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Systematic Scoring of Tubular Injury Patterns Reveals Interplay between Distinct Tubular and Glomerular Lesions in ANCA-Associated Glomerulonephritis. J Clin Med 2021; 10:jcm10122682. [PMID: 34207078 PMCID: PMC8235178 DOI: 10.3390/jcm10122682] [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] [Received: 05/25/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 12/25/2022] Open
Abstract
Background: Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a small vessel vasculitis, most frequently presenting as microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA). Acute tubular injury with the presence of tubulitis was previously reported to be of prognostic value in ANCA glomerulonephritis (GN). In particular, distinct tubular injury lesions were associated with the deterioration of kidney function at AAV disease onset, as well as renal resistance to treatment, and higher risk of progression to composite outcome in patients with AAV. To expand our knowledge regarding distinct tubular lesions in AAV, we aimed to describe acute tubular injury patterns in association with glomerular lesions in ANCA GN by systematic histological scoring. Methods: A total number of 48 renal biopsies with confirmed renal involvement of AAV admitted to the University Medical Center Göttingen from 2015 to 2020 were retrospectively examined. By systematic scoring of tubular injury lesions, the association between clinical parameters, laboratory markers, and histopathological findings was explored. Results: We have shown that cellular casts in renal biopsies were frequently observed in the majority of cases with ANCA GN. Furthermore, we showed that tubular epithelial simplification with dilatation correlated with MPA and MPO subtypes, C3c hypocomplementemia, severe renal involvement, and uACR. Red blood cell (RBC) casts were associated with increased levels of C-reactive protein (CRP), leukocyturia, and hematuria. Finally, we found that hyaline casts were associated with an increased fraction of glomeruli with global glomerular sclerosis. Conclusions: Acute tubular injury patterns were correlated with active ANCA GN, whereas tubular injury lesions reflecting the later stages of kidney disease correlated with chronic glomerular lesions. These results suggest an interplay between different renal compartments.
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Tampe D, Korsten P, Ströbel P, Hakroush S, Tampe B. Proteinuria Indicates Decreased Normal Glomeruli in ANCA-Associated Glomerulonephritis Independent of Systemic Disease Activity. J Clin Med 2021; 10:jcm10071538. [PMID: 33917561 PMCID: PMC8038827 DOI: 10.3390/jcm10071538] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/01/2021] [Accepted: 04/02/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Renal involvement is a common and severe complication of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), potentially resulting in a pauci-immune necrotizing and crescentic ANCA glomerulonephritis (GN) with acute kidney injury (AKI), end-stage renal disease (ESRD) or death. There is recent evidence that the degree of proteinuria at diagnosis is associated with long-term renal outcome in ANCA GN. Therefore, we here aimed to systematically describe the association between proteinuria and clinicopathological characteristics in 53 renal biopsies with ANCA GN and corresponding urinary samples at admission. Methods: A total number of 53 urinary samples at admission and corresponding renal biopsies with confirmed renal involvement of AAV were retrospectively included from 2015 to 2021 in a single-center study. Results: Proteinuria correlated with myeloperoxidase (MPO) subtype, diagnosis of microscopic polyangiitis (MPA) and severe deterioration of kidney function. Proteinuria was most prominent in sclerotic class ANCA GN and ANCA renal risk score (ARRS) high risk attributed to nonselective proteinuria, including both glomerular and tubular proteinuria. Finally, there was no association between proteinuria and systemic disease activity, suggesting that proteinuria reflected specific renal involvement in AAV rather that systemic disease activity. Conclusions: In conclusion, proteinuria correlated with distinct clinicopathological characteristics in ANCA GN, mostly attributed to a reduced fraction of normal glomeruli. Furthermore, proteinuria in ANCA GN reflected specific renal involvement in AAV rather than systemic disease activity. Therefore, urinary findings could further improve our understanding of mechanisms promoting kidney injury and progression of ANCA GN.
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Affiliation(s)
- Désirée Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37075 Göttingen, Germany; (D.T.); (P.K.)
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37075 Göttingen, Germany; (D.T.); (P.K.)
| | - Philipp Ströbel
- Institute of Pathology, University Medical Center Göttingen, 37075 Göttingen, Germany; (P.S.); (S.H.)
| | - Samy Hakroush
- Institute of Pathology, University Medical Center Göttingen, 37075 Göttingen, Germany; (P.S.); (S.H.)
| | - Björn Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37075 Göttingen, Germany; (D.T.); (P.K.)
- Correspondence: ; Tel.: +49-551-3910575
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Kitching AR, Anders HJ, Basu N, Brouwer E, Gordon J, Jayne DR, Kullman J, Lyons PA, Merkel PA, Savage COS, Specks U, Kain R. ANCA-associated vasculitis. Nat Rev Dis Primers 2020; 6:71. [PMID: 32855422 DOI: 10.1038/s41572-020-0204-y] [Citation(s) in RCA: 455] [Impact Index Per Article: 113.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/14/2020] [Indexed: 02/07/2023]
Abstract
The anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAVs) are a group of disorders involving severe, systemic, small-vessel vasculitis and are characterized by the development of autoantibodies to the neutrophil proteins leukocyte proteinase 3 (PR3-ANCA) or myeloperoxidase (MPO-ANCA). The three AAV subgroups, namely granulomatosis with polyangiitis (GPA), microscopic polyangiitis and eosinophilic GPA (EGPA), are defined according to clinical features. However, genetic and other clinical findings suggest that these clinical syndromes may be better classified as PR3-positive AAV (PR3-AAV), MPO-positive AAV (MPO-AAV) and, for EGPA, by the presence or absence of ANCA (ANCA+ or ANCA-, respectively). Although any tissue can be involved in AAV, the upper and lower respiratory tract and kidneys are most commonly and severely affected. AAVs have a complex and unique pathogenesis, with evidence for a loss of tolerance to neutrophil proteins, which leads to ANCA-mediated neutrophil activation, recruitment and injury, with effector T cells also involved. Without therapy, prognosis is poor but treatments, typically immunosuppressants, have improved survival, albeit with considerable morbidity from glucocorticoids and other immunosuppressive medications. Current challenges include improving the measures of disease activity and risk of relapse, uncertainty about optimal therapy duration and a need for targeted therapies with fewer adverse effects. Meeting these challenges requires a more detailed knowledge of the fundamental biology of AAV as well as cooperative international research and clinical trials with meaningful input from patients.
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Affiliation(s)
- A Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia. .,Departments of Nephrology and Paediatric Nephrology, Monash Health, Clayton, Victoria, Australia.
| | - Hans-Joachim Anders
- Renal Division, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians University, Munich, Germany
| | - Neil Basu
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
| | - Elisabeth Brouwer
- Vasculitis Expertise Centre Groningen, Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Jennifer Gordon
- Department of Neuroscience and Center for Neurovirology, Temple University School of Medicine, Philadelphia, PA, USA
| | - David R Jayne
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK
| | | | - Paul A Lyons
- Department of Medicine, University of Cambridge School of Clinical Medicine, University of Cambridge, Cambridge Biomedical Campus, Cambridge, UK.,Cambridge Institute for Therapeutic Immunology and Infectious Disease, Jeffrey Cheah Biomedical Centre, University of Cambridge, Cambridge, UK
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine and Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Caroline O S Savage
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Renate Kain
- Department of Pathology, Medical University Vienna, Vienna, Austria
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4
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van Daalen EE, Wester Trejo MA, Göçeroğlu A, Ferrario F, Joh K, Noël LH, Ogawa Y, Wilhelmus S, Ball MJ, Honsova E, Hruskova Z, Kain R, Kimura T, Kollar M, Kronbichler A, Lindhard K, Puéchal X, Salvatore S, Szpirt W, Takizawa H, Tesar V, Berden AE, Dekkers OM, Hagen EC, Oosting J, Rahmattulla C, Wolterbeek R, Bos WJ, Bruijn JA, Bajema IM. Developments in the Histopathological Classification of ANCA-Associated Glomerulonephritis. Clin J Am Soc Nephrol 2020; 15:1103-1111. [PMID: 32723805 PMCID: PMC7409752 DOI: 10.2215/cjn.14561119] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 05/22/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The histopathologic classification for ANCA-associated GN distinguishes four classes on the basis of patterns of injury. In the original validation study, these classes were ordered by severity of kidney function loss as follows: focal, crescentic, mixed, and sclerotic. Subsequent validation studies disagreed on outcomes in the crescentic and mixed classes. This study, driven by the original investigators, provides several analyses in order to determine the current position of the histopathologic classification of ANCA-associated GN. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A validation study was performed with newly collected data from 145 patients from ten centers worldwide, including an analysis of interobserver agreement on the histopathologic evaluation of the kidney biopsies. This study also included a meta-analysis on previous validation studies and a validation of the recently proposed ANCA kidney risk score. RESULTS The validation study showed that kidney failure at 10-year follow-up was significantly different between the histopathologic classes (P<0.001). Kidney failure at 10-year follow-up was 14% in the crescentic class versus 20% in the mixed class (P=0.98). In the meta-analysis, no significant difference in kidney failure was also observed when crescentic class was compared with mixed class (relative risk, 1.15; 95% confidence interval, 0.94 to 1.41). When we applied the ANCA kidney risk score to our cohort, kidney survival at 3 years was 100%, 96%, and 77% in the low-, medium-, and high-risk groups, respectively (P<0.001). These survival percentages are higher compared with the percentages in the original study. CONCLUSIONS The crescentic and mixed classes seem to have a similar prognosis, also after adjusting for differences in patient populations, treatment, and interobserver agreement. However, at this stage, we are not inclined to merge the crescentic and mixed classes because the reported confidence intervals do not exclude important differences in prognosis and because an important histopathologic distinction would be lost.
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Affiliation(s)
- Emma E. van Daalen
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Arda Göçeroğlu
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Kensuke Joh
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Laure-Hélène Noël
- Department of Pathology, Necker Hospital, René Descartes University, Paris, France
| | - Yayoi Ogawa
- Hokkaido Renal Pathology Center, Sapporo, Japan
| | | | - Miriam J. Ball
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Eva Honsova
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Zdenka Hruskova
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Renate Kain
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Tomoyoshi Kimura
- Department of Nephrology, Japan Community Healthcare Organization, Sendai Hospital, Sendai, Japan
| | - Marek Kollar
- Department of Pathology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Kristine Lindhard
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Xavier Puéchal
- Department of Internal Medicine, National Referral Center for Rare Autoimmune and Systemic Diseases, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Steven Salvatore
- Department of Pathology, Weill Cornell Medical College, New York, New York
| | - Wladimir Szpirt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Hideki Takizawa
- Department of Nephrology, Teine Keijinkai Hospital, Sapporo, Japan
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Annelies E. Berden
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Olaf M. Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - E. Christiaan Hagen
- Department of Nephrology, Meander Medical Center, Amersfoort, The Netherlands
| | - Jan Oosting
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Chinar Rahmattulla
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ron Wolterbeek
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem Jan Bos
- Department of Internal Medicine, St. Antoniusziekenhuis, Nieuwegein, The Netherlands
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan A. Bruijn
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ingeborg M. Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
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5
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Wu L, Yang M, Feng X, Jin L, Wu C, Cui S, Zhou Z, Zhong X, Shi M, Yang Z, Cao W. Urinary angiotensinogen: an indicator of active antineutrophil cytoplasmic antibody-associated glomerulonephritis. Nephrol Dial Transplant 2020; 34:838-847. [PMID: 29733413 DOI: 10.1093/ndt/gfy112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND One of the major challenges in improving the management of antineutrophil cytoplasmic antibody-associated glomerulonephritis (ANCA-GN) is the lack of a disease-specific indicator for histological lesions and disease activity. Here we tested the utility of urinary angiotensinogen (UAGT) as a biomarker of renal disease activity in ANCA-GN. METHODS A prospective, two-stage cohort study was performed in ANCA-GN patients. In Stage I, UAGT was measured at the time of renal biopsy in 69 patients from two centers (test set) and 25 patients from two other centers (validation set). In Stage II, UAGT was monitored in 50 subjects in the test set for 24 months. RESULTS In Stage I, UAGT significantly increased in ANCA-GN patients, correlating well with cellular crescents formation and active interstitial inflammation. Patients with crescentic ANCA-GN exhibited the highest UAGT compared with other histopathological classes of ANCA-GN. After multivariable adjustment, the highest quartile of UAGT, compared with the lowest quartile, associated with a 6-fold increased risk of crescentic ANCA-GN. For predicting crescentic ANCA-GN, UAGT [area under the receiver operating characteristics curve (AUC) = 0.88] outperformed albuminuria (AUC = 0.73) and estimated glomerular filtration rate (AUC = 0.69). UAGT improved the performance of those clinical markers in diagnosing crescentic ANCA-GN (P < 0.034), suggesting a role of UAGT in identifying active crescentic ANCA-GN. In Stage II, UAGT decreased after immunotherapy and increased at the time of renal relapse during the 2-year follow-up, suggesting the usefulness of UAGT to monitor disease activity over time. CONCLUSIONS These results suggest the potential use of UAGT for assessing disease activity and renal relapse in ANCA-GN.
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Affiliation(s)
- Liling Wu
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Manqiu Yang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaogang Feng
- Division of Nephrology, Guangzhou Development District Hospital, Guangzhou, China
| | - Lingwei Jin
- Division of Nephrology, Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chunyi Wu
- Division of Nephrology, Affiliated Foshan Hospital of Southern Medical University, Guangzhou, China
| | - Shuang Cui
- Division of Nephrology, First Affiliated Hospital, Jinan University, Guangzhou, China
| | - Zhanmei Zhou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaohong Zhong
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Meng Shi
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhichen Yang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei Cao
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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6
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Wu SJ, Yang X, Xu PC, Chen T, Gao S, Hu SY, Wei L, Yan TK. Urinary mitochondrial DNA is a useful biomarker for assessing kidney injury of antineutrophil cytoplasmic antibody -associated vasculitis. Clin Chim Acta 2020; 502:263-268. [DOI: 10.1016/j.cca.2019.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/04/2019] [Accepted: 11/10/2019] [Indexed: 12/18/2022]
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7
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Brix SR, Noriega M, Tennstedt P, Vettorazzi E, Busch M, Nitschke M, Jabs WJ, Özcan F, Wendt R, Hausberg M, Sellin L, Panzer U, Huber TB, Waldherr R, Hopfer H, Stahl RA, Wiech T. Development and validation of a renal risk score in ANCA-associated glomerulonephritis. Kidney Int 2018; 94:1177-1188. [DOI: 10.1016/j.kint.2018.07.020] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/14/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
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8
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Salvadori M, Tsalouchos A. Antineutrophil cytoplasmic antibody associated vasculitides with renal involvement: Open challenges in the remission induction therapy. World J Nephrol 2018; 7:71-83. [PMID: 29736379 PMCID: PMC5937030 DOI: 10.5527/wjn.v7.i3.71] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/12/2018] [Accepted: 04/18/2018] [Indexed: 02/06/2023] Open
Abstract
Renal involvement with rapidly progressive glomerulonephritis is a common manifestation of antineutrophil cytoplasmic antibody (ANCA) associated vasculitides, which is characterized by end-stage renal disease and high mortality rates in untreated and/or late referral patients. The long-term renal survival has improved dramatically since the addition of cyclophosphamide (CYC) and recently of rituximab (RTX) in association with corticosteroids in the remission induction therapeutic regimens. However, renal prognosis remains unfavorable for many patients and the mortality rate is still significantly high. In this review, we analyze the open challenges to be addressed to optimize the induction remission therapy, principally in patients with advanced kidney failure. This concern the first-line therapy (CYC or RTX) based on different parameters (estimated glomerular filtration rate at baseline, new or relapsed disease, ANCA specificity, tissue injury, safety), the role of plasma exchange and the role of new therapies. Indeed, we discuss future perspectives in induction remission therapy by reporting recent advances in new targeted therapies with particular reference to avacopan, an orally administered selective C5a receptor inhibitor.
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Affiliation(s)
- Maurizio Salvadori
- Department of Nephrology and Renal Transplantation, Careggi University Hospital, Florence 50139, Italy
| | - Aris Tsalouchos
- Department of Nephrology and Dialysis, Saints Cosmas and Damian Hospital, Pescia 51017, Italy
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9
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Geetha D, Sethi S, De Vriese AS, Specks U, Kallenberg CGM, Lim N, Spiera R, St Clair EW, Merkel PA, Seo P, Monach PA, Lepori N, Fessler BJ, Langford CA, Hoffman GS, Sharma R, Stone JH, Fervenza FC. Interstitial Immunostaining and Renal Outcomes in Antineutrophil Cytoplasmic Antibody-Associated Glomerulonephritis. Am J Nephrol 2017; 46:231-238. [PMID: 28881339 DOI: 10.1159/000480443] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 08/18/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Immunopathologic features predict renal function at baseline and follow-up in antineutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis (GN). The interstitial infiltrate consists predominantly of T lymphocytes, but their pathophysiologic significance is unclear, especially in light of the success of B-cell-directed therapy. METHODS Renal biopsies from 33 patients treated with cyclophosphamide (CYC; n = 17) or rituximab (RTX; n = 16) in the RTX in ANCA-associated vasculitis (RAVE) trial were classified according to the new ANCA GN classification. T- and B-cell infiltration in the interstitium was assessed by immunostaining for CD3 and CD20. Correlations of clinical and histologic parameters with renal function at set time points were examined. RESULTS The mean (SD) baseline estimated glomerular filtration rate was 36 (20) mL/min/1.73 m2. ANCA GN class distribution was 46% focal, 33% mixed, 12% sclerotic and 9% crescentic. The interstitial infiltrate consisted of >50% CD3 positive cells in 69% of biopsies, but >50% CD20 positive cells only in 8% of biopsies. In a multiple linear regression model, only baseline glomerular filtration rate (GFR) correlated with GFR at 6, 12, and 18 months. Interstitial B- and T-cell infiltrates had no significant impact on long-term prognosis, independent of the treatment limb. A differential effect was noted only at 6 months, where a dense CD3 positive infiltrate predicted lower GFR in the RTX group and a CD20 positive infiltrate predicted higher GFR in the CYC group. CONCLUSIONS In ANCA-associated GN, the interstitial infiltrate contains mainly T lymphocytes. However, it is neither reflecting baseline renal function nor predictive of response to treatment, regardless of the immunosuppression regimen employed.
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Affiliation(s)
- Duvuru Geetha
- Division of Nephrology and Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
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10
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Chen Y, Bao H, Liu Z, Liu X, Gao E, Zeng C, Zhang H, Liu Z, Hu W. Risk Factors for Renal Survival in Chinese Patients with Myeloperoxidase-ANCA-Associated GN. Clin J Am Soc Nephrol 2017; 12:417-425. [PMID: 28148558 PMCID: PMC5338707 DOI: 10.2215/cjn.06200616] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 12/05/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Our study explored the association of histopathologic classification of ANCA-associated GN with renal survival in Chinese patients with myeloperoxidase-ANCA-associated GN. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Two hundred fifteen patients with biopsy-proven myeloperoxidase-ANCA-associated GN were included from January of 1996 to December of 2014. The biopsies included focal (n=27), mixed (n=82), crescentic (n=47), and sclerotic (n=59) classes. The long-term renal outcome and risk factors of myeloperoxidase-ANCA-associated GN for different histopathologic classes were retrospectively analyzed. RESULTS During a median follow-up time of 22 (9-51) months, 88 (40.9%) patients reached ESRD. The 5-year renal survival (overall 58.7%) was highest in the focal class (100.0%) and lowest in the sclerotic class (20.7%), with no difference between the mixed (58.9%) and crescentic (67.4%) classes. Patients in the mixed (hazard ratio, 0.34; 95% confidence interval, 0.20 to 0.57; P<0.001) and crescentic (hazard ratio, 0.31; 95% confidence interval, 0.16 to 0.59; P<0.001) classes were at lower risk for ESRD compared with patients in the sclerotic class, as were patients who received glucocorticoids plus mycophenolate mofetil (hazard ratio, 0.32; 95% confidence interval, 0.18 to 0.60; P<0.001) compared with those receiving glucocorticoids alone. In addition, patients with a serum creatinine level ≥4 mg/dl (hazard ratio, 2.93; 95% confidence interval, 1.77 to 4.85; P<0.001) or hypoalbuminemia (hazard ratio, 2.11; 95% confidence interval, 1.32 to 3.34; P=0.002) were at higher risk for ESRD. A serum creatinine level ≥4 mg/dl and a percentage of global sclerotic glomeruli ≥60% were the two independent risk factors for ESRD in the sclerotic class. CONCLUSIONS The histopathologic classification of ANCA-associated GN in combination with serum creatinine and serum albumin levels and treatment regimen is associated with renal outcome in myeloperoxidase-ANCA-associated GN. The evaluation of serum creatinine level and percentage of global sclerotic glomeruli provides additional information on the risk of renal survival in the sclerotic class of myeloperoxidase-ANCA-associated GN.
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Affiliation(s)
- Yinghua Chen
- National Clinical Research Centre of Kidney Diseases, Nanjing Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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11
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TANNA ANISHA, PUSEY CHARLESD. The Histopathological Classification of ANCA-associated Glomerulonephritis Comes of Age. J Rheumatol 2017; 44:265-267. [DOI: 10.3899/jrheum.170006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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12
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Neidig LE, Owston MA, Ball E, Dick EJ. Pauci-immune glomerulonephritis in a captive chimpanzee (Pan troglodytes), and a review of spontaneous cases in animals. J Med Primatol 2016; 45:336-341. [PMID: 27506330 DOI: 10.1111/jmp.12233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Crescentic glomeruli are the hallmark finding in rapidly progressive glomerulonephritis (RPGN) and are characterized by disruption and proliferation of the glomerular capsule and an influx of cells into Bowman's space. Pauci-immune-type RPGN is identified by a lack of immunoglobulins and immune complexes in the glomerular basement membrane. METHODS Complete necropsy and histology were performed on the affected chimpanzee. Electron microscopy was performed on kidney sections. A search of the literature was performed to identify spontaneous RPGN in animals. RESULTS We report a case of crescentic glomerulonephritis of the pauci-immune-type in a hepatitis C virus-infected 28-year-old male chimpanzee (Pan troglodytes) who was humanely euthanized for a cardiac-related decline in health. CONCLUSION To our knowledge, this is the first report describing pauci-immune crescentic glomerulonephritis in a non-human primate.
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Affiliation(s)
- Lauren E Neidig
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, USA.,Department of Comparative Medicine, University of Washington, Seattle, WA, USA
| | - Michael A Owston
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, USA
| | - Erin Ball
- Veterinary Pathology Services, Joint Pathology Center, Silver Spring, MD, USA
| | - Edward J Dick
- Southwest National Primate Research Center, Texas Biomedical Research Institute, San Antonio, TX, USA
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ANCA-associated vasculitis - clinical utility of using ANCA specificity to classify patients. Nat Rev Rheumatol 2016; 12:570-9. [PMID: 27464484 DOI: 10.1038/nrrheum.2016.123] [Citation(s) in RCA: 175] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are a heterogeneous group of rare syndromes characterized by necrotizing inflammation of small and medium-sized blood vessels and the presence of ANCAs. Several clinicopathological classification systems exist that aim to define homogeneous groups among patients with AAV, the main syndromes being microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA) and eosinophilic GPA (EGPA). Two main types of ANCA can be detected in patients with AAV. These ANCAs are defined according to their autoantigen target, namely leukocyte proteinase 3 (PR3) and myeloperoxidase (MPO). Patients with GPA are predominantly PR3-ANCA-positive, whereas those with MPA are predominantly MPO-ANCA-positive, although ANCA specificity overlaps only partially with these clinical syndromes. Accumulating evidence suggests that ANCA specificity could be better than clinical diagnosis for defining homogeneous groups of patients, as PR3-ANCA and MPO-ANCA are associated with different genetic backgrounds and epidemiology. ANCA specificity affects the phenotype of clinical disease, as well as the patient's initial response to remission-inducing therapy, relapse risk and long-term prognosis. Thus, the classification of AAV by ANCA specificity rather than by clinical diagnosis could convey clinically useful information at the time of diagnosis.
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Jarrot PA, Kaplanski G. Pathogenesis of ANCA-associated vasculitis: An update. Autoimmun Rev 2016; 15:704-13. [DOI: 10.1016/j.autrev.2016.03.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 03/01/2016] [Indexed: 01/17/2023]
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van Daalen E, Ferrario F, Noël LH, Waldherr R, Hagen EC, Bruijn JA, Bajema IM. Twenty-five years of RENHIS: a history of histopathological studies within EUVAS. Nephrol Dial Transplant 2015; 30 Suppl 1:i31-6. [PMID: 25805748 DOI: 10.1093/ndt/gfv035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In the early 1990s, an international working group of experienced renal pathologists, the Renal Histology group, set up a scoring system for biopsies with anti-neutrophil cytoplasmic autoantibody (ANCA)-associated glomerulonephritis. This scoring system subdivided glomerular, interstitial and vascular lesions and served as a tool for the evaluation of all renal biopsies from studies of the European Vasculitis Study Group (EUVAS). Histopathological studies gave new insights into the prediction of renal outcome in patients with ANCA-associated glomerulonephritis. Percentage of normal glomeruli and a selected number of interstitial parameters were reliable predictors of long-term follow-up glomerular filtration rate in all studies. Out of these results, a histopathological classification distinguishing focal, crescentic, mixed and sclerotic classes of ANCA-associated glomerulonephritis was developed. Until today, 13 studies have validated this classification system. Future studies will try to determine if and how renal histology could be helpful in guiding treatment of ANCA-associated glomerulonephritis.
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Affiliation(s)
- Emma van Daalen
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Franco Ferrario
- Department of Pathology, University Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Laure-Hélène Noël
- Department of Pathology, Necker Hospital, INSERM U845, Paris, France
| | - Rüdiger Waldherr
- Department of Pathology, University of Heidelberg, Heidelberg, Germany
| | - E Christiaan Hagen
- Department of Internal Medicine, Meander Medical Centre, Amersfoort, The Netherlands
| | - Jan A Bruijn
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Ingeborg M Bajema
- Department of Pathology, Leiden University Medical Centre, Leiden, The Netherlands
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McAdoo SP, Tanna A, Randone O, Tam FWK, Tarzi RM, Levy JB, Griffith M, Lightstone L, Cook HT, Cairns T, Pusey CD. Necrotizing and crescentic glomerulonephritis presenting with preserved renal function in patients with underlying multisystem autoimmune disease: a retrospective case series. Rheumatology (Oxford) 2014; 54:1025-32. [PMID: 25431483 PMCID: PMC4476844 DOI: 10.1093/rheumatology/keu445] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Indexed: 01/13/2023] Open
Abstract
Objective. Necrotizing and crescentic GN usually presents with rapidly declining renal function, often in association with multisystem autoimmune disease, with a poor outcome if left untreated. We aimed to describe the features of patients who have presented with these histopathological findings but minimal disturbance of renal function. Methods. We conducted a retrospective review (1995–2011) of all adult patients with native renal biopsy–proven necrotizing or crescentic GN and normal serum creatinine (<120 μmol/l) at our centre. Results. Thirty-eight patients were identified. The median creatinine at presentation was 84 μmol/l and the median proportion of glomeruli affected by necrosis or crescents was 32%. Clinicopathological diagnoses were ANCA-associated GN (74%), LN (18%), anti-GBM disease (5%) and HScP (3%). Only 18% of cases had pre-existing diagnoses of underlying multisystem autoimmune disease, although the majority (89%) had extra-renal manifestations accompanying the renal diagnosis. All patients received immunosuppression and most had good long-term renal outcomes (median duration of follow-up 50 months), although two progressed to end-stage renal disease within 3 years. We estimate that renal biopsy had an important influence on treatment decisions in 82% of cases. Conclusion. Necrotizing and crescentic GN may present in patients with no or only minor disturbance of renal function. This often occurs in patients with underlying systemic autoimmune disease; early referral for biopsy may affect management and improve long-term outcomes in these cases.
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Affiliation(s)
- Stephen P McAdoo
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
| | - Anisha Tanna
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
| | - Olga Randone
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
| | - Frederick W K Tam
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
| | - Ruth M Tarzi
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
| | - Jeremy B Levy
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
| | - Megan Griffith
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
| | - Liz Lightstone
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
| | - H Terence Cook
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
| | - Tom Cairns
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
| | - Charles D Pusey
- Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK Renal and Vascular Inflammation Section, Imperial College London, Multidisciplinary Vasculitis and Lupus Clinics, Imperial College Healthcare NHS Trust, London UK, Department of Nephrology, Ospedale Cardinal Massaia, Asti, Italy, Centre for Complement and Inflammation Research, Imperial College London, and Department of Pathology, Imperial College Healthcare NHS Trust, London UK
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