Pathogenesis of membranous nephropathy in systemic lupus erythematosus: possible role of nonprecipitating DNA antibody

Dissecting the relationships of IgG subclasses and complements in membranous lupus nephritis and idiopathic membranous nephropathy

Membranous lupus nephritis (MLN) and idiopathic membranous nephropathy (IMN) are kidney diseases with similar morphology, but distinct etiologies, both producing glomeruli with immune deposits. Immunoglobulins and complements, the main components of the deposits, can be detected by immunofluorescence (IF) microscopy. Previous researches characterized the immune deposits only individually, but not the interactions between them. To study these relationships we analyzed an IF profile of IgG subclasses and complements (IgG1, IgG2, IgG3, IgG4, C3, C1q, and C4) in 53 and 95 cases of biopsy-confirmed MLNs and IMNs, respectively, mainly using information theory and Bayesian networks. We identified significant entropy differences between MLN and IMN for all markers except C3 and IgG1, but mutual information (a measure of mutual dependence) were not significantly different for all the pairs of markers. The entropy differences between MLN and IMN, therefore, were not attributable to the mutual information. These findings suggest that disease type directly and/or indirectly influences the glomerular deposits of most of IgG subclasses and complements, and that the interactions between any pair of the markers were similar between the two diseases. A Markov chain of IgG subclasses was derived from the mutual information about each pair of IgG subclass. Finally we developed an integrated disease model, consistent with the previous findings, describing the glomerular immune deposits of the IgG subclasses and complements based on a Bayesian network using the Markov chain of IgG subclasses as seed. The relationships between the markers were effectively explored by information theory and Bayesian network. Although deposits of IgG subclasses and complements depended on both disease type and the other markers, the interaction between the markers appears conserved, independent from the disease type. The disease model provided an integrated and intuitive representation of the relationships of the IgG subclasses and complements in MLN and IMN.

[Membranous nephropathy]

Membranous nephropathy is characterized by immune complex deposits on the outer side of the glomerular basement membrane. Activation of complement and of oxidation lead to basement membrane lesions. The most frequent form is idiopathic. At 5 and 10 years, renal survival is around 90 and 65% respectively. A prognostic model based on proteinuria, level and duration, progression of renal failure in a few months can refine prognosis. The urinary excretion of C5b-9, β2 and α1 microglobuline and IgG are strong predictors of outcome. Symptomatic treatment is based on anticoagulation in case of nephrotic syndrome, angiotensin conversion enzyme inhibitors, angiotensin II receptor blockers and statins. Immunosuppressive therapy should be discussed for patients having a high risk of progression. Corticoids alone has no indication. Treatment should include a simultaneous association or more often alternating corticoids and alkylant agent for a minimum of 6 months. Adrenocorticoid stimulating hormone and steroids plus mycophenolate mofetil may be equally effective. Steroids plus alkylant decrease the risk of end stage renal failure. Cyclosporine and tacrolimus decrease proteinuria but are associated with a high risk of recurrence at time of withdrawal and are nephrotoxic. Rituximab evaluated on open studies needs further evaluations to define its use.

Antinuclear and antinative DNA antibodies during captopril treatment

Antinuclear antibodies (ANA) developed in 13 out of 78 patients treated with captopril for a mean period of 11 months. In another 11 patients, who were ANA-positive before captopril therapy, no increase in ANA titer was observed during treatment. Neither the development nor the presence of ANA before captopril treatment were associated with (drug-induced) lupus erythematosus or increased incidence of clinical side-effects, although development of ANA was accompanied by a serum-sickness-like syndrome in one patient. The ANA were mainly of the IgM class, did not fix complement and were transiently present. In three patients, antinative DNA antibodies, exclusively of IgM class and not complement-fixing, were transiently present without clinical signs of systemic lupus erythematosus, although recurrence of these antibodies was associated with slight proteinuria in one of them.

Relationship between antibodies to dsDNA and to soluble cellular antigens and histologically defined glomerulonephritis in patients with SLE

To better define the relationships between circulating autoantibodies and renal involvement in systemic lupus erythematosus (SLE), antibodies to both dsDNA and soluble cellular antigens were detected in sera from a large series of SLE patients. Significantly higher dsDNA binding activities and lower complement levels at onset were found in patients with renal disease; however, this was uniquely due to subjects with diffuse or focal proliferative glomerulonephritis. Patients with membranous nephropathy (MGN) showed very low dsDNA binding activities (6/9 of them being negative for dsDNA antibodies) and normal mean C3 and C4 levels. A comparison between patients with proliferative nephritis and patients without renal involvement with high dsDNA binding activities revealed significantly lower complement levels in the former group. No significant difference was observed in the prevalence of antibodies to soluble cellular antigens between patients with or without renal disease; however, nRNP antibody was two-fold more frequent in patients with MGN than in all other subgroups. This study highlights the close relationship between concurrently high anti-dsDNA and low complement levels and proliferative glomerulonephritis in SLE, and suggests that subjects with MGN may represent a subgroup of SLE patients showing peculiar serological features. Different mechanisms possibly involved in the pathogenesis of MGN in SLE are discussed.

Membranous and vascular choroidopathy: two patterns of immune deposits in systemic lupus erythematosus

Two patterns of immune aggregate localization were demonstrated by immunofluorescence and electron microscopy in the choroid plexus of four young women with fatal systemic lupus erythematosus. The two patients with granular immune aggregates localized to the basement membrane of the choroid epithelium (membranous choroidopathy) had subepithelial and intramembranous electron-dense deposits and membranous glomerulopathy in their kidneys. The two patients with immune aggregates in the walls of choroidal blood vessels (vascular choroidopathy) had subendothelial electron-dense deposits and proliferative glomerulonephritis. Vascular deposits in the choroid plexus were associated with capillary thrombi and extravasation of fibrinoid material, while isolated membranous choroidopathy had no histopathologic evidence of inflammation. The clinical presentation and serological studies of blood and cerebrospinal fluid were compared in an effort to discriminate between patients with membranous and vascular choroidopathy. All patients had variable neuropsychiatric symptoms and major motor seizures. While those with vascular choroidopathy had more evidence of disease activity in their sera, both groups demonstrated elevated titers of immune-complexed antinuclear antibodies in cerebrospinal fluid. Although both patterns of choroidal localization of immune aggregates were associated with neuropsychiatric dysfunction, we were unable to identify discrete clinical-symptom complexes which differentiated patients with membranous and vascular choroidopathy. These contrasting patterns of choroid plexus immunopathology suggest that factors responsible for differential localization of immune aggregates are not restricted to the renal glomerulus.

Differential characteristics of immune-bound antibodies in diffuse proliferative and membranous forms of lupus glomerulonephritis

Diffuse proliferative (PGN) and membranous (MGN) glomerulonephritis represent contrasting histologic lesions in systemic lupus erythematosus (SLE). Serum, cryoglobulins, and renal biopsies in 8 SLE patients with PGN and 8 with MGN were studied in order to determine whether variations in the properties of immune-bound antibodies correlate with the pattern of glomerular involvement. Several immunologic parameters suggested differences in complement activation between the two groups. PGN cryoglobulins demonstrated immunoglobulin G (IgG) anti-native DNA (nDNA) subclass heterogeneity with highest titers of IgG3. These findings contrasted with the observation that MGN was characterized by a predominance of IgG4 in cryoglobulins. The major glomerular IgG subclasses in PGN were IgG3 and IgG1, while MGN biopsies demonstrated IgG4 in largest amount. Serum C1q was lower in PGN than in MGN. Serum anti-nDNA antibodies, solid-phase C1q-binding IgG immune complexes, and cryoglobulin protein concentrations were higher in PGN sera. Cryoglobulin complement component and control protein concentrations were greater in PGN than in MGN, while cryoglobulin Ig and immune-bound anti-nDNA were not different. In vitro C3 fixation by cryoglobulin anti-nDNA was greater in PGN than in MGN. Glomerular C1q, C4-binding protein (C4bp), and C3c were present in comparable amounts to IgG deposits in PGN biopsies, while in MGN IgG was demonstrable in greater quantities than C1q, C4bp, and C3c. In contrast, glomerular C3d (alpha 2d), C5, C6, P, and H were comparable in the two groups. It was concluded that immune-bound antibodies in cryoglobulins and in glomerular immune deposits in SLE PGN appear to activate complement via the classical and alternative pathways, while complement activation in MGN appears to occur predominantly via the alternative pathway. These differences in IgG subclass composition may account for the differential complement activation and may explain the contrasting histologic expression of immune aggregate localization in glomerular capillaries in these variants of lupus nephritis.

Subepithelial electron-dense deposits in proliferative glomerulonephritis of systemic lupus erythematosus

Subepithelial electron-dense deposits (SED) were found in the renal biopsies of 36 of 59 patients with systemic lupus erythematosus (SLE). The SED were divided into two groups based on their ultrastructural appearance and distribution within the glomeruli. Type I SED were regular in size and shape, had a homogeneous electron density and a diffuse distribution within the glomeruli, and involved all of the glomeruli in the biopsy. In contrast, the type II SED were irregular in size and shape, tended to be quite large, and had variable electron density. They were present in reduced numbers in involved capillary loops, and they were absent from other loops within the same glomerulus. Type I SED were seen in cases of membranous SLE glomerulonephritis (GN), and type II SED were associated with severe proliferative SLE GN. Although the patients with proliferative GN had more active urinary sediments at the time of biopsy than did the patients with membranous GN, the mean serum creatinine and urinary protein excretion were not significantly different in the two groups. The mean followup was almost twice as long for the membranous compared to the proliferative lesions (33.70 months +/- SE 7.96 vs. 16.78 +/- 4.21), but at the end of the study, mean renal function was better preserved in patients with proliferative GN (2.13 mg/dl +/- SE 0.49). As a group, patients with type I SED had mild serologic abnormalities compared to patients with type II SED. In contrast the abnormal serologies of the patients with type II SED were not significantly different from patients with proliferative SLE GN in general. The results suggest that the heterogeneous morphology of SED may reflect different pathogenetic mechanisms responsible for their formation. When focal and segmental SED (type II) are seen in proliferative SLE GN, they should be interpreted with caution, for they have very different clinical, prognostic, and therapeutic implications from type I SED.

Pathopysiological aspects of immune complex diseases. Part II. Phagocytosis, exocytosis, and pathogenic depositions

Elimination of IC by the phagocytic system occurs mainly by macrophages and contrarotates to the pathogenic effect. Decisive to prevent systemic IC disease is the capacity of the phagocytic system. In the case of its saturation, the danger of the occurrence of IC disease is greatly enhanced. Conclusive evidence seems to exist that IC of extremely small or extremely high lattice structure (precipitates) are less pathogenic than soluble IC of medium network. Small IC in extreme antigen and antibody excess or precipitates exhibit a reduced complement activating potency. Small IC in extreme antigen or antibody excess hardly interact in vitro with membrane receptors and do not induce IC disease when injected or formed in vivo. Highly lattices IC, especially precipitates, are eliminated extremely quickly from the circulation, mainly by macrophages and there deposition in the kidney is significantly reduced. Thus, lack of quality of the antibody to precipitate the antigen and a reduced capacity and effectivity of the phagocytic system to eliminate the IC may be extremely important in the generation of IC diseases. Facing the overwhelming and partly even inconsistant data of this topic, one may doubt whether IC diseases may be regarded to be a defined and coherent disease. Too many variables and questions exist concerning the nature of the antigen, especially in tumor and autoimmune diseases, concerning the quality of the antibody and the characteristics of the pathogenic IC and concerning localization and the elimination process. Nevertheless, common pathophysiological pathways of IC diseases may be recognized.

Diminished synthesis of immunoglobulin by peripheral lymphocytes of patients with idiopathic membranous glomerulonephropathy

Some studies of animal models of serum-sickness nephritis have shown that the lesions of membranous nephropathy develop in animals exhibiting a poor antibody response to the administered antigen (if given in constant amounts). It is postulated that patients with idiopathic membranous nephropathy may share a similar characteristic, namely, a diminished capacity to produce sufficient amounts of antibody. To test this hypothesis, we examined the ability of lymphocytes isolated from 11 patients with this disorder to produce immunoglobulin (Ig)G and IgM on stimulation with a polyclonal B-cell activator, pokeweed mitogen. The peripheral blood lymphocytes (2 x 10(6) cells) from 24 normal individuals had geometric mean production rates of 1,779 ng for IgG, and 2,940 ng for IgM after 7 d of culture in the presence of pokeweed mitogen. By contrast, under identical conditions, lymphocytes from the 11 patients with membranous nephropathy produced significantly lower quantities of both immunoglobulins, with geometric mean concentrations of 511 ng for IgG and 439 ng for IgM. When lymphocytes from patients with membranous nephropathy were co-cultured with normal lymphocytes, the production of immunoglobulin by normal lymphocytes was depressed by 22-82%, suggesting that a population of suppressor cells was responsible for this disturbance in B-cell function. By co-culturing normal lymphocytes with patient lymphocytes depleted of either T cells or monocytes, the suppressor cell was identified as a monocyte.

Influence of dietary restriction on immunologic function and renal disease in (NZB x NZW) F1 mice

In (NZB x NZW)F(1) (B/W) mice, moderate caloric intake [10 kcal (41.8 kJ) per day] from the time of weaning was associated with maintenance of lower body weight, greater capacity of spleen cells to be stimulated with T-cell mitogens, and better preserved capacity to generate cytotoxic cells in response to in vitro and in vivo stimulation with allogeneic tumor cells. Plaque-forming cell response to sheep erythrocytes was also well maintained in animals on the restricted diets when sensitization was accomplished either in vitro or in vivo. Spontaneous suppressor cell activity against plaque-forming cells that developed in controls did not appear in the mice on the restricted diet. Significantly less circulating antibody to native DNA was present in the blood of mice 10 months of age when their dietary intake had been restricted. Histological analysis revealed that the development of renal disease and the deposition of gamma globulin in the glomerular capillaries was markedly inhibited in the mice on restricted diets. Dietary restriction from the time of weaning thus appears to prolong significantly the life of autoimmunity-prone (NZB x NZW)F(1) male and female mice and to alter lymphoid cell immune function, thereby decreasing the autoimmune processes and immunological assault associated with progressive renal disease in these animals.