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Elahi T, Ahmed S, Mubarak M, Ahmed E. Clinicopathological characteristics and renal outcomes of adult patients with pauci-immune necrotizing glomerulonephritis according to ANCA status. Clin Rheumatol 2024; 43:2669-2678. [PMID: 38954279 DOI: 10.1007/s10067-024-07047-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 06/21/2024] [Accepted: 06/26/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Pauci-immune necrotizing glomerulonephritis (PING) is commonly associated with the presence of antineutrophilic cytoplasmic antibodies (ANCAs) but a significant number of patients do not have these antibodies. The significance of ANCA-negativity in the context of Berden's classification of PING is not known. METHODS A retrospective analysis was conducted on all patients with histopathological diagnosis of idiopathic PING irrespective of ANCA status diagnosed between January 1998 to December 2018 and followed up at renal clinic for > 12 months. All biopsies were reclassified by Berden's classification. Clinicopathological characteristics and renal outcomes of ANCA-positive and ANCA-negative patients were compared. RESULTS Out of 134 patients, 66 (49.5%) were ANCA-negative. The mean age was 34.76 ± 13.3 years. Compared with the ANCA-positive patients, ANCA-negative patients had significantly greater prevalence of nephrotic-range proteinuria (74.23% Vs 57.9%, P = 0.036) with less extra-renal manifestations (P < 0.05)). On histology, focal and crescentic classes dominated with less number of globally sclerosed glomeruli (2.7% Vs 5.07%, P = 0.02) and more mesangial proliferation (22.7% Vs 4.41%, P = 0.002) in the ANCA-negative group, whereas sclerotic was predominant in the ANCA-positive group (P = 0.05). More patients achieved complete and partial recovery in ANCA-negative patients (42.4% Vs 20.5%, P < 0.05) with better renal survival (27.27% Vs 16.17%, log-rank test: P = 0.03) and less patient mortality (13.63% vs 30.8%, log-rank test: P = 0.04) at 2 years. CONCLUSION Our study confirms high prevalence of ANCA negativity among our cohort and this group presents with isolated renal involvement with better renal and patient survival. The ANCA-positive group showed significantly more patients in the sclerotic class, lower 2-year renal survival, and higher 2-year mortality as compared to the ANCA-negative group. However, the complete and partial responses to treatment were significantly better in the ANCA-negative group. Key Points • This study shows a high prevalence of ANCA negativity in cases of PING in Pakistani population, as almost half of patients in this study did not have these antibodies. • This negativity is more prevalent in the Asian populations but its significance in the context of Berden's classification of PING is unknown. • ANCA-negative group exhibited less severe phenotype and better outcomes compared with ANCA-positive group.
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Affiliation(s)
- Tabassum Elahi
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Chand Bibi Road Near Civil Hospital, Karachi, 74200, Pakistan.
| | - Saima Ahmed
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Chand Bibi Road Near Civil Hospital, Karachi, 74200, Pakistan
| | - Muhammed Mubarak
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Chand Bibi Road near Civil Hospital, Karachi, 74200, Pakistan
| | - Ejaz Ahmed
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Chand Bibi Road Near Civil Hospital, Karachi, 74200, Pakistan
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Mann SK, Bone JN, Bosman ES, Cabral DA, Morishita KA, Brown KL. Predictive utility of ANCA positivity and antigen specificity in the assessment of kidney disease in paediatric-onset small vessel vasculitis. RMD Open 2024; 10:e004315. [PMID: 38886004 PMCID: PMC11184192 DOI: 10.1136/rmdopen-2024-004315] [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: 03/08/2024] [Accepted: 05/12/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVES The objective of this study is to evaluate whether anti-neutrophil cytoplasmic antibody (ANCA) seropositivity and antigen specificity at diagnosis have predictive utility in paediatric-onset small vessel vasculitis. METHODS Children and adolescents with small vessel vasculitis (n=406) stratified according to the absence (n=41) or presence of ANCA for myeloperoxidase (MPO) (n=129) and proteinase-3 (PR3) (n=236) were compared for overall and kidney-specific disease activity at diagnosis and outcomes between 1 and 2 years using retrospective clinical data from the ARChiVe/Paediatric Vasculitis Initiative registry to fit generalised linear models. RESULTS Overall disease activity at diagnosis was higher in PR3-ANCA and MPO-ANCA-seropositive individuals compared with ANCA-negative vasculitis. By 1 year, there were no significant differences, based on ANCA positivity or specificity, in the likelihood of achieving inactive disease (~68%), experiencing improvement (≥87%) or acquiring damage (~58%). Similarly, and in contrast to adult-onset ANCA-associated vasculitis, there were no significant differences in the likelihood of having a relapse (~11%) between 1 and 2 years after diagnosis. Relative to PR3-ANCA, MPO-ANCA seropositivity was associated with a higher likelihood of kidney involvement (OR 2.4, 95% CI 1.3 to 4.7, p=0.008) and severe kidney dysfunction (Kidney Disease Improving Global Outcomes (KDIGO) stages 4-5; OR 6.04, 95% CI 2.77 to 13.57, p<0.001) at onset. Nonetheless, MPO-ANCA seropositive individuals were more likely to demonstrate improvement in kidney function (improved KDIGO category) within 1 year of diagnosis than PR3-ANCA seropositive individuals with similarly severe kidney disease at onset (p<0.001). CONCLUSIONS The results of this study suggest important paediatric-specific differences in the predictive value of ANCA compared with adult patients that should be considered when making treatment decisions in this population.
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Affiliation(s)
- Simranpreet K Mann
- Department of Microbiology and Immunology, Faculty of Science, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Else S Bosman
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David A Cabral
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Kimberly A Morishita
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Kelly L Brown
- British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Gupta P, Bhargava V, Malik M, Gupta A, Bhalla AK, Gupta A, Tiwari V, Rana DS, Sapra RL. Comparison of Clinico-pathologic features and outcomes of ANCA negative and ANCA positive pauci immune crescentic glomerulonephritis: A single centre study. INDIAN J PATHOL MICR 2024; 67:86-91. [PMID: 38358194 DOI: 10.4103/ijpm.ijpm_604_22] [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] [Indexed: 02/16/2024] Open
Abstract
Introduction Pauci-immune crescentic glomerulonephritis (PICN) is an important cause of rapidly progressive renal failure. 10-40% of PICN cases have ANCA (antineutrophil cytoplasmic antibody) negative serology. The present study compared clinico-pathologic features, Brix's renal risk score, Berden's histopathological classes and differences in outcome between ANCAnegative vs ANCA positive PICN patients. Materials and Methods Sixty-one patients of biopsy-proven PICN were studied. Biochemical findings and ANCA serology were recorded. Renal biopsy slides were reviewed along with direct immunofluorescence. Clinical and histological features were compared between ANCA negative and positive PICN using the Man Whitney U test and Chi-square test. Patients were compared for distribution in Berden's histological classes and Brix's renal risk categories. Patient and renal survival were compared using Kaplan-Meier survival analysis. Results ANCA negative PICN patients were younger (44.9 ± 16.5 years vs 53.6 ± 15.1 years, P = 0.049). Nasal (0 vs 18%, P = 0.035) and pulmonary involvement (9% vs 38%, P = 0.014) were lower in ANCA negative group. Both ANCA groups had similar renal biochemical profiles, percentage normal glomeruli, 16.3 ± 18.2 vs 21.7 ± 20.4 and percentage glomeruli with crescents, 64.5 ± 28.1 vs 64.3 ± 27.1. Twenty-seven per cent of ANCA negative cases fell in the sclerotic class in Berden's classification vs just 2.5% in ANCA positive group (p = 0.037) without significant difference in Brix's renal risk categories (p = 0.329). Thirteen per cent of ANCA negative patients achieved complete remission on treatment compared to 33% in ANCA positive patients. Patient survival and overall probability of progressing to ESRD were similar in the two groups. Conclusion ANCA negative PICN cases present at younger ages. Nasal and pulmonary involvement is uncommon in these patients. Patient survival and progression to ESRD are similar in both ANCA groups.
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Affiliation(s)
- Pallav Gupta
- Senior Consultant Histopathology, Department of Statistics, Sir Ganga Ram Hospital, New Delhi, India
| | - Vinant Bhargava
- Senior Consultant Nephrology, Department of Statistics, Sir Ganga Ram Hospital, New Delhi, India
| | - Manish Malik
- Senior Consultant Nephrology, Department of Statistics, Sir Ganga Ram Hospital, New Delhi, India
| | - Anurag Gupta
- Senior Consultant Nephrology, Department of Statistics, Sir Ganga Ram Hospital, New Delhi, India
| | - Anil K Bhalla
- Senior Consultant Nephrology, Department of Statistics, Sir Ganga Ram Hospital, New Delhi, India
| | - Ashwini Gupta
- Senior Consultant Histopathology, Department of Statistics, Sir Ganga Ram Hospital, New Delhi, India
| | - Vaibhav Tiwari
- Associate Consultant Nephrology, Department of Statistics, Sir Ganga Ram Hospital, New Delhi, India
| | - Devinder S Rana
- Senior Consultant Nephrology, Department of Statistics, Sir Ganga Ram Hospital, New Delhi, India
| | - Ramesh L Sapra
- Ex Consultant, Department of Statistics, Sir Ganga Ram Hospital, New Delhi, India
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Yazılıtaş F, Çakıcı EK, Kurt Şükür ED, Özdel S, Güngör T, Bağlan E, Çelikkaya E, Karakaya D, Orhan D, Bülbül M. Clinical spectrum of immunoglobulin A vasculitis in children and determining the best timing of urine examination to predict renal involvement. Postgrad Med 2022; 134:441-447. [PMID: 35354357 DOI: 10.1080/00325481.2022.2061165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Immunoglobulin A (IgA) vasculitis (also known as Henoch-Schonlein purpura) is the most common small vessel vasculitis of childhood. The long-term prognosis depends on renal involvement. The aim of this study was to evaluate the risk factors associated with renal involvement in children with IgA vasculitis and to investigate the best timing of urine examination to predict the presence of renal involvement at the sixth month after the diagnosis. METHODS In this prospective observational study, medical records, demographic data, clinical findings, laboratory tests, and urine microscopic examinations of pediatric patients diagnosed with IgA vasculitis were evaluated to identify potential risk factors associated with renal involvement. RESULTS A total of 178 patients with a median age of 6 years were involved in the study. Renal involvement was found in 24 (13.5%) patients. Most of the patients (85.7%), whose urine examination was found to be abnormal at the sixth month after the diagnosis, also had abnormalities in the first month urine examination. Factors significantly associated with renal involvement were as follows: older age, presence of hematuria and or proteinuria in the first month urine examination and patients who presented the disease in the spring season. Multivariate logistic regression analysis showed age ≥8 years (p = 0.005), the season of onset (p = 0.025), serum creatinine levels (p = 0.016), and abnormal urine examinations at the first-month visits (p = 0.005) significantly increased the risk of renal involvement. CONCLUSION This study has demonstrated that the optimal date to predict the presence of hematuria and/or proteinuria in the sixth month is the urine examination performed in the first month of the disease. Therefore, we think that patients with IgA vasculitis who show a presence of hematuria and/or proteinuria in the first-month urine examination should be followed more closely.
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Affiliation(s)
- Fatma Yazılıtaş
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Evrim Kargın Çakıcı
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Eda Didem Kurt Şükür
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Semanur Özdel
- Department of Pediatric Rheumatology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Tülin Güngör
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Esra Bağlan
- Department of Pediatric Rheumatology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Evra Çelikkaya
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Deniz Karakaya
- Department of Pediatric Nephrology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
| | - Diclehan Orhan
- Department of Pathology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mehmet Bülbül
- Department of Pediatric Nephrology and Rheumatology, SBÜ Ankara Dr. Sami Ulus Kadın Doğum Çocuk Sağlığı ve Hastalıkları Eğitim Araştırma Hastanesi, Ankara, Turkey
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5
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Ronsin C, Georges M, Chapelet-Debout A, Augusto JF, Audard V, Lebourg L, Rubin S, Quemeneur T, Bataille P, Karras A, Daugas E, Titeca-Beauport D, Boffa JJ, Vigneau C, Halimi JM, Isnard-Bagnis C, Durault S, Renaudineau E, Bridoux F, Testa A, Le Quintrec M, Renaudin K, Fakhouri F. ANCA-Negative Pauci-Immune Necrotizing Glomerulonephritis: A Case Series and a New Clinical Classification. Am J Kidney Dis 2021; 79:56-68.e1. [PMID: 34119564 DOI: 10.1053/j.ajkd.2021.03.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 03/29/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Pauci-immune necrotizing glomerulonephritis (PING) is usually associated with the presence of antineutrophil cytoplasmic antibodies (ANCA). However, a minority (2%-3%) of patients with PING do not have detectable ANCA. We assessed the clinical spectrum and outcome of patients with ANCA-negative PING. STUDY DESIGN Case series. SETTING & PARTICIPANTS 74 patients with ANCA-negative PING diagnosed in 19 French nephrology centers between August 2006 and December 2018 were included in the series. Patients' medical files were reviewed, and kidney biopsies were centrally reexamined by pathologists who were masked to the diagnosis. FINDINGS Median age at diagnosis was 69 (IQR, 61-76) years. The clinical and pathological features were remarkable for a high frequency of extrarenal manifestations (54%), nephrotic syndrome (32%), and endocapillary hypercellularity (31%). Three main subtypes of ANCA-negative PING were observed: infection-associated (n=9[12%]), malignancy-associated (n=6[8%]), and primary (n=57[77%]). For patients with primary PING, induction treatment included mainly corticosteroids (n=56[98%]), cyclophosphamide (n=37[65%]), and rituximab (n=5[9%]). Maintenance treatment consisted mainly of corticosteroids (n=42[74%]), azathioprine (n=18[32%]), and mycophenolate mofetil (n=11[19%]). After a median follow-up period of 28 months, 28 (38%) patients had died and 20 (27%) developed kidney failure (estimated glomerular filtration rate<15mL/min/1.73m2). Eleven (21%) patients (9 with primary and 2 with malignancy-associated PING) relapsed. LIMITATIONS Retrospective study and limited number of patients; electron microscopy was not performed to confirm the absence of glomerular immune deposits. CONCLUSIONS Within the spectrum of ANCA-negative PING, infection and malignancy-associated forms represent a distinct clinical subset. This new clinical classification may inform the management of ANCA-negative PING, which remains a severe form of vasculitis with high morbidity and mortality rates despite immunosuppressive treatments.
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Affiliation(s)
- Charles Ronsin
- Department of Nephrology and Immunology, Center Hospitalier Universitaire de Nantes, Nantes, France
| | - Marie Georges
- Department of Pathology, Center Hospitalier Universitaire de Nantes, Nantes, France
| | - Agnès Chapelet-Debout
- Department of Nephrology and Immunology, Center Hospitalier Universitaire de Nantes, Nantes, France; Centre de Recherche en Transplantation et en Immunologie, UMR 1064, INSERM, Université de Nantes, France
| | | | - Vincent Audard
- Department of Nephrology and Renal Transplantation, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, INSERM U955, Université Paris Est Créteil, Paris, France
| | | | | | - Thomas Quemeneur
- Department of Nephrology and Internal Medicine, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Pierre Bataille
- Department of Nephrology, Centre Hospitalier de Boulogne-sur-Mer, Boulogne sur Mer, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges-Pompidou, Université Paris Descartes, Paris, France
| | - Eric Daugas
- Department of Nephrology, CHU Bichat, Paris, France
| | | | - Jean-Jacques Boffa
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | | | | | - Corinne Isnard-Bagnis
- Department of Nephrology, Groupe Hospitalier Universitaire Pitié-Salpêtrière, Paris, France
| | - Sandrine Durault
- Department of Nephrology, Centre Hospitalier de Saint Nazaire, Saint Nazaire, France
| | - Eric Renaudineau
- Department of Nephrology, Centre Hospitalier de Saint Malo, Saint Malo, France
| | - Frank Bridoux
- Department of Nephrology, CHU Poitiers, Poitiers, France
| | - Angelo Testa
- Centre ECHO, Site Confluent-Rezé, Nantes, France
| | | | - Karine Renaudin
- Department of Pathology, Center Hospitalier Universitaire de Nantes, Nantes, France; Centre de Recherche en Transplantation et en Immunologie, UMR 1064, INSERM, Université de Nantes, France.
| | - Fadi Fakhouri
- Department of Nephrology and Immunology, Center Hospitalier Universitaire de Nantes, Nantes, France; Centre de Recherche en Transplantation et en Immunologie, UMR 1064, INSERM, Université de Nantes, France.
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Claudel SE, Tucker BM, Kleven DT, Pirkle JL, Murea M. Narrative Review of Hypercoagulability in Small-Vessel Vasculitis. Kidney Int Rep 2020; 5:586-599. [PMID: 32405580 PMCID: PMC7210611 DOI: 10.1016/j.ekir.2019.12.018] [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: 10/08/2019] [Revised: 12/03/2019] [Accepted: 12/31/2019] [Indexed: 01/08/2023] Open
Abstract
Pauci-immune necrotizing and crescentic glomerulonephritis (GN) is the most common etiology of rapidly progressive GN. Clinical presentation in those afflicted is usually related to rapid loss of kidney function. We report the case of a 70-year-old woman who came to medical attention for signs and symptoms related to lower-extremity deep vein thrombosis (DVT). At presentation, the patient had biochemical abnormalities consistent with active GN, which quickly progressed to rapid loss in kidney function requiring renal replacement therapy. Kidney biopsy revealed small-vessel vasculitis with glomerular crescents. Serologic studies were negative for antineutrophil cytoplasmic antibody antibodies and other causes of acute GN. Plasmapheresis, immunosuppressive, and anticoagulant therapies were prescribed. Absence of other apparent end-organ involvement with vasculitis pointed toward renal-limited small-vessel vasculitis, yet presence of unprovoked DVT argues for systemic vascular inflammation. This case illustrates that venous thrombosis can be the presenting manifestation in patients with vasculitis and silent, severe end-organ involvement. The epidemiology and pathophysiology of venous thromboembolism in small-vessel vasculitis are discussed in this report.
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Affiliation(s)
| | - Bryan M. Tucker
- Department of Internal Medicine, Section of Nephrology, Baylor College of Medicine, Houston, Texas, USA
| | - Daniel T. Kleven
- Department of Pathology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - James L. Pirkle
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
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Pankow JD, Richard-Carpentier G, Daver NG, Glass WF, Kala J. Unique case of ANCA-negative pauci-immune necrotizing glomerulonephritis with diffuse alveolar hemorrhage, potentially associated with midostaurin. CEN Case Rep 2020; 9:147-151. [PMID: 31955389 DOI: 10.1007/s13730-020-00443-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 12/29/2019] [Indexed: 10/25/2022] Open
Abstract
We present a 61-year-old male with FLT3-mutated acute myeloid leukemia treated with midostaurin who developed acute kidney injury requiring hemodialysis and pulmonary renal syndrome. Antibodies to proteinase-3, myeloperoxidase, and glomerular basement membrane were negative. Renal biopsy confirmed acute pauci-immune focal necrotizing glomerulonephritis (GN) with fibrin crescents indicating rapidly progressing glomerulonephritis. He improved with pulse methylprednisolone, intravenous cyclophosphamide, and plasma exchange with resolution of hemoptysis. This case highlights the importance of prompt renal biopsy to guide early initiation of life-saving therapies. To our knowledge, this is the first reported case of ANCA-negative pauci-immune necrotizing GN likely secondary to midostaurin.
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Affiliation(s)
- Jonathan D Pankow
- Renal Diseases and Hypertension, McGovern Medical School UT Houston, 6431 Fannin, MSB 5.134, Houston, TX, 77030, USA
| | | | - Naval G Daver
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - William F Glass
- Department of Pathology and Laboratory Medicine, McGovern Medical School UT Houston, Houston, TX, USA
| | - Jaya Kala
- Renal Diseases and Hypertension, McGovern Medical School UT Houston, 6431 Fannin, MSB 5.134, Houston, TX, 77030, USA.
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8
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Mahesh S, Jaggi L, Jaggi A, Tsintzas D, Vithoulkas G. Individualised Homeopathic Therapy in ANCA Negative Rapidly Progressive Necrotising Crescentic Glomerulonephritis with Severe Renal Insufficiency - A Case Report. J Med Life 2019; 12:49-55. [PMID: 31123525 PMCID: PMC6527409 DOI: 10.25122/jml-2019-0001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Anti-Neutrophil Cytoplasmic Antibody (ANCA)-negative Rapidly Progressive Glomerulonephritis (RPGN) is a severe form of autoimmune renal injury with a bleak prognosis. A 60-year-old Indian woman was treated with classical homeopathy for ANCA-negative RPGN, and after one year of treatment, serum creatinine and other parameters indicating renal injury dropped steadily despite the withdrawal of immunosuppressive drugs; renal dialysis, which was conducted twice a week initially, was made rarer and stopped after one year. Classical homeopathy may be considered a potential therapeutic modality in severe pathologies. Controlled studies are required to establish further the extent to which classical homeopathy may relieve patients from procedures such as dialysis that cause considerable physical and economic discomfort.
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Affiliation(s)
- Seema Mahesh
- Centre for Classical Homeopathy, Bangalore, India
| | - Latika Jaggi
- H3 Centre for Classical Homeopathy, Nashik, India
| | - Atul Jaggi
- H3 Centre for Classical Homeopathy, Nashik, India
| | | | - George Vithoulkas
- International Academy of Classical Homeopathy, University of the Aegean, Greece
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Ayaash A, Maan D, Kapetanos A, Bunker M, Wasko MC, Clark B. Significance of Crescentic Glomeruli in Acute Kidney Injury with Rheumatoid Arthritis. Case Rep Nephrol Dial 2019; 9:42-48. [PMID: 31192227 PMCID: PMC6528077 DOI: 10.1159/000500105] [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: 12/28/2018] [Accepted: 04/02/2019] [Indexed: 11/19/2022] Open
Abstract
Crescentic glomerulonephritis (GN) without immune reactants or deposits (referred to as pauci-immune) is typically characterized by the presence of anti-neutrophilic cytoplasmic antibodies (ANCA). While ANCA-negative patients might be expected to have a more benign course, they often have poor renal outcomes, especially without treatment with steroids and immune-modulating therapy. Pauci-immune crescentic GN can also co-exist with other autoimmune conditions, including rheumatoid arthritis (RA). Here, we describe an ANCA-negative patient with RA who developed dialysis-requiring acute kidney injury (AKI) with findings consistent with focal pauci-immune crescentic GN (i.e., no IgG or immune complex on kidney biopsy). Coexistent conditions included Klebsiella sepsis attributed to pneumonia, rhabdomyolysis, leukocytoclastic immune-mediated skin vasculitis, and positive ANA. He had spontaneous improvement in renal function without immunosuppressive therapy. This crescentic GN was not associated with poor renal outcome as AKI resolved with supportive care and treatment of his infection. The AKI was likely multifactorial with co-existing acute tubular necrosis in the setting of Kebsiella sepsis and rhabdomyolysis, and the crescentic GN was felt more likely to be related to the infection rather than having a primary role. This case highlights the importance of viewing crescentic GN in the context of the clinical picture, as it may not always lead to the need of aggressive immune suppression and is not a universally poor prognostic kidney finding. However, these cases do warrant close follow-up as our patient had recurrent RA disease manifestations over the next 2 years that eventually led to his death from severe pulmonary hypertension.
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Affiliation(s)
- Ali Ayaash
- Allegheny General Hospital, Allegheny Health Network, Drexel University School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dipesh Maan
- Division of Nephrology, Allegheny General Hospital, Allegheny Health Network, Drexel University School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anastasios Kapetanos
- Department of Medicine, Allegheny General Hospital, Allegheny Health Network, Drexel University School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mark Bunker
- Department of Pathology, Allegheny General Hospital, Allegheny Health Network, Drexel University School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mary Chester Wasko
- Division of Rheumatology, Allegheny General Hospital, Allegheny Health Network, Drexel University School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Barbara Clark
- Division of Nephrology, Allegheny General Hospital, Allegheny Health Network, Drexel University School of Medicine, Pittsburgh, Pennsylvania, USA
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Naidu GSRSNK, Misra DP, Rathi M, Sharma A. Is granulomatosis with polyangiitis in Asia different from the West? Int J Rheum Dis 2018; 22 Suppl 1:90-94. [PMID: 30338654 DOI: 10.1111/1756-185x.13398] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 08/18/2018] [Accepted: 08/23/2018] [Indexed: 01/20/2023]
Abstract
The incidence and clinical features of antineutrophil cytoplasmic antibody (ANCA) associated vasculitis (AAV) have been shown to vary according to geographical areas, with granulomatosis with polyangiitis (GPA) being more common in northern Europe and microscopic polyangiitis (MPA) being more common in Asian countries. The annual incidence of GPA among Asians varies between 0.37/million to 2.1/million population. The prevalence of GPA has been estimated to be 1.94/100 000 in a Chinese population. Polymorphisms in class II major histocompatibility genes and ETS1 proto-oncogene has been shown in Asian patients with GPA. There is a difference in mean age at onset and proteinase 3 (PR3) or myeloperoxidase (MPO) positivity in GPA patients from different Asian countries. Those from India had mean age of 40 years and those from Japan had mean age of 65 years. Sixty percent of GPA patients from China and Japan were MPO ANCA positive while the majority of patients from India and Korea were PR3 positive. Geographical variation with lower frequency of renal involvement in Indian studies and higher frequency in Chinese patients has also been noted. Treatment outcomes have been similar to those reported from other parts of the world. Remission was achieved in about two-thirds of patients while relapses were noted in one-third to half of the patients. Apart from minor differences in the organ systems involved, MPO-ANCA GPA and PR3-ANCA GPA had similar rates of remission and relapses.
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Affiliation(s)
- Godasi S R S N K Naidu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Durga Prasanna Misra
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Qaisar H, Hossain MA, Akula M, Cheng J, Patel M, Min Z, Kuzyshyn H, Levitt M, Coley SM, Asif A. Methimazole-Induced Pauci-Immune Glomerulonephritis and Anti-Phospholipid Syndrome: An Important Association to Be Aware of. J Clin Med Res 2018; 10:786-790. [PMID: 30214651 PMCID: PMC6135002 DOI: 10.14740/jocmr3530w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 08/30/2018] [Indexed: 11/24/2022] Open
Abstract
While methimazole (MMI) is the first line treatment for hyperthyroidism, this medication is not devoid of adverse effects. In this article, we present a 70-year-old male who admitted the hospital with right lower extremity pain and rash. The patient was recently treated with MMI for hyperthyroidism. Imaging studies revealed bilateral renal and splenic infarcts along with thrombosis of popliteal artery. Laboratory data revealed hematuria and proteinuria with positive (MPO), anti-proteinase-3 (PR3) and anti-cardiolipin IgG antibodies. Renal biopsy revealed pauci-immune glomerulonephritis and features with anti-phospholipid antibody syndrome (APS). MMI was discontinued and the patient was treated successfully with steroid therapy and anti-coagulation with resolution of proteinuria, hematuria and normalization of laboratory parameters. While MMI-induced pauci-immune glomerulonephritis has been previously reported, its association with APS has never been described before. Our case demonstrates that this rare diagnosis can be treated by early withdrawal of MMI and initiation of steroids along with anticoagulation.
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Affiliation(s)
- Huzaif Qaisar
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mohammad A Hossain
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Monika Akula
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Jennifer Cheng
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mayurkumar Patel
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Zheng Min
- Department of Pathology, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Halyna Kuzyshyn
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Michael Levitt
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Shana M Coley
- Department of Pathology, Columbia University Medical Center, NY Presbyterian/Columbia, New York, NY 10032, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
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12
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Histopathological Classification-A Prognostic Tool for Rapidly Progressive Glomerulonephritis. ACTA ACUST UNITED AC 2018; 54:medicina54020017. [PMID: 30344248 PMCID: PMC6037248 DOI: 10.3390/medicina54020017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/08/2018] [Accepted: 04/13/2018] [Indexed: 12/02/2022]
Abstract
Background: Recently proposed histopathological classification may predict patient outcome in pauci-immune glomerulonephritis. This study sought to prove that the prognostic effect could be extended to all types of rapidly progressive glomerulonephritis. Methods: Retrospective analysis of patients diagnosed with rapidly progressive glomerulonephritis between April 1999 and August 2015 was performed. Epidemiological and clinical data were collected from medical records. The descriptions of renal biopsies were reviewed and classified into focal, sclerotic, crescentic and mixed class according to classification proposed by Berden et al. The study end points were end stage renal disease (ESRD) or death. Survival analyses were modelled using Cox regression. Results: 73 renal biopsies with diagnosis of rapidly progressive glomerulonephritis were included in the study. 25 (34.2%), 16 (21.9%), 24 (32.9%) and 8 (11%) patients were assigned to focal, crescentic, mixed and sclerotic class, respectively. Thirty-two (42.5%) patients were anti-neutrophil cytoplasmic antibody (ANCA) negative, of which eight (10.9%) were anti–glomerular basement membrane antibody (anti–GBM) positive and 24 (32.8%) were negative for autoimmune antibodies. Six (8.2%) patients died within one year. Among patients who survived, median change in estimated glomerular filtration rate (eGFR) values were: −10.5 mL/min in focal, 4.2 mL/min in crescentic, −4.3 mL/min in mixed and 4.1 mL/min in sclerotic group, p > 0.05. In the Cox regression model, there was no significant predictor of patient survival whereas the sclerotic group (HR 3.679, 95% CI, 1.164–11.628, p < 0.05) and baseline eGFR of <15 mL/min (HR 4.832, 95% CI, 1.55–15.08, p < 0.01) had an unfavorable effect for renal survival. Conclusions: Predominant glomerular sclerosis and low eGFR at baseline are associated with higher risk of ESRD in cases with crescentic glomerulonephritis. Therefore, despite the origin of injury, histological classification might aid in prediction of patient outcomes in rapidly progressive glomerulonephritis.
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Bambauer R, Latza R, Burgard D, Schiel R. Therapeutic Apheresis in Immunologic Renal and Neurological Diseases. Ther Apher Dial 2017; 21:6-21. [PMID: 28078733 DOI: 10.1111/1744-9987.12499] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Accepted: 08/17/2016] [Indexed: 12/18/2022]
Abstract
Since the mid 1970s, when membrane modules became available, plasma separation techniques have gained in importance especially in the past few years. The advantages of this method are a complete separation of the corpuscular components from the plasma and due to increased blood flow rate and higher efficacy. Systemic autoimmune diseases based on an immune pathogenesis produce autoantibodies and circulating immune complexes, which cause inflammation in the tissues of various organs. In most cases, these diseases have a poor prognosis without treatment. Therapeutic apheresis (TA) in combination with immunosuppressive therapies has led to a steady increase in survival rates over the last 40 years. The updated information on immunology and molecular biology of different immunologic diseases are discussed in relation to the rationale for apheresis therapy and its place in combination with other modern treatments. The different diseases can be treated by various apheresis methods such as therapeutic plasma exchange (TPE) with substitution solution, or with online plasma or blood purification using adsorption columns, which contain biological or non-biological agents. Here, the authors provide an overview of the most important pathogenic aspects indicating that TA can be a supportive therapy in systemic autoimmune diseases such as renal and neurological disorders. For the immunological diseases that can be treated with TA, the guidelines of the German Working Group of Clinical Nephrology and of the Apheresis Committee of the American Society for Apheresis are cited.
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Affiliation(s)
- Rolf Bambauer
- Formerly: Institute for Blood Purification, Homburg, Germany
| | | | | | - Ralf Schiel
- Inselklinik Heringsdorf GmbH, Seeheilbad Heringsdorf, Germany
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