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Attieh RM, Yang Y, Rosenstock JL. Updates on the Diagnosis and Management of Fibrillary Glomerulonephritis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:374-383. [PMID: 39084762 DOI: 10.1053/j.akdh.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/15/2024] [Accepted: 03/25/2024] [Indexed: 08/02/2024]
Abstract
Fibrillary glomerulonephritis (FGN) is a rare kidney disease typically affecting individuals in middle age, frequently presenting with advanced renal failure, proteinuria, and hypertension. FGN can be associated with autoimmune diseases, hepatitis C infection, and malignancies. Its exact pathogenesis remains elusive, and the exact role of DnaJ homolog subfamily B member 9 is yet to be determined. On renal biopsy, FGN exhibits distinctive Congo-red-negative, nonbranching fibrils, approximately 20 nm in diameter. DnaJ homolog subfamily B member 9 immunohistochemical staining has become a gold standard for diagnosis. Atypical variants exist, including congophilic, monotypic, and crescentic FGN, highlighting the disease's heterogeneity. Treatment with immunosuppression, including rituximab, has shown variable success, with no standard therapy established. FGN often leads to end-stage kidney disease, with a median progression time of 2-4 years postdiagnosis. Kidney transplantation is a viable option for FGN-related end-stage kidney disease, but recurrence in transplanted kidneys is not rare.
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Affiliation(s)
- Rose Mary Attieh
- Division of Kidney Diseases and Hypertension, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York
| | - Yihe Yang
- Department of Pathology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York
| | - Jordan L Rosenstock
- Division of Nephrology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY.
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Javaugue V, Said SM, Bu L, Bridoux F, François A, Goujon JM, Fayad R, Ross D, Sastry A, Fervenza FC, Leung N, Nasr SH. Prognostic Value of Diffuse Crescentic Lesions in Fibrillary Glomerulonephritis. Am J Kidney Dis 2023; 81:368-370. [PMID: 36228825 DOI: 10.1053/j.ajkd.2022.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 08/11/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Vincent Javaugue
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France.
| | - Samar M Said
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Lihong Bu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Frank Bridoux
- Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Arnaud François
- Department of Pathology, Centre Hospitalier Universitaire, Rouen, France
| | - Jean-Michel Goujon
- Department of Pathology and Ultrastructural Pathology, Centre Hospitalier Universitaire, Poitiers, France
| | - Ramy Fayad
- Nephrology Consultants of Northwest Ohio, Toledo, Ohio
| | - Dennis Ross
- Kansas Nephrology Physicians, Wichita, Kansas
| | - Ashok Sastry
- Department of Internal Medicine, Florida State University School of Medicine, Sarasota, Florida
| | - Fernando C Fervenza
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nelson Leung
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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Singh PP, Krishna A, Sharma A, Kumar O. Fibrillary glomerulonephritis presenting as crescentic glomerulonephritis in a young female: a case study. Ultrastruct Pathol 2020; 44:501-504. [PMID: 32657244 DOI: 10.1080/01913123.2020.1792598] [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: 10/23/2022]
Abstract
Fibrillary glomerulonephritis (FGN) is a rare disorder accounting for up to 1% of all glomerulonephritis (GN). FGN usually manifests as nephrotic or subnephrotic proteinuria, hematuria, and hypertension in patients after the sixth decade. The overall prognosis of FGN is very poor. Crescentic presentation of FGN is uncommon which may be diagnosed as rapidly progressive glomerulonephritis (RPGN) unless electron microscopy and/or special stains are done. We report a case of a young female who presented as RPGN but diagnosis was revised to crescentic FGN after electron microscopy and immunohistochemical staining with DNAJB9 stain. Patient remained dialysis-dependent after treatment with steroid and cyclophosphamide for 2 months and progressed to end-stage renal disease (ESRD). Crescentic FGN usually does not respond to treatment and invariably progresses to ESRD over few months. This case emphasizes the defining role of electron microscopy and special stains in diagnosing uncommon glomerular diseases.
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Affiliation(s)
- Prit Pal Singh
- Department of Nephrology, Indira Gandhi Institute of Medical Sciences , Sheikhpura, Patna, India
| | - Amresh Krishna
- Department of Nephrology, Indira Gandhi Institute of Medical Sciences , Sheikhpura, Patna, India
| | - Alok Sharma
- Department of Renal Pathology & Electron Microscopy, National Reference Lab, Dr Lal Pathlab , New Delhi, India
| | - Om Kumar
- Department of Nephrology, Indira Gandhi Institute of Medical Sciences , Sheikhpura, Patna, India
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Klomjit N, Alexander MP, Zand L. Fibrillary Glomerulonephritis and DnaJ Homolog Subfamily B Member 9 (DNAJB9). ACTA ACUST UNITED AC 2020; 1:1002-1013. [DOI: 10.34067/kid.0002532020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/02/2020] [Indexed: 11/27/2022]
Abstract
Fibrillary GN (FGN) is a rare glomerular disease that is diagnosed based on the presence of fibrils in glomeruli. The fibrils are typically noncongophilic, randomly oriented, and measure 12–24 nm. Traditionally, electron microscopy (EM) has been an important tool to aid in the diagnosis of FGN by identifying the fibrils and to distinguish it from other entities that could mimic FGN. However, recently DnaJ homolog subfamily B member 9 (DNAJB9) has emerged as both a specific and sensitive biomarker in patients with FGN. It allows prompt diagnosis and alleviates reliance on EM. DNAJB9 is a cochaperone of heat shock protein 70 and is involved in endoplasmic reticulum protein-folding pathways. But its role in the pathogenesis of FGN remains elusive. DNAJB9 may act as a putative antigen or alternatively it may secondarily bind to misfolded IgG in the glomeruli. These hypotheses need future studies to elucidate the role of DNAJB9 in the pathogenesis of FGN. The treatment regimen for FGN has been limited due to paucity of studies. Most patients receive combination immunosuppressive regimens. Rituximab has been studied the most in FGN and it may delay disease progression. Prognosis of FGN remains poor and 50% require dialysis within 2 years of diagnosis. Despite its poor prognosis in native kidneys, the rate of recurrence post-transplantation is low (20%) and patient as well as allograft outcomes are similar to patients without FGN.
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Shah HH, Thakkar J, Pullman JM, Mathew AT. Fibrillary glomerulonephritis presenting as crescentic glomerulonephritis. Indian J Nephrol 2017; 27:157-160. [PMID: 28356674 PMCID: PMC5358162 DOI: 10.4103/0971-4065.200521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Fibrillary glomerulonephritis (FGN) is a rare primary glomerular disease that commonly presents clinically with hypertension, proteinuria, microscopic hematuria, and varying degree of renal insufficiency. Histologically, FGN can present with different patterns of glomerular injury, more commonly mesangioproliferative, membranoproliferative, and membranous nephropathy. While crescent formation has been described in some kidney biopsy series of FGN, crescentic glomerulonephritis pattern of glomerular injury has been rarely described. Optimal therapy and outcomes in FGN presenting with crescentic GN is not currently known. We report an adult patient who presented with massive proteinuria and severe renal failure. The kidney biopsy revealed crescentic FGN (C-FGN). The patient remained dialysis dependent despite immunosuppressive therapy. We also briefly review FGN, and the few reported cases of C-FGN that presented as rapidly progressive or advanced renal failure in the literature.
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Affiliation(s)
- H H Shah
- Department of Medicine, Division of Kidney Diseases and Hypertension, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, USA
| | - J Thakkar
- Department of Medicine, Division of Kidney Diseases and Hypertension, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, USA
| | - J M Pullman
- Department of Pathology, Montefiore Medical Center, Bronx, New York, USA
| | - A T Mathew
- Department of Medicine, Division of Kidney Diseases and Hypertension, North Shore University Hospital and Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Great Neck, USA
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Troxell ML, Houghton DC. Atypical anti-glomerular basement membrane disease. Clin Kidney J 2015; 9:211-21. [PMID: 26985371 PMCID: PMC4792615 DOI: 10.1093/ckj/sfv140] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/17/2015] [Indexed: 12/23/2022] Open
Abstract
Background Anti-glomerular basement membrane (anti-GBM) disease classically presents with aggressive necrotizing and crescentic glomerulonephritis, often with pulmonary hemorrhage. The pathologic hallmark is linear staining of GBMs for deposited immunoglobulin G (IgG), usually accompanied by serum autoantibodies to the collagen IV alpha-3 constituents of GBMs. Methods Renal pathology files were searched for cases with linear anti-GBM to identify cases with atypical or indolent course. Histopathology, laboratory studies, treatment and outcome of those cases was reviewed in detail. Results Five anti-GBM cases with atypical clinicopathologic features were identified (accounting for ∼8% of anti-GBM cases in our laboratory). Kidney biopsies showed minimal glomerular changes by light microscopy; one patient had monoclonal IgG deposits in an allograft (likely recurrent). Three patients did not have detectable serum anti-GBM by conventional assays. Three patients had indolent clinical courses after immunosuppressive treatment. One patient, untreated after presenting with brief mild hematuria, re-presented after a short interval with necrotizing and crescentic glomerulonephritis. Conclusions Thorough clinicopathologic characterization and close follow-up of patients with findings of atypical anti-GBM on renal biopsy are needed. Review of the literature reveals only rare well-documented atypical anti-GBM cases to date, only one of which progressed to end-stage kidney disease.
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Affiliation(s)
- Megan L Troxell
- Department of Pathology , Oregon Health & Science University , Portland, OR , USA
| | - Donald C Houghton
- Department of Pathology , Oregon Health & Science University , Portland, OR , USA
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Cheungpasitporn W, Zacharek CC, Fervenza FC, Cornell LD, Sethi S, Herrera Hernandez LP, Nasr SH, Alexander MP. Rapidly progressive glomerulonephritis due to coexistent anti-glomerular basement membrane disease and fibrillary glomerulonephritis. Clin Kidney J 2015; 9:97-101. [PMID: 26798468 PMCID: PMC4720204 DOI: 10.1093/ckj/sfv126] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 11/01/2015] [Indexed: 01/01/2023] Open
Abstract
Anti-glomerular basement membrane (anti-GBM) disease is a major cause of rapidly progressive glomerulonephritis (RPGN). On the other hand, fibrillary glomerulonephritis (GN) typically presents as proteinuria, hematuria and renal insufficiency, but rarely as RPGN. Without electron microscopy, the diagnosis of fibrillary GN can be missed. We report a 68-year-old white woman who presented with RPGN with kidney biopsy demonstrating diffuse crescentic GN on light microscopy. By immunofluorescence, there was bright linear staining of the GBMs and smudgy mesangial staining for immunoglobulin G, C3, and kappa and lambda light chain. Electron microscopy revealed fibrillary deposits in the GBM and mesangium. A serum test for anti-GBM antibody was positive. To our knowledge, this is the first report of coexistence of fibrillary GN in a patient with anti-GBM disease. Electron microscopy is critical to identify the coexistence of other GN in patients presenting with crescentic GN.
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Affiliation(s)
| | | | | | - Lynn D Cornell
- Division of Anatomic Pathology , Mayo Clinic , Rochester, MN , USA
| | - Sanjeev Sethi
- Division of Anatomic Pathology , Mayo Clinic , Rochester, MN , USA
| | | | - Samih H Nasr
- Division of Anatomic Pathology , Mayo Clinic , Rochester, MN , USA
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