Characteristics and outcome of anti-glomerular basement membrane disease: a single-center experience

Epidemiology, clinical features, risk factors, and outcomes in anti-glomerular basement membrane disease: A systematic review and meta-analysis

Anti-glomerular basement membrane (GBM) disease is a small-vessel vasculitis that represents the most aggressive form of autoimmune glomerulonephritis. The study aimed to investigate the prevalence, clinical characteristics, risk factors, and outcomes of anti-GBM disease through a systematic review and meta-analysis involving 47 studies with 2830 patients. The overall incidence of anti-GBM disease ranged from 0.60 to 1.79 per million population per annum. In rapidly progressive glomerulonephritis and crescentic glomerulonephritis, the pooled incidence rates were 8.0% and 12.8%, respectively. The pooled prevalence rates of anti-GBM antibodies, antineutrophil cytoplasmic antibodies (ANCA), and lung hemorrhage were 88.8%, 27.4%, and 32.6%, respectively. Patients with combined ANCA positivity demonstrated a prognosis comparable to those patients with only anti-GBM antibodies, though with differing clinical features. The pooled one-year patient and kidney survival rates were 76.2% and 30.2%, respectively. Kidney function on diagnosis and normal glomeruli percentage were identified as strong prognostic factors. This study represents the first comprehensive meta-analysis on anti-GBM disease, providing insights into its management. However, caution is warranted in interpreting some results due to the observational nature of the included studies and high heterogeneity.

Short-chain fatty acids ameliorate experimental anti-glomerular basement membrane disease

BACKGROUND

Short-chain fatty acids (SCFAs), as the link between gut microbiota and the immune system, had been reported to be protective in many autoimmune diseases by the modulation of T cell differentiation. The pathogenic role of autoreactive Th1 and Th17 cells and the protective role of Treg cells in the pathogenesis of anti-GBM disease have been fully demonstrated. Thus, the present study aimed to investigate the therapeutic effects of SCFAs in a rat model of anti-GBM disease.

MATERIALS AND METHODS

Experimental anti-GBM disease was constructed by immunizing Wistar Kyoto rats with a nephrogenic T cell epitope α3127-148, and intervened by sodium acetate, sodium propionate, or sodium butyrate, 150 mM in the drinking water from day 0 to 42. Kidney injury was accessed by the biochemical analyzer, immunofluorescence, and immunohistochemistry. Antibody response was detected by ELISA. T cell clustering and proliferation were detected by flow cytometry. Human kidney 2 (HK2) cells were stimulated in vitro and cytokines were assessed by quantitative real-time PCR.

RESULTS

Treatment with sodium acetate, sodium propionate, or sodium butyrate ameliorated the severity of kidney impairment in rats with anti-GBM glomerulonephritis. In the sodium butyrate-treated rats, the urinary protein, serum creatinine, and blood urea nitrogen levels were significantly lower; the percentage of crescent formation in glomeruli was significantly reduced; and the kidneys showed reduced IgG deposition, complement activation, T cell, and macrophage infiltration as well as the level of circulating antibodies against anti-α3(IV)NC1. The treatment of sodium butyrate reduced the α3127-148-specific T cell activation and increased the Treg cells differentiation and the intestinal beneficial bacteria flora. It also alleviated the damage of HK2 cells treated with inflammatory factors and complement.

CONCLUSION

Treatment with SCFAs, especially butyrate, alleviated anti-GBM nephritis in rat model, indicating its potential therapeutic effects in clinical usage.

The Immunobiological Agents for Treatment of Antiglomerular Basement Membrane Disease

Combination therapy with glucocorticoids, cyclophosphamide, and plasmapheresis is recommended as the standard treatment for anti-glomerular basement membrane (anti-GBM) disease, but the prognosis of this disease remains poor. Several immunobiological agents have been administered or are expected to be useful for anti-GBM disease in light of refractory disease or the standard treatments' tolerability. Many data regarding the use of biologic agents for anti-GBM disease have accumulated, verifying the effectiveness and potential of biologic agents as a new treatment option for anti-GBM disease. Tumor necrosis factor (TNF) inhibitors were shown to be useful in animal studies, but these agents have no clinical use and were even shown to induce anti-GBM disease in several cases. Although the efficacy of the TNF-receptor antagonist has been observed in animal models, there are no published case reports of its clinical use. There are also no published reports of animal or clinical studies of anti-B-cell-activating factor, which is a member of the TNF family of agents. Anti-interleukin (IL)-6 antibodies have been demonstrated to have no effect on or to exacerbate nephritis in animal models. Anti-C5 inhibitor was observed to be useful in a few anti-GBM disease cases. Among the several immunobiological agents, only rituximab has been demonstrated to be useful in refractory or poor-tolerance patients or small uncontrolled studies. Rituximab is usually used in combination with steroids and plasma exchange and is used primarily as an alternative to cyclophosphamide, but there is insufficient evidence regarding the efficacy of rituximab for anti-GBM disease, and thus, randomized controlled studies are required.

Disease activity prediction and prognosis of anti-GBM nephritis based on T lymphocyte subset ratios

Introduction

Cell-mediated autoimmunity, especially the autoreactivity of T cells, is known to underlie the initiation of anti-glomerular basement membrane disease. However, the T lymphocyte subsets that determine the disease activity, renal fibrosis, and prognosis of anti-GBM disease have not been clearly elucidated.

Methods

The T lymphocyte subsets (CD4+ and CD8+) were examined on peripheral blood and renal biopsy tissues from 65 patients with biopsy proven anti-GBM disease. Patients were divided into the high ratio group and low ratio group according to the cutoff values in the receiver operating characteristic curve analysis. The correlations of T lymphocyte subsets with clinical, pathological data, and renal outcome were analyzed.

Results

By the end of follow-up, 45 patients (69.2%) developed end-stage renal disease (ESRD). In peripheral blood, the CD4+/CD8+ ratio showed a predictive ability with a sensitivity and specificity of 91.3% and 52.9%, respectively, which gave rise to a cutoff value of 0.89. There was a significant difference in the activity index between these two groups (3.91 ± 1.38 vs. 2.89 ± 1.13, p = 0.007). In the renal tissues, the CD4+/CD8+ ratio had the optimal cutoff point of 0.82 with a sensitivity of 57.8% and specificity of 85%. The renal activity index was higher for the renal tissues with high CD4+/CD8+ ratios than that of tissues with low CD4+/CD8+ ratios (4.32 ± 1.55 vs. 3.37 ± 1.41, p = 0.016). Peripheral blood CD4+/CD8+ ratios of ≥0.89 or renal tissue CD4+/CD8+ ratios of < 0.82 positively correlated with poor renal prognosis in patients with anti-GBM nephritis.

Conclusions

The CD4+/CD8+ ratio was associated with renal activity index both in peripheral blood and renal tissue and predicts the renal prognosis of patients with anti-GBM nephritis.

Predicting Outcome in Patients with Anti-GBM Glomerulonephritis

BACKGROUND AND OBJECTIVES

Large studies on long-term kidney outcome in patients with anti-glomerular basement membrane (anti-GBM) GN are lacking. This study aimed to identify clinical and histopathologic parameters that predict kidney outcome in these patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective analysis included a total of 123 patients with anti-GBM GN between 1986 and 2015 from six centers worldwide. Their kidney biopsy samples were classified according to the histopathologic classification for ANCA-associated GN. Clinical data such as details of treatment were retrieved from clinical records. The primary outcome parameter was the occurrence of ESRD. Kidney survival was analyzed using the log-rank test and Cox regression analyses.

RESULTS

The 5-year kidney survival rate was 34%, with an improved rate observed among patients diagnosed after 2007 (P=0.01). In patients with anti-GBM GN, histopathologic class and kidney survival were associated (P<0.001). Only one of 15 patients with a focal class biopsy sample (≥50% normal glomeruli) developed ESRD. Patients with a sclerotic class biopsy sample (≥50% globally sclerotic glomeruli) and patients with 100% cellular crescents did not recover from dialysis dependency at presentation. In multivariable analysis, dialysis dependency at presentation (hazard ratio [HR], 3.17; 95% confidence interval [95% CI], 1.59 to 6.32), percentage of normal glomeruli (HR, 0.97; 95% CI, 0.95 to 0.99), and extent of interstitial infiltrate (HR, 2.02; 95% CI, 1.17 to 3.50) were predictors of ESRD during follow-up.

CONCLUSIONS

Dialysis dependency, low percentage of normal glomeruli, and large extent of interstitial infiltrate are associated with poor kidney outcome in anti-GBM GN. Kidney outcome has improved during recent years; the success rate doubled after 2007.

PODCAST

This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2017_11_21_CJASNPodcast_18_1_v.mp3.

The clinicopathologic characteristics and outcome of atypical anti-glomerular basement membrane nephritis

Classic anti-glomerular basement membrane (GBM) disease presents with rapidly progressive glomerulonephritis (GN) with or without pulmonary hemorrhage. On biopsy typical disease displays bright polytypic linear GBM staining for IgG by immunofluorescence and diffuse crescentic/necrotizing GN on light microscopy. Here, we studied 20 patients with atypical anti-GBM nephritis typified by bright linear GBM staining for immunoglobulins but without a diffuse crescentic phenotype. Patients had hematuria, proteinuria, and mild renal insufficiency, without pulmonary hemorrhage. Light microscopy showed endocapillary proliferative GN in 9 patients, mesangial proliferative GN in 6, membranoproliferative GN in 3, and focal segmental glomerulosclerosis with mesangial hypercellularity in 2. Eight of the 20 showed features of microangiopathy. Crescents/necrosis were absent in 12 and were focal in 8 patients. Bright linear GBM staining for IgG was seen in 17 patients, IgM in 2, and IgA in 1 patient, which was polytypic in 10 patients and monotypic in 10 patients. No circulating α3NC1 antibodies were detected by commercial ELISA. The 1-year patient and renal survival rates were 93% and 85%, respectively. Thus, atypical anti-GBM nephritis is a rare variant of anti-GBM disease characterized clinically by an indolent course, no pulmonary involvement, and undetectable circulating α3NC1 antibodies. Further studies are needed to characterize the molecular architecture of GBM autoantigens in these patients and establish optimal therapy.

Near-lethal acute kidney injury due to Goodpasture's syndrome: A case report

We report a case of a 75-year-old patient who presented with severe acute kidney injury due to Goodpasture's syndrome. It is an uncommon autoimmune condition, requiring treatment with immunosuppressive drugs and plasma exchange. Prognosis depends largely on early diagnosis, so it is important to be aware of these rarer causes whenever anyone presents with acute kidney injury. She had two cardiac arrests in the emergency department, had a long stay in the intensive care unit and went on to develop pulmonary haemorrhage which improved with treatment. However, she developed end-stage renal failure for which she is on life-long dialysis.

Goodpasture's disease following extracorporeal shock wave lithotripsy: a case report & literature review

Shock wave lithotripsy may unmask epitopes within the glomerular basement membrane, leading to the formation of anti-glomerular basement membrane (GBM) antibodies and clinical disease in susceptible individuals. Although rare, our case highlights the need for vigilant monitoring of renal function following extracorporeal shock wave lithotripsy. This may allow for early recognition, treatment and improved outcome of anti-GBM disease.

Characteristics and outcome of Goodpasture's disease in children

Antiglomerular basement membrane antibody disease (aGD) remains a very uncommon entity in the pediatric population, characterized by pulmonary hemorrhage, glomerulonephritis, and antibodies against the glomerular basement membrane. We herein describe the case of a 14-year-old girl with primary pulmonary symptoms diagnosed with aGD. Furthermore, we review 23 cases described in English literature over a 25-year period. Our case is the fourth child that presented with only pulmonary symptoms and no or minimal renal involvement. Based on the 23 cases, we present data on demographics and clinical symptoms, diagnostic tools, and prognosis. aGD presents in children with a male/female ratio of 1:2. Most children (91 %) survive, but in many cases renal disease progresses to end stage, requiring maintenance therapy on dialysis and some undergo kidney transplantation. However, no case was identified with signs of relapse after remission. aGD should be considered in the differential diagnosis of diffuse lung hemorrhage despite the lack of renal abnormalities. Antiglomerular basement membrane antibody testing can be of great value in confirming the diagnosis.

Anti-glomerular basement membrane antibody disease: a rare autoimmune disorder affecting the kidney and the lung

Anti-glomerular basement membrane antibody disease is a rare, but well characterized cause of glomerulonephritis. By definition serum anti-GBM antibody and/or a linear binding of IgG detected by direct immunofluorescence (IF) in a histological specimen of the kidney or the lung have to be detected. These antibodies can lead to acute rapid progressive glomerulonephritis(RPGN) and/or pulmonary hemorrhage (PH) because of collagen similarities in the basement membrane. Principally anti-GBM antibody disease can be divided into two groups: anti-GBM antibody disease without PH was regarded as renal-limited anti-GBM antibody disease and that with PH was defined as Goodpasture's syndrome (GPS). The important determinant for the response of therapy and long term diagnosis on anti-GBM disease is early diagnosis to prevent endstage renal disease. Therefore, standard treatment is a combined therapy of plasmapherisis, prednisolone and cyclophosphamide. The aim of this review is an overview of the pathogenesis, clinical presentation, diagnosis and treatment of anti-GBM disease.

Crescentic Glomerulonephritis: an update on Pauci-immune and Anti-GBM diseases

Crescentic glomerulonephritis (GN) in a renal biopsy is a widely accepted "critical diagnosis" in Anatomic Pathology practice. Prompt biopsy evaluation and notification of the referring physician is essential to facilitate rapid therapeutic intervention. The differential diagnostic categories of crescentic GN include pauci-immune GN, anti-glomerular basement membrane (GBM) nephritis and immune complex-mediated GN, distinguished from one another by immunofluorescence and electron microscopic study of the renal biopsy. Immune complex-mediated GN is characterized by abundant glomerular deposits and encompasses several diseases including but not limited to lupus nephritis, cryoglobulinemic GN and immunoglobulin A nephropathy. Pauci-immune GN, with paucity of deposits, correlates closely with antineutrophil cytoplasmic antibody disease due to the identifiable circulating pathogenic antineutrophil cytoplasmic antibody in most patients. Recent studies have identified other antibodies in pauci-immune GN and implicated infectious organisms in triggering autoimmunity in a susceptible host by molecular mimicry of host antigens. Anti-GBM nephritis is a rare but potentially life-threatening autoimmune disease with circulating antibodies against GBM epitopes in α3 chain of type IV collagen. It is characterized by a linear immunoglobulin G deposition along GBM on immunofluorescence microscopy. Environmental triggers including infections and solvent exposure seem to change the tertiary structure of the type IV collagen α345 hexamer in GBM, expose neoepitopes, and initiate autoimmunity. Even in light of advances in understanding of pathophysiology and serologic testing, renal biopsy remains the mainstay of diagnosis of crescentic GN.

Cutting edge issues in Goodpasture's disease

Goodpasture's disease, or anti-glomerular basement membrane (anti-GBM) disease, is a systemic autoimmune disorder defined by anti-GBM antibody-mediated damage (mainly immunoglobulin G-1) resulting in progressive crescentic glomerulonephritis and, frequently, diffuse pulmonary alveolar hemorrhage. It may be regarded as a "conformeropathy" where the quaternary structure of the α345NC1 hexamer that constitutes GBM undergoes a conformational change, exposing pathogenic epitopes on the α3 and α5 chains, eliciting a pathogenic autoantibody anti-GBM response. Goodpasture's disease accounts for 20% of all patients presenting with a pulmonary-renal syndrome and may be associated with detectable perinuclear antineutrophil cytoplasmic autoantibody positivity in up to a third of patients. Associated triggers may include tobacco smoking, hydrocarbon solvent exposure, and cocaine abuse. Cough, hemoptysis, and dyspnea with fatigue are the commonest presenting features. It is critical to rapidly distinguish Goodpasture's disease from other causes of pulmonary-renal syndromes such as Wegener's granulomatosis. Early and intensive treatment with plasmapheresis and immunosuppression with systemic corticosteroids pending results of diagnostic testing, and later cyclophosphamide, is often beneficial, with 90% of patients surviving the acute presentation of Goodpasture's disease. The need for hemodialysis on initial presentation, a serum creatinine >5 mg/dL, and 50% to 100% crescents on renal biopsy, portend the necessity of long-term hemodialysis. Further elucidation of the molecular pathobiology of Goodpasture's disease, particularly the regulation of involved antigen-specific T cells, may improve early diagnosis, treatment, and outcomes in this rare but potentially lethal autoimmune disorder.

Anti-glomerular basement membrane disease: outcomes of different therapeutic regimens in a large single-center Chinese cohort study

Anti-glomerular basement membrane (GBM) disease usually presents with rapidly progressive glomerulonephritis accompanied by pulmonary hemorrhage. The low incidence and fulminant course of disease preclude a large randomized controlled study to define the benefits of any given therapy. We conducted a retrospective survey of 221 consecutive patients seen from 1998 to 2008 in our hospital, and report here the patient and renal survival and the risk factors affecting the outcomes. Considering the similar clinical features of the patients, we could compare the effects of 3 different treatment regimens: 1) combination therapy of plasmapheresis and immunosuppression, 2) steroids and cytotoxic agents, and 3) steroids alone.The patient and renal survival rates were 72.7% and 25.0%, respectively, at 1 year after disease presentation. The serum level of anti-GBM antibodies (increased by 20 U/mL; hazard ratio [HR], 1.16; p = 0.009) and the presentation of positive antineutrophil cytoplasmic antibodies (ANCA) (HR, 2.18; p = 0.028) were independent predictors for patient death. The serum creatinine at presentation (doubling from 1.5 mg/dL; HR, 2.07; p < 0.001) was an independent predictor for renal failure.The combination therapy of plasmapheresis plus corticosteroids and cyclophosphamide had an overall beneficial effect on both patient survival (HR for patient mortality, 0.31; p = 0.001) and renal survival (HR for renal failure, 0.60; p = 0.032), particularly patient survival for those with Goodpasture syndrome (HR for patient mortality, 0.29; p = 0.004) and renal survival for those with anti-GBM nephritis with initial serum creatinine over 6.8 mg/dL (HR for renal failure, 0.52; p = 0.014). The treatment with corticosteroids plus cyclophosphamide was found not to improve the renal outcome of disease (p = 0.73). In conclusion, the combination therapy was preferred for patients with anti-GBM disease, especially those with pulmonary hemorrhage or severe renal damage. Early diagnosis was crucial to improving outcomes.

Clinical features and outcomes of anti-glomerular basement membrane disease in older patients

BACKGROUND

Anti-glomerular basement membrane (GBM) disease is being recognized increasingly in older patients. Disease presentation and outcomes of these patients are unclear.

STUDY DESIGN

Case series.

SETTING & PARTICIPANTS

221 consecutive Chinese patients with anti-GBM disease diagnosed in 1998-2008 in our tertiary referral center. Anti-GBM disease was defined as positive anti-GBM antibodies in circulation and/or linear immunoglobulin G deposition along the GBM on kidney biopsy.

PREDICTOR

Older age, defined as 65 years or older, and antineutrophil cytoplasmic antibody, detected using immunofluorescence and enzyme-linked immunosorbent assay, at presentation.

OUTCOMES

Clinical features, kidney pathologic characteristics, end-stage renal disease (ESRD), and mortality. Multivariate Cox proportional hazard models were used to assess the contribution of age, sex, clinical measures, and treatments to ESRD and mortality.

RESULTS

50 of 221 (22.6%) patients were 65 years or older. Older patients had a male predominance (male/female ratio, 1.9:1). They had a higher proportion of positive antineutrophil cytoplasmic antibody results (46.0% vs 14.6%; P < 0.001), lower prevalence of hemoptysis (26.0% vs 46.2%; P = 0.01), lower urine protein excretion (1.4 ± 1.0 vs 3.9 ± 3.3 g/d; P = 0.001), and higher estimated glomerular filtration rate (eGFR) at presentation (8.4 vs 5.1 mL/min/1.73 m(2); P = 0.007) compared with younger patients. During follow-up, 30 of 37 (81.1%) and 21 of 37 (56.8%) patients developed ESRD and died in the older group compared with 115 of 139 (82.7%) and 35 of 139 (25.2%) in the younger group (P = 0.1 and P = 0.001, respectively). For older patients, multivariate Cox regression analysis showed that higher initial eGFR was an independent predictor for both ESRD (HR, 0.86; 95% CI, 0.78-0.96; P = 0.005) and death (HR, 0.79; 95% CI, 0.66-0.94; P = 0.008).

LIMITATIONS

Not all patients underwent kidney biopsy, especially those with very old age or ESRD at presentation.

CONCLUSIONS

Older patients with anti-GBM disease had milder kidney damage and less pulmonary involvement. Outcomes were predicted by initial eGFR. Thus, early diagnosis was crucial to improve outcomes.

Successful treatment of resistant antiglomerular basement membrane antibody positivity with mycophenolic acid

Anti-glomerular basement membrane (GBM) antibody disease may progress to end-stage renal failure, requiring either dialysis or renal transplantation. In patients with end-stage renal disease (ESRD) due to anti-GBM-ab disease, the recurrence rate after transplantation is as high as 50% (2) and delaying renal transplantation until circulating anti-GBM antibody levels have been undetectable for at least 12 months reduces the recurrence rate to 5-15%. We report a case of ESRD due to renal limited anti-GBM disease with circulating anti-GBM-ab resistant to standard treatment approach who achieved undetectable anti-GBM-ab with mycophenolic acid.

Anti-glomerular basement membrane antibody disease in Japan: part of the nationwide rapidly progressive glomerulonephritis survey in Japan

Anti-glomerular basement membrane (anti-GBM) antibody disease is a rare, but well characterized cause of glomerulonephritis. It is defined by the presence of autoantibodies directed at specific antigenic targets within the glomerular basement membrane. This pattern of rapidly progressive glomerulonephritis and alveolar hemorrhage is often referred to as Goodpasture's syndrome. The prognosis for patients with anti-GBM antibody disease is poor. In Japan, to improve the prognosis of patients with rapidly progressive glomerulonephritis (RPGN), we conducted a nationwide survey of patients with RPGN and investigated the initial symptoms, laboratory findings including renal biopsy findings, treatment methods, and outcomes. Among patients with RPGN, patients with anti-GBM antibody disease were rare: 6.6% (47/715). Alveolar hemorrhage (Goodpasture's syndrome) was observed in 23.4% of patients with anti-GBM antibody disease. Most patients with anti-GBM antibody disease had renal failure at the time of diagnosis. The mean serum creatinine level of patients with renal-limited anti-GBM antibody disease was 7.07 +/- 4.21 mg/dl and that of patients with Goodpasture's syndrome was 7.99 +/- 4.31 mg/dl. The mean level of crescent formation was 78.99 +/- 23.54% in patients with anti-GBM antibody disease, and a cellular crescent form was observed in 63.2% of those patients. The prognosis for patients with anti-GBM antibody disease is poor; the renal survival rate at 6 months after onset was 20.9%, and the mortality at 6 months after onset was 23.3%. To improve the prognosis for anti-GBM antibody disease, it may be necessary to detect this disease in the early stages and to treat it without delay.

Alveolar hemorrhage in anti-basement membrane antibody disease: a series of 28 cases

Anti-basement membrane antibody disease is a rare disorder characterized by the presence of autoantibodies binding to the alveolar and glomerular basement membranes, and mediating both alveolar hemorrhage and acute glomerulonephritis. We retrospectively analyzed 28 cases of anti-basement membrane antibody disease with alveolar hemorrhage proven by bronchoalveolar lavage. The median age of patients at diagnosis was 23 years; 68% were male, 89% were active smokers, and 36% were exposed to some other inhaled agent. At diagnosis, 46% had predominant pulmonary involvement with normal initial serum creatinine. Lung function tests disclosed a restrictive ventilatory defect in 28% (n = 11) and hypoxemia (moderate in 29% and severe in 29%, n = 21). Carbon monoxide transfer factor was elevated in only 25% (n = 12). Bronchoalveolar lavage was more sensitive than any other criterion for detecting alveolar hemorrhage. After onset of treatment, new hemoptysis or transient worsening of hypoxemia occurred in 29% but did not affect pulmonary outcome. In contrast, worsening of renal function occurred in 33% and adversely affected renal outcome. At last follow-up (median, 2.6 yr; n = 24), all patients were alive and a complete cure was achieved in 50%. Long-term dialysis or renal transplantation was required in 42%, and 8% had mild chronic renal insufficiency. Last chest X-ray was normal in all cases, and no patient had respiratory insufficiency. All patients with predominant pulmonary involvement at presentation maintained independent renal function. In summary, this cohort was characterized by frequent exposure to tobacco smoking and other inhaled agents, and a constantly favorable pulmonary outcome contrasting with frequent chronic renal failure. Renal outcome was excellent in the subgroup of patients with predominant pulmonary involvement.

Recurrent Goodpasture’s disease secondary to a monoclonal IgA1-κ antibody autoreactive with the α1/α2 chains of type IV collagen

Goodpasture's disease is characterized by crescentic glomerulonephritis and lung hemorrhage in the presence of anti-glomerular basement membrane (anti-GBM) antibodies. This disease usually is mediated by IgG autoantibodies directed against the noncollagenous domain of the alpha3(IV) collagen chain, the Goodpasture autoantigen. In rare cases, anti-GBM antibodies of IgA or IgM class are involved, but their specificity has not been determined, and their target antigen remains unknown. The authors present the case of a 62-year-old man with anti-GBM disease mediated by a monoclonal IgA-kappa antibody, which progressed to end-stage renal disease despite intensive immunosuppression. The patient underwent living-related kidney transplantation, but lung hemorrhage and crescentic glomerulonephritis recurred, causing the loss of the allograft 2 years later. Indirect immunofluorescence found the presence of circulating IgA antibodies reactive with a basement membrane component, identified by enzyme-linked immunoabsorbent assay and Western blot as the alpha1/alpha2(IV) collagen chains. Sensitivity to digestion with collagenase indicated that IgA bound to epitopes located in the collagenous domain. This is the first case of recurrent Goodpasture's disease secondary to an autoreactive IgA antibody. The specificity of an IgA antibody implicated in the pathogenesis of anti-GBM disease has been investigated for the first time, identifying the alpha1/alpha2(IV) collagen chains as a novel target for nephritogenic antibodies.

Characteristics and Prognosis of Chinese Patients with Anti-Glomerular Basement Membrane Disease

BACKGROUND

Patients with anti-glomerular basement membrane (GBM) disease were predominantly reported in Caucasian population and reports from Chinese were lacking. The general picture of Chinese patients with anti-GBM disease was still unclear. This study is to investigate the characteristics and prognosis of Chinese patients with anti-GBM disease.

METHODS

Data from 105 patients with anti-GBM disease diagnosed in our hospital, between 1997 and 2002, were analyzed retrospectively. All the 105 sera were screened by enzyme-linked immunosorbent assay (ELISA) using highly purified bovine alpha(IV)NC1 as solid phase ligands. Clinical and pathological data of 69 patients with complete clinical remission (n = 5), partial remission (n = 10), and treatment failure (n = 54) were compared and the prognostic factors were evaluated.

RESULTS

Patients increased chronologically and three quarters of the 105 patients were diagnosed in the last 3 years. Most of the patients were between 20 and 29 years (n = 31) and a smaller second peak was found in patients over 60 years. 25/105 (24%) were also ANCA-positive. Patients with both anti-GBM antibodies and ANCA positive were elder (50 +/- 19 vs. 34 +/- 15 years, p < 0.01) and female predominant (15/25 vs. 16/80, p < 0.05). 56/97 (58%) patients presented as Goodpasture syndrome, 40/97 (41%) patients presented as rapidly progressive glomerulonephritis and one patient had pulmonary hemorrhage only. The following factors predict poor prognosis: (1) serum creatinine more than 600 micromol/l on diagnosis (p < 0.01); (2) oliguria or anuria on diagnosis (p < 0.01); (3) a high percentage (>85%) of glomeruli had crescents (p < 0.01), and (4) renal involvement before pulmonary hemorrhage (p < 0.05). Patients with serum creatinine over 600 micromol/l on diagnosis had higher levels of anti-GBM antibodies (106 +/- 48% vs. 73 +/- 40%, p < 0.01). Intensive plasma exchange therapy predicts a better prognosis in the patients with serum creatinine less than 600 mumol/l (p < 0.05).

CONCLUSIONS

Anti-GBM disease is not rare in China and behaves similarly to elsewhere. Early diagnosis and intensive plasmapheresis might be the most promising approaches to improve the outcome.

Rheumatologic diseases in the intensive care unit: epidemiology, clinical approach, management, and outcome

Patients with systemic rheumatic diseases may be admitted to the ICU because of worsening of or development of a new manifestation of the rheumatic disease, infections caused by immunosuppression, or adverse effects of drugs used to treat rheumatic diseases. Sometimes an unrelated, acute disorder may become life threatening because of the underlying rheumatic disorder. Rheumatoid arthritis is the most common rheumatic disease seen in ICU patients, followed by systemic lupus erythematosus and scleroderma. These three conditions together account for up to 75% of rheumatic cases admitted to the ICU. The respiratory system is the organ system most commonly affected in the acute process, followed by the renal, gastrointestinal, and nervous systems. More than 50% of admissions result from infections, and 25% to 35% result from exacerbation of the underlying rheumatic condition. In about 20% of patients, the rheumatic disorder may be diagnosed for the first time in the ICU. An aggressive approach should be pursued to establish the diagnosis of either disease exacerbation or infection. Delay in instituting appropriate immunosuppressive or antimicrobial therapy may result in multiple organ system failure and a poor outcome. The mortality rate in patients with rheumatic disease exceeds that predicted by the APACHE II or SAPS II scores and is higher than that in nonrheumatologic ICU admissions. The mortality may exceed 50% in patients admitted for infection; the prognosis is comparatively better for patients with exacerbations of disease activity. Renal failure, coma, and acute abdomen are predictors of poor outcome. Early recognition of abdominal complications requiring surgical intervention may help reduce mortality.

Outcomes in patients with Goodpasture's syndrome and hydrocarbon exposure

Goodpasture's Syndrome has been associated with hydrocarbon exposure. No study has examined outcomes in these patients. All reported cases of Goodpasture's Syndrome and hydrocarbon exposure were identified using MEDLINE and was analyzed for factors related to outcomes. A total of 43 cases were identified since 1969. The mean age of patients was 28 years old. There was a slight predilection for males (60%) when analyzing gender. Various types of hydrocarbons were identified and the duration of exposure varied from minutes to years. A majority of patients (86%) had pulmonary hemorrhage and antiglomerular basement membrane antibodies (AGBM) (92%). Patients were treated with immunosuppressive agents. The only significant statistical correlation was female patients with hydrocarbon exposure were younger. There was no correlation between age, gender, duration of exposure, presence of pulmonary hemorrhage or AGBM, or other risk factors and outcome. The relationship between hydrocarbon exposure and Goodpasture's Syndrome remains unclear since only 6% of cases in the literature had exposure. Even though most patients survived, no factor studied affected outcome making it difficult to predict prognosis in these patients.