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Uchida T, Oda T. The Prevalence, Characteristics, and Putative Mechanisms of Dual Antigen-Positive Membranous Nephropathy: The Underestimated Condition. Int J Mol Sci 2024; 25:5931. [PMID: 38892120 PMCID: PMC11172907 DOI: 10.3390/ijms25115931] [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: 04/08/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Following the discovery of podocyte phospholipase A2 receptor and thrombospondin type-1 domain-containing 7A, various potential target antigens for membranous nephropathy (MN) have been reported one after another. MN target antigens have now been identified in a significant proportion of patients, and a new classification framework classifies patients with MN based on the detected antigen and associated disease phenotype. A serology-based approach that does not require a histological diagnosis for patients suspected of having MN has also been proposed. However, there have been cases in which dual positivity for MN antigens and/or corresponding antibodies has been shown. Importantly, some of them showed a transition of the affected patient's immune responses to MN antigens, suggesting that serological diagnosis changes depending on the timing of the analysis. In this review, we provide detailed information on these cases and present an overview of our recent understanding of their putative mechanisms involved in these cases. Greater awareness is required to adequately recognize and develop appropriate therapeutic strategies for this condition.
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Affiliation(s)
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji 193-0998, Japan;
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2
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Bobart SA, Tehranian S, Sethi S, Alexander MP, Nasr SH, Moura Marta C, Vrana JA, Said S, Giesen CD, Lieske JC, Fervenza FC, De Vriese AS. A Target Antigen-Based Approach to the Classification of Membranous Nephropathy. Mayo Clin Proc 2021; 96:577-591. [PMID: 33673911 DOI: 10.1016/j.mayocp.2020.11.028] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe the clinical and pathological phenotype of membranous nephropathy (MN) associated with M-type-phospholipase-A2-receptor (PLA2R), thrombospondin-type-1-domain-containing-7A (THSD7A), semaphorin 3B (SEMA3B), neural-epidermal-growth-factor-like-1-protein (NELL-1), protocadherin 7 (PCDH7), exostosin 1/exostosin 2 (EXT1/EXT2) and neural cell adhesion molecule 1 (NCAM-1) as target antigens. METHODS A retrospective cohort of 270 adult patients with biopsy-proven MN diagnosed between January 2015 and April 2020 was classified as PLA2R-, THSD7A-, SEMA3B-, NELL-1-, PCDH7-, EXT1/EXT2-, NCAM-1-associated or septuple-negative MN using serologic tests, immunostaining, and/or mass spectrometry. Clinical, biochemical, pathologic, and follow-up data were systematically abstracted from the medical records, including disease activity of conditions traditionally associated with MN and occurring within 5 years of MN diagnosis. RESULTS Patients with PLA2R-associated MN were predominantly middle-aged white men without associated disease. The presence of associated disease did not affect the clinical and pathologic characteristics of PLA2R-associated MN, suggesting that they were coincidental rather than causally linked. THSD7A-, NELL-1-, PCDH7-, and NCAM-1-associated MN were rare and SEMA3B-associated MN was not discovered in our cohort. EXT1/EXT2-associated MN was primarily diagnosed in younger women with active systemic autoimmunity. A significant proportion of septuple-negative patients had associated malignancy or systemic autoimmunity. CONCLUSION The widely used distinction between primary and secondary MN has limitations. We propose a refined terminology that combines the target antigen and associated disease to better classify MN and guide clinical decision making.
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Affiliation(s)
- Shane A Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Cleveland Clinic Florida, Weston
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Julie A Vrana
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Samar Said
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Callen D Giesen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Ghent University, Ghent, Belgium.
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Iio R, Akiyama S, Mitsumoto K, Iwata Y, Okushima H, Shimada K, Ota N, Tomida K, Fushimi H, Shoji T, Matsumoto M, Hayashi T. Thrombotic thrombocytopenic purpura developed during the conservative treatment of anti-phospholipase A 2 receptor antibody-positive idiopathic membranous nephropathy: a case report. BMC Nephrol 2020; 21:431. [PMID: 33046023 PMCID: PMC7552470 DOI: 10.1186/s12882-020-02086-z] [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: 07/08/2020] [Accepted: 10/02/2020] [Indexed: 11/10/2022] Open
Abstract
Background Idiopathic membranous nephropathy (MN) is one of the major glomerulonephritis that cause nephrotic syndrome. The phospholipase A2 receptor (PLA2R) has recently been identified as an endogenous antigen of idiopathic MN. Thrombotic thrombocytopenic purpura (TTP) is a disorder characterized by schistocytes, hemolytic anemia, thrombocytopenia, and organ dysfunction which occurs as a result of thrombi. Patients with acquired TTP have autoantibodies against a disintegrin and metalloprotease with thrombospondin type 1 motif 13 (ADAMTS13). These autoantibodies act as an inhibitor and cause ADAMTS13 deficiency. Idiopathic MN and acquired TTP are usually considered as independent autoimmune diseases. We experienced a patient who developed TTP during the conservative treatment of idiopathic MN, with the coexistence of ADAMTS13 inhibitor and anti-PLA2R antibody. Case presentation A 73-year-old man presented with thrombocytopenia, hemolytic anemia, disturbance of consciousness, and acute kidney injury after 4-year course of biopsy-proven idiopathic MN. ADAMTS13 activity was undetectable and the ADAMTS13 inhibitor was identified. Additionally, he was positive for anti-PLA2R antibody. The patient did not have any diseases that could cause secondary thrombotic microangiopathy, and he was diagnosed with acquired TTP. Steroid therapy and plasma exchange were initiated and the acquired TTP resolved. MN achieved remission 3 months after the anti-PLA2R antibody disappeared. Conclusions This is the first reported case of acquired TTP developed during conservative treatment of idiopathic MN, with both ADAMTS13 inhibitor and anti-PLA2R antibody positive at the onset of the TTP. The present case suggests that idiopathic MN might be associated with the development of some cases of acquired TTP.
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Affiliation(s)
- Rei Iio
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Shin'ichi Akiyama
- Division of Nephrology, Department of Internal Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Kensuke Mitsumoto
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Yukimasa Iwata
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Hiroki Okushima
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Karin Shimada
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Naomi Ota
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Kodo Tomida
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Hiroaki Fushimi
- Department of Pathology, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Tatsuya Shoji
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, 558-8558, Japan
| | - Masanori Matsumoto
- Department of Blood Transfusion Medicine, Nara Medical University, 840 Shijyo-cho, Kashihara, Nara, 634-8522, Japan
| | - Terumasa Hayashi
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
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Nikolopoulou A, Huang-Doran I, McAdoo SP, Griffith ME, Cook HT, Pusey CD. Membranous Glomerulonephritis With Crescents. Kidney Int Rep 2019; 4:1577-1584. [PMID: 31890999 PMCID: PMC6933443 DOI: 10.1016/j.ekir.2019.07.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/15/2019] [Accepted: 07/31/2019] [Indexed: 01/10/2023] Open
Abstract
Introduction Membranous glomerulonephritis (MGN) is rarely associated with necrotizing and crescentic glomerulonephritis (NCGN). Methods We report the clinical and pathologic findings in 15 patients with MGN and NCGN associated with anti-neutrophil cytoplasm antibodies (ANCAs), anti-glomerular basement membrane (GBM), or anti-phospholipase A2 receptor (PLA2R) antibodies. Results The cohort consisted of 15 patients: 7 males and 8 females with a median age of 63 years (range: 18-79). In 12 of 15 patients, MGN and NCGN were diagnosed at the time of the biopsy, and in 3 cases, MGN predated the NCGN. ANCA was positive in 7 cases (6 MPO myeloperoxidase (MPO)-ANCA and 1 PR3-ANCA), anti-GBM antibodies were detected in 5 cases, and anti-PLA2R antibodies were found in 2 cases. One case was negative for all antibodies. Microscopic hematuria was present in all but one patient who was anuric, and median urinary protein-to-creatinine ratio was 819.5 mg/mmol (range: 88-5600). Pathologic evaluation revealed MGN and NCGN with crescents involving 28% of glomeruli (median; range: 5%-100%). Follow-up was available for all 15 patients; all were treated with steroids; 10 with cyclophosphamide, and 6 also received rituximab. At a median follow-up of 72 months, 9 had stabilization or improvement of renal function, 6 had progressed to end-stage renal disease, and 4 died during the follow-up period. Conclusion MGN with crescents associated with ANCAs or anti-GBM antibodies is a rare dual glomerulopathy. Patients present with heavy proteinuria, microscopic hematuria, and acute kidney injury and should be treated for a rapidly progressive glomerulonephritis. Prognosis is variable, and 40% of patients progress to end-stage renal disease.
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Affiliation(s)
- Aikaterini Nikolopoulou
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Isabel Huang-Doran
- University of Cambridge, Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Cambridge, UK
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Megan E Griffith
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - H Terence Cook
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
| | - Charles D Pusey
- Centre for Inflammatory Disease, Division of Immunology and Inflammation, Department of Medicine, Imperial College London, London, UK
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Tominaga K, Uchida T, Imakiire T, Itoh K, Shimazaki H, Nakanishi K, Kumagai H, Oshima N. Anti-neutrophil cytoplasmic antibody-associated glomerulonephritis with detection of myeloperoxidase and phospholipase A 2 receptor in membranous nephropathy-lesions: report of two patients with microscopic polyangiitis. BMC Nephrol 2018; 19:120. [PMID: 29792176 PMCID: PMC5966893 DOI: 10.1186/s12882-018-0922-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 05/16/2018] [Indexed: 11/23/2022] Open
Abstract
Background Podocyte phospholipase A2 receptor (PLA2R) is a major target antigen in idiopathic adult membranous nephropathy (MN). Histological PLA2R staining in the renal tissue has proven to be useful for the detection of idiopathic MN. However, glomerular PLA2R deposits have also been recently observed in several patients with secondary MN, such as hepatitis B virus-associated, hepatitis C virus-associated, and neoplasm-associated MN. Certain inflammatory environments have been suggested to lead to abnormal expression of PLA2R epitopes, with the resulting production of PLA2R autoantibodies. Case presentation We report two patients diagnosed with anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis with MN-lesions, in whom ANCA titers for myeloperoxidase (MPO) were persistently positive. The first patient was a 52-years-old man who presented with interstitial pneumonitis. Microscopic hematuria and proteinuria were found when the interstitial pneumonitis became more severe. Renal biopsy findings yielded a diagnosis of ANCA-associated glomerulonephritis (mixed class) with MN-lesions. The second patient was a 63-years-old woman who had been treated for relapsing polychondritis. Her renal tissue showed evidence of focal ANCA-associated glomerulonephritis with MN-lesions. Interestingly, both MPO and PLA2R were detected in the glomerular subepithelial deposits of both patients. Immunoglobulin G (IgG) 1 and IgG2 were positive in the glomeruli of patient 2, and all subclasses of IgGs were positive in patient 1. Conclusion The present cases suggest that ANCA-associated glomerulonephritis could expose PLA2R, leading to the development of MN-lesions.
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Affiliation(s)
- Kenta Tominaga
- Department of Nephrology and Endocrinology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan.
| | - Takahiro Uchida
- Department of Nephrology and Endocrinology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Toshihiko Imakiire
- Department of Nephrology and Endocrinology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Kenji Itoh
- Division of Hematology and Rheumatology, Department of Internal Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hideyuki Shimazaki
- Department of Laboratory Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kuniaki Nakanishi
- Department of Laboratory Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Hiroo Kumagai
- Department of Nephrology and Endocrinology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
| | - Naoki Oshima
- Department of Nephrology and Endocrinology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513, Japan
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Manabe S, Hatano M, Nakano M, Fujii T, Nitta K, Nagata M. Myeloperoxidase-antineutrophil cytoplasmic antibody causes different renal diseases by immune-complex formation and pauci-immune mechanism: A case report. Pathol Int 2017; 67:419-424. [PMID: 28580649 DOI: 10.1111/pin.12545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 05/03/2017] [Indexed: 11/26/2022]
Abstract
Antineutrophil cytoplasmic antibody (ANCA) has been known to cause pauci-immune crescentic glomerulonephritis. In addition, several reports described membranous glomerulonephritis (MN) concurrent with ANCA-associated glomerulonephritis. Because the two glomerular diseases simultaneously appear in an ANCA-positive patient, the mechanisms whereby ANCA causes the two different glomerular diseases remain ambiguous. Herein, we report a case of 19-year-old man who presented with hematuria, pre-nephrotic proteinuria, and high titer of myeloperoxidase (MPO)-ANCA. The first renal biopsy revealed MN with chronic glomerular scar lesions of unknown etiology. Predominant immunoglobulin (Ig) G1 subclass and negative phospholipase-A2 receptor staining, together with granular-positive glomerular capillary co-localization of MPO and IgG staining, suggested secondary MN due to MPO-MPO-ANCA immune-complex. Five years later, the patient presented with fever, severe renal dysfunction, and alveolar hemorrhage with high titer of MPO-ANCA that indicated pulmonary renal syndrome due to ANCA-associated vasculitis. The second renal biopsy revealed pauci-immune crescentic glomerulonephritis without either apparent MN-lesion or glomerular IgG staining. This is the first reported case showing that MPO-ANCA caused two different glomerular diseases, MN and pauci-immune crescentic glomerulonephritis, in the same patient at the different time points. Our case indicated that common MPO-ANCA might cause different glomerular diseases by different immune mechanisms.
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Affiliation(s)
- Shun Manabe
- Kidney and Vascular Pathology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.,Department of Nephrology, Yokohama Rosai Hospital, Kanagawa, Japan.,Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Michiyasu Hatano
- Department of Nephrology, Yokohama Rosai Hospital, Kanagawa, Japan
| | - Marie Nakano
- Department of Nephrology, Yokohama Rosai Hospital, Kanagawa, Japan.,Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Teruhiro Fujii
- Department of Nephrology, Yokohama Rosai Hospital, Kanagawa, Japan.,Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, Tokyo, Japan
| | - Michio Nagata
- Kidney and Vascular Pathology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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Wang J, Zhu P, Cui Z, Qu Z, Zhang YM, Wang F, Wang X, Wang JW, Zhu SN, Liu G, Zhou FD, Zhao MH. Clinical Features and Outcomes in Patients With Membranous Nephropathy and Crescent Formation. Medicine (Baltimore) 2015; 94:e2294. [PMID: 26683965 PMCID: PMC5058937 DOI: 10.1097/md.0000000000002294] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Cases of membranous nephropathy (MN) with crescent formation, in the absence of lupus, hepatitis B virus infection, anti-glomerular basement membrane (GBM) nephritis, or antineutrophil cytoplasmic antibody (ANCA), are on record. Clinical presentation and treatment outcomes in these patients are unclear. All patients with biopsy-proven MN diagnosed between years 2008 and 2014 and followed up were enrolled retrospectively. Patients with ANCA, anti-GBM antibodies, lupus, hepatitis B virus infection, or malignance were excluded. Clinical features and outcomes were compared between MN patients with and without crescent. Out of 401 consecutive patients with idiopathic MN, 28 (6.9%) showed crescent formation in 4.9% (2.2%-16.7%) of glomeruli. Mean age of these patients was 50.1 ± 11.1 years, and they presented with heavy proteinuria (6.5 ± 4.8 g/24 h) and hematuria; 21.4% of these patients had declined estimated glomerular filtration rate (<60 mL/min/1.73 m2) on biopsy. Anti-phospholipase A2 receptor antibody was detectable in 79.7% of these patients. These clinical features were comparable to the MN patients without crescent (P > 0.05). Twelve (42.9%) patients received steroids plus immunosuppressive therapy similar to that in patients without crescent (41.3%). Fewer patients with crescents achieved remission (67.9% vs 86.7%, P = 0.029). Crescent formation was a risk factor for no response to the treatments (odds ratio [OR] = 3.1, P = 0.033). Higher percentage of crescents predicted more risk for no remission (OR = 1.2, P = 0.038). Patients with crescents presented more frequencies of abnormal serum creatinine during follow-up (10.7% vs 1.3%, P = 0.031). Crescent formation was also a risk factor for worse renal outcome (relative risk = 10.2, P = 0.046). MN patients with crescents showed unfavorable therapeutic response and tended to have worse renal outcomes. More aggressive treatments and renal protection might be considered to improve the outcomes.
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Affiliation(s)
- Jia Wang
- From the Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing (JW, PZ, ZC, ZQ, Y-mZ, FW, XW, J-wW, GL, F-DZ, M-hZ); Renal Division (PZ), Department of Medicine, The First College of Clinical Medical Science, China Three Gorges University, Yichang; Department of Biostatistics (S-nZ), Peking University First Hospital; and Peking-Tsinghua Center for Life Sciences (M-hZ), Beijing, China
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Balafa O, Kalaitzidis R, Liapis G, Xiromeriti S, Zarzoulas F, Baltatzis G, Elisaf M. Crescentic glomerulonephritis and membranous nephropathy: a rare coexistence. Int Urol Nephrol 2015; 47:1373-7. [DOI: 10.1007/s11255-015-1031-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 06/07/2015] [Indexed: 11/24/2022]
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9
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Barrett CMF, Troxell ML, Larsen CP, Houghton DC. Membranous glomerulonephritis with crescents. Int Urol Nephrol 2013; 46:963-71. [PMID: 24217802 DOI: 10.1007/s11255-013-0593-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 10/22/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE The coexistence of membranous glomerulonephritis (MGN) and necrotizing and crescentic glomerulonephritis (NCGN) is an unusual finding in a renal biopsy except in lupus nephritis. Little is known about whether these lesions are causally related in any clinical setting. METHODS We reviewed the pathology, presentation, and clinical course of 13 non-lupus patients with combined MGN and NCGN in native kidney biopsies (nine females, four males; median age 69 years), with particular attention to evidence of secondary MGN. Additional IgG subclass and phospholipase A2 receptor (PLA2R) immunofluorescence studies were conducted in seven cases. RESULTS Eight biopsies were pauci-immune other than the capillary wall deposits of MGN; one patient had a non-lupus immune complex disease, and four had mesangial deposits, including one with rare subendothelial deposits. None had anti-glomerular basement membrane disease. IgG4 was dominant or codominant in the capillary wall deposits in three cases and virtually absent in four; PLA2R was positive in two cases, and negative in five. Seven patients were judged to have secondary MGN, including five of eight ANCA+ patients. Twelve patients were treated with combinations of steroids, cyclophosphamide, rituximab, followed by durable response in seven and relentless progression to end stage renal disease in four. CONCLUSIONS Secondary MGN occurs with higher frequency in ANCA-positive NCGN than in the general MGN population. A causal relationship between MGN and NCGN was not established in any patient, but circumstances suggest a common cause in several, including immune complex disease, drug reaction and paraneoplastic syndrome.
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Affiliation(s)
- Caroline M F Barrett
- Department of Pathology, Oregon Health and Science University, L471, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
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10
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Combined membranous nephropathy and crescentic glomerulonephritis with concurrent anti-glomerular basement membrane antibody and myeloperoxidase-specific anti-neutrophil cytoplasmic antibody. CEN Case Rep 2013; 2:107-111. [PMID: 28509234 DOI: 10.1007/s13730-012-0054-x] [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: 10/23/2012] [Accepted: 11/25/2012] [Indexed: 10/27/2022] Open
Abstract
We report a case of a 71-year-old man with rapidly progressive nephritic syndrome and dual positivity for anti-glomerular basement membrane antibody and myeloperoxidase-specific anti-neutrophil cytoplasmic antibody. Renal biopsy revealed crescentic, mainly cellular, glomerulonephritis with granulomatous lesions, and advanced membranous changes. Membranous nephropathy had apparently existed for an extended period before the development of crescentic glomerulonephritis. In some studies reporting the simultaneous occurrence of both diseases, membranous nephropathy might be followed by crescentic glomerulonephritis, presumably from a histological point of view. Although we cannot prove a causal relationship between the two diseases, we caution that precise observations, especially histological, are necessary in similar cases.
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11
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Svobodova B, Honsova E, Ronco P, Tesar V, Debiec H. Kidney biopsy is a sensitive tool for retrospective diagnosis of PLA2R-related membranous nephropathy. Nephrol Dial Transplant 2012; 28:1839-44. [PMID: 23223223 DOI: 10.1093/ndt/gfs439] [Citation(s) in RCA: 133] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antibodies against M-type phospholipase A2 receptor (PLA2R) are serological markers of disease activity in patients with idiopathic membranous nephropathy (iMN). To determine the most sensitive test for the diagnosis of PLA2R-related membranous nephropathy (MN) irrespective of sampling time, we investigated the presence of PLA2R in glomerular immune deposits and assessed circulating anti-PLA2R antibodies in a retrospective cohort of Czech patients with idiopathic, lupus and other few secondary MN. METHODS We tested archival paraffin-embedded kidney biopsies of 84 consecutive patients with biopsy-proven MN, for the presence of PLA2R in glomerular immune deposits and we measured circulating anti-PLA2R antibodies using the indirect immunofluorescence test, all reagents being commercially available. RESULTS In 45 of 65 (69%) patients with iMN, PLA2R was detected in a finely granular pattern in sub-epithelial deposits along glomerular capillary loops. Circulating anti-PLA2R antibodies were detected in 20 of 31 (65%) sera from patients sampled during active disease. Six patients with active disease were negative for circulating anti-PLA2R antibodies despite PLA2R antigen positivity in the kidney biopsies. Only 8 of 37 (22%) sera sampled at the time of remission were PLA2R positive while PLA2R antigen was found in 22 of the 37 (59%) corresponding biopsies. PLA2R was found in immune deposits in 3 patients with secondary MN (2 with hepatitis B, and 1 with sarcoidosis) but in none of the 16 patients with lupus. CONCLUSIONS In case of delayed serum sampling, assessment of PLA2R antigen in biopsy specimens is more sensitive than the serological test for the diagnosis of PLA2R-related MN which can be established retrospectively.
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Affiliation(s)
- Barbora Svobodova
- Department of Nephrology, First Faculty of Medicine and General University Hospital, Prague, Czech Republic
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12
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Ronco P, Debiec H. Pathophysiological lessons from rare associations of autoimmune diseases. Clin Kidney J 2012; 5:91-93. [PMID: 29497510 PMCID: PMC5783216 DOI: 10.1093/ckj/sfs016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 02/06/2012] [Indexed: 11/26/2022] Open
Affiliation(s)
- Pierre Ronco
- INSERM UMR_S702, AP-HP, Tenon Hospital, Paris, France
- UPMC Univ-Paris 6, Tenon Hospital, Paris, France
- AP-HP, Tenon Hospital, Paris, France
| | - Hanna Debiec
- INSERM UMR_S702, AP-HP, Tenon Hospital, Paris, France
- UPMC Univ-Paris 6, Tenon Hospital, Paris, France
- AP-HP, Tenon Hospital, Paris, France
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