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Chauveau B, Gibier JB, Olagne J, Morel A, Aydin S, McAdoo SP, Viallet N, Perrochia H, Pambrun E, Royal V, Demoulin N, Kemeny JL, Philipponnet C, Hertig A, Boffa JJ, Plaisier E, Domenger C, Brochériou I, Deltombe C, Duong Van Huyen JP, Buob D, Roufosse C, Hellmark T, Audard V, Mihout F, Nasr SH, Renaudin K, Moktefi A, Rabant M. Atypical Anti-Glomerular Basement Membrane Nephritis: A Case Series From the French Nephropathology Group. Am J Kidney Dis 2024; 83:713-728.e1. [PMID: 38171412 DOI: 10.1053/j.ajkd.2023.11.003] [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: 06/13/2023] [Revised: 10/06/2023] [Accepted: 11/02/2023] [Indexed: 01/05/2024]
Abstract
RATIONALE & OBJECTIVE Atypical anti-glomerular basement membrane (GBM) nephritis is characterized by a bright linear immunoglobulin staining along the GBM by immunofluorescence without a diffuse crescentic glomerulonephritis nor serum anti-GBM antibodies by conventional enzyme-linked immunosorbent assay (ELISA). We characterized a series of patients with atypical anti-GBM disease. STUDY DESIGN Case series. SETTING & PARTICIPANTS Patients identified by the French Nephropathology Group as having atypical anti-GBM nephritis between 2003 and 2022. FINDINGS Among 38 potential cases, 25 were included, of whom 14 (56%) were female and 23 (92%) had hematuria. The median serum creatinine at diagnosis was 150 (IQR, 102-203) μmol/L and median urine protein-creatinine ratio (UPCR) was 2.4 (IQR, 1.3-5.2) g/g. Nine patients (36%) had endocapillary proliferative glomerulonephritis (GN), 4 (16%) had mesangial proliferative GN, 4 (16%) had membranoproliferative GN, 2 (8%) had pure and focal crescentic GN, 1 (4%) had focal segmental glomerulosclerosis, and 5 had glomeruli that were unremarkable on histopathology. Nine patients (36%) had crescents, involving a median of 9% of glomeruli. Bright linear staining for IgG was seen in 22 cases (88%) and for IgA in 3 cases (12%). The 9 patients (38%) who had a monotypic staining pattern tended to be older with less proteinuria and rarely had crescents. Kidney survival rate at 1 year was 83% and did not appear to be associated with the light chain restriction. LIMITATIONS Retrospective case series with a limited number of biopsies including electron microscopy. CONCLUSIONS Compared with typical anti-GBM disease, atypical anti-GBM nephritis frequently presents with an endocapillary or mesangial proliferative glomerulonephritis pattern and appears to have a slower disease progression. Further studies are needed to fully characterize its pathophysiology and associated clinical outcomes. PLAIN-LANGUAGE SUMMARY Atypical anti-glomerular basement membrane (GBM) nephritis is characterized histologically by bright linear immunoglobulin staining along the GBM without diffuse crescentic glomerulonephritis or circulating anti-GBM antibodies. We report a case series of 25 atypical cases of anti-GBM nephritis in collaboration with the French Nephropathology Group. Compared with typical anti-GBM disease, we observed a slower disease progression. Patients frequently presented with heavy proteinuria and commonly had evidence of endocapillary or mesangial proliferative glomerulonephritis. About half of the patients displayed a monotypic immune staining pattern; they tended to be older, with less proteinuria, and commonly without glomerular crescents in biopsy specimens. No concomitant circulating monoclonal gammopathy was detected. Further studies are needed to fully characterize its pathophysiology and associated clinical outcomes.
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Affiliation(s)
- Bertrand Chauveau
- Department of Pathology, Pellegrin Hospital, Bordeaux University Hospital, Bordeaux, France; CNRS UMR 5164, ImmunoConcEpT, University of Bordeaux, Bordeaux, France.
| | - Jean-Baptiste Gibier
- UMR9020-U1277, CANTHER, Cancer Heterogeneity Plasticity and Resistance to Therapies, University of Lille, Lille, France; Institute of Pathology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jérôme Olagne
- Department of Nephrology and Transplantation, Strasbourg University Hospital, Strasbourg, France; Department of Pathology, Strasbourg University Hospital, Strasbourg, France
| | - Antoine Morel
- Nephrology and Renal Transplantation Department, Assistance Publique des Hôpitaux de Paris (AP-HP), Henri Mondor Hospital University, Rare Disease Center "Idiopathic Nephrotic Syndrome," Fédération Hospitalo-Universitaire "Innovative Therapy for Immune Disorders", Créteil, France
| | - Selda Aydin
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Department of Pathology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Immunology & Inflammation, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Nicolas Viallet
- Department of Nephrology-Transplantation, Centre Hospitalier Universitaire de la Réunion Felix Guyon, Saint Denis, Réunion, France
| | - Hélène Perrochia
- Pathology Department, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Emilie Pambrun
- Department of Nephrology Dialysis Apheresis, Nîmes University Hospital, Nîmes, France
| | - Virginie Royal
- Department of Pathology, Hôpital Maisonneuve-Rosemont, University of Montreal, Quebec, Canada
| | - Nathalie Demoulin
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Cliniques Universitaires Saint-Luc, Brussels, Belgium; Division of Nephrology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Jean-Louis Kemeny
- Pathology Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Carole Philipponnet
- Nephrology, Dialysis, and Transplantation Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | | | - Jean-Jacques Boffa
- Department of Nephrology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Emmanuelle Plaisier
- Department of Nephrology, Association pour l'Utilisation du Rein Artificiel Paris Plaisance, Paris, France; Unité Mixte de Recherche S1155, Sorbonne Université and Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Camille Domenger
- Department of Nephrology, Dialysis and Transplantation, Polynésie Française Hospital, Pirae, Tahiti
| | - Isabelle Brochériou
- INSERM UMR S1155, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France; Department of Pathology, Pitié-Salpêtrière Hospital, Paris, France
| | - Clément Deltombe
- Nephrology and Transplantation Department, Department of Nephrology and Immunology, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Jean-Paul Duong Van Huyen
- Department of Pathology, Centre Hospitalier Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - David Buob
- INSERM UMR S1155, Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France; Department of Pathology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Candice Roufosse
- Centre for Inflammatory Disease, Department of Immunology & Inflammation, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Thomas Hellmark
- Nephrology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Vincent Audard
- Nephrology and Renal Transplantation Department, Assistance Publique des Hôpitaux de Paris (AP-HP), Henri Mondor Hospital University, Rare Disease Center "Idiopathic Nephrotic Syndrome," Fédération Hospitalo-Universitaire "Innovative Therapy for Immune Disorders", Créteil, France; Institut Mondor de Recherche Biomédicale, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Université Paris-Est Créteil, Créteil, France
| | - Fabrice Mihout
- Department of Nephrology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Karine Renaudin
- Department of Pathology, Centre Hospitalier Universitaire de Nantes, Nantes, France; Centre de Recherche en Transplantation et en Immunologie, UMR 1064, INSERM, Université de Nantes, Nantes, France
| | - Anissa Moktefi
- Institut Mondor de Recherche Biomédicale, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Université Paris-Est Créteil, Créteil, France; Department of Pathology, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Créteil, France
| | - Marion Rabant
- Department of Pathology, Centre Hospitalier Universitaire Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM U1151, CNRS UMR 8253, Institut Necker-Enfants Malades, Département Croissance et Signalisation, University of Paris Cité, Paris, France
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Monich A, Romani R, Carneiro J. Crescentic glomerulonephritis due to linear IgA anti-glomerular basement membrane disease: report of a rare case. Braz J Med Biol Res 2024; 57:e13466. [PMID: 38716984 PMCID: PMC11085031 DOI: 10.1590/1414-431x2024e13466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 03/19/2024] [Indexed: 05/12/2024] Open
Abstract
Anti-glomerular basement membrane (GBM) disease is a rare and severe vasculitis that affects the glomerular and pulmonary capillaries and has an incidence of less than 2 cases per million individuals per year. Anti-GBM disease is mediated by autoantibodies against the α3 chain of type IV collagen. In the majority of cases, the autoantibodies are of the immunoglobulin G (IgG) class, with rare cases being mediated by immunoglobulin M (IgM) or immunoglobulin A (IgA); there are less than 15 IgA-mediated cases reported in the literature worldwide. The classic form of this disease manifests with rapidly progressive glomerulonephritis (RPGN), with or without pulmonary hemorrhage, and the diagnosis consists of identifying high titers of autoantibodies in the serum and/or deposited in the tissues. IgA antibodies are not identified in routine immunoassay tests, and renal biopsy with immunofluorescence is essential for diagnosis. We present a case of RPGN due to anti-GBM disease with linear IgA deposition, whose diagnosis was made exclusively by renal biopsy and with an unfavorable prognosis.
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Affiliation(s)
- A.G. Monich
- Serviço de Nefrologia, Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brasil
| | - R.F. Romani
- Serviço de Nefrologia, Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brasil
- Disciplina de Nefrologia, Faculdade Evangélica Mackenzie do Paraná, Curitiba, PR, Brasil
| | - J.L.S. Carneiro
- Serviço de Nefrologia, Hospital Universitário Evangélico Mackenzie, Curitiba, PR, Brasil
- Disciplina de Nefrologia, Faculdade Evangélica Mackenzie do Paraná, Curitiba, PR, Brasil
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Mignano SE, Nasr SH, Fidler ME, Herrera Hernandez LP, Alexander MP, Sethi S, Messias N, Alhamad T, Alrata L, Albadri ST, Cornell LD. Recurrent atypical antiglomerular basement membrane nephritis in the kidney transplant. Am J Transplant 2024; 24:123-133. [PMID: 37774840 DOI: 10.1016/j.ajt.2023.09.007] [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: 08/17/2023] [Revised: 09/06/2023] [Accepted: 09/09/2023] [Indexed: 10/01/2023]
Abstract
Atypical antiglomerular basement membrane (anti-GBM) nephritis can be defined as linear GBM staining for monotypic or polytypic immunoglobulin (Ig) by immunofluorescence (IF) without a diffuse crescentic pattern. We describe the clinicopathologic features of 6 patients (18 biopsies) in this first series of recurrent atypical anti-GBM nephritis after kidney transplantation. Recurrent glomerulonephritis occurred at a mean of 3.8 months posttransplant (range 1-7 months). Three index biopsies were for clinical indication, and 3 were protocol biopsies. Glomerular histologic changes were mild, with 2 showing segmental endocapillary hypercellularity, 1 focal glomerular microangiopathy, and the others no significant glomerular histologic changes. All 6 allografts showed monotypic linear glomerular Ig staining by IF: IgG kappa (n = 2), IgG lambda, IgA kappa, IgA lambda, and IgM lambda. Follow-up biopsies were available for 5 patients and showed similar histologic and IF findings without evidence of significant progression. No patients had detectable serum anti-GBM antibody or monoclonal proteins. The mean serum creatinine level on follow-up (24-62 months posttransplant) was 1.8 (range 0.93-2.77) mg/dL; no grafts were lost to recurrent disease. This series demonstrates that monotypic atypical anti-GBM recurs in the allograft and supports the idea that this disease is due to a circulating monoclonal protein.
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Affiliation(s)
- Salvatore E Mignano
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Samih H Nasr
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary E Fidler
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Loren P Herrera Hernandez
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mariam P Alexander
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sanjeev Sethi
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nidia Messias
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Tarek Alhamad
- Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Louai Alrata
- Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Sam T Albadri
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, Florida, USA
| | - Lynn D Cornell
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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Zhao Z, Jin Q, Chen F, Peng T, Yu S. A large-scale dataset of patient summaries for retrieval-based clinical decision support systems. Sci Data 2023; 10:909. [PMID: 38110415 PMCID: PMC10728216 DOI: 10.1038/s41597-023-02814-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 12/01/2023] [Indexed: 12/20/2023] Open
Abstract
Retrieval-based Clinical Decision Support (ReCDS) can aid clinical workflow by providing relevant literature and similar patients for a given patient. However, the development of ReCDS systems has been severely obstructed by the lack of diverse patient collections and publicly available large-scale patient-level annotation datasets. In this paper, we collect a novel dataset of patient summaries and relations called PMC-Patients to benchmark two ReCDS tasks: Patient-to-Article Retrieval (ReCDS-PAR) and Patient-to-Patient Retrieval (ReCDS-PPR). Specifically, we extract patient summaries from PubMed Central articles using simple heuristics and utilize the PubMed citation graph to define patient-article relevance and patient-patient similarity. PMC-Patients contains 167k patient summaries with 3.1 M patient-article relevance annotations and 293k patient-patient similarity annotations, which is the largest-scale resource for ReCDS and also one of the largest patient collections. Human evaluation and analysis show that PMC-Patients is a diverse dataset with high-quality annotations. We also implement and evaluate several ReCDS systems on the PMC-Patients benchmarks to show its challenges and conduct several case studies to show the clinical utility of PMC-Patients.
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Affiliation(s)
- Zhengyun Zhao
- Center for Statistical Science, Tsinghua University, Beijing, 100084, China
| | - Qiao Jin
- School of Medicine, Tsinghua University, Beijing, 100084, China
| | - Fangyuan Chen
- School of Medicine, Tsinghua University, Beijing, 100084, China
| | - Tuorui Peng
- Department of Physics, Tsinghua University, Beijing, 100084, China
| | - Sheng Yu
- Center for Statistical Science, Tsinghua University, Beijing, 100084, China.
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Kazemzadeh K, Kabiri Naeini E, Moeinzadeh F, Naimi A. Anti-GBM disease with positive serum anti-GBM antibodies but negative IgG deposition: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231189767. [PMID: 37533486 PMCID: PMC10392201 DOI: 10.1177/2050313x231189767] [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: 04/13/2023] [Accepted: 07/07/2023] [Indexed: 08/04/2023] Open
Abstract
Anti-glomerular basement membrane antibodies are significantly specific for detecting anti-glomerular basement membrane disease. These antibodies are typically targeted against the non-collagenous (NC1) domain of the alpha 3 chain of type IV collagen and, to a lesser extent, the α4(IV) or α5(IV) chains, which create a triple-helical structure in the glomerular basement membrane. The modification of the hexameric structure of NC1 (α3(IV)) results in the exposure of new epitopes, leading to an immune reaction and the subsequent deposition of linear antibodies along the glomerular basement membrane, culminating in crescentic glomerulonephritis. Anti-glomerular basement membrane antibodies that are positive are believed to be pathogenic and capable of binding to the glomerular basement membrane in vivo, particularly in the context of rapidly progressive glomerulonephritis. Herein, we present a patient with positive serum anti-glomerular basement membrane antibodies but negative IgG deposition. The current findings are significant for raising physicians' awareness of the probable errors in detecting anti-glomerular basement membrane antibody disease as a possible cause of irreversible kidney failure.
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Affiliation(s)
- Kimia Kazemzadeh
- Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Interest Group Department, Universal Scientific Education and Research Network, Tehran, Iran
| | - Elham Kabiri Naeini
- Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Firouzeh Moeinzadeh
- Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azar Naimi
- Department of Pathology, Isfahan University of Medical Sciences, Isfahan, Iran
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Bharati J, Yang Y, Sharma P, Jhaveri KD. Atypical Anti-Glomerular Basement Membrane Disease. Kidney Int Rep 2023; 8:1151-1161. [PMID: 37284681 PMCID: PMC10239794 DOI: 10.1016/j.ekir.2023.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 02/09/2023] [Accepted: 03/15/2023] [Indexed: 06/08/2023] Open
Abstract
Atypical anti-glomerular basement membrane (anti-GBM) disease is characterized by linear immunoglobulin G (IgG) deposition along the GBM without circulating IgG anti-GBM antibodies. Compared to classic anti-GBM disease, atypical anti-GBM disease tends to be milder with a more indolent course in certain cases. Moreover, pathologic disease pattern is much more heterogenous in atypical anti-GBM disease than in the classic type, which is uniformly characterized by diffuse crescentic and necrotizing glomerulonephritis. Although there is no single well-established target antigen in atypical anti-GBM disease, the target antigen (within the GBM) and the autoantibody type are hypothesized to be different from the classic type. Some patients have the same antigen as the Goodpasture antigen that are detected only by a highly sensitive technique (biosensor analysis). Some cases of atypical anti-GBM disease have autoantibodies of a different subclass restriction like IgG4, or of monoclonal nature. Antibodies targeting antigen/epitope structure other than the Goodpasture antigen can be detected using modified assays in some cases. Patients with IgA- and IgM-mediated anti-GBM disease are known to have negative circulating antibodies because conventional assays do not detect these classes of antibodies. A significant proportion of cases with atypical anti-GBM disease do not have any identifiable antibodies despite extensive evaluation. Nevertheless, extensive evaluation of atypical autoantibodies using modified assays and sensitive techniques should be attempted, if feasible. This review summarizes the recent literature on atypical anti-GBM disease.
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Affiliation(s)
- Joyita Bharati
- Department of Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Yihe Yang
- Department of Pathology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Purva Sharma
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Department of Medicine, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, New York, USA
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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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8
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Guo C, Ye M, Li S, Zhu TT, Rao XR. Anti-glomerular basement membrane disease with IgA nephropathy: A case report. World J Clin Cases 2022; 10:3916-3922. [PMID: 35647148 PMCID: PMC9100739 DOI: 10.12998/wjcc.v10.i12.3916] [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: 09/16/2021] [Revised: 11/18/2021] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Anti-glomerular basement membrane (GBM) disease is a rare autoimmune disease manifesting as acute progressive nephritis syndrome with or without varying degrees of pulmonary hemorrhage. Anti-GBM disease coexisting with Immunoglobulin A (IgA) nephropathy is rarer and has different clinical manifestations and prognoses than simple anti-GBM disease. We describe a case of coexistence of these two diseases.
CASE SUMMARY A 49-year-old man with hematuria and proteinuria accompanied by a slight elevation of serum creatinine was admitted to our hospital. The pathological results of renal biopsy and the elevated serum anti-GBM antibody titer supported a diagnosis of anti-GBM disease combined with IgA nephropathy. After treatment with corticosteroids and cyclophosphamide, the patient's serum creatinine was relatively stable, and the hematuria and proteinuria moderately improved in the subsequent six months.
CONCLUSION Anti-GBM disease coexisting with IgA nephropathy is rare. The clinical manifestations and prognosis are better than those of simple anti-GBM disease. In this case, the patient's condition was improved and his renal function remained relatively stable with corticosteroid and cyclophosphamide treatment. New detection methods to identify whether the crescents in this case were derived from anti-GBM disease or IgA nephropathy are worthy of further exploration.
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Affiliation(s)
- Chuan Guo
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
| | - Ming Ye
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
| | - Shen Li
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
| | - Ting-Ting Zhu
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
| | - Xiang-Rong Rao
- Department of Nephrology, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, Beijing 100053, China
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Zahir Z, Wani AS, Prasad N, Jain M. Clinicopathological characteristics and predictors of poor outcome in anti-glomerular basement membrane disease - a fifteen year single center experience. Ren Fail 2021; 43:79-89. [PMID: 33334228 PMCID: PMC7751384 DOI: 10.1080/0886022x.2020.1854301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction Anti-glomerular basement membrane (anti-GBM) disease is a small vessel vasculitis affecting the renal and lung capillary beds. We aim to study the clinicopathological characteristics and predictors of poor outcome of this disease in our population. Materials and methods This is a 15 year retrospective, single center observational study of Indian cohort. Patients with biopsy proven anti-GBM disease were studied. Results Anti-GBM disease was found in 0.5% of the total cases. The mean age at presentation was 46.7 years. Compared to renal limited disease those with pulmonary-renal syndrome had a higher frequency of hypertension, oliguria, percentage of crescents, interstitial inflammation and glomerulosclerosis. Double positive (anti-GBM and ANCA antibodies) patients showed more of glomerulosclerosis, tubular atrophy/interstitial fibrosis (IFTA) as well as periglomerular granulomas on biopsy. Patient survival at one year was 40.4% and death censored renal survival was 9.7%. Factors affecting the dialysis dependency at presentation were oligoanuria (p = .04), creatinine levels >5.7 mg/dl (p = .003), and high mean anti-GBM titers (p = .008). Atypical cases accounted for 8.3% of these patients. Oligoanuria (HR = 5.0, p = .05), high serum creatinine (HR = 1.55, p = .05), severe glomerulosclerosis (HR = 1.09, p = .03), and IFTA (HR = 2, p = .04) were associated with poor renal outcome. Advanced age (HR = 1.92, p = .03), high serum creatinine (HR = 1.9, p = .04) and high anti-GBM titers (HR = 1.01, p = .03) were associated with poor patient survival. Conclusions Anti-GBM is a rare disease with poor prognosis and varied presentations. Patients with pulmonary-renal syndrome showed severe disease whereas double positive had more of chronic changes. The predictors of poor prognosis include advanced age, oliguria, serum anti-GBM levels, serum creatinine levels, degree of glomerulosclerosis and IFTA. Atypical anti-GBM cases should be kept in mind while evaluating renal biopsies.
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Affiliation(s)
- Zafirah Zahir
- PDCC Renal Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Asif Sadiq Wani
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.,Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Narayan Prasad
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Manoj Jain
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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10
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Garcia GE, Lu YJ, Truong LD, Roncal-Jiménez CA, Miyazaki M, Miyazaki-Anzai S, Cara-Fuentes G, Andres-Hernando A, Lanaspa M, Johnson RJ, Leamon CP. A Novel Treatment for Glomerular Disease: Targeting the Activated Macrophage Folate Receptor with a Trojan Horse Therapy in Rats. Cells 2021; 10:2113. [PMID: 34440885 PMCID: PMC8393837 DOI: 10.3390/cells10082113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 02/07/2023] Open
Abstract
Since activated macrophages express a functional folate receptor β (FRβ), targeting this macrophage population with folate-linked drugs could increase selectivity to treat inflammatory diseases. Using a macrophage-mediated anti-glomerular basement membrane (anti-GBM) glomerulonephritis (GN) in WKY rats, we investigated the effect of a novel folic acid-aminopterin (AMT) conjugate (EC2319) designed to intracellularly deliver AMT via the FR. We found that treatment with EC2319 significantly attenuated kidney injury and preserved renal function. Kidney protection with EC2319 was blocked by a folate competitor, indicating that its mechanism of action was specifically FRβ-mediated. Notably, treatment with methotrexate (MTX), another folic acid antagonist related to AMT, did not protect from kidney damage. EC2319 reduced glomerular and interstitial macrophage infiltration and decreased M1 macrophage recruitment but not M2 macrophages. The expression of CCL2 and the pro-fibrotic cytokine TGF-β were also reduced in nephritic glomeruli with EC2319 treatment. In EC2319-treated rats, there was a significant decrease in the deposition of collagens. In nephritic kidneys, FRβ was expressed on periglomerular macrophages and macrophages present in the crescents, but its expression was not observed in normal kidneys. These data indicate that selectively targeting the activated macrophage population could represent a novel means for treating anti-GBM GN and other acute crescentic glomerulonephritis.
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Affiliation(s)
- Gabriela E. Garcia
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Yingjuan J. Lu
- Endocyte, Inc., Novartis Institutes for Biomedical Research, West Lafayette, IN 47906, USA; (Y.J.L.); (C.P.L.)
| | - Luan D. Truong
- Department of Pathology, The Houston Methodist Hospital, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Carlos A. Roncal-Jiménez
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Makoto Miyazaki
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Shinobu Miyazaki-Anzai
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Gabriel Cara-Fuentes
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Ana Andres-Hernando
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Miguel Lanaspa
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Richard J. Johnson
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Christopher P. Leamon
- Endocyte, Inc., Novartis Institutes for Biomedical Research, West Lafayette, IN 47906, USA; (Y.J.L.); (C.P.L.)
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11
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Khor C, Wong MG, Reagh J. Anti-glomerular basement membrane disease and IgA nephropathy in a patient with previous renal cell carcinoma. BMJ Case Rep 2021; 14:14/7/e236555. [PMID: 34315734 PMCID: PMC8319966 DOI: 10.1136/bcr-2020-236555] [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
A 66-year-old Asian woman presented with severe kidney injury, microscopic haematuria and subnephrotic range proteinuria with elevated serum anti-glomerular basement membrane (anti-GBM) titre. She had a history of renal cell carcinoma. Renal biopsy revealed dual pathology with immunofluorescence showing 3+ linear glomerular IgG staining and 3+ IgA mesangial staining. Cellular crescents were present on light microscopy and electron microscopy revealed increased mesangial matrix. She was treated with plasma exchange and immunosuppression and remained in stage 4 chronic kidney disease. This case describes the coexistence of anti-GBM disease and IgA nephropathy, a phenomenon not well described in the literature. The report also explores the association of malignancy and glomerulonephritis as well as the role of genetics and the utility of human leukocyte antigen (HLA) typing in risk stratification.
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Affiliation(s)
- Candice Khor
- Department of Nephrology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Muh Geot Wong
- Department of Nephrology, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Department of Medicine, Univeristy of Sydney, Sydney, New South Wales, Australia
| | - Jessica Reagh
- Department of Anatomical Pathology, Royal North Shore Hospital, Sydney, New South Wales, Australia
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12
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Atypical Antiglomerular Basement Membrane Disease in a Pediatric Patient Successfully Treated with Rituximab. Case Rep Nephrol 2021; 2021:2586693. [PMID: 34336318 PMCID: PMC8313325 DOI: 10.1155/2021/2586693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/10/2021] [Indexed: 11/19/2022] Open
Abstract
Classic antiglomerular basement membrane (anti-GBM) disease is an exceedingly rare but extremely aggressive form of glomerulonephritis, typically caused by autoantibodies directed against cryptic, conformational epitopes within the noncollagenous domain of the type IV collagen alpha-3 subunit. Pathologic diagnosis is established by the presence of strong, diffuse, linear staining for immunoglobulin on immunofluorescence microscopy. Recently, patients with atypical clinical and pathologic findings of anti-GBM disease have been described. These patients tend to have an indolent clinical course, without pulmonary involvement, and laboratory testing rarely reveals the presence of anti-GBM antibodies. Specific guidelines for the treatment and management of these patients are unclear. Here, we describe a case of atypical anti-GBM disease in a young child who presented with hematuria and prominent proteinuria. Throughout the course of his illness, creatinine remained normal. He was conservatively treated with steroids and rituximab, resulting in resolution of his clinical symptoms and normalization of laboratory findings.
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13
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Bonilla M, Bijol V, Kello N, Jhaveri KD, Ross DW. A Case of Glomerulopathy Associated With Monoclonal Glomerular Basement Membrane Antibody. Kidney Int Rep 2021; 6:1444-1448. [PMID: 34013123 PMCID: PMC8116727 DOI: 10.1016/j.ekir.2021.02.028] [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: 01/25/2021] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Marco Bonilla
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell and Northwell Health, New York, USA
| | - Vanesa Bijol
- The Glomerular Disease Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell and Northwell Health, New York, USA.,Department of Pathology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell and Northwell Health, New York, USA
| | - Nina Kello
- Division of Rheumatology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell and Northwell Health, New York, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell and Northwell Health, New York, USA.,The Glomerular Disease Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell and Northwell Health, New York, USA
| | - Daniel W Ross
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell and Northwell Health, New York, USA
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14
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Guo N, Yin Q, Lei S, He Y, Fu P. Atypical anti-glomerular basement membrane disease with anti-GBM antibody negativity and ANCA positivity: a case report. BMC Nephrol 2021; 22:53. [PMID: 33546629 PMCID: PMC7863514 DOI: 10.1186/s12882-021-02232-1] [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: 05/08/2020] [Accepted: 01/04/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Anti-glomerular basement membrane (anti-GBM) disease is an organ-specific autoimmune disease that involves the lung and kidneys and leads to rapid glomerulonephritis progression, with or without diffuse alveolar hemorrhage, and even respiratory failure. Classic cases of anti-GBM disease are diagnosed based on the presence of the anti-GBM antibody in serum samples and kidney or lung biopsy tissue samples. However, atypical cases of anti-GBM disease are also seen in clinical practice. CASE PRESENTATION We herein report the rare case of a patient with atypical anti-GBM disease whose serum was negative for the anti-GBM antibody but positive for the myeloperoxidase (MPO) anti-neutrophil cytoplasmic antibody (p-ANCA) and another atypical ANCA. Laboratory test results showed severe renal insufficiency with a creatinine level of 385 μmol/L. Renal biopsy specimen analysis revealed 100% glomeruli with crescents; immunofluorescence showed immunoglobulin G (IgG) linearly deposited alongside the GBM. Finally, the patient was discharged successfully after treatment with plasmapheresis, methylprednisolone and prednisone. CONCLUSION This patient, whose serum was negative for the anti-GBM antibody but positive for p-ANCA and another atypical ANCA, had a rare case of anti-GBM disease. Insights from this unusual case might help physicians diagnose rare forms of glomerulonephritis and treat affected patients in a timely manner.
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Affiliation(s)
- Na Guo
- Kidney Research Institute, Division of Nephrology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qinghua Yin
- Kidney Research Institute, Division of Nephrology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Song Lei
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yanjun He
- Department of Pathology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ping Fu
- Kidney Research Institute, Division of Nephrology, West China Hospital, Sichuan University, Chengdu, 610041, China.
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15
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Atypical anti-glomerular basement membrane disease complicated by methicillin-susceptible Staphylococcus aureus infection-related rapidly progressive glomerulonephritis: a case report and literature review. CEN Case Rep 2021; 10:348-353. [PMID: 33460013 DOI: 10.1007/s13730-020-00564-9] [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] [Received: 08/21/2020] [Accepted: 12/04/2020] [Indexed: 10/22/2022] Open
Abstract
Atypical anti-glomerular basement membrane (GBM) disease, which is characterized by low levels of or negativity for anti-GBM antibodies in circulation but positivity in the kidney, has been recognized in this decade. However, a therapeutic strategy has not been established to date because its outcome is better than that of classic anti-GBM disease. This case report and literature review highlight atypical anti-GBM disease in infection-related rapidly progressive glomerulonephritis. A 72-year-old Japanese man diagnosed with methicillin-susceptible Staphylococcus aureus (MSSA)-induced vertebral osteomyelitis experienced for 2 months was referred to our hospital because of renal insufficiency. He developed rapidly progressive glomerulonephritis with a serum creatinine level of 6.8 mg/dL, C-reactive protein level of 9.7 mg/dL, urinary protein-to-creatinine ratio of 3.37 g/gCr, and gross hematuria. The serum anti-GBM antibody concentration was 3.5 U/mL, which was slightly above the normal range (< 3.0 U/mL). Conservative treatment, mainly with antibiotics, improved the symptoms and renal function. The serum anti-GBM antibody concentration peaked at 4.0 U/mL on day 7 and decreased to an undetectable range at the end of eight-week antibiotic therapy. This is the first case report describing the presentation and disappearance of serum anti-GBM antibody in a patient with MSSA infection. Conservative treatment may be effective for patients with atypical anti-GBM disease complicated by infectious diseases.
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16
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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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17
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Shen CR, Jia XY, Cui Z, Yu XJ, Zhao MH. Clinical-Pathological Features and Outcome of Atypical Anti-glomerular Basement Membrane Disease in a Large Single Cohort. Front Immunol 2020; 11:2035. [PMID: 33013861 PMCID: PMC7494752 DOI: 10.3389/fimmu.2020.02035] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/27/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Atypical cases of anti-glomerular basement membrane (GBM) disease had absent circulating antibodies but linear IgG deposits along GBM in the kidneys. Herein, we reported the clinical-pathological features and outcome of these rare cases. Methods: Linear IgG deposit along GBM were examined by immunofluorescence on renal specimens, with exclusion of diabetic kidney disease. Circulating anti-GBM antibodies were tested by commercial ELISA assay. Clinical, pathological and follow-up data were retrospectively analyzed. Results: From 2013 to 2018, a total of 60 patients were diagnosed as atypical anti-GBM disease. They had a male predominance, with an average age of 51.7 ± 15.6 years. Three (5.0%) patients had alveolar hemorrhage. Forty five percent of them presented with acute kidney disease. All patients had linear IgG deposit along GBM, some in addition on tubular basement membrane and/or Bowmans' capsules. C3 deposition was found in 65.0% of the patients. 41.7% (25/60) of the patients showed crescent formation and the percentage of crescent was (34.7 ± 23.5)% in those patients. They had higher prevalence of hematuria and C3 deposit, higher levels of serum creatinine, worse renal and patient survival than those without crescent (P < 0.05). During the follow-up of 35.7 ± 21.4 months, 14 (23.3%) patients progressed to ESRD. The serum creatinine on diagnosis [per 200 μmol/L increase, HR (95% CI): 2.663 (1.372, 5.172), P = 0.004], serum C3 [per 0.1 g/L increase, HR (95% CI): 0.689(0.483, 0.984), P = 0.040] and the intensity of kidney C3 staining [per 1+ increase, HR (95% CI): 2.770 (1.115, 6.877), P = 0.028] were independent predictive factors for kidney outcome. Nine (15.0%) patients died of all causes. Conclusions: Atypical anti-GBM disease manifested milder kidney injury and scarce pulmonary hemorrhage compared to the classical cases. Though heterogeneous, a substantial number of the patients had complement activation and crescent formation. Patients having crescents presented with more severe clinical course and worse outcomes. The poor kidney and patient prognosis emphasize prompt interventions from physicians. The immunosuppressive intervention was not associated with kidney or patient outcome. Further studies are needed to address the optimal therapeutic regimen.
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Affiliation(s)
- Cong-Rong Shen
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Yu Jia
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Juan Yu
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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18
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Elshirbeny M, Alkadi MM, Mujeeb I, Fituri O. Atypical Anti-Glomerular Basement Membrane Disease With Diffuse Crescentic Membranoproliferative Glomerulonephritis: Case Report and Review of Literature. Qatar Med J 2020; 2020:16. [PMID: 32391252 PMCID: PMC7199789 DOI: 10.5339/qmj.2020.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 01/05/2020] [Indexed: 12/28/2022] Open
Abstract
Anti-glomerular basement membrane (anti-GBM) disease occurs in fewer than two cases per million population. Patients usually present with features of rapidly progressive glomerulonephritis (RPGN) with or without pulmonary involvement. Anti-GBM disease is classically diagnosed by both demonstrating GBM linear immunofluorescence staining on kidney biopsy and detecting anti-GBM antibodies in serum. More than 90% of patients with anti-GBM disease either become dialysis-dependent or die if left untreated. Here, we report a 37-year-old man who presented with bilateral lower limb edema, hypertension, acute kidney injury (creatinine of 212 μmol/L), microscopic hematuria, and nephrotic range proteinuria (15 g/day). His kidney biopsy showed diffuse crescentic membranoproliferative glomerulonephritis and bright linear staining of GBM by immunoglobulin G consistent with anti-GBM disease; however, serum anti-GBM antibodies were negative. The patient was diagnosed with atypical anti-GBM disease and treated aggressively with intravenous pulse steroids, plasmapheresis, oral cyclophosphamide, and oral prednisolone with significant improvement in kidney function and proteinuria. Atypical anti-GBM disease should be considered in patients presenting with RPGN, even in the absence of serum anti-GBM antibodies. Early diagnosis and aggressive treatment in such cases are warranted to prevent irreversible kidney damage as the course of the disease might not be as benign as previously thought.
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Affiliation(s)
- Mostafa Elshirbeny
- Division of Nephrology, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Mohamad M Alkadi
- Division of Nephrology, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Imaad Mujeeb
- Division of Nephrology, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Omar Fituri
- Division of Nephrology, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
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19
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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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20
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Olivier M, Watson H, Lee D, Mohanlal V, Madruga M, Carlan S. Monotypic IgG1-kappa Atypical Anti-Glomerular Basement Membrane Nephritis: A Case Report. Case Rep Nephrol Dial 2019; 9:8-14. [PMID: 31019927 PMCID: PMC6465719 DOI: 10.1159/000498844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/09/2019] [Indexed: 11/19/2022] Open
Abstract
Anti-glomerular basement membrane (anti-GBM) glomerulonephritis is a rare disease caused by autoantibodies against the glomerular basement membrane. Atypical anti-GBM nephritis is clinically less aggressive and characterized by the absence of circulating autoantibodies to the basement membrane. A previously healthy 53-year-old white woman presented with a rising creatinine over a short observation period. Renal biopsy, urinary sediment, and laboratory testing confirmed the diagnosis of atypical anti-GBM disease. She received plasmapheresis, steroids, and cyclophosphamide. She developed hemorrhagic cystitis early in the treatment from oral cyclophosphamide and mycophenolate mofetil was substituted as a first-line drug. She responded favorably and continued on mycophenolate mofetil without evidence of relapse. Despite the absence of circulating autoantibodies, a diagnosis of atypical anti-GBM nephritis should not be excluded if a high index of clinical suspicion exists. Early renal biopsy should be considered. Mycophenolate mofetil may be a reasonable replacement for oral cyclophosphamide in the treatment of atypical anti-GBM disease when cyclophosphamide is contraindicated.
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Affiliation(s)
- Maxim Olivier
- Department of Medicine, Orlando Regional Healthcare, Orlando, Florida, USA
| | - Harold Watson
- Department of Medicine, Orlando Regional Healthcare, Orlando, Florida, USA
| | - Danielle Lee
- Department of Medicine, Orlando Regional Healthcare, Orlando, Florida, USA
| | - Viresh Mohanlal
- Division of Nephrology, Orlando Regional Healthcare, Orlando, Florida, USA
| | - Mario Madruga
- Department of Medicine, Orlando Regional Healthcare, Orlando, Florida, USA
| | - Steven Carlan
- Division of Academic Affairs and Research, Orlando Regional Healthcare, Orlando, Florida, USA
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21
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Liang D, Liang S, Xu F, Zhang M, Li X, Tu Y, Liu Z, Zeng C. Clinicopathological features and outcome of antibody-negative anti-glomerular basement membrane disease. J Clin Pathol 2018; 72:31-37. [PMID: 30315136 DOI: 10.1136/jclinpath-2018-205278] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 08/17/2018] [Accepted: 08/22/2018] [Indexed: 12/12/2022]
Abstract
AIM To explore the clinicopathological characteristics of patients with anti-GBM antibody-negative anti-GBM disease. METHODS The clinical and renal pathological findings were retrospectively studied in 19 patients. All patients met the following inclusion criteria: linear GBM IgG deposition on immunofluorescence(IF); and lack of serum anti-GBM antibodies by ELISA and indirect immunofluorescence assay. RESULTS There were 17 male and two female patients, with a median age of 36 years (range 15-61 years). Hypertension was present in 68% of cases, nephrotic-range proteinuria (> 3.5 g/24 hours) in 42%, nephrotic syndrome in 37%, microhaematuria in 95%, renal insufficiency in 63% and lung involvement in 16%. On biopsy all patients had linear GBM staining for polyclonal IgG by IF. The dominant IgG subtype was IgG4 or IgG1. By light microscopy, mesangial proliferative GN without crescents was seen in four patients; proliferative GN (mesangial proliferative GN in eight; endocapillary proliferative GN in two; and membranoproliferative GN in two) with crescents (focal in 11; diffuse in one) in 12 patients; and crescentic GN without mesangial or endocapillary proliferative or membranoproliferative changes in three patients. By electron microscopy, six patients showed scarce electron dense deposits in glomeruli and 11 patients had global podocyte effacement. Totally, 10 (53%) patients received immunosuppressive therapy. The median follow-up was 15 months and six (32%) patients progressed to end-stage renal disease. CONCLUSIONS Anti-GBM antibody-negative anti-GBM disease was different from classic anti-GBM disease clinically and pathologically. The pathogenesis of the renal injury in these patients has not been elucidated until now and it should be studied and identified further.
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Affiliation(s)
- Dandan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.,National Clinical Research Center of Kidney Diseases, Jinling Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Shaoshan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Feng Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Mingchao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiaomei Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Yiyao Tu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.,National Clinical Research Center of Kidney Diseases, Jinling Clinical Medical College of Nanjing Medical University, Nanjing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China .,National Clinical Research Center of Kidney Diseases, Jinling Clinical Medical College of Nanjing Medical University, Nanjing, China
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22
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Yamada T, Mugishima K, Higo S, Yoshida Y, Itagaki F, Yui S, Kashiwagi T, Endo Y, Shimizu A, Tsuruoka S. A Case of Anti-Glomerular Basement Membrane Antibody-Positive Systemic Lupus Erythematosus with Pulmonary Hemorrhage Successfully Treated at an Early Stage of the Disease. J NIPPON MED SCH 2018; 85:138-144. [PMID: 29731498 DOI: 10.1272/jnms.2018_85-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We report here a case of systemic lupus erythematosus (SLE) with pulmonary hemorrhage and anti-glomerular basement membrane (anti-GBM) antibodies. A 42-year-old woman was admitted to our hospital with complaints of exanthema, arthralgia, shortness of breath, and hemoptysis. Plain chest computed tomography (CT) scan revealed pericardial effusion, bilateral pleural effusions, and pulmonary hemorrhage. Laboratory findings on admission revealed proteinuria, microscopic hematuria, anemia, leukopenia, hypoalbuminemia, hypocomplementemia, and slightly elevated levels of serum creatinine. Serological tests revealed elevated titers of serum anti-GBM antibodies, proteinase 3-antineutrophil cytoplasmic antibodies (PR3-ANCA), and anti-double stranded deoxyribonucleic acid (dsDNA)-immunoglobulin G (IgG) antibodies. Early treatment with steroid pulse therapy combined with plasma exchange resolved the patient's pulmonary hemorrhage and renal dysfunction. Renal biopsy carried out after the treatment revealed a recovery phase of acute tubular injury with minor glomerular abnormalities without linear IgG deposition along the GBMs. For a good prognosis, it is necessary to start treatment immediately in patients with anti-GBM antibody-positive SLE associated with pulmonary hemorrhage.
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Affiliation(s)
- Takehisa Yamada
- Department of Nephrology, Nippon Medical School Chiba Hokusoh Hospital
| | - Koji Mugishima
- Department of Nephrology, Nippon Medical School Chiba Hokusoh Hospital
| | - Seiichiro Higo
- Department of Nephrology, Nippon Medical School Chiba Hokusoh Hospital
| | - Yukie Yoshida
- Department of Nephrology, Nippon Medical School Chiba Hokusoh Hospital
| | - Fumiaki Itagaki
- Department of Nephrology, Nippon Medical School Chiba Hokusoh Hospital
| | - Shizuka Yui
- Department of Nephrology, Nippon Medical School Chiba Hokusoh Hospital
| | - Tetsuya Kashiwagi
- Department of Nephrology, Nippon Medical School Chiba Hokusoh Hospital
| | - Yoko Endo
- Department of Analytic Human Pathology, Nippon Medical School
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School
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23
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18F-FDG PET/CT Imaging of Necrotizing Crescentic Glomerulonephritis With Anti-Glomerular Basement Membrane Disease. Clin Nucl Med 2018; 43:e96-e97. [PMID: 29293138 DOI: 10.1097/rlu.0000000000001960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A 30-year-old woman presented with lethargy, night sweats, and fever with raised inflammatory markers. Anti-neutrophil cytoplasmic antibody was negative. Abdominopelvic CT was unremarkable. Subsequently, she underwent FDG PET/CT showing globally enlarged kidneys with diffuse hypermetabolic activity within the renal parenchyma bilaterally. Renal biopsies showed morphologic features of an active necrotizing crescentic glomerulonephritis, which was confirmed clinically and treated. This case demonstrates the role that FDG PET/CT can play in inflammatory conditions, such as glomerulonephritis, where it may be clinically useful when the presentation is atypical.
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24
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Abstract
Anti-glomerular basement membrane (anti-GBM) disease is a rare small vessel vasculitis that affects the capillary beds of the kidneys and lungs. It is an archetypic autoimmune disease, caused by the development of directly pathogenic autoantibodies targeting a well characterized autoantigen expressed in the basement membranes of these organs, although the inciting events that induce the autoimmune response are not fully understood. The recent confirmation of spatial and temporal clustering of cases suggests that environmental factors, including infection, may trigger disease in genetically susceptible individuals. The majority of patients develop widespread glomerular crescent formation, presenting with features of rapidly progressive GN, and 40%-60% will have concurrent alveolar hemorrhage. Treatment aims to rapidly remove pathogenic autoantibody, typically with the use of plasma exchange, along with steroids and cytotoxic therapy to prevent ongoing autoantibody production and tissue inflammation. Retrospective cohort studies suggest that when this combination of treatment is started early, the majority of patients will have good renal outcome, although presentation with oligoanuria, a high proportion of glomerular crescents, or kidney failure requiring dialysis augur badly for renal prognosis. Relapse and recurrent disease after kidney transplantation are both uncommon, although de novo anti-GBM disease after transplantation for Alport syndrome is a recognized phenomenon. Copresentation with other kidney diseases such as ANCA-associated vasculitis and membranous nephropathy seems to occur at a higher frequency than would be expected by chance alone, and in addition atypical presentations of anti-GBM disease are increasingly reported. These observations highlight the need for future work to further delineate the immunopathogenic mechanisms of anti-GBM disease, and how to better refine and improve treatments, particularly for patients presenting with adverse prognostic factors.
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Affiliation(s)
- Stephen P McAdoo
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, United Kingdom
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25
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Bahrainwala JZ, Stokes MB, Hannani AK, Hogan JJ. Atypical Antiglomerular Basement Membrane Disease With IgG1-κ Staining. Kidney Int Rep 2016; 2:80-83. [PMID: 29142944 PMCID: PMC5678821 DOI: 10.1016/j.ekir.2016.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jehan Z Bahrainwala
- Renal Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - M Barry Stokes
- Department of Pathology, Columbia University, New York, NY, USA
| | | | - Jonathan J Hogan
- Renal Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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26
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Glassock RJ. Atypical anti-glomerular basement membrane disease: lessons learned. Clin Kidney J 2016; 9:653-6. [PMID: 27679709 PMCID: PMC5036901 DOI: 10.1093/ckj/sfw068] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 06/29/2016] [Indexed: 11/12/2022] Open
Abstract
Anti-glomerular basement membrane (GBM) disease usually pursues a self-limited course, at least from the immunological perspective. In addition, circulating antibodies to cryptic, conformational epitopes within the NC1 domain of the alpha 3 chain of Type IV Collagen are commonly found at the zenith of the clinical disease. However, exceptions to these general rules do occur, as exemplified by two remarkable cases reported in this issue of the Clinical Kidney Journal. The possible explanations for and the lessons learned from these uncommon occurrences are discussed in this short commentary.
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Affiliation(s)
- Richard J Glassock
- David Geffen School of Medicine at UCLA , Laguna Niguel, Los Angeles, CA , USA
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