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Ahmadpoor P, Garo F, Patrier L, Michel M, Moranne O. Anti-GBM antibody in a patient with diabetic nephropathy; all that glitters is not gold. J Nephrol 2024:10.1007/s40620-024-01926-7. [PMID: 38805170 DOI: 10.1007/s40620-024-01926-7] [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: 05/24/2023] [Accepted: 02/28/2024] [Indexed: 05/29/2024]
Abstract
We present the case of a 58-year-old male diabetic patient admitted to our department for a slight decrease in kidney function, with nephrotic range proteinuria, hematuria (16,000/ml) and positive anti-glomerular basement membrane antibodies. Kidney biopsy revealed diabetic nephropathy with no evidence of crescent formation or linear immunoglobulin deposits along the basement membrane. We discuss the various clinical settings involving positive anti-glomerular basement membrane in the absence of crescentic glomerulonephritis.
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Affiliation(s)
- Pedram Ahmadpoor
- Service Néphrologie, Dialyse Aphérèse, Hôpital Universitaire de Nîmes, CHU Carémeau, Nimes, France
| | - Florian Garo
- Service Néphrologie, Dialyse Aphérèse, Hôpital Universitaire de Nîmes, CHU Carémeau, Nimes, France
- Service Anatomopathologie, Hôpital Universitaire de Nîmes, CHU Carémeau, Nimes, France
| | - Laure Patrier
- Service Néphrologie, Dialyse Aphérèse, Hôpital Universitaire de Nîmes, CHU Carémeau, Nimes, France
| | - Moise Michel
- IDESP, Université de Montpellier, Montpellier, France
- Laboratoire d'Immunologie, Hôpital Universitaire de Nîmes, CHU Carémeau, Nimes, France
| | - Olivier Moranne
- Service Néphrologie, Dialyse Aphérèse, Hôpital Universitaire de Nîmes, CHU Carémeau, Nimes, France.
- IDESP, Université de Montpellier, Montpellier, France.
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2
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Kunaprayoon L, Scheffel ETC, Abdel-Rahman EM. Management of Double-Seropositive Anti-Glomerular Basement Membrane and Anti-Neutrophil Cytoplasmic Antibodies with 100% Crescentic Glomerulonephritis and Nephrotic Range Proteinuria in a Young Female. Biomedicines 2024; 12:906. [PMID: 38672260 PMCID: PMC11048036 DOI: 10.3390/biomedicines12040906] [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: 03/23/2024] [Revised: 04/09/2024] [Accepted: 04/17/2024] [Indexed: 04/28/2024] Open
Abstract
Nephrotic range proteinuria in the setting of dual-positive anti-glomerular basement membrane (AGBM) and anti-neutrophil cytoplasmic antibodies (ANCAs) is rare. Furthermore, using rituximab as a primary immunosuppressant along with steroids and plasmapheresis has not been widely studied. We present a case of dual AGBM and ANCA with nephrotic range proteinuria in a young female, where rituximab was used as a primary immunosuppressant with partial recovery.
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Affiliation(s)
- Lalida Kunaprayoon
- Division of Nephrology, University of Virginia, Charlottesville, VA 22903, USA;
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3
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Kuang H, Jiang N, Jia XY, Cui Z, Zhao MH. Epidemiology, clinical features, risk factors, and outcomes in anti-glomerular basement membrane disease: A systematic review and meta-analysis. Autoimmun Rev 2024; 23:103531. [PMID: 38493958 DOI: 10.1016/j.autrev.2024.103531] [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: 03/04/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 03/19/2024]
Abstract
Anti-glomerular basement membrane (GBM) disease is a small-vessel vasculitis that represents the most aggressive form of autoimmune glomerulonephritis. The study aimed to investigate the prevalence, clinical characteristics, risk factors, and outcomes of anti-GBM disease through a systematic review and meta-analysis involving 47 studies with 2830 patients. The overall incidence of anti-GBM disease ranged from 0.60 to 1.79 per million population per annum. In rapidly progressive glomerulonephritis and crescentic glomerulonephritis, the pooled incidence rates were 8.0% and 12.8%, respectively. The pooled prevalence rates of anti-GBM antibodies, antineutrophil cytoplasmic antibodies (ANCA), and lung hemorrhage were 88.8%, 27.4%, and 32.6%, respectively. Patients with combined ANCA positivity demonstrated a prognosis comparable to those patients with only anti-GBM antibodies, though with differing clinical features. The pooled one-year patient and kidney survival rates were 76.2% and 30.2%, respectively. Kidney function on diagnosis and normal glomeruli percentage were identified as strong prognostic factors. This study represents the first comprehensive meta-analysis on anti-GBM disease, providing insights into its management. However, caution is warranted in interpreting some results due to the observational nature of the included studies and high heterogeneity.
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Affiliation(s)
- 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
| | - Nan Jiang
- 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
| | - 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
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4
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Takahashi G, Watanabe T, Satoh T. Infective Endocarditis Caused by Streptococcus sanguinis Resulting in Stroke, Ruptured Infected Pseudoaneurysm of Superior Mesenteric Artery, and Rapidly Progressive Glomerulonephritis. Intern Med 2024; 63:413-417. [PMID: 37344426 PMCID: PMC10901719 DOI: 10.2169/internalmedicine.2017-23] [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: 03/23/2023] [Accepted: 05/11/2023] [Indexed: 06/23/2023] Open
Abstract
A 71-year-old-man was admitted to our hospital with a cerebral embolism and diagnosed with infective endocarditis (IE) caused by Streptococcus sanguinis. Mitral valve replacement was performed. About one month later, he experienced sudden abdominal pain and shock due to a ruptured infected mesenteric artery pseudoaneurysm. Forty-four days after abdominal surgery, he presented with rapidly progressive glomerulonephritis with anti-glomerular basement membrane antibodies. He was treated with plasma exchange and prednisolone, and his renal function gradually improved. Since postoperative complications often occur within a few years after surgery for IE, careful follow-up is important, even after antimicrobial therapy and valve surgery.
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Affiliation(s)
- Go Takahashi
- Division of Internal Medicine, Health Co-op. Watari Hospital, Japan
| | - Tomoyuki Watanabe
- Division of Cardiology and Internal Medicine, Health Co-op. Watari Hospital, Japan
| | - Takeshi Satoh
- Division of Rehabilitation, Internal Medicine, Health Co-op. Watari Hospital, Japan
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5
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Hellmich B, Sanchez-Alamo B, Schirmer JH, Berti A, Blockmans D, Cid MC, Holle JU, Hollinger N, Karadag O, Kronbichler A, Little MA, Luqmani RA, Mahr A, Merkel PA, Mohammad AJ, Monti S, Mukhtyar CB, Musial J, Price-Kuehne F, Segelmark M, Teng YKO, Terrier B, Tomasson G, Vaglio A, Vassilopoulos D, Verhoeven P, Jayne D. EULAR recommendations for the management of ANCA-associated vasculitis: 2022 update. Ann Rheum Dis 2024; 83:30-47. [PMID: 36927642 DOI: 10.1136/ard-2022-223764] [Citation(s) in RCA: 102] [Impact Index Per Article: 102.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/21/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Since the publication of the EULAR recommendations for the management of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) in 2016, several randomised clinical trials have been published that have the potential to change clinical care and support the need for an update. METHODS Using EULAR standardised operating procedures, the EULAR task force undertook a systematic literature review and sought opinion from 20 experts from 16 countries. We modified existing recommendations and created new recommendations. RESULTS Four overarching principles and 17 recommendations were formulated. We recommend biopsies and ANCA testing to assist in establishing a diagnosis of AAV. For remission induction in life-threatening or organ-threatening AAV, we recommend a combination of high-dose glucocorticoids (GCs) in combination with either rituximab or cyclophosphamide. We recommend tapering of the GC dose to a target of 5 mg prednisolone equivalent/day within 4-5 months. Avacopan may be considered as part of a strategy to reduce exposure to GC in granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA). Plasma exchange may be considered in patients with rapidly progressive glomerulonephritis. For remission maintenance of GPA/MPA, we recommend rituximab. In patients with relapsing or refractory eosinophilic GPA, we recommend the use of mepolizumab. Azathioprine and methotrexate are alternatives to biologics for remission maintenance in AAV. CONCLUSIONS In the light of recent advancements, these recommendations provide updated guidance on AAV management. As substantial data gaps still exist, informed decision-making between physicians and patients remains of key relevance.
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Affiliation(s)
- Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | | | - Jan H Schirmer
- Rheumatology & Clinical Immunology and Cluster of Excellence Precision Medicine in Chronic Inflammation, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Alvise Berti
- CIBIO, Universita degli Studi di Trento, Trento, Italy
- Rheumatology, Santa Chiara Hospital, Trento, Italy
| | - Daniel Blockmans
- Department of Internal Medicine, University Hospital of Leuven, Leuven, Belgium
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Julia U Holle
- Rheumazentrum Schleswig-Holstein Mitte, Neumuenster, Germany
| | - Nicole Hollinger
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Medius Kliniken, Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim unter Teck, Germany
| | - Omer Karadag
- Division of Rheumatology, Department of Internal Medicine, Vasculitis Research Center, Hacettepe University School of Medicine, Anakra, Turkey
| | - Andreas Kronbichler
- Department of Internal Medicine IV, Medical University, Innsbruck, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity College Dublin, Dublin, Ireland
| | - Raashid A Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | - Alfred Mahr
- Klinik für Rheumatologie, Kantonspital St Gallen, St Gallen, Switzerland
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, Division of Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aladdin J Mohammad
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Sciences, Lund University & Department of Rheumatology, Skåne Hospital, Lund, Sweden
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Jacek Musial
- 2nd Department of Internal Medicine, Jagiellonian University Medical College, Kraków, Poland
| | | | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences, Lund University, Skane University Hospital, Lund, Sweden
| | - Y K Onno Teng
- Centre of Expertise for Lupus-, Vasculitis-, and Complement-Mediated Systemic Autoimmune Diseases (LuVaCs), Department of Internal Medicine, Section Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Benjamin Terrier
- National Referral Center for Rare Systemic Autoimmune Diseases, Université Paris Descartes, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - Gunnar Tomasson
- Department of Epidemiology and Biostatistics, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Rheumatology and Centre for Rheumatology Research, University Hospital Reykjavik, Reykjavik, Iceland
| | - Augusto Vaglio
- Nephrology Unit, Meyer Children's Hospital, and Department of Biomedical, Experimental and Clinical Science, University of Florence, Florence, Italy
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology-Rheumatology Unit, National and Kapodistrian University of Athens, School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Peter Verhoeven
- Dutch Patient Vasculitis Organization, Haarlem, The Netherlands
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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6
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Gluhovschi C, Gadalean F, Velciov S, Nistor M, Petrica L. Three Diseases Mediated by Different Immunopathologic Mechanisms-ANCA-Associated Vasculitis, Anti-Glomerular Basement Membrane Disease, and Immune Complex-Mediated Glomerulonephritis-A Common Clinical and Histopathologic Picture: Rapidly Progressive Crescentic Glomerulonephritis. Biomedicines 2023; 11:2978. [PMID: 38001978 PMCID: PMC10669599 DOI: 10.3390/biomedicines11112978] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/26/2023] Open
Abstract
Immune mechanisms play an important role in the pathogenesis of glomerulonephritis (GN), with autoimmunity being the main underlying pathogenetic process of both primary and secondary GN. We present three autoimmune diseases mediated by different autoimmune mechanisms: glomerulonephritis in vasculitis mediated by anti-neutrophil cytoplasmic antibodies (ANCAs), glomerulonephritis mediated by anti-glomerular basement membrane antibodies (anti-GBM antibodies), and immune complex-mediated glomerulonephritis. Some of these diseases represent a common clinical and histopathologic scenario, namely rapidly progressive crescentic glomerulonephritis. This is a severe illness requiring complex therapy, with the main role being played by therapy aimed at targeting immune mechanisms. In the absence of immune therapy, the crescents, the characteristic histopathologic lesions of this common presentation, progress toward fibrosis, which is accompanied by end-stage renal disease (ESRD). The fact that three diseases mediated by different immunopathologic mechanisms have a common clinical and histopathologic picture reveals the complexity of the relationship between immunopathologic mechanisms and their clinical expression. Whereas most glomerular diseases progress by a slow process of sclerosis and fibrosis, the glomerular diseases accompanied by glomerular crescent formation can progress, if untreated, in a couple of months into whole-nephron glomerulosclerosis and fibrosis. The outcome of different immune processes in a common clinical and histopathologic phenotype reveals the complexity of the relationship of the kidney with the immune system. The aim of this review is to present different immune processes that lead to a common clinical and histopathologic phenotype, such as rapidly progressive crescentic glomerulonephritis.
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Affiliation(s)
- Cristina Gluhovschi
- Division of Nephrology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (F.G.); (L.P.)
- Centre for Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
| | - Florica Gadalean
- Division of Nephrology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (F.G.); (L.P.)
- Centre for Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
- Division of Nephrology, County Emergency Hospital Timisoara, 300041 Timișoara, Romania
| | - Silvia Velciov
- Centre for Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
- Division of Nephrology, County Emergency Hospital Timisoara, 300041 Timișoara, Romania
| | - Mirabela Nistor
- Division of Nephrology, County Emergency Hospital Timisoara, 300041 Timișoara, Romania
| | - Ligia Petrica
- Division of Nephrology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (F.G.); (L.P.)
- Centre for Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
- Division of Nephrology, County Emergency Hospital Timisoara, 300041 Timișoara, Romania
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7
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Sato M, Nishibata Y, Masuda S, Nagamori T, Ishibazawa E, Yoshida Y, Takahashi H, Ishizu A, Takahashi S. Demonstration of equivocal anti-glomerular basement membrane antibody positivity as a non-specific reaction through multiple immunologic assays in a case of pediatric asymptomatic hematuria. Clin Biochem 2023; 120:110650. [PMID: 37734646 DOI: 10.1016/j.clinbiochem.2023.110650] [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: 05/25/2023] [Revised: 09/14/2023] [Accepted: 09/18/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Anti-glomerular basement membrane (anti-GBM) antibody is essential for the diagnosis of anti-GBM disease. The major epitope consists of the α3 subunits of type IV collagen non-collagenous domain (α 3(IV)NC1). There have been only a few reports of patients false-positive for anti-GBM antibody. CASE REPORT We experienced an 8-year-old boy who presented with asymptomatic hematuria followed by positivity for anti-GBM antibody as evaluated by a commercially available chemiluminescent enzyme immunoassay (CLEIA). While his condition remained stable other than continuing hematuria, his anti-GBM antibody titer increased. Further examination of another anti-GBM antibody assay (fluoroenzyme immunoassay) showed negative results. Thus, evaluation of the accuracy of his positivity for anti-GBM antibody was required. We conducted the following examinations: A) enzyme-linked immunosorbent assay, B) immunoblotting for recombinant α 1-5(IV)NC1, and C) immunohistochemical analysis of normal kidney tissue sections. Specimens used for the analysis were sera in A and IgG from the patient in B and C, respectively. As a result, no anti-GBM antibody was detected in A. In B, no band specific to α 1-5(IV)NC1 was observed. In C, the kidney tissue was not stained. Taken together, these results led us to judge the positive anti-GBM result in CLEIA of our patient to be a non-specific reaction. CONCLUSION The commercial assays for anti-GBM antibody can lead to false-positive results. We recommend confirmation of anti-GBM antibody positivity through the use of multiple assays in patients demonstrating an atypical clinical course for anti-GBM disease.
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Affiliation(s)
- Masayuki Sato
- Department of Pediatrics, Asahikawa Medical University, Asahikawa, Japan.
| | - Yuka Nishibata
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Sakiko Masuda
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Tsunehisa Nagamori
- Department of Pediatrics, Asahikawa Medical University, Asahikawa, Japan
| | - Emi Ishibazawa
- Department of Pediatrics, Asahikawa Medical University, Asahikawa, Japan
| | - Yoichiro Yoshida
- Department of Pediatrics, Asahikawa Medical University, Asahikawa, Japan
| | - Hironori Takahashi
- Department of Pediatrics, Asahikawa-Kosei General Hospital, Asahikawa, Japan
| | - Akihiro Ishizu
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Satoru Takahashi
- Department of Pediatrics, Asahikawa Medical University, Asahikawa, Japan
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8
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Tang A, Zhao X, Tao T, Xie D, Xu B, Huang Y, Li M. Unleashing the power of complement activation: unraveling renal damage in human anti-glomerular basement membrane disease. Front Immunol 2023; 14:1229806. [PMID: 37781380 PMCID: PMC10540768 DOI: 10.3389/fimmu.2023.1229806] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023] Open
Abstract
Anti-glomerular basement membrane (GBM) disease is a rare but life-threatening autoimmune disorder characterized by rapidly progressive glomerulonephritis with or without pulmonary hemorrhage. Renal biopsies of anti-GBM patients predominantly show linear deposition of IgG and complement component 3 (C3), indicating a close association between antigen-antibody reactions and subsequent complement activation in the pathogenesis of the disease. All three major pathways of complement activation, including the classical, lectin, and alternative pathways, are involved in human anti-GBM disease. Several complement factors, such as C3, C5b-9, and factor B, show a positive correlation with the severity of the renal injury and act as risk factors for renal outcomes. Furthermore, compared to patients with single positivity for anti-GBM antibodies, individuals who are double-seropositive for anti-neutrophil cytoplasmic antibody (ANCA) and anti-GBM antibodies exhibit a unique clinical phenotype that lies between ANCA-associated vasculitis (AAV) and anti-GBM disease. Complement activation may serve as a potential "bridge" for triggering both AAV and anti-GBM conditions. The aim of this article is to provide a comprehensive review of the latest clinical evidence regarding the role of complement activation in anti-GBM disease. Furthermore, potential therapeutic strategies targeting complement components and associated precautions are discussed, to establish a theoretical basis for complement-targeted therapies.
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Affiliation(s)
- Anqi Tang
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xin Zhao
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Tian Tao
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dengpiao Xie
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bojun Xu
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Youqun Huang
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Mingquan Li
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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9
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Matsuno S, Itabashi M, Komatsu A, Taito K, Izawa A, Tsuchiya T, Yamanaka N, Oka M, Yumura W, Arai T, Takei T. Anti-glomerular basement membrane disease developing 3 years after the development of Sweet syndrome and 1 year after the development of anti-neutrophil cytoplasmic antibody-associated vasculitis: a case report. CEN Case Rep 2023; 12:259-264. [PMID: 36456780 PMCID: PMC10393910 DOI: 10.1007/s13730-022-00758-3] [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: 09/15/2022] [Accepted: 11/19/2022] [Indexed: 12/03/2022] Open
Abstract
A 73-year-old Japanese woman, with a history of Sweet syndrome diagnosed 3 years earlier and anti-myeloperoxidase (MPO) antibody anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis diagnosed 1 year earlier, presented with an episode of rapidly progressive glomerulonephritis (RPGN) with anti-glomerular basement membrane (GBM) disease. At the time of diagnosis of the ANCA-associated vasculitis 1 year earlier, serological testing yielded a negative result for anti-GBM antibody. However, at the present visit, serology for anti-MPO antibody was negative, while that for anti-GBM antibody was positive. This is the first report of anti-GBM disease developing sequentially after Sweet syndrome and ANCA-associated vasculitis. This case may provide clues to the potential immunological links among these three distinct conditions.
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Affiliation(s)
- Shiho Matsuno
- Departments of Nephrology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Mitsuyo Itabashi
- Departments of Nephrology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan.
| | - Akiko Komatsu
- Departments of Pathology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Kenta Taito
- Departments of Nephrology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Ayano Izawa
- Departments of Nephrology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Takaaki Tsuchiya
- Departments of Nephrology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Noriko Yamanaka
- Departments of Nephrology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Masatoshi Oka
- Departments of Nephrology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Wako Yumura
- Departments of Nephrology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Tomio Arai
- Departments of Pathology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
| | - Takashi Takei
- Departments of Nephrology, Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, 35-2 Sakae-Cho, Itabashi-Ku, Tokyo, 173-0015, Japan
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10
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Yamazaki T, Takahashi H, Takeuchi K, Sakamoto E, Tominaga K, Sakurabayashi S, Abe T, Sano T, Wada Y, Kuwahara N, Shimizu A, Takeuchi Y. Rare case of exostosin 1/exostosin 2-related membranous lupus nephritis concomitant with dual ANCA- and anti-GBM antibody-associated crescentic glomerulonephritis effectively diagnosed by mass spectrometry: a case report. BMC Nephrol 2023; 24:218. [PMID: 37488532 PMCID: PMC10364369 DOI: 10.1186/s12882-023-03268-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/13/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Recent developments in mass spectrometry (MS) have revealed target antigens for membranous nephropathy (MN), including phospholipase A2 receptor and exostosin 1/exostosin 2 (EXT1/2). EXT1/2 are known antigens of autoimmune disease-related MN, especially membranous lupus nephritis. We describe the case of an elderly man who developed nephrotic syndrome followed by progressive renal dysfunction. CASE PRESENTATION A 78-year-old man presented with rapidly progressive renal dysfunction with proteinuria and hematuria. Three years previously, he had developed leg edema but did not receive any treatment. Laboratory tests showed elevated anti-nuclear antibody (Ab), anti-dsDNA Ab titer, and hypocomplementemia, indicating systemic lupus erythematous. Myeloperoxidase anti-neutrophil cytoplasmic Ab (ANCA) and anti-glomerular basement membrane (GBM) Ab were also detected. The renal pathologic findings were compatible with crescentic glomerulonephritis (GN), whereas non-crescentic glomeruli exhibited MN without remarkable endocapillary or mesangial proliferative change. Immunofluorescence microscopy revealed glomerular IgG, C3, and C1q deposition. All IgG subclasses were positive in glomeruli. Anti-PLA2R Ab in serum was negative. MS analysis was performed to detect the antigens of MN, and EXT1/2 was detected in glomeruli. Therefore, we reached a diagnosis of membranous lupus nephritis concurrent with both ANCA-associated vasculitis and anti-GBM-GN. The simultaneous occurrence of these three diseases is extremely rare. CONCLUSIONS This is the first report of EXT1/2-related membranous lupus nephritis concurrent with ANCA-associated vasculitis and anti-GBM-GN. This case demonstrates the usefulness of MS in diagnosing complicated cases of MN.
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Affiliation(s)
- Takuya Yamazaki
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | - Haruka Takahashi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
- Omigawahimawari Clinic, Chiba, Japan
| | - Kazuhiro Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan.
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan.
| | - Emi Sakamoto
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Kenta Tominaga
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Syun Sakurabayashi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | - Tetsuya Abe
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | | | - Yukihiro Wada
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | - Naomi Kuwahara
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Yasuo Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
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11
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Matsuno T, Okumura T. Anti-glomerular Basement Membrane Disease After Diagnosis of Immunoglobulin A Nephropathy: A Case Report. Cureus 2023; 15:e39737. [PMID: 37398717 PMCID: PMC10310401 DOI: 10.7759/cureus.39737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Anti-glomerular basement membrane (anti-GBM) disease has one of the worst prognoses of nephritis and is rarely associated with other forms of glomerulonephritis. In this report, we present the case of a 76-year-old man who developed anti-GBM disease four months after being diagnosed with IgA nephropathy (IgAN). To our knowledge, although there have been several reports of IgAN combined with anti-GBM disease, there have been no cases in which we were able to confirm that the anti-GBM antibody titer changed from negative to positive over the disease course. This case suggests that even patients with previously diagnosed chronic glomerulonephritis, including IgAN, and an unusually rapid clinical course should be evaluated for the presence of autoantibodies to exclude overlapping autoimmune diseases.
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12
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Gulati K, Pusey CD. Plasma exchange as an adjunctive therapy in anti-neutrophil cytoplasm antibody-associated vasculitis. Expert Rev Clin Immunol 2023; 19:417-430. [PMID: 36860127 DOI: 10.1080/1744666x.2023.2184354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
INTRODUCTION We summarize evidence for the role of therapeutic plasma exchange (TPE) in the treatment of anti-neutrophil cytoplasm antibody (ANCA)-associated vasculitis (AAV). TPE rapidly removes ANCA IgG, complement and coagulation factors important in the pathogenesis of AAV. TPE has been used in patients with rapidly deteriorating renal function to achieve early disease control, allowing time for immunosuppressive agents to prevent resynthesis of ANCA. The PEXIVAS trial challenged the utility of TPE in AAV, as it did not show benefit of adjunctive TPE on a combined end point of end stage kidney disease (ESKD) and death. AREAS COVERED We analyze data from PEXIVAS and other trials of TPE in AAV, an up-to-date meta-analysis, and recently published large cohort studies. EXPERT OPINION There remains a role for the use of TPE in AAV in certain groups of patients, in particular those with severe renal involvement (Cr >500 μmol/L or dialysis-dependent). It should be considered in patients with Cr >300 μmol/L and rapidly deteriorating function, or with life-threatening pulmonary hemorrhage. A separate indication is patients double positive for anti-GBM antibodies and ANCA. TPE may have the greatest benefit as part of steroid-sparing immunosuppressive treatment strategies.
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Affiliation(s)
- Kavita Gulati
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Centre for Inflammatory Disease, Imperial College London, London, UK
| | - Charles D Pusey
- Vasculitis Clinic, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Centre for Inflammatory Disease, Imperial College London, London, UK
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13
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Ponticelli C, Calatroni M, Moroni G. Anti-glomerular basement membrane vasculitis. Autoimmun Rev 2023; 22:103212. [PMID: 36252931 DOI: 10.1016/j.autrev.2022.103212] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/11/2022] [Indexed: 12/27/2022]
Abstract
Antiglomerular basement membrane disease (anti-GBM) is a rare life-threatening autoimmune vasculitis that involves small vessels and it is characterized by circulating autoantibodies directed against type IV collagen antigens expressed in glomerular and alveolar basement membrane. The typical clinical manifestations are the rapidly progressive glomerulonephritis and the alveolar hemorrhage. The diagnosis is usually confirmed by the detection of anti-GBM circulating antibodies. If not rapidly recognized, anti-GBM disease can lead to end stage kidney disease (ESKD). An early diagnosis and prompt treatment with immunosuppressive therapies and plasmapheresis are crucial to prevent a poor outcome. In this review, we discuss the primary form of anti-GBM (the so called Goodpasture syndrome) but also cases associated with other autoimmune diseases such as antineutrophil-cytoplasmic-antibody (ANCA) vasculitis, membranous nephropathy, IgA nephritis and systemic lupus erythematosus (SLE), as well as the few cases of anti-GBM vasculitis complicating kidney transplantation in the Alport syndrome.
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Affiliation(s)
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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14
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Zhang S, Li C, Huang J, Zhou Y, Gao C, Sun M, Wang R, Chen B. Clinical and pathological features of anti-glomerular basement membrane disease associated with membranous nephropathy: an observational study. Ren Fail 2022; 44:1904-1914. [DOI: 10.1080/0886022x.2022.2141645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Shasha Zhang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chaofan Li
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jing Huang
- Department of Nephrology, Jinan Shizhong People’s Hospital, Jinan, China
| | - Yan Zhou
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Caifeng Gao
- Department of Nephrology, Jinan Shizhong People’s Hospital, Jinan, China
| | - Mengyao Sun
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bing Chen
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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15
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Ge Y, Liu K, Yang G, Yu X, Sun B, Zhang B, Yuan Y, Zeng M, Wang N, Xing C, Mao H. Clinicopathological characteristics and outcome predictors of anti-glomerular basement membrane glomerulonephritis. Ren Fail 2022; 44:2037-2045. [PMID: 36408940 PMCID: PMC9683053 DOI: 10.1080/0886022x.2022.2147673] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To explore the clinicopathological features of anti-glomerular basement membrane (anti-GBM) glomerulonephritis (anti-GBM-GN) and the prognostic values of clinical and laboratory indicators at diagnosis on renal and patient survival. Methods A total of 76 patients (34 males and 42 females) with anti-GBM-GN who were hospitalized in the First Affiliated Hospital of Nanjing Medical University between January 2010 and June 2021 were included in this study. The baseline clinical features, histopathological data from renal biopsies, and predictors of renal and patient survival were retrospectively analyzed. Results Among the 76 patients, the median serum creatinine at diagnosis was 618.0 (350.98, 888.25) μmol/L and the median estimated glomerular filtration rate (eGFR) was 6.62 (4.39, 14.41) mL/min. Of these 76 patients, 55 (72.4%) received initial kidney replacement therapy (KRT) and 39 (51.3%) received plasma exchange or double-filtered plasmapheresis (DFPP). During a median follow-up duration of 28.5 (6.0, 71.8) months, 53 (69.7%) patients progressed to kidney failure with replacement therapy (KFRT) and received maintenance dialysis. Initial KRT (HR = 3.48, 95% CI = 1.22–9.97, p = 0.020) was a significant risk factor for renal survival. During the follow-up, 49 (64.5%) of 76 patients survived. Age (≥60 years, HR = 4.13, 95% CI = 1.65–10.38, p = 0.003) and initial KRT (HR = 2.87, 95% CI = 1.01–8.14, p = 0.047) were predictive of patient survival. Conclusions Among patients with anti-GBM-GN, initial KRT at presentation was predictive of KFRT while older age and initial KRT were associated with higher all-cause mortality.
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Affiliation(s)
- Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kang Liu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangbao Yu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bin Sun
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bo Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yanggang Yuan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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16
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Boyle N, O'Callaghan M, Ataya A, Gupta N, Keane MP, Murphy DJ, McCarthy C. Pulmonary renal syndrome: a clinical review. Breathe (Sheff) 2022; 18:220208. [PMID: 36865943 PMCID: PMC9973488 DOI: 10.1183/20734735.0208-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/11/2022] [Indexed: 01/11/2023] Open
Abstract
The term "pulmonary renal syndrome" describes a clinical syndrome which is characterised by the presence of both diffuse alveolar haemorrhage and glomerulonephritis. It encompasses a group of diseases with distinctive clinical and radiological manifestations, as well as different pathophysiological processes. The most common diseases implicated are anti-neutrophil cytoplasm antibodies (ANCA)-positive small vessel vasculitis and anti-glomerular basement membrane (anti-GBM) disease. Prompt recognition is required as respiratory failure and end-stage renal failure can rapidly occur. Treatment includes a combination of glucocorticoids, immunosuppression, plasmapheresis and supportive measures. The use of targeted treatments has significantly reduced mortality. Thus, an understanding of pulmonary renal syndrome is essential for the respiratory physician.
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Affiliation(s)
- Niamh Boyle
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland
| | - Marissa O'Callaghan
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland,School of Medicine, University College Dublin, Dublin, Ireland
| | - Ali Ataya
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL, USA
| | - Nishant Gupta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Michael P. Keane
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland,School of Medicine, University College Dublin, Dublin, Ireland
| | - David J. Murphy
- School of Medicine, University College Dublin, Dublin, Ireland,Department of Radiology, St. Vincent's University Hospital, Dublin, Ireland
| | - Cormac McCarthy
- Department of Respiratory Medicine, St. Vincent's University Hospital, Dublin, Ireland,School of Medicine, University College Dublin, Dublin, Ireland,Corresponding author: Cormac McCarthy ()
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17
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Aymonnier K, Amsler J, Lamprecht P, Salama A, Witko‐Sarsat V. The neutrophil: A key resourceful agent in immune‐mediated vasculitis. Immunol Rev 2022; 314:326-356. [PMID: 36408947 DOI: 10.1111/imr.13170] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The term "vasculitis" refers to a group of rare immune-mediated diseases characterized by the dysregulated immune system attacking blood vessels located in any organ of the body, including the skin, lungs, and kidneys. Vasculitides are classified according to the size of the vessel that is affected. Although this observation is not specific to small-, medium-, or large-vessel vasculitides, patients show a high circulating neutrophil-to-lymphocyte ratio, suggesting the direct or indirect involvement of neutrophils in these diseases. As first responders to infection or inflammation, neutrophils release cytotoxic mediators, including reactive oxygen species, proteases, and neutrophil extracellular traps. If not controlled, this dangerous arsenal can injure the vascular system, which acts as the main transport route for neutrophils, thereby amplifying the initial inflammatory stimulus and the recruitment of immune cells. This review highlights the ability of neutrophils to "set the tone" for immune cells and other cells in the vessel wall. Considering both their long-established and newly described roles, we extend their functions far beyond their direct host-damaging potential. We also review the roles of neutrophils in various types of primary vasculitis, including immune complex vasculitis, anti-neutrophil cytoplasmic antibody-associated vasculitis, polyarteritis nodosa, Kawasaki disease, giant cell arteritis, Takayasu arteritis, and Behçet's disease.
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Affiliation(s)
- Karen Aymonnier
- INSERM U1016, Institut Cochin, Université Paris Cité, CNRS 8104 Paris France
| | - Jennifer Amsler
- INSERM U1016, Institut Cochin, Université Paris Cité, CNRS 8104 Paris France
| | - Peter Lamprecht
- Department of Rheumatology and Clinical Immunology University of Lübeck Lübeck Germany
| | - Alan Salama
- Department of Renal Medicine, Royal Free Hospital University College London London UK
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18
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Ibrahim D, Brodsky SV, Satoskar AA, Biederman L, Maroz N. Triple hit to the kidney-dual pathological crescentic glomerulonephritis and diffuse proliferative immune complex-mediated glomerulonephritis: A case report. World J Clin Cases 2022; 10:11869-11876. [PMID: 36405258 PMCID: PMC9669835 DOI: 10.12998/wjcc.v10.i32.11869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/25/2022] [Accepted: 08/21/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Anti-glomerular basement membrane (GBM) disease is a rare rapidly progressive glomerulonephritis, frequently associated with alveolar hemorrhage in the lungs and involving the kidney by crescentic glomerulonephritis. It has been described in association with other glomerulonephritides [such as anti-neutrophilic antibody (ANCA)-glomerulonephritis, membranous nephropathy, and immunoglobulin (Ig)A nephropathy].
CASE SUMMARY Herein we present an unusual case of concurrent anti-GBM disease, ANCA-associated crescentic glomerulonephritis and diffuse proliferative immune complex mediated glomerulonephritis with predominant staining for IgA and C3 by immunofluorescence. The patient is a 46-year-old Caucasian male who presented to the emergency department with acute onset of flank pain and was found to have high serum creatinine levels of 15 mg/dL, proteinuria, and hematuria. He rapidly deteriorated and became anuric. He was found to have high anti-GBM antibodies titers (151 units) and high anti-neutrophil cytoplasmic-ANCA. Despite prompt and early treatment, the patient’s condition worsened, and he succumbed to his illness.
CONCLUSION Our case emphasizes the importance of a renal biopsy in anti-GBM disease, even in the presence of positive serum anti-GBM antibodies, to identify other potential causes of rapidly progressive glomerulonephritis. The challenge in treating such cases lies in the different therapy modalities.
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Affiliation(s)
- Dalia Ibrahim
- Department of Pathology, Ohio State University, Columbus, OH 43210, United States
| | - Sergey V Brodsky
- Department of Pathology, Ohio State University, Columbus, OH 43210, United States
| | - Anjali A Satoskar
- Department of Pathology, Ohio State University, Columbus, OH 43210, United States
| | - Laura Biederman
- Department of Pathology, Ohio State University, Columbus, OH 43210, United States
| | - Natallia Maroz
- Department of Medicine, Wright State University, Dayton, OH 45409, United States
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19
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Cheng T, Zhi H, Liu Y, Zhang S, Song Z, Li Y. Dual Anti-Glomerular Basement Membrane and Anti-Neutrophil Cytoplasmic Antibodies-Positive Rapidly Progressive Glomerulonephritis with Rheumatoid Arthritis and Sjogren's Syndrome: A Case Report and Literature Review. J Clin Med 2022; 11:jcm11226793. [PMID: 36431270 PMCID: PMC9697768 DOI: 10.3390/jcm11226793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 11/18/2022] Open
Abstract
Rapidly progressive glomerulonephritis (RPGN) is a life-threatening disease characterized by rapid progressive deterioration of renal function and extensive formation of crescents. Some antibodies tend to be positive, such as a perinuclear anti-neutrophil cytoplasmic antibody (p-ANCA) and anti-glomerular basement membrane (anti-GBM) antibodies, in most patients with the disease. However, cases of double positivity for the above antibodies are considered to be rare. In addition, both rheumatoid arthritis (RA) and Sjogren's syndrome (SS) are deemed to be independent immune disorders that can cause renal impairment. Nevertheless, the association between RPGN and these two diseases has not been elucidated in previous studies. Here, we provide a case of RPGN with the concurrence of RA and SS characterized by double positivity in anti-GBM antibodies and p-ANCA. After aggressive treatment with cyclophosphamide, glucocorticoids, and plasma exchange, the patient improved significantly. Despite the malignant event of arteriovenous fistula rupture and bleeding during treatment, the patient survived with renal function recovery for the rest of the follow-up period.
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Affiliation(s)
- Ting Cheng
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan 030000, China
- Key Laboratory of Cellular Physiology, Shanxi Medical University, Ministry of Education, Taiyuan 030000, China
| | - Huiwen Zhi
- Department of Nephrology, Shanxi Provincial People’s Hospital (Fifth Hospital), Shanxi Medical University, Taiyuan 030000, China
| | - Yunxiao Liu
- Department of Pathology, Shanxi Provincial People’s Hospital (Fifth Hospital), Shanxi Medical University, Taiyuan 030000, China
| | - Shengxiao Zhang
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan 030000, China
- Key Laboratory of Cellular Physiology, Shanxi Medical University, Ministry of Education, Taiyuan 030000, China
| | - Ziyi Song
- Department of Rheumatology, The Second Hospital of Shanxi Medical University, Taiyuan 030000, China
- Key Laboratory of Cellular Physiology, Shanxi Medical University, Ministry of Education, Taiyuan 030000, China
| | - Yafeng Li
- Department of Nephrology, Shanxi Provincial People’s Hospital (Fifth Hospital), Shanxi Medical University, Taiyuan 030000, China
- Shanxi Provincial Key Laboratory of Kidney Disease, Taiyuan 030000, China
- Core Laboratory, Shanxi Provincial People’s Hospital (Fifth Hospital), Shanxi Medical University, Taiyuan 030000, China
- Academy of Microbial Ecology, Shanxi Medical University, Taiyuan 030000, China
- Correspondence:
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20
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Chevet B, Cornec D, Casal Moura M, Cornec-Le Gall E, Fervenza FC, Warrington KJ, Specks U, Berti A. Diagnosing and treating ANCA-associated vasculitis: an updated review for clinical practice. Rheumatology (Oxford) 2022; 62:1787-1803. [PMID: 36315063 DOI: 10.1093/rheumatology/keac623] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/14/2022] [Accepted: 10/05/2022] [Indexed: 03/29/2023] Open
Abstract
Abstract
ANCA-associated vasculitides (AAV) are a group of rare, primary, systemic necrotizing small-vessel vasculitides. Granulomatosis with polyangiitis and microscopic polyangiitis account for ∼80–90% of all AAV. Exposure to silica dust, farming and chronic nasal Staphylococcus aureus carriage are associated with increased risk of developing AAV. When a diagnosis of AAV is suspected, as in patients with multisystem organ dysfunction or those with features such as chronic recurrent rhinosinusitis, cavitated lung nodules, palpable purpura or acute kidney injury, then appropriate further investigations are needed, including ANCA testing. In this scenario, a structured clinical assessment should be conducted, evaluating all the organs possibly involved, and tissue biopsy may be necessary for confirmation of the diagnosis. Therapeutic algorithms vary based on the severity of AAV, the clinical diagnosis/ANCA specificity, and the patient’s age, weight, comorbidities and prognosis. Recent data favour rituximab as a preferable option for both induction and maintenance of remission. In addition, regimens with less glucocorticoids are equally effective and safer in inducing remission compared with conventional regimens, and avacopan is an effective glucocorticoid-sparing option. In contrast, there is not compelling evidence to support the routine use of plasma exchange in addition to standard remission-induction therapy in AAV. ANCA and other biomarkers can be helpful in association with clinical assessment to guide diagnosis and treatment decisions. Patients should be frequently evaluated during follow-up for possible disease relapses or treatment-related morbidity, and for monitoring damage accrual, especially metabolic and cardiovascular damage.
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Affiliation(s)
- Baptiste Chevet
- LBAI, UMR1227, Univ Brest, Inserm, Labex IGO, CHU de Brest, Brest, France
| | - Divi Cornec
- LBAI, UMR1227, Univ Brest, Inserm, Labex IGO, CHU de Brest, Brest, France
| | - Marta Casal Moura
- Department Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | | | | | | | - Ulrich Specks
- Department Division of Pulmonary and Critical Care Medicine, Department of Medicine, and Thoracic Research Disease Unit, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Alvise Berti
- Rheumatology, Santa Chiara Regional Hospital, APSS Trento, and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Italy
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21
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Hu X, Shen C, Meng T, Ooi JD, Eggenhuizen PJ, Zhou YO, Luo H, Chen JB, Lin W, Gong Y, Xiong Q, Xu J, Liu N, Xiao X, Tang R, Zhong Y. Clinical features and prognosis of MPO-ANCA and anti-GBM double-seropositive patients. Front Immunol 2022; 13:991469. [PMID: 36389826 PMCID: PMC9648717 DOI: 10.3389/fimmu.2022.991469] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 10/07/2022] [Indexed: 10/03/2023] Open
Abstract
BACKGROUND Several lines of evidence implicate that there are distinct differences between patients with myeloperoxidase (MPO)-antineutrophil cytoplasmic antibody (ANCA) and anti-glomerular basement membrane (GBM) antibody double-seropositive patients (DPPs) and single-positive patients. Hence, we conducted a retrospective study from a single center in China to analyze the clinical and pathological features, and prognosis of DPPs. METHODS 109 patients with MPO-ANCA-associated vasculitis (MPO-AAV), 20 DPPs and 23 patients diagnosed with anti-GBM disease from a large center in China were included in this study. The ratio of patients with renal biopsy in three groups were 100%, 50% and 100%, respectively. Their clinical and pathological characteristics, and outcomes were analyzed. The intensity of immune deposits in the kidney at diagnosis was detected by immunofluorescence (IF). Furthermore, multivariate Cox hazard model analysis was used to assess the clinical and histological predictors of end-stage renal disease (ESRD) and death for DPPs. RESULTS In our study, we found that patients in the DPPs group were older than the other two groups (p = 0.007, MPO-AAV vs. DPPs; p < 0.001, DPPs vs. anti-GBM). The DPPs group had a higher value of serum creatinine (p = 0.041) and lower estimated glomerular filtration rate (eGFR) (p = 0.032) compared with MPO-AAV patients. On the contrary, the DPPs group had a lower serum creatinine (p = 0.003) compared with patients with anti-GBM group. The proportion of patients with cardiac system involvement in the DPPs group was higher than anti-GBM patients (p = 0.014). Cellular crescents could be generally observed in renal biopsy of DPPs and patients with anti-GBM glomerulonephritis. In addition, Bowman's capsule rupture was more common in DPPs than MPO-AAV patients (p = 0.001). MPO-AAV had a better renal and overall survival outcome than DPPs (p < 0.001). There was no significant difference of renal and overall survival outcome between DPPs and patients with anti-GBM disease. The incidence of ESRD in DPPs was negatively associated with lymphocyte count (HR 0.153, 95% CI 0.027 to 0.872, p = 0.034) and eGFR (HR 0.847, 95% CI 0.726 to 0.989, p = 0.036). Elevated serum creatinine was confirmed as a risk factor of both renal (HR 1.003, 95% CI 1.000 to 1.005, p = 0.019) and patient survival in DPPs (HR1.461, 95% CI 1.050 to 2.033, p = 0.024). CONCLUSION In summary, compared with anti-GBM disease, DPPs tended to involve multi-organ damage rather than limited to the kidney. It is highlighted that serologic DPPs have a worse renal and patient prognosis than MPO-AAV. Moreover, we found that the risk factors of renal survival of DPPs include low lymphocyte count, elevated serum creatinine and reduced eGFR, and serum creatinine can predict patient survival.
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Affiliation(s)
- Xueling Hu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
| | - Chanjuan Shen
- Department of Hematology, The Affiliated Zhuzhou Hospital of Xiangya Medical College, Central South University, Zhuzhou, China
| | - Ting Meng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
| | - Joshua D. Ooi
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
- Centre for Inflammatory Diseases, Department of Medicine, Monash Medical Centre, Monash University, Clayton, VIC, Australia
| | - Peter J. Eggenhuizen
- Centre for Inflammatory Diseases, Department of Medicine, Monash Medical Centre, Monash University, Clayton, VIC, Australia
| | - Ya-ou Zhou
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, China
| | - Hui Luo
- Department of Rheumatology and Immunology, Xiangya Hospital, Central South University, Changsha, China
| | - Jin-biao Chen
- Department of Medical Records and Information, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Lin
- Department of Pathology, Xiangya Hospital, Central South University, Changsha, China
| | - Yizi Gong
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
| | - Qi Xiong
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
| | - Jia Xu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
| | - Ning Liu
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
| | - Xiangcheng Xiao
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
| | - Rong Tang
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
| | - Yong Zhong
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Biological Nanotechnology of National Health Commission, Xiangya Hospital, Central South University, Changsha, China
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22
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Sánchez-Agesta M, Rabasco C, Soler MJ, Shabaka A, Canllavi E, Fernández SJ, Cazorla JM, López-Rubio E, Romera A, Barroso S, Huerta A, Calle L, Sierra M, Domínguez-Torres P, Moreno-Ramírez M, Afonso S, Mascarós V, Coca A, Espinosa M. Anti-glomerular Basement Membrane Glomerulonephritis: A Study in Real Life. Front Med (Lausanne) 2022; 9:889185. [PMID: 35865174 PMCID: PMC9295717 DOI: 10.3389/fmed.2022.889185] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Anti-glomerular basement membrane (anti-GBM) disease is a severe entity with few therapeutic options including plasma exchange and immunosuppressive agents. The aim of this study was to analyze the clinical and pathological features that predict the evolution of end-stage kidney disease (ESKD) and the kidney survival in a cohort of patients with anti-GBM disease with renal involvement in real life. Methods A retrospective multicentre observational study including 72 patients from 18 nephrology departments with biopsy-proven anti-GBM disease from 1999 to 2019 was performed. Progression to ESKD in relation to clinical and histological variables was evaluated. Results Creatinine at admission was 8.6 (± 4) mg/dL and 61 patients (84.7%) required dialysis. Sixty-five patients (90.3%) underwent plasma exchange. Twenty-two patients (30.6%) presented pulmonary hemorrhage. Kidney survival was worse in patients with creatinine levels > 4.7 mg/dL (3 vs. 44% p < 0.01) and in patients with > 50% crescents (6 vs. 49%; p = 0.03). Dialysis dependence at admission and creatinine levels > 4.7 mg/dL remained independent significant predictors of ESKD in the multivariable analysis [HR (hazard ratio) 3.13 (1.25–7.84); HR 3 (1.01–9.14); p < 0.01]. The discrimination value for a creatinine level > 4.7 mg/dL and 50.5% crescents had an area under the curve (AUC) of 0.9 (95% CI 0.82–0.97; p < 0.001) and 0.77 (95% CI 0.56–0.98; p = 0.008), respectively. Kidney survival at 1 and 2 years was 13.5 and 11%, respectively. Patient survival at 5 years was 81%. Conclusion In real life, patients with severe anti-GBM disease (creatinine > 4.7 mg/dL and > 50% crescents) remained with devastating renal prognosis despite plasma exchange and immunosuppressive treatment. New therapies for the treatment of this rare renal disease are urgently needed.
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Affiliation(s)
- Marina Sánchez-Agesta
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
- *Correspondence: Marina Sánchez-Agesta,
| | - Cristina Rabasco
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - María J. Soler
- Department of Nephrology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Amir Shabaka
- Department of Nephrology, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Saulo J. Fernández
- Department of Nephrology, Hospital Universitario Insular de Gran Canaria, Las Palmas, Spain
| | - Juan M. Cazorla
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | - Ana Romera
- Department of Nephrology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Sergio Barroso
- Department of Nephrology, Hospital Universitario de Badajoz, Badajoz, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- RedinRen ISCIII RETYC 16/009, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Leonardo Calle
- Department of Nephrology, Complejo Asistencial de Segovia, Segovia, Spain
| | - Milagros Sierra
- Department of Nephrology, Hospital San Pedro, Logroño, Spain
| | | | | | - Sara Afonso
- Department of Nephrology, Hospital Universitario La Paz, Madrid, Spain
| | - Victoria Mascarós
- Department of Nephrology, Hospital Francesc Borja de Gandía, Valencia, Spain
| | - Armando Coca
- Department of Nephrology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
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23
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Sethi S, De Vriese AS, Fervenza FC. Acute glomerulonephritis. Lancet 2022; 399:1646-1663. [PMID: 35461559 DOI: 10.1016/s0140-6736(22)00461-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 02/10/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
Glomerulonephritis is a heterogeneous group of disorders that present with a combination of haematuria, proteinuria, hypertension, and reduction in kidney function to a variable degree. Acute presentation with full blown nephritic syndrome or rapidly progressive glomerulonephritis is uncommon and is mainly restricted to patients with post-infectious glomerulonephritis, anti-neutrophil cytoplasmic antibodies-associated vasculitis, and anti-glomerular basement membrane disease. Most frequently, patients present with asymptomatic haematuria and proteinuria with or without reduced kidney function. All glomerulonephritis disorders can show periods of exacerbation, but disease flairs characteristically occur in patients with IgA nephropathy or C3 glomerulopathy. The gold standard for the diagnosis of a glomerulonephritis is a kidney biopsy, with a hallmark glomerular inflammation that translates into various histopathological patterns depending on the location and severity of the glomerular injury. Traditionally, glomerulonephritis was classified on the basis of the different histopathological patterns of injury. In the last few years, substantial progress has been made in unravelling the underlying causes and pathogenetic mechanisms of glomerulonephritis and a causal approach to the classification of glomerulonephritis is now favoured over a pattern-based approach. As such, glomerulonephritis can be broadly classified as immune-complex glomerulonephritis (including infection-related glomerulonephritis, IgA nephropathy, lupus nephritis, and cryoglobulinaemic glomerulonephritis), anti-neutrophil cytoplasmic antibodies-associated (pauci-immune) glomerulonephritis, anti-glomerular basement membrane glomerulonephritis, C3 glomerulopathy, and monoclonal immunoglobulin-associated glomerulonephritis. We provide an overview of the clinical presentation, pathology, and the current therapeutic approach of the main representative disorders in the spectrum of glomerulonephritis.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
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24
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Bhuwania P, Veerappan I, Sethuraman R. A Rare Case of Type 4 Rapidly Progressive Glomerulonephritis (Atypical) with Mesangial IgA Deposits: A Case Report. Indian J Nephrol 2021; 31:488-491. [PMID: 34880562 PMCID: PMC8597790 DOI: 10.4103/ijn.ijn_364_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/06/2020] [Accepted: 10/18/2020] [Indexed: 11/05/2022] Open
Abstract
Rapidly progressive glomerulonephritis can result from glomerular deposition of anti-GBM antibody, immune complexes, or may involve pauci-immune mechanisms. The coexistence of IgA nephropathy, anti-GBM, and anti-neutrophilic cytoplasmic antibodies is unheard of, and the pathogenic role of these antibodies in IgA nephropathy or vice versa remains unclear. Herein, we describe a case of a patient with type 4 rapidly progressive glomerulonephritis who was found to have significant mesangial IgA deposits. The prognosis of this remains unclear but our patient responded well to cytotoxic therapy and plasmapheresis and achieved remission by 6 months. The findings suggest an overlap syndrome of IgA nephropathy-associated type 4 crescentic glomerulonephritis that resembles the former histologically and the latter in its potential to respond to aggressive therapy if detected relatively early in its course.
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Affiliation(s)
- Puneet Bhuwania
- Department of Nephrology, KG Hospital and PG Institute, Coimbatore, Tamil Nadu, India
| | - Ilangovan Veerappan
- Department of Nephrology, KG Hospital and PG Institute, Coimbatore, Tamil Nadu, India
| | - Ramaswami Sethuraman
- Department of Nephrology, KG Hospital and PG Institute, Coimbatore, Tamil Nadu, India
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25
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Riedel JH, Wiech T, Krebs C, Panzer U. Kreatininanstieg, Fieber und Hämoptysen. DER NEPHROLOGE 2021; 16:386-390. [PMID: 33688377 PMCID: PMC7934114 DOI: 10.1007/s11560-021-00495-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 10/27/2022]
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26
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Gupta RK, Ellis BK. Concurrent anti-GBM nephritis and ANCA-mediated glomerulonephritis after second dose of SARS-CoV-2 mRNA vaccination. Kidney Int Rep 2021; 7:127-128. [PMID: 34746518 PMCID: PMC8556066 DOI: 10.1016/j.ekir.2021.10.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 12/04/2022] Open
Affiliation(s)
- Rajib K Gupta
- Department of Pathology and translational pathobiology, Ochsner-LSU Health Shreveport, 1501 Kings Highway, Shreveport, LA 71103
| | - Brigid K Ellis
- Tower Health-Reading Hospital, 420 S 5 Ave, West Reading, PA 19611
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27
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Philip R, Dumont A, Martin Silva N, de Boysson H, Aouba A, Deshayes S. ANCA and anti-glomerular basement membrane double-positive patients: A systematic review of the literature. Autoimmun Rev 2021; 20:102885. [PMID: 34242834 DOI: 10.1016/j.autrev.2021.102885] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Double-positive patients (DPP) exhibiting anti-glomerular basement membrane (GBM) and anti-neutrophil cytoplasmic antibodies (ANCAs) belong to an entity that is newly and poorly described, mainly in short series. We aimed to better characterize the epidemiological features, clinical presentation and therapeutic outcomes of these patients through a systematic review. METHODS We performed a systematic review of English-, German-, Spanish- and French-written publications from February 1987 to March 2020 reporting cases of DPP using the following databases: PubMed, Scielo, ScienceDirect, Google Scholar, The Cochrane Library, Open Grey, The Grey Literature Report, Clinicaltrials.gov and International Clinical Trial Registry Platform of the World Health Organization. RESULTS In total, 538 DPP were identified from 90 articles. Their clinical presentations were often severe, and the majority exhibited acute kidney failure (91.8%) with a median initial serum creatinine level of 873 μmol/L; 50.7% had alveolar haemorrhage. Other manifestations were present in 30.3% of DPP, mainly ear, nose, throat and articular manifestations. ANCAs were predominantly directed against MPO (n = 377/523; 72.1%) compared to PR3 (n = 107/523; 20.5%), with rare cases of triple positivity (n = 15/538; 2.9%). Although most patients received initial immunosuppressive therapy (n = 285/317; 89.9%), the one-year overall, renal and relapse-free survival rates were 64.8%, 38.7% and 71.1%, respectively. CONCLUSION DPP are associated with the characteristics of two eponymous vasculitis types, responsible for a poor overall and renal prognosis. Thus, simultaneous testing of both antibodies and systematic renal biopsy should be recommended in every patient with rapidly progressive glomerulonephritis to recognize this difficult-to-treat and rare disease.
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Affiliation(s)
- Rémi Philip
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France
| | - Anael Dumont
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France
| | - Nicolas Martin Silva
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France
| | - Hubert de Boysson
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France
| | - Achille Aouba
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France.
| | - Samuel Deshayes
- Department of Clinical Immunology and Internal Medicine, CHU of Caen Normandie, 14000 Caen, France; Normandie Univ, UNICAEN, CHU de Caen Normandie, 14000 Caen, France
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28
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Le Moine C, Jourde‐Chiche N, Kemlin D, Terrier B, Vandergheynst F. Sequential development of ANCA-associated vasculitis and anti-GBM disease: A report of two cases. Clin Case Rep 2021; 9:e04553. [PMID: 34322270 PMCID: PMC8301573 DOI: 10.1002/ccr3.4553] [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: 03/31/2021] [Revised: 05/27/2021] [Accepted: 06/16/2021] [Indexed: 11/09/2022] Open
Abstract
In case of AAV with kidney involvement, physicians should explore anti-GBM antibodies and be aware of the possible sequential development of AAV, especially with MPO-ANCA, and anti-GBM glomerulonephritis. This sequential disease history is associated with a poor renal outcome, highlighting the need for urgent diagnosis and management.
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Affiliation(s)
| | - Noémie Jourde‐Chiche
- Department of NephrologyHôpital de la ConceptionMarseilleFrance
- French Vasculitis Study GroupParisFrance
| | | | - Benjamin Terrier
- French Vasculitis Study GroupParisFrance
- Department of Internal MedicineNational Referral Center for Rare Systemic Autoimmune Diseases. Hôpital CochinParisFrance
| | - Frédéric Vandergheynst
- Department of Internal Medicine. Hôpital ErasmeBrusselsBelgium
- French Vasculitis Study GroupParisFrance
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29
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Clerte M, Philip R, Levi C, Cornec-Le Gall E, Audard V, Huart A, Puéchal X, Touzot M, Rabot N, Thervet É, Aouba A, Karras A. Renal and overall outcomes of double-positive (ANCA and anti-GBM antibodies) patients compared to ANCA-associated vasculitis patients with severe renal involvement: A multicenter retrospective study with systematic renal pathology analysis. Scand J Rheumatol 2021; 51:205-213. [PMID: 34169779 DOI: 10.1080/03009742.2021.1920120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: Double-positive patients (DPPs), combining serum and/or histological findings for glomerular basement membrane (GBM) disease and anti-neutrophil cytoplasmic antibodies (ANCAs), are rare and poorly described. This study aimed to compare characteristics between DPPs and ANCA-associated vasculitis (AAV) patients with severe renal involvement.Method: This retrospective multicentre study compared 33 DPPs and 45 AAV patients with severe renal involvement (serum creatinine > 300 μmol/L), all with biopsy-proven nephropathy.Results: All DPPs (including 18% exhibiting negative serum anti-GBM antibodies) presented severe acute kidney failure with histological GBM involvement. Compared to AAV patients, they had higher serum creatinine (719 vs 501 μmol/L; p = 0.006) and a higher proportion of patients requiring initial renal replacement therapy (82% vs 36%; p < 0.001). Berden classification differed significantly (p = 0.003), with more crescentic glomerulonephritis and fewer sclerotic lesions in DPPs. One-year renal survival was significantly lower in DPPs than in AAV patients (27% vs 64%; p < 0.0002). With comparable proportions of ANCA subtypes (two-thirds with anti-myeloperoxidase autoantibodies), numbers of extrarenal manifestations (mostly pulmonary in two-thirds), remission-inducing immunosuppressants, and median follow-ups (3 years) between groups, relapse rates were similar: 9.1% of DPPs and 10% of AAV patients.Conclusion: Although DPPs have features of both kinds of vasculitis, the anti-GBM component is the dominant phenotype, with more severe renal presentation and prognosis compared to AAV patients with severe renal failure. Simultaneous testing of both antibodies and systematically performed renal biopsy should be recommended in all rapidly progressing glomerulonephritis patients to recognize this difficult-to-treat, rare disease.
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Affiliation(s)
- M Clerte
- Department of Nephrology, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), University of Paris, Paris, France
| | - R Philip
- Division of Clinical Immunology and Internal Medicine, Normandie University, Caen, France
| | - C Levi
- Department of Nephrology, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), University of Paris, Paris, France
| | - E Cornec-Le Gall
- Division of Immmunology and Nephrology, Bretonneau Hospital, Tours, France
| | - V Audard
- Paris Est Créteil University, INSERM IMRB, Department of Nephrology and Renal Transplantation, Reference Centre of Idiopathic Nephrotic Syndrome, University Hospital Henri Mondor, APHP, Créteil, France
| | - A Huart
- Division of Nephrology and Transplantation, Reference Centre of Rare Renal Diseases, University Paul Sabatier - Toulouse III, Toulouse, France
| | - X Puéchal
- National Referral Center for Rare Systemic Autoimmune Diseases, Université de Paris, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
| | - M Touzot
- Division of Dialysis and Therapeutic Apheresis, Health Centre of Aura Paris Plaisance, Paris, France
| | - N Rabot
- Division of Immunology and Nephrology, Bretonneau Hospital, Tours, France
| | - É Thervet
- Department of Nephrology, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), University of Paris, Paris, France
| | - A Aouba
- Division of Clinical Immunology and Internal Medicine, Normandie University, Caen, France
| | - A Karras
- Department of Nephrology, European Hospital Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), University of Paris, Paris, France
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Windpessl M, Bettac EL, Gauckler P, Shin JI, Geetha D, Kronbichler A. ANCA Status or Clinical Phenotype - What Counts More? Curr Rheumatol Rep 2021; 23:37. [PMID: 33909191 PMCID: PMC8081707 DOI: 10.1007/s11926-021-01002-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW There is ongoing debate concerning the classification of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. That is, whether classification should be based on the serotype (proteinase 3 (PR3)- or myeloperoxidase (MPO)-ANCA) or on the clinical phenotype (granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA)). To add clarity, this review focused on integration of the most recent literature. RECENT FINDINGS Large clinical trials have provided evidence that a serology-based risk assessment for relapses is more predictive than distinction based on the phenotype. Research conducted in the past decade indicated that a serology-based approach more closely resembles the genetic associations, the clinical presentation (i.e., lung involvement), biomarker biology, treatment response, and is also predicting comorbidities (such as cardiovascular death). Our review highlights that a serology-based approach could replace a phenotype-based approach to classify ANCA-associated vasculitides. In future, clinical trials and observational studies will presumably focus on this distinction and, as such, translate into a "personalized medicine."
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Affiliation(s)
- Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Grieskirchnerstrasse 42, 4600, Wels, Austria
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040, Linz, Austria
| | - Erica L Bettac
- Department of Psychology, Washington State University Vancouver, 14204 NE Salmon Creek Avenue, Vancouver, WA, USA
| | - Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, 03722, Republic of Korea
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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31
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Li L, Liu LQ, Yang YY, Hu ZX. C3 glomerulonephritis associated with ANCA positivity: a case report. BMC Nephrol 2021; 22:143. [PMID: 33882866 PMCID: PMC8061169 DOI: 10.1186/s12882-021-02354-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 04/13/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND C3 glomerulopathy (C3G) is a recent disease classification that is characterized by the presence of glomerular deposits (composed of C3) in the absence of significant amounts of immunoglobulin and comprises dense deposit disease and C3 glomerulonephritis (C3GN). Most C3GN manifests as membranoproliferative, mesangial proliferative glomerulonephritis patterns via light microscopy. Pure membranous nephropathy (MN)-like glomerular lesions are rare manifestations of C3GN. Anti-neutrophil cytoplasmic antibodies (ANCAs) are also seldomly reported to be positive in C3GN. Herein, we report the case of a C3GN patient presenting with an MN-like glomerular pattern with ANCA positivity. CASE PRESENTATION A 68-year-old woman was admitted to a local hospital with elevated serum creatinine for two weeks. Laboratory tests showed a hemoglobin level of 85 g/L. Urinalysis was positive for 2 + protein and 360 RBCs/HPF. Blood biochemistry analysis revealed the following concentrations: albumin, 30.3 g/L; globulin, 46.2 g/L; blood urea nitrogen, 19.9 mmol/L; and serum creatinine, 234 µmol/L. The serum C3 level was 0.4950 g/L, and the serum C4 level was 0.1050 g/L. The direct Coombs test was positive. Serologic testing for ANCA revealed the presence of p-ANCA (1:10) by indirect immunofluorescence microscopy assay, as well as the presence of PR3 1.2 (normal range < 1) and MPO 3.5 (normal range < 1) by enzyme immunoassay. Renal biopsy sample pathology showed 2/6 cellular crescents and thickened glomerular basement membranes. Immunofluorescence testing revealed only diffuse, finely granular depositions of C3 along the glomerular capillary walls in frozen and paraffin-embedded tissue sections. Electron microscopy demonstrated the presence of subepithelial electron-dense deposits, similar to those that are observed in membranous nephropathy. Corticosteroid and cyclophosphamide were administered, with a subsequent improvement in renal function. CONCLUSIONS We present the rare case of a patient with MN-like C3GN with ANCA positivity. C3GN with ANCA positivity may be represented by more crescents, severe renal dysfunction and more extrarenal manifestations. More cases are needed to elucidate the clinicopathologic features and optimal treatments of these patients.
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Affiliation(s)
- Ling Li
- Renal Division, Department of Medicine, West China Hospital of Sichuan University, 610041, Chengdu, China
| | - Li-Qin Liu
- West China School of Medicine, Sichuan University, 610041, Chengdu, China
| | - Ying-Ying Yang
- Renal Division, Department of Medicine, West China Hospital of Sichuan University, 610041, Chengdu, China
| | - Zhang-Xue Hu
- Renal Division, Department of Medicine, West China Hospital of Sichuan University, 610041, Chengdu, China.
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Helander L, Hanna M, Annen K. Pediatric double positive anti-glomerular basement membrane antibody and anti-neutrophil cytoplasmic antibody glomerulonephritis-A case report with review of literature. J Clin Apher 2021; 36:505-510. [PMID: 33629780 DOI: 10.1002/jca.21886] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/02/2020] [Accepted: 01/24/2021] [Indexed: 12/12/2022]
Abstract
Anti-glomerular basement membrane (GBM) disease is a rarely described entity in the pediatric population, especially in those less than 3 years old. Even rarer, is double seropositive disease, consisting of anti-GBM antibody plus anti-neutrophil cytoplasmic antibodies. Both single and double antibody positive diseases are characterized by rapidly progressive glomerulonephritis, often without pulmonary involvement in the pediatric population. We report the case of a 2-year-old child with double seropositive anti-GBM disease, the youngest in the current literature, along with the role of therapeutic plasma exchange and rituximab in disease treatment.
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Affiliation(s)
- Louise Helander
- ClinImmune Labs, Aurora, Colorado, USA.,School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Melisha Hanna
- School of Medicine, University of Colorado, Aurora, Colorado, USA.,Children's Hospital Colorado, Aurora, Colorado, USA
| | - Kyle Annen
- Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Pathology, University of Colorado, Aurora, Colorado, USA
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Vavilapalli S, Madireddy N, Uppin MS, Kalidindi K, Gudithi S, Taduri G, Raju SB. Anti-glomerular basement membrane disease: A clinicomorphological study of 16 cases. INDIAN J PATHOL MICR 2021; 63:226-229. [PMID: 32317520 DOI: 10.4103/ijpm.ijpm_712_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Antiglomerular basement membrane disease manifests as rapidly progressive glomerulonephritis and alveolar hemorrhage. It encompasses 10-15% of crescentic glomerulonephritis and is associated with poor outcome. In this study, we have elaborated on the clinical details, morphological features, and outcome of anti-GBM glomerulonephritis. Materials and Methods All the consecutive biopsy-proven cases of anti-GBM glomerulonephritis over a period of 4½ years were analyzed, retrospectively. Results Sixteen cases were diagnosed as anti-GBM glomerulonephritis during the study period. Twelve patients presented with rapidly progressive renal failure of which four patients required hemodialysis at the time of presentation. Goodpasture's syndrome was noted in two patients. Thirteen cases were positive for circulating anti-GBM antibodies and two patients showed double positivity for both anti-GBM antibodies and ANCA. Fifteen biopsies revealed crescentic glomerulonephritis with linear deposition of IgG along the glomerular basement membrane in all the 16 cases. Conclusion Renal biopsy analysis is important in the diagnosis of Anti GBM nephritis. Morphology is an important predictor of disease progression.
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Affiliation(s)
- Srinivasrao Vavilapalli
- Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Nishika Madireddy
- Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Megha S Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Karthik Kalidindi
- Department of Nephrology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Swarnalatha Gudithi
- Department of Nephrology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Gangadhar Taduri
- Department of Nephrology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
| | - Sree Bhushan Raju
- Department of Nephrology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, Telangana, India
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Shimamura Y, Maeda T, Abe K, Ogawa Y, Takizawa H. Clinical and immunologic characteristics of Japanese patients with anti-glomerular basement membrane disease: case reports and literature review. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00317-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Clinical studies of anti-glomerular basement membrane (GBM) disease were limited because of the low incidence. We aimed to report the characteristics, treatments, and outcomes of patients with anti-GBM disease at a tertiary reference medical center in Japan and review the literature of mortality in patients with anti-GBM disease.
Case presentation
Case 1 was a 72-year-old Japanese man that was referred with worsening of the serum creatinine (from 1.1 to 27.3 mg/dL). Anti-GBM disease was confirmed by renal biopsy, and treatments with oral prednisolone and plasmapheresis were initiated. Although his anti-GBM antibody decreased (from 476 to 18 units/mL) after the treatments, the patient died from lung abscess. Case 2 was a 32-year-old Japanese man that presented with fever and macroscopic hematuria. At presentation, his serum creatinine was 4.2 mg/dL, and anti-GBM antibody was 265 units/mL. Renal biopsy confirmed the diagnosis of anti-GBM disease, and intensive treatments with plasmapheresis and methyl prednisolone were started, followed by oral prednisolone. Living-donor kidney transplantation was performed because his anti-GBM antibody had remained undetectable for 1 year after diagnosis. In the main text, clinicopathological characteristics of 12 patients with anti-GBM disease at our institution were summarized.
Conclusions
We found that the 1-year survival rate of patients with anti-GBM disease was 88% in our cohort, which was comparable to previous studies. Multicenter, nationwide studies are expected to evaluate prognosis of Japanese patients with this rare entity.
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Sengupta M, Dasgupta S, Basu K, Mukherjee S, Sarkar S, Chowdhury AR, Pandey R, Bandopadhyay M. A tale of tripartite: An experience from a tertiary care center of Eastern India. INDIAN J PATHOL MICR 2021; 64:497-503. [PMID: 34341260 DOI: 10.4103/ijpm.ijpm_445_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background Crescentic glomerulonephritis (Cr GN) is pattern of glomerular injury resulting from wide range of diseases sharing a common pathogenesis. Objectives The objective of our study was to analyze the clinicopathological spectrum and outcome of Cr GN with special reference to its immunopathological subtypes using a panel of immunofluorescence stains. Materials and Methods Native renal biopsies with crescentic pattern of injury were included. Detailed Clinical and laboratory variables were analyzed along with the treatment protocol and renal outcome, wherever available. Renal biopsy slides were evaluated for various glomerular and extraglomerular features. Both qualitative and quantitative data were analyzed. Results A total of 57 cases of Cr GN were included; majority (47.36%) of cases were pauci-immune in nature. Among clinical features, ranges of proteinuria and creatinine level were significantly different between subgroups. The various light microscopic parameters, including proportion of cellular crescents and capillary wall necrosis were different. Presence of arteriolar changes also showed association with unfavorable outcome. Three unusual associations, including IgA nephropathy, membranous glomerulonephritis and Hepatitis B infection were detected. Adequate follow-up information was available in 35 of the patients. Of these, 14 were dialysis-dependent at the last follow-up. Conclusions Type III Cr GN (pauci-immune Cr GN) was the commonest cause of Cr GN in our population. Adult patients required renal replacement therapy more frequently than pediatric cases those are chiefly infection associated. Critical appraisal of clinical, histopathological and immunofluorescence finding help to identify individual subtypes as treatment and outcome varies accordingly.
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Affiliation(s)
- Moumita Sengupta
- Department of Pathology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Saugat Dasgupta
- Department of Nephrology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Keya Basu
- Department of Pathology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Sriranjan Mukherjee
- Department of Pathology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | - Sucharita Sarkar
- Department of Pathology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
| | | | - Rajendra Pandey
- Department of Nephrology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
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Abstract
Since the first clinicopathologic description by Ernest Goodpasture of a patient whom he considered to have died of influenza in 1919, substantial progress has been made in our knowledge of anti-glomerular basement membrane disease. This has led to a significant decrease in the morbidity and mortality associated with this disease. In this paper, we aim to review the literature that has enhanced our understanding of classic anti-glomerular basement membrane disease and its clinic-pathologic variants in the key areas of immunopathogenesis and histopathology. We also summarize varied clinical presentations and therapeutic strategies.
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Bourse Chalvon N, Orquevaux P, Giusti D, Gatouillat G, Tabary T, Tonye Libyh M, Chrusciel J, Drame M, Stockton-Bliard G, Amoura Z, Arnaud L, Lorenz HM, Blaison G, Bonnotte B, Magy-Bertrand N, Revuz S, Voll RE, Hinschberger O, Schwarting A, Pham BN, Martin T, Pennaforte JL, Servettaz A. Absence of Anti-Glomerular Basement Membrane Antibodies in 200 Patients With Systemic Lupus Erythematosus With or Without Lupus Nephritis: Results of the GOODLUPUS Study. Front Immunol 2020; 11:597863. [PMID: 33381119 PMCID: PMC7768036 DOI: 10.3389/fimmu.2020.597863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 11/10/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction Anti-glomerular basement membrane (GBM) antibodies are pathogenic antibodies first detected in renal-limited anti-GBM disease and in Goodpasture disease, the latter characterized by rapidly progressive crescentic glomerulonephritis combined with intra-alveolar hemorrhage. Studies have suggested that anti-GBM antibody positivity may be of interest in lupus nephritis (LN). Moreover, severe anti-GBM vasculitis cases in patients with systemic lupus erythematosus (SLE) have been described in the literature, but few studies have assessed the incidence of anti-GBM antibodies in SLE patients. Objective The main study objective was to determine if positive anti-GBM antibodies were present in the serum of SLE patients with or without proliferative renal damage and compared to a healthy control group. Methodology This retrospective study was performed on SLE patients’ sera from a Franco-German European biobank, developed between 2011 and 2014, from 17 hospital centers in the Haut-Rhin region. Patients were selected according to their renal involvement, and matched by age and gender. The serum from healthy voluntary blood donors was also tested. Anti-GBM were screened by fluorescence enzyme immunoassay (FEIA), and then by indirect immunofluorescence (IIF) in case of low reactivity detection (titer >6 U/ml). Results The cohort was composed of 100 SLE patients with proliferative LN (27% with class III, 67% with class IV, and 6% with class V), compared to 100 SLE patients without LN and 100 controls. Patients were mostly Caucasian and met the ACR 1997 criteria and/or the SLICC 2012 criteria. Among the 300 tested sera, no significant levels of anti-GBM antibodies were detected (>10 U/ml) by the automated technique, three sera were found “ambivalent” (>7 U/ml): one in the SLE with LN group and two in the SLE without LN group. Subsequent IIF assays did not detect anti-GBM antibodies. Conclusion Anti-GBM antibodies were not detected in the serum of Caucasian patients with SLE, even in case of renal involvement, a situation favoring the antigenic exposure of glomerular basement membranes. Our results reaffirm the central role of anti-GBM antibodies as a specific diagnostic biomarker for Goodpasture vasculitis and therefore confirm that anti-GBM antibody must not be carried out in patients with SLE (with or without LN) in the absence of disease-suggestive symptoms.
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Affiliation(s)
- Nellie Bourse Chalvon
- Département de médecine interne, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Pauline Orquevaux
- Département de médecine interne, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Delphine Giusti
- Département d'immunologie biologique (laboratoire d'immunologie), Centre Hospitalier Universitaire de Reims, Reims, France
| | - Gregory Gatouillat
- Département d'immunologie biologique (laboratoire d'immunologie), Centre Hospitalier Universitaire de Reims, Reims, France
| | - Thierry Tabary
- Département d'immunologie biologique (laboratoire d'immunologie), Centre Hospitalier Universitaire de Reims, Reims, France
| | - Marcelle Tonye Libyh
- Département d'immunologie biologique (laboratoire d'immunologie), Centre Hospitalier Universitaire de Reims, Reims, France
| | - Jan Chrusciel
- Département d'information médicale et d'évaluation des performances, santé publique, Centre Hospitalier de Troyes, Troyes, France
| | - Moustapha Drame
- Département de Délégation à la Recherche Clinique et à l'Innovation, University Hospital of Martinique, Fort-de-France, Martinique
| | | | - Zahir Amoura
- Service de Médecine interne, Assistance Publique Hôpitaux de Paris (APHP), Paris, France
| | - Laurent Arnaud
- Service de Rhumatologie, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Hanns-Martin Lorenz
- Division of Rheumatology, Clinic for Hematology, Oncology and Rheumatology, Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Gilles Blaison
- Département de médecine interne, Hôpital Pasteur, Colmar, France
| | - Bernard Bonnotte
- Département de Médecine Interne et d'immunologie Clinique, Centre Hospitalier Regional Universitaire De Dijon, Dijon, France
| | - Nadine Magy-Bertrand
- Département de médecine interne, Centre Hospitalier Universitaire de Besançon, Besancon, France
| | - Sabine Revuz
- Département de médecine interne, Hôpital Belle-Isle, Metz, France
| | - Reinhard Edmund Voll
- Department of Rheumatology and Clinical Immunology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Oliver Hinschberger
- Département de médecine interne, Groupe Hospitalier de la Région de Mulhouse et Sud Alsace (GHRMSA), Mulhouse, France
| | - Andreas Schwarting
- Universitäres Centrum für Autoimmunität Mainz, Johannes Gutenberg-Universität Mainz, Mainz, Germany
| | - Bach Nga Pham
- Département d'immunologie biologique (laboratoire d'immunologie), Centre Hospitalier Universitaire de Reims, Reims, France
| | - Thierry Martin
- Immunologie Clinique et Médecine Interne, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jean-Loup Pennaforte
- Département de médecine interne, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Amelie Servettaz
- Département de médecine interne, Centre Hospitalier Universitaire de Reims, Reims, France
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Busch MH, Aendekerk JP, van Beers JJBC, van Paassen P, Damoiseaux JGMC. Evaluation of the diagnostic performance of an immunoblot for ANCA and anti-GBM antibody detection. Autoimmunity 2020; 54:45-50. [PMID: 33215537 DOI: 10.1080/08916934.2020.1846185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The use of high-quality antigen-specific immunoassays for detecting anti-neutrophil cytoplasmic antibodies (ANCA) and anti-glomerular basement membrane (GBM) autoantibodies is recommended in patients with suspected ANCA vasculitis and/or anti-GBM disease. We analysed the diagnostic performance of a semi-quantitative and rapid immunoblot (EUROIMMUN AG, Lübeck, Germany) in two settings. Patient sera from different cohorts (ANCA vasculitis n = 187, anti-GBM disease n = 19, and disease controls n = 51) were used. The diagnostic performance of the immunoblot was assessed when used as a confirmatory test for the presence of ANCA in suspected ANCA vasculitis and when evaluating the presence of ANCA and/or anti-GBM antibodies in AAV and/or anti-GBM disease patients with a rapidly progressive glomerulonephritis (RPGN). In a confirmatory test setting, the immunoblot had an optimal sensitivity and specificity of 97.4 and 98.1% for PR3-ANCA and 98.5 and 96.4% for MPO-ANCA, respectively. With increasing test result ranges, a higher interval likelihood ratio (LR) was found for both ANCA entities. When evaluating for ANCA in patients with RPGN, the highest diagnostic accuracy (sensitivity 92.9% and specificity 100%) was obtained by using different cut-off values of positivity for PR3- (>5) and MPO-ANCA (>10). Also, the diagnostic performance for detecting anti-GBM was good (sensitivity 100% and specificity 100%). There are advantages over other assays in terms of time, costs, and interpretation of results. The immunoblot is a useful addition to current guidelines, particularly when a rapid diagnosis is necessary.
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Affiliation(s)
- Matthias H Busch
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joop P Aendekerk
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Joyce J B C van Beers
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Pieter van Paassen
- Department of Nephrology and Clinical Immunology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jan G M C Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Center, Maastricht, The Netherlands
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Moiseev S, Cohen Tervaert JW, Arimura Y, Bogdanos DP, Csernok E, Damoiseaux J, Ferrante M, Flores-Suárez LF, Fritzler MJ, Invernizzi P, Jayne D, Jennette JC, Little MA, McAdoo SP, Novikov P, Pusey CD, Radice A, Salama AD, Savige JA, Segelmark M, Shoenfeld Y, Sinico RA, Sousa MJ, Specks U, Terrier B, Tzioufas AG, Vermeire S, Zhao MH, Bossuyt X. 2020 international consensus on ANCA testing beyond systemic vasculitis. Autoimmun Rev 2020; 19:102618. [PMID: 32663621 DOI: 10.1016/j.autrev.2020.102618] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023]
Abstract
This document follows up on a 2017 revised international consensus on anti-neutrophil cytoplasm antibodies (ANCA) testing in granulomatosis with polyangiitis and microscopic polyangiitis and focuses on the clinical and diagnostic value of ANCA detection in patients with connective tissue diseases, idiopathic interstitial pneumonia, autoimmune liver diseases, inflammatory bowel diseases, anti-glomerular basement membrane (GBM) disease, infections, malignancy, and during drug treatment. Current evidence suggests that in certain settings beyond systemic vasculitis, ANCA may have clinical, pathogenic and/or diagnostic relevance. Antigen-specific ANCA targeting proteinase-3 and myeloperoxidase should be tested by solid phase immunoassays in any patient with clinical features suggesting ANCA-associated vasculitis and in all patients with anti-GBM disease, idiopathic interstitial pneumonia, and infective endocarditis associated with nephritis, whereas in patients with other aforementioned disorders routine ANCA testing is not recommended. Among patients with autoimmune liver diseases or inflammatory bowel diseases, ANCA testing may be justified in patients with suspected autoimmune hepatitis type 1 who do not have conventional autoantibodies or in case of diagnostic uncertainty to discriminate ulcerative colitis from Crohn's disease. In these cases, ANCA should be tested by indirect immunofluorescence as the target antigens are not yet well characterized. Many questions concerning the optimal use of ANCA testing in patients without ANCA-associated vasculitis remain to be answered.
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Affiliation(s)
- Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia.
| | - Jan Willem Cohen Tervaert
- Department of Medicine, Division of Rheumatology, University of Alberta, Edmonton, Canada and Maastricht University, Maastricht, The Netherlands
| | - Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Larissa, Greece
| | - Elena Csernok
- Department of Internal Medicine, Rheumatology and Immunology, Vasculitis-Center Tübingen-Kirchheim, Medius Klinik Kirchheim, University of Tübingen, Kirchheim-Teck, Germany
| | - Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marc Ferrante
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Luis Felipe Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Invernizzi
- Division Gastroenterology and Center for Autoimmune Liver Diseases, University of Milano-Bicocca School of Medicine, Monza, Italy
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - J Charles Jennette
- Division of Nephropathology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Dublin, Ireland
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Pavel Novikov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Charles D Pusey
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Antonella Radice
- Microbiology and Virology Institute, ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milan, Italy
| | - Alan D Salama
- UCL Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Judith A Savige
- Department of Medicine, Melbourne Health, University of Melbourne, Melbourne, Australia
| | - Mårten Segelmark
- Department of Clinical Sciences, Lund University, Department of Nephrology and Rheumatology, Skane University Hospital, Lund, Sweden
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Renato A Sinico
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Maria-José Sousa
- Immunopathology and Autoimmunity Department, Centro de Medicina Laboratorial Germano de Sousa, Lisbon, Portugal
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Athanasios G Tzioufas
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Severine Vermeire
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking-Tsinghua Centre for Life Sciences, Beijing, China
| | - Xavier Bossuyt
- Laboratory Medicine, University Hospitals Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Segelmark M, Hellmark T. Anti-glomerular basement membrane disease: an update on subgroups, pathogenesis and therapies. Nephrol Dial Transplant 2020; 34:1826-1832. [PMID: 30371823 DOI: 10.1093/ndt/gfy327] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 09/20/2018] [Indexed: 12/12/2022] Open
Abstract
Most patients with anti-glomerular basement membrane (anti-GBM) disease present with rapidly progressive glomerulonephritis with or without pulmonary haemorrhage; however, there are several variants and vigilance is necessary to make a correct diagnosis. Such variants include overlap with anti-neutrophil cytoplasm antibodies-associated vasculitis and membranous nephropathy as well as anti-GBM occurring de novo after renal transplantation. Moreover, patients can present with isolated pulmonary haemorrhage as well as with negative tests for circulating anti-GBM. Virtually all patients with anti-GBM disease have autoantibodies that react with two discrete epitopes on the α3 chain of type IV collagen. Recent evidence suggests that healthy persons have low-affinity natural antibodies reacting with the same epitopes, but most people are protected from developing disease-causing high-affinity autoantibodies by human leukocyte antigen-dependent regulatory T-cells (Tregs). The α3 chain-derived peptides presented by the HLA-DR15 antigen lack the ability to promote the development of such Tregs. The detection of anti-GBM in circulation using the rapid assay test has led to early diagnosis and improved prognosis. However, our present tools to curb the inflammation and to eliminate the assaulting antibodies are insufficient. Only about one-third of all patients survive with functioning native kidneys. More effective therapies need to be developed; agents that inhibit neutrophil recruitment, deplete B cells and cleave immunoglobulin G (IgG) in vivo may become new weapons in the arsenal to combat anti-GBM disease.
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Affiliation(s)
- Mårten Segelmark
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Thomas Hellmark
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
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Severe Infection in Anti-Glomerular Basement Membrane Disease: A Retrospective Multicenter French Study. J Clin Med 2020; 9:jcm9030698. [PMID: 32143501 PMCID: PMC7141378 DOI: 10.3390/jcm9030698] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 12/23/2022] Open
Abstract
In patients presenting with anti-glomerular basement membrane (GBM) disease with advanced isolated kidney involvement, the benefit of intensive therapy remains controversial due to adverse events, particularly infection. We aim to describe the burden of severe infections (SI) (requiring hospitalization or intravenous antibiotics) and identify predictive factors of SI in a large cohort of patients with anti-GBM disease. Among the 201 patients (median [IQR] age, 53 [30–71] years) included, 74 had pulmonary involvement and 127 isolated glomerulonephritis. A total of 161 SI occurred in 116 patients during the first year after diagnosis. These infections occurred during the early stage of care (median [IQR] time, 13 [8–19] days after diagnosis) with mainly pulmonary (45%), catheter-associated bacteremia (22%) and urinary tract (21%) infections. In multivariable analysis, positive ANCA (HR [95% CI] 1.62 [1.07−2.44]; p = 0.02) and age at diagnosis (HR [95% CI] 1.10 [1.00–1.21]; p = 0.047) remained independently associated with SI. Age-adjusted severe infection during the first three months was associated with an increased three-year mortality rate (HR [95% CI] 3.13 [1.24–7.88]; p = 0.01). Thus, SI is a common early complication in anti-GBM disease, particularly in the elderly and those with positive anti-neutrophil cytoplasmic antibodies (ANCA). No significant association was observed between immunosuppressive strategy and occurrence of SI.
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Impact of ANCA-Associated Vasculitis on Outcomes of Hospitalizations for Goodpasture's Syndrome in the United States: Nationwide Inpatient Sample 2003-2014. ACTA ACUST UNITED AC 2020; 56:medicina56030103. [PMID: 32121573 PMCID: PMC7142422 DOI: 10.3390/medicina56030103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 12/27/2022]
Abstract
Background and objectives: Goodpasture’s syndrome (GS) is a rare, life-threatening autoimmune disease. Although the coexistence of anti-neutrophil cytoplasmic antibody (ANCA) with Goodpasture’s syndrome has been recognized, the impacts of ANCA vasculitis on mortality and resource utilization among patients with GS are unclear. Materials and Methods: We used the National Inpatient Sample to identify hospitalized patients with a principal diagnosis of GS from 2003 to 2014 in the database. The predictor of interest was the presence of ANCA-associated vasculitis. We tested the differences concerning in-hospital treatment and outcomes between GS patients with and without ANCA-associated vasculitis using logistic regression analysis with adjustment for other clinical characteristics. Results: A total of 964 patients were primarily admitted to hospital for GS. Of these, 84 (8.7%) had a concurrent diagnosis of ANCA-associated vasculitis. Hemoptysis was more prevalent in GS patients with ANCA-associated vasculitis. During hospitalization, GS patients with ANCA-associated required non-significantly more mechanical ventilation and non-invasive ventilation support, but non-significantly less renal replacement therapy and plasmapheresis than those with GS alone. There was no significant difference in in-hospital outcomes, including organ failure and mortality, between GS patients with and without ANCA-associated vasculitis. Conclusions: Our study demonstrated no significant differences between resource utilization and in-hospital mortality among hospitalized patients with coexistence of ANCA vasculitis and GS, compared to those with GS alone.
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Philip R, Dumont A, Le Mauff B, Martinet M, Martin Silva N, de Boysson H, Lobbedez T, Aouba A, Deshayes S. [ANCA and anti-MBG double-positive vasculitis: An update on the clinical and therapeutic specificities and comparison with the two eponymous vasculitis]. Rev Med Interne 2019; 41:21-26. [PMID: 31839271 DOI: 10.1016/j.revmed.2019.10.334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 07/21/2019] [Accepted: 10/21/2019] [Indexed: 01/19/2023]
Abstract
Double-positive vasculitis with anti-polynuclear cytoplasm (ANCA) and anti-glomerular basement membrane (GBM) antibodies is a rare entity of systemic vasculitis defined by the presence of ANCA and anti-GBM antibodies. The gradual accumulation of clinical and therapeutic data shows the usefulness of identifying and differentiating this entity from the two vasculitis respectively associated with the isolated presence of each of these two antibodies. Indeed, the double-positive ANCA and anti-GBM vasculitis appears to associate the characteristics of the demography and the extra-renal and pulmonary involvement of the ANCA-associated vasculitis on the one hand, and of the histological type and severe renal prognosis of the anti-MBG vasculitis on the other hand, with the renal involvement which is the only involvement consistently observed in double-positive vasculitis. The aim of this focus is to describe the epidemiological, clinico-biological, histological and prognostic characteristics of this entity, in light of recent literature and ongoing therapeutic changes in the two eponymous vasculitis.
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Affiliation(s)
- R Philip
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - A Dumont
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - B Le Mauff
- Laboratoire d'Immunologie, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - M Martinet
- Laboratoire d'Immunologie, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - N Martin Silva
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - H de Boysson
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - T Lobbedez
- Service de néphrologie, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
| | - A Aouba
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France.
| | - S Deshayes
- Service de médecine interne et immunologie clinique, UNICAEN, Normandie Université, CHU de Caen Normandie, 14000 Caen, France
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Ahmed A, Ahmad N, Dibbur V, Price E, Roberts ISD. Odd combinations-coexistence of anti-glomerular basement membrane disease and Sjögren's syndrome. Rheumatology (Oxford) 2019; 58:2339-2342. [PMID: 31170292 DOI: 10.1093/rheumatology/kez208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - Vinod Dibbur
- Nephrology Department, Great Western Hospital, Swindon, Oxford, UK
| | | | - Ian S D Roberts
- Department of Cellular Pathology, John Radcliffe Hospital, Oxford, UK
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45
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Rituximab for the Treatment of Pediatric Double-Positive Small-Vessel Vasculitis. Kidney Int Rep 2019; 5:235-238. [PMID: 32043039 PMCID: PMC7000840 DOI: 10.1016/j.ekir.2019.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/15/2019] [Accepted: 11/18/2019] [Indexed: 01/30/2023] Open
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Ikeda Y, Fukunari K, Uchiumi S, Awanami Y, Kanaya A, Matsumoto K, Fukuda M, Takashima T, Miyazono M, Ikeda Y. A case of anti-neutrophil cytoplasmic antibody-associated vasculitis with anti-glomerular basement membrane antibodies that was successfully treated with mizoribine as a safe and effective remission maintenance therapy with prednisolone and plasma exchange. CEN Case Rep 2019; 9:42-47. [PMID: 31612361 PMCID: PMC6990334 DOI: 10.1007/s13730-019-00423-2] [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: 08/12/2018] [Accepted: 09/29/2019] [Indexed: 11/05/2022] Open
Abstract
We herein report the case of myeloperoxidase (MPO) anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis with anti-glomerular basement membrane (anti-GBM) antibody positivity that successfully treated with mizoribine (MZR) as an immunosuppressive drug for remission maintenance therapy after the initiation of dialysis in addition to plasma exchange (PE) and glucocorticoid treatment to control the disease condition. A 79-year-old woman developed serious renal dysfunction and pulmonary alveolar hemorrhaging due to MPO–ANCA and anti-GBM antibody double-positive vasculitis. She was started on hemodialysis and was treated with methylprednisolone (m-PSL) pulse therapy with PE, followed by oral prednisolone (PSL). The pulmonary alveolar hemorrhaging disappeared, and both antibody titers immediately decreased but then rose again. Thus, m-PSL pulse therapy performed again in combination with combined with MZR treatment. Her poor renal function was irreversible; however, this therapy decreased both antibody titers, and they did not increase again. The patient developed pancytopenia and hyperuricemia. It was considered likely that these conditions developed in association with MZR treatment. We, therefore, measured the patient’s blood concentration of MZR, and the maintenance dose was finally set at 50 mg after each dialysis session. The patient’s pancytopenia and hyperuricemia improved and PSL could be smoothly tapered. This is the first case report of the use of MZR for remission maintenance therapy in a patient on hemodialysis who was positive for both ANCA and anti-GBM antibodies. The findings suggest that MZR can be used safely and effectively in such cases.
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Affiliation(s)
- Yuki Ikeda
- Department of Nephrology, Sasebo Kyosai Medical Center, 10-17 Shimanjityo, Sasebo, Nagasaki, 857-8575, Japan.
| | - Kenichi Fukunari
- Department of Nephrology, Sasebo Kyosai Medical Center, 10-17 Shimanjityo, Sasebo, Nagasaki, 857-8575, Japan
| | - Saori Uchiumi
- Department of Nephrology, Sasebo Kyosai Medical Center, 10-17 Shimanjityo, Sasebo, Nagasaki, 857-8575, Japan
| | - Yuki Awanami
- Department of Nephrology, Sasebo Kyosai Medical Center, 10-17 Shimanjityo, Sasebo, Nagasaki, 857-8575, Japan
| | - Akiko Kanaya
- Department of Nephrology, Sasebo Kyosai Medical Center, 10-17 Shimanjityo, Sasebo, Nagasaki, 857-8575, Japan
| | - Keiichiro Matsumoto
- Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Makoto Fukuda
- Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Tsuyoshi Takashima
- Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Motoaki Miyazono
- Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Yuji Ikeda
- Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
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Suh KS, Choi SY, Bae GE, Choi DE, Yeo MK. Concurrent Anti-glomerular Basement Membrane Nephritis and IgA Nephropathy. J Pathol Transl Med 2019; 53:399-402. [PMID: 31525832 PMCID: PMC6877440 DOI: 10.4132/jptm.2019.08.05] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/05/2019] [Indexed: 11/17/2022] Open
Abstract
Anti–glomerular basement membrane (GBM) nephritis is characterized by circulating anti-GBM antibodies and crescentic glomerulonephritis (GN) with deposition of IgG along the GBM. In a limited number of cases, glomerular immune complexes have been identified in anti-GBM nephritis. A 38-year-old female presented azotemia, hematuria, and proteinuria without any pulmonary symptoms. A renal biopsy showed crescentic GN with linear IgG deposition along the GBM and mesangial IgA deposition. The patient was diagnosed as concurrent anti-GBM nephritis and IgA nephropathy. Therapies with pulse methylprednisolone and cyclophosphamide administration were effective. Concurrent cases of both anti-GBM nephritis and IgA nephropathy are rare among cases of anti-GBM diseases with deposition of immune complexes. This rare case of concurrent anti-GBM nephritis and IgA nephropathy with literature review is noteworthy.
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Affiliation(s)
- Kwang-Sun Suh
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Song-Yi Choi
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Go Eun Bae
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Dae Eun Choi
- Department of Nephrology, Chungnam National University School of Medicine, Daejeon, Republic of Korea
| | - Min-Kyung Yeo
- Department of Pathology, Chungnam National University School of Medicine, Daejeon, Republic of Korea
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48
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Balderia PG, Andeen N, Jefferson JA. Characteristics and Outcomes of Patients with Anti-Glomerular Basement Membrane Antibody Disease and Anti-Neutrophil Cytoplasmic Antibodies. Curr Rheumatol Rev 2019; 15:224-228. [DOI: 10.2174/1573397114666180516131240] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 04/29/2018] [Accepted: 05/02/2018] [Indexed: 11/22/2022]
Abstract
Background:
It is unclear whether patients with Anti-Glomerular Basement Membrane
(GBM) disease and Anti-Neutrophil Cytoplasmic Antibodies (ANCA), so called “Double-Positive”
(DP), have a different clinical presentation and outcome compared to patients with anti-GBM antibody
disease alone. This study describes the clinical and histologic characteristics as well as the patient
and renal outcomes of DP patients at the University of Washington compared to patients with
anti-GBM antibody disease alone.
Methods:
Adults admitted to the University of Washington and Harborview Medical Centers from
2000 to 2016 who had a kidney biopsy showing anti-GBM disease characterized by crescentic
glomerulonephritis with strong linear staining of glomerular basement membranes for IgG by immunofluorescence
were included. Subjects were classified into anti-GBM or DP based on serologic
testing. Information on demographics, clinical presentation, biopsy findings, initial treatment, and
rates of relapse and patient and renal survival were collected. Continuous and categorical variables
were analyzed using the Mann-Whitney U and Fisher’s exact tests, respectively.
Results:
There were 6 anti-GBM and 7 DP patients. Two patients were lost to follow-up after one
year. There was no significant difference in clinical presentation or outcomes between the two
groups. Two DP patients had greater than 50% global glomerulosclerosis. All the subjects developed
ESRD. Two DP patients had a relapse while off immunosuppression. Two patients in each
group died within 5 years of diagnosis.
Conclusion:
Two DP patients in our cohort had a relapse within 5 years of diagnosis. Multicenter
studies are needed to determine whether DP patients have a higher relapse rate and need prolonged
immunosuppression.
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Affiliation(s)
- Percy G. Balderia
- Division of Rheumatology, University of Washington School of Medicine, Seattle, Washington, United States
| | - Nicole Andeen
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, United States
| | - Jonathan A. Jefferson
- Division of Nephrology, University of Washington School of Medicine, Seattle, Washington, United States
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49
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Marques C, Carvelli J, Biard L, Faguer S, Provôt F, Matignon M, Boffa JJ, Plaisier E, Hertig A, Touzot M, Moranne O, Belenfant X, Annane D, Quéméneur T, Cadranel J, Izzedine H, Bréchot N, Cacoub P, Piedrafita A, Jourde-Chiche N, Saadoun D. Prognostic Factors in Anti-glomerular Basement Membrane Disease: A Multicenter Study of 119 Patients. Front Immunol 2019; 10:1665. [PMID: 31396214 PMCID: PMC6662558 DOI: 10.3389/fimmu.2019.01665] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 07/03/2019] [Indexed: 01/10/2023] Open
Abstract
We report the overall and renal outcome in a French nationwide multicenter cohort of 119 patients with anti-glomerular basement membrane (anti-GBM) disease. Sixty-four patients (54%) had an exclusive renal involvement, 7 (6%) an isolated alveolar hemorrhage and 48 (40%) a combined renal and pulmonary involvement. Initial renal replacement therapy (RRT) was required in 78% of patients; 82% received plasmapheresis, 82% cyclophosphamide, and 9% rituximab. ANCA positive (28%) patients were older (70 vs. 47 years, p < 0.0001), less frequently smokers (26 vs. 54%, p = 0.03), and had less pulmonary involvement than ANCA- patients. The 5 years overall survival was 92%. Risk factors of death (n = 11, 9.2%) were age at onset [HR 4.10 per decade (1.89-8.88) p = 0.003], hypertension [HR 19.9 (2.52-157 0.2) p = 0.005], dyslipidemia [HR 11.1 (2.72-45) p = 0.0008], and need for mechanical ventilation [HR 5.20 (1.02-26.4) p = 0.047]. The use of plasmapheresis was associated with better survival [HR 0.29 (0.08-0.98) p = 0.046]. At 3 months, 55 (46%) patients had end-stage renal disease (ESRD) vs. 37 (31%) ESRD-free and 27 (23%) unevaluable with follow-up < 3 months. ESRD patients were older, more frequently female and had a higher serum creatinine level at presentation than those without ESRD. ESRD-free survival was evaluated in patients alive without ESRD at 3 months (n = 37) using a landmark approach. In conclusion, this large French nationwide study identifies prognosis factors of renal and overall survival in anti-GBM patients.
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Affiliation(s)
- Cindy Marques
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Université, UPMC Univ Paris 06, UMR 7211, Paris, France.,INSERM, UMR_S 959, Paris, France.,CNRS, FRE3632, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France.,Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, Paris, France
| | - Julien Carvelli
- Aix-Marseille Univ, APHM, C2VN, INRA 1260, INSERM 1263, CHU de la Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Lucie Biard
- Department of Biostatistics and Medical Information, INSERM UMR1153 ECSTRRA Team, Hôpital Saint Louis, AP-HP, Paris, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'organes, Centre de référence des maladies rénales rares, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - François Provôt
- Department of Nephrology, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | - Marie Matignon
- Department of Nephrology and Renal Transplantation, Groupe Hospitalier Henri-Mondor, AP-HP, Créteil, France
| | - Jean-Jacques Boffa
- Sorbonne Université, UPMC Université Paris 06, Hôpital Tenon, Urgences Néphrologiques et Transplantation Rénale, Paris, France
| | - Emmanuelle Plaisier
- Sorbonne Université, UPMC Université Paris 06, Hôpital Tenon, Urgences Néphrologiques et Transplantation Rénale, Paris, France
| | - Alexandre Hertig
- Sorbonne Université, UPMC Université Paris 06, Hôpital Tenon, Urgences Néphrologiques et Transplantation Rénale, Paris, France
| | | | - Olivier Moranne
- Service Néphrologie-Dialyses-Aphérèse, Hôpital Caremeau, CHU Nîmes, et Faculté de Médecine Université de Montpellier-nimes, Nîmes, France
| | - Xavier Belenfant
- Nephrology and Dialysis, Centre Hospitalier Intercommunal André Grégoire, Montreuil, France
| | - Djillali Annane
- General ICU, Hôpital Raymond Poincaré, AP-HP, Garches, France
| | - Thomas Quéméneur
- Department of Internal Medicine, Centre Hospitalier, Valenciennes, France
| | - Jacques Cadranel
- Chest Department and Constitutive Center for Rare Pulmonary Disease, Hôpital Tenon, AP-HP; Inflammation-Immunopathology-Biotherapy Department (DHU i2B) and Sorbonne Université, Paris, France
| | - Hassan Izzedine
- Department of Nephrology, Peupliers Private Hospital, Ramsay Générale de Santé, Paris, France
| | - Nicolas Bréchot
- Medical-Surgical Intensive Care Unit, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Patrice Cacoub
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Université, UPMC Univ Paris 06, UMR 7211, Paris, France.,INSERM, UMR_S 959, Paris, France.,CNRS, FRE3632, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France.,Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, Paris, France
| | - Alexis Piedrafita
- Département de Néphrologie et Transplantation d'organes, Centre de référence des maladies rénales rares, Hôpital Rangueil, CHU de Toulouse, Toulouse, France
| | - Noémie Jourde-Chiche
- Aix-Marseille Univ, APHM, C2VN, INRA 1260, INSERM 1263, CHU de la Conception, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - David Saadoun
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Université, UPMC Univ Paris 06, UMR 7211, Paris, France.,INSERM, UMR_S 959, Paris, France.,CNRS, FRE3632, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France.,Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, Paris, France
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50
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Sinniah R, Kop T, Chin G. A novel case of linear IgG4-antibody mediated tubulointerstitial nephritis with concomitant HLA-B7, ANCA-MPO. Pathology 2019; 51:539-543. [PMID: 31248620 DOI: 10.1016/j.pathol.2019.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Rajalingam Sinniah
- Department of Anatomic Pathology, PathWest Laboratory Medicine, Perth, WA, Australia; Department of Nephrology, Fiona Stanley Hospital, Perth, WA, Australia; University of Western Australia, Perth, WA, Australia.
| | - Terry Kop
- Department of Anatomic Pathology, PathWest Laboratory Medicine, Perth, WA, Australia
| | - George Chin
- Department of Nephrology, Fiona Stanley Hospital, Perth, WA, Australia
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