acting at the same time related to both streptococcus and host factors. Addressing these points should help us to better understand APSGN physiopathology.
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Affiliation(s)
- Jesús Mosquera
- Facultad de Medicina, Instituto de Investigaciones Clínicas "Dr. Américo Negrette", Universidad del Zulia, Maracaibo, Venezuela
| | - Adriana Pedreañez
- Facultad de Medicina, Cátedra de Inmunología, Escuela de Bioanálisis, Universidad del Zulia, Maracaibo, Venezuela
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Noda S, Mandai S, Oda T, Shinoto T, Sato H, Sato K, Hirokawa K, Noda Y, Uchida S. Asymptomatic sinusitis as an origin of infection-related glomerulonephritis manifesting steroid-resistant nephrotic syndrome: A case report. Medicine (Baltimore) 2020; 99:e20572. [PMID: 32569182 PMCID: PMC7310930 DOI: 10.1097/md.0000000000020572] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
RATIONALE Infection is a major trigger or pathogenic origin in a substantial proportion of glomerulonephritis (GN) patients, typically manifesting infection-related GN (IRGN). Various microorganisms, infection sites, and clinical and histopathological features are involved in IRGN. Once an infectious origin is identified and successfully eradicated, nephrotic syndrome or kidney dysfunction is spontaneously resolved. However, if patients are asymptomatic and the origin is undetermined, the diagnosis and treatment of GN is challenging. This case presentation reported on an IRGN case manifesting steroid-resistant nephrotic syndrome associated with asymptomatic sinusitis as a pathogenic origin. PATIENT CONCERNS A 68-year-old male presented with severe kidney dysfunction and edema in both extremities. DIAGNOSIS The patient was clinically diagnosed with hypocomplementemic nephrotic syndrome and kidney dysfunction and histopathologically with diffuse proliferative GN and a focal pattern of membranoproliferative GN. The findings suggested that idiopathic membranoproliferative glomerulonephritis type I was more likely than IRGN, given a critical lack of apparent infection. INTERVENTIONS Combined intravenous methylprednisolone, oral prednisolone, and cyclosporin did not improve the patient's condition. Thus, IRGN associated with inapparent infectious origin was suspected. Repeated thorough and careful examinations including CT scan showed sinusitis in his left maxillary sinus. Moreover, reanalysis of kidney specimen revealed positive nephritis-associated plasmin receptor in glomeruli, a typical finding for IRGN, supporting a pathogenic significance of his sinusitis. Medical treatment was initiated with 200 mg oral clarithromycin daily. OUTCOMES Oral clarithromycin gradually improved proteinuria and hypocomplementemia and resulted in nephrotic syndrome remission in parallel with opacification resolution of sinuses shown on CT. LESSONS This case presentation showed that asymptomatic sinusitis is potentially a pathogenic IRGN origin. A gold standard therapy for idiopathic GN, corticosteroid could be damaging in uncontrolled or underdiagnosed infection. In asymptomatic patients, a thorough screening of infectious diseases, including sinusitis, together with a renal histological evaluation of glomerular nephritis-associated plasmin receptor deposition is also essential in treating a wide spectrum of GN.
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Affiliation(s)
- Shohei Noda
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
| | - Shintaro Mandai
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Tokyo Medical University Hachioji Medical Center, Hachioji
| | - Tomoko Shinoto
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
| | - Hidehiko Sato
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
| | - Keiko Sato
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
| | - Katsuiku Hirokawa
- Department of Clinical Pathology, Nitobe Memorial Nakano General Hospital, Nakano, Tokyo, Japan
| | - Yumi Noda
- Department of Nephrology, Nitobe Memorial Nakano General Hospital, Nakano
| | - Shinichi Uchida
- Department of Nephrology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Bunkyo
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Glomerular Deposition of Nephritis-Associated Plasmin Receptor (NAPlr) and Related Plasmin Activity: Key Diagnostic Biomarkers of Bacterial Infection-related Glomerulonephritis. Int J Mol Sci 2020; 21:ijms21072595. [PMID: 32276523 PMCID: PMC7178002 DOI: 10.3390/ijms21072595] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/07/2020] [Accepted: 04/08/2020] [Indexed: 02/06/2023] Open
Abstract
It is widely known that glomerulonephritis (GN) often develops after the curing of an infection, a typical example of which is GN in children following streptococcal infections (poststreptococcal acute glomerulonephritis; PSAGN). On the other hand, the term “infection-related glomerulonephritis (IRGN)” has recently been proposed, because infections are usually ongoing at the time of GN onset in adult patients, particularly in older patients with comorbidities. However, there has been no specific diagnostic biomarker for IRGN, and diagnosis is based on the collection of several clinical and pathological findings and the exclusion of differential diagnoses. Nephritis-associated plasmin receptor (NAPlr) was originally isolated from the cytoplasmic fraction of group A streptococcus as a candidate nephritogenic protein for PSAGN and was found to be the same molecule as streptococcal glyceraldehyde-3-phosphate dehydrogenase and plasmin receptor. NAPlr deposition and related plasmin activity were observed with a similar distribution pattern in the glomeruli of patients with PSAGN. However, glomerular NAPlr deposition and plasmin activity could be observed not only in patients with PSAGN but also in patients with other glomerular diseases, in whom a preceding streptococcal infection was suggested. Furthermore, such glomerular staining patterns have been demonstrated in patients with IRGN induced by bacteria other than streptococci. This review discusses the recent advances in our understanding of the pathogenesis of bacterial IRGN, which is characterized by NAPlr and plasmin as key biomarkers.
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Yano K, Suzuki H, Oda T, Ueda Y, Tsukamoto T, Muso E. Crescentic poststreptococcal acute glomerulonephritis accompanied by small vessel vasculitis: case report of an elderly male. BMC Nephrol 2019; 20:471. [PMID: 31852436 PMCID: PMC6921464 DOI: 10.1186/s12882-019-1663-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 12/10/2019] [Indexed: 12/15/2022] Open
Abstract
Background Poststreptococcal acute glomerulonephritis (PSAGN) in the elderly tends to have a severe clinical course and often presents with crescentic necrotizing glomerulonephritis in the renal biopsy. However, vasculitis lesions are unusual. Case presentation We present a 71-year-old man who was admitted to our hospital for a recurrent gout attack with a rapid decline of renal function. Low C3 levels and a high anti-streptolysin O titer were observed, while myeloperoxidase- and proteinase 3- antineutrophil cytoplasmic antibody (ANCA) were negative. In addition to cellular crescent and necrosis lesions, diffuse peritubular capillaritis and venulitis as well as small arteriole vasculitis in the glomerular hilus were also apparent. Although granular C3c deposits in the capillary wall and hump lesions were not found, immunofluorescent staining for nephritis-associated plasmin receptor (NAPlr) and in situ zymography for plasmin activity were both positive. We thus diagnosed PSAGN accompanied by small vessel vasculitis. Steroid therapy gradually improved the patient’s renal function, and hemodialysis was discontinued after 1 month. Conclusions In our case, streptococcus infection might have concurrently provoked vasculitis, and NAPlr staining was useful for confirming diagnosis.
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Affiliation(s)
- Keiko Yano
- Department of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan. .,Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Hiroyuki Suzuki
- Department of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo, 193-0998, Japan
| | - Yoshihiko Ueda
- Department of Pathology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minami Koshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Tatsuo Tsukamoto
- Department of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan
| | - Eri Muso
- Department of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ohgimachi, Kita-ku, Osaka, 530-8480, Japan.,Department of Food and Nutrition, Faculty of Contemporary Home Economics, Kyoto Kacho University, 3-456 Rinka-cho, Higashiyama-ku, Kyoto, 605-0062, Japan
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Liu Y, Zhang H, Liu Y, Han Q, Tang Y, Zhao L, Qiao F, Xu Z, Yu M, Yuan Z. Risk factors and short-term prognosis of preoperative renal insufficiency in infective endocarditis. J Thorac Dis 2018; 10:3679-3688. [PMID: 30069366 DOI: 10.21037/jtd.2018.06.11] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The incidence of postoperative complications and the in-hospital mortality rate of infective endocarditis (IE) complicated with renal insufficiency are relatively high. This study aimed to analyze the clinical features, etiological characteristics, diagnosis and treatment, and prognosis of IE with renal insufficiency and to explore the risk factors for renal damage. Methods IE patients undergoing valvular surgery between 2008 and 2017 in two cardiac centers were retrospectively analyzed. They were divided into renal insufficiency (RI) [endogenous creatinine clearance rate (Ccr) <60 mL/min/1.73 m2] and normal renal function (NRF) (Ccr ≥60 mL/min/1.73 m2) groups. The disease conditions at admission, etiology, treatment, and prognosis were compared between the two groups. Multivariate regression analysis was performed for the related factors. Results A total of 8,055 cases of valvular surgery was performed during the study period. We analyzed 401 IE patients [average age 43.9±15 years; RI, n=56 (14%); NRF, n=345 (86%)], after the exclusion of 2 patients with primary glomerulonephritis. RI patients showed higher perioperative mortality (14.3% vs. 4.5%, P=0.042) and streptococcal infection (71.4% vs. 43.8%, P=0.001) rates. The RI group was also older and had worse heart function, greater decreases in hemoglobin and platelet levels, a higher rate of prosthetic valve involvement, more cases of postoperative dialysis, and worse prognosis (all P<0.05). Binary logistic multivariate regression analysis showed that the incidence of streptococcal infection [odds ratio (OR) =4.271, 95% confidence interval (CI), 1.846-9.884; P=0.001], age ≥51 years (OR =5.138, 95% CI, 2.258-11.694; P<0.001), and New York Heart Association (NYHA) functional class III-IV (OR =10.768, 95% CI, 2.417-47.972; P=0.002) were independent risk factors for preoperative renal insufficiency. Conclusions IE patients with preoperative renal insufficiency had a high mortality rate and poor prognosis, with streptococcal infection predisposing to a higher risk of renal insufficiency. Moreover, older the age and worse heart function in IE resulted in a greater risk for renal insufficiency.
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Affiliation(s)
- Yang Liu
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Hang Zhang
- Department of Cardiovascular Surgery, Shanghai General Hospital, Nanjing Medical University, Shanghai 200080, China.,Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Yaoyang Liu
- Department of Rheumatology and Immunology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - Qingqi Han
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Yangfeng Tang
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Libo Zhao
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Fan Qiao
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Zhiyun Xu
- Department of Cardiovascular Surgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China
| | - Min Yu
- Department of Cardiovascular Surgery, Shanghai General Hospital, Nanjing Medical University, Shanghai 200080, China.,Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Zhongxiang Yuan
- Department of Cardiovascular Surgery, Shanghai General Hospital, Nanjing Medical University, Shanghai 200080, China.,Department of Cardiovascular Surgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
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Abstract
Post-infectious glomerulonephritis (PIGN) is one of the most common causes of acute glomerulonephritis in children. Although post-streptococcal glomerulonephritis (PSGN) is still common, there is a wide spectrum of causative agents of PIGN. Non-streptococcal organisms are emerging as the main aetiological agents in high-income countries. Nephritis-associated plasmin receptor (NAPlr) and streptococcal pyrogenic exotoxin B (SPeB) are the two common antigens implicated in the pathogenesis of PSGN. Both NAPlr and SPeB activate the alternative complement pathway, resulting in low serum complement levels, and have an affinity to plasmin and glomerular proteins. The clinical presentation of PIGN varies from a benign asymptomatic condition to rapidly progressive glomerulonephritis requiring dialysis. In most cases, PIGN is self-limiting and the evidence base for the treatments used is quite weak. Renal biopsy is indicated when there are atypical features, rapid progression or inadequate recovery, or where an alternative diagnosis has to be considered. IgA-dominant nephritis, endocarditis-associated nephritis and shunt nephritis are special sub-subtypes of PIGN. The prognosis is generally excellent, although long-term follow-up may be needed.
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Affiliation(s)
- Ramnath Balasubramanian
- a Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - Stephen D Marks
- a Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK.,b University College London Great Ormond Street Institute of Child Health , London , UK
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Martin WJ, Steer AC, Smeesters PR, Keeble J, Inouye M, Carapetis J, Wicks IP. Post-infectious group A streptococcal autoimmune syndromes and the heart. Autoimmun Rev 2015; 14:710-25. [PMID: 25891492 DOI: 10.1016/j.autrev.2015.04.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 04/10/2015] [Indexed: 12/16/2022]
Abstract
There is a pressing need to reduce the high global disease burden of rheumatic heart disease (RHD) and its harbinger, acute rheumatic fever (ARF). ARF is a classical example of an autoimmune syndrome and is of particular immunological interest because it follows a known antecedent infection with group A streptococcus (GAS). However, the poorly understood immunopathology of these post-infectious diseases means that, compared to much progress in other immune-mediated diseases, we still lack useful biomarkers, new therapies or an effective vaccine in ARF and RHD. Here, we summarise recent literature on the complex interaction between GAS and the human host that culminates in ARF and the subsequent development of RHD. We contrast ARF with other post-infectious streptococcal immune syndromes - post-streptococcal glomerulonephritis (PSGN) and the still controversial paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), in order to highlight the potential significance of variations in the host immune response to GAS. We discuss a model for the pathogenesis of ARF and RHD in terms of current immunological concepts and the potential for application of in depth "omics" technologies to these ancient scourges.
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Affiliation(s)
- William John Martin
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia.
| | - Andrew C Steer
- Centre for International Child Health, Department of Pediatrics, University of Melbourne and Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia; Group A Streptococcus Laboratory, Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia
| | - Pierre Robert Smeesters
- Centre for International Child Health, Department of Pediatrics, University of Melbourne and Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia; Group A Streptococcus Laboratory, Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia
| | - Joanne Keeble
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia
| | - Michael Inouye
- Medical Systems Biology, Department of Pathology and Department of Microbiology and Immunology, University of Melbourne, VIC 3010, Australia
| | | | - Ian P Wicks
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia; Rheumatology Unit, Royal Melbourne Hospital, Parkville, VIC 3052, Australia.
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Burova L, Pigarevsky P, Duplik N, Snegova V, Suvorov A, Schalen C, Totolian A. Immune complex binding Streptococcus pyogenes type M12/emm12 in experimental glomerulonephritis. J Med Microbiol 2013; 62:1272-1280. [PMID: 23788594 DOI: 10.1099/jmm.0.059196-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In a rabbit model, we have previously reported evidence for a pathogenic role of streptococcal IgG Fc-binding proteins (IgGFcBP) in poststreptococcal glomerulonephritis (PSGN). These proteins, of the M protein family, were shown to trigger anti-IgG production and enhance renal deposition of IgG and/or immune complexes (ICs), with resulting activation of complement and cytokine cascades. In the present study, type M12/emm12, group A streptococci (GAS) were found often to bind artificial ICs, viz. peroxidase-anti-peroxidase rabbit IgG (PAP) or tetanus toxoid-anti-tetanus human IgG (TAT), rather than monomeric IgG. Animals injected with each of four IC binding clinical isolates (from patients with scarlet fever or PSGN) showed pronounced inflammatory and degenerative glomerular changes, morphologically similar to human PSGN, with membrane thickening and IgG and complement C3 deposition, as well as secretion of IL-6 and TNF-α by mesangial and endothelial cells. In contrast, non-binding strains (two from asymptomatic carriers and one from a PSGN case) failed to trigger any renal changes. Only the IC binding strains induced elevated titres of anti-IgG. Though the streptococcal binding component(s) has not been demonstrated, the selective binding of ICs by type M12/emm12 strains appears important for the well-known, marked nephritogenic potential of this GAS type.
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Affiliation(s)
- Larissa Burova
- Institute of Experimental Medicine RAMS, St-Petersburg, Russia
| | | | - Nadezhda Duplik
- Institute of Experimental Medicine RAMS, St-Petersburg, Russia
| | - Vlada Snegova
- Institute of Experimental Medicine RAMS, St-Petersburg, Russia
| | | | - Claes Schalen
- Department of Laboratory Medicine, University of Lund, Sweden
| | - Artem Totolian
- Institute of Experimental Medicine RAMS, St-Petersburg, Russia
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Nasr SH, Radhakrishnan J, D'Agati VD. Bacterial infection-related glomerulonephritis in adults. Kidney Int 2013; 83:792-803. [PMID: 23302723 DOI: 10.1038/ki.2012.407] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In the past, most cases of bacterial infection-related glomerulonephritis (IRGN) occurred in children following streptococcal upper respiratory tract or skin infections and were called postinfectious GN. Over the past 3 decades, there has been an important shift in epidemiology, bacteriology, and outcome of IRGN. A significant percentage of cases now target adults, particularly the elderly or immunocompromised. Because adult infections are often ongoing at the time of diagnosis, the term IRGN appears more appropriate. The sites of infection in adult IRGN are more heterogeneous than in children, and include the upper respiratory tract, skin, lung, heart, urinary tract, teeth/oral mucosa, and bone. In adults, the disease is more likely to be secondary to non-streptococcal infections, particularly staphylococcal infection. In contrast to the favorable course in children, a significant proportion of adults with IRGN, especially the elderly and diabetics, do not recover renal function. Whereas the pathogenesis of post-streptococcal glomerulonephritis has been studied extensively, leading to the identification of two candidate nephritogenic streptococcal antigens, glyceraldehyde-3-phosphate dehydrogenase and pyrogenic exotoxin B, few investigations have focused on IRGN caused by other bacteria. This review will address the current status of sporadic bacterial IRGN in adults.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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The role of nephritis-associated plasmin receptor (NAPlr) in glomerulonephritis associated with streptococcal infection. J Biomed Biotechnol 2012; 2012:417675. [PMID: 23118507 PMCID: PMC3477576 DOI: 10.1155/2012/417675] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 07/20/2012] [Indexed: 12/04/2022] Open
Abstract
It is well known that glomerulonephritis can occur after streptococcal infection, which is classically referred to as acute poststreptococcal glomerulonephritis (APSGN). The pathogenic mechanism of APSGN has been described by so-called immune complex theory, which involves glomerular deposition of nephritogenic streptococcal antigen and subsequent formation of immune complexes in situ and/or the deposition of circulating antigen-antibody complexes. However, the exact entity of the causative antigen has remained a matter of debate. We isolated a nephritogenic antigen for APSGN from the cytoplasmic fractions of group A streptococcus (GAS) depending on the affinity for IgG of APSGN patients. The amino acid and the nucleotide sequences of the isolated protein revealed to be highly identical to those of reported plasmin(ogen) receptor of GAS. Thus, we termed this antigen nephritis-associated plasmin receptor (NAPlr). Immunofluorescence staining of the renal biopsy tissues with anti-NAPlr antibody revealed glomerular NAPlr deposition in essentially all patients with early-phase APSGN. Furthermore, glomerular plasmin activity was detected by in situ zymography in the distribution almost identical to NAPlr deposition in renal biopsy tissues of APSGN patients. These data suggest that NAPlr has a direct, nonimmunologic function as a plasmin receptor and may contribute to the pathogenesis of APSGN by maintaining plasmin activity.
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Abstract
Postinfectious glomerulonephritis (PIGN) is an immunologically mediated glomerular injury triggered by an infection. Poststreptococcal glomerulonephritis (PSGN) is a classic example of PIGN with diffuse proliferative and exudative glomerular histology, dominant C3 staining and subepithelial "humps." Only the nephritogenic streptococcal infections cause PSGN and susceptibility to develop PSGN depends on both host and microbial factors. Over the last decade, two nephritogenic antigens, "nephritis-associated plasmin receptor" and "streptococcal pyrogenic exotoxin B" have been identified. PSGN is a self-limited disease, especially in children, but long-term follow-up studies indicate persistent low-grade renal abnormalities in a significant proportion of patients. PSGN continues to be a serious public health concern in third world countries, but the incidence of streptococcal infections has steadily declined in industrialized nations. PIGN in the western world is now primarily because of nonstreptococcal infections, often affecting older individuals with comorbidities such as diabetes mellitus or alcoholism, and is associated with poor outcomes. Although the acute PIGN has diffuse proliferative, focal segmental proliferative or mesangioproliferative patterns of glomerular injury, chronic or subacute infection-associated glomerulonephritis typically results in membranoproliferative appearance. PIGN has dominant C3 staining with frequent occurrence of subepithelial "humps" as well as subendothelial deposits. The immunoglobulin staining on immunofluorescence is typically weak, but immunoglobulin A-dominant PIGN is a recently defined entity often associated with staphylococcal infections. The wide spectrum of morphologic changes seen in PIGN poses a diagnostic challenge, especially if adequate clinical and serological data are lacking.
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Okabe M, Tsuboi N, Yokoo T, Miyazaki Y, Utsunomiya Y, Hosoya T. A case of idiopathic membranoproliferative glomerulonephritis with a transient glomerular deposition of nephritis-associated plasmin receptor antigen. Clin Exp Nephrol 2011; 16:337-41. [PMID: 22183562 DOI: 10.1007/s10157-011-0570-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2011] [Accepted: 11/14/2011] [Indexed: 11/28/2022]
Abstract
The differential diagnosis of acute poststreptococcal glomerulonephritis (APSGN) and idiopathic membranoproliferative glomerulonephritis (MPGN) is sometimes difficult, as they share several key features in their laboratory and histological findings, especially during the acute phase of the diseases. We herein report an idiopathic case of MPGN in which the glomerular deposition of nephritis-associated plasmin receptor (NAPlr), a recently identified nephritic antigen for APSGN, was demonstrated. A 24-year-old postpartum woman developed nephrotic syndrome and hypocomplementemia. Although she showed no apparent findings of a prior infection, her serum titer of antistreptolysin O antibody was elevated. Renal biopsies were performed twice at intervals of 6 months, both of which showed findings fully consistent with those of MPGN. Of note, fluorescent immunostaining for NAPlr was positive in the glomeruli of the first biopsy but not in the second. Despite the use of a corticosteroid, hypocomplementemia persisted for more than 1 year. It was therefore suggested that a streptococcal infection may have influenced the development of glomerular injury in this idiopathic case of MPGN.
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Affiliation(s)
- Masahiro Okabe
- Division of Kidney and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
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Uchida T, Oda T, Watanabe A, Izumi T, Higashi K, Kushiyama T, Miura S, Kumagai H. Clinical and histologic resolution of poststreptococcal glomerulonephritis with large subendothelial deposits and kidney failure. Am J Kidney Dis 2011; 58:113-7. [PMID: 21684437 DOI: 10.1053/j.ajkd.2011.04.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 04/14/2011] [Indexed: 11/11/2022]
Abstract
A 16-year-old male adolescent who had fallen and scratched his knee developed cold-like symptoms. Gross hematuria, oliguria, and peripheral edema appeared about 2 weeks after his fall. Tests showed hypocomplementemia, increased antistreptolysin O titers, and severe kidney failure with hematuria/proteinuria. Kidney biopsy showed endocapillary proliferative glomerulonephritis visible using light microscopy and deposits of complement C3 on capillary walls, detectable using immunofluorescence microscopy. Although these findings suggested that he had acute poststreptococcal glomerulonephritis (APSGN), electron microscopy failed to detect subepithelial humps, a feature typical of APSGN; instead, massive electron-dense deposits were visible in the subendothelial space. A second biopsy performed 3 months later showed mesangial cell proliferation without endocapillary proliferation using light microscopy and the disappearance of subendothelial electron-dense deposits in electron micrographs, suggesting that APSGN had resolved. Glomerular deposition of nephritis-associated plasmin receptor, a nephritogenic streptococcal antigen, was observed in the first biopsy specimen, but not the second. The patient required 4 hemodialysis treatments, and within 1 year of supportive therapy only, kidney function and urinalysis had normalized. This is an interesting case of APSGN presenting with acute kidney injury and atypical massive subendothelial deposits, but no subepithelial deposits on electron microscopy, a pattern resembling that in membranoproliferative glomerulonephritis type I.
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Affiliation(s)
- Takahiro Uchida
- Department of Nephrology, National Defense Medical College, Tokorozawa, Saitama, Japan.
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