Recurrence of anti-glomerular basement membrane antibody mediated glomerulonephritis in an isograft

Epidemiology, Impact, and Management Strategies of Anti-Glomerular Basement Membrane Disease

Anti-glomerular basement membrane (anti-GBM) disease is a rare but serious autoimmune disease, which is characterized by the development of pathogenic antibodies to type IV collagen antigens in the glomerular and alveolar basement membranes. This results in rapidly progressive glomerulonephritis (GN), alveolar hemorrhage, or both. A variety of environmental factors can trigger the disease in genetically predisposed patients. Temporal associations with influenza, SARS-CoV-2 infection, and COVID-19 vaccination have been described although there is insufficient evidence to suggest causality. Anti-GBM disease accounts for approximately 20% of the cases of rapidly progressive GN cases secondary to crescentic GN, but is an uncommon cause of end-stage kidney disease. Early diagnosis by detection of circulating antibodies, increased awareness of atypical as well as complex clinical variants of the disease, and combined therapy with immunosuppression and plasma exchange has improved the prognosis of patients with this potentially fatal disease. Progress has been hampered by the rarity of anti-GBM disease, but new agents and therapeutic regimens are emerging.

Recurrence and Outcome of Anti-Glomerular Basement Membrane Glomerulonephritis After Kidney Transplantation

Introduction

Recurrence of anti-glomerular basement membrane (anti-GBM) glomerulonephritis in the kidney graft is a rare event, described in limited reports. The aim of this study was to evaluate, in a large cohort of patients with long follow-up, the risk of recurrence of anti-GBM disease, the risk factors associated with clinical recurrence, and the long-term patient and graft survival.

Methods

This was a multicenter retrospective study. Inclusion criteria were patients with anti-GBM glomerulonephritis who underwent transplantation of a kidney between 1977 and 2015. Exclusion criteria were systemic vasculitis, lupus erythematosus, and cryoglobulinemia. Recurrence was defined as reappearance of clinical signs of glomerulonephritis along with histological signs of proliferative glomerulonephritis and linear IgG staining on kidney biopsy, with or without anti-GBM antibodies.

Results

A total of 53 patients were included. Recurrence of anti-GBM glomerulonephritis in a first kidney transplant occurred in only 1 patient 5 years after transplantation (a prevalence rate of 1.9%) in the context of cessation of immunosuppressive drugs, and resulted in graft loss due to recurrence. Linear IgG staining on kidney biopsy in the absence of histological signs of proliferative glomerulonephritis was observed in 4 patients, in the context of cellular rejection. Patient survival was 100%, 94%, and 89% at 5, 10, and 15 years, respectively. Death-censored first-graft survival rates were 88%, 83%, and 79% at 5, 10, and 15 years, respectively.

Conclusion

The recurrence rate of anti-GBM glomerulonephritis after transplantation is very low but is associated with graft loss. The long-term patient and graft survival rates are excellent.

Long-term outcomes in kidney transplant recipients with end-stage kidney disease due to anti-glomerular basement membrane disease

Anti-glomerular basement membrane (GBM) disease causes rapidly progressive glomerulonephritis and end-stage kidney disease (ESKD). Studies of post-transplant outcomes in patients with ESKD due to anti-GBM disease in the United States are lacking. To better characterize outcomes of transplant recipients with a history of anti-GBM disease, we examined patient survival and graft survival among recipients with anti-GBM disease compared with IgA nephropathy at a single center in the United States. We analyzed patient survival, graft survival, disease recurrence, and malignancy rates for kidney transplant recipients with ESKD due to biopsy-proven anti-GBM disease who underwent kidney transplantation at our center between 1994 and 2015. 26 patients with biopsy-proven anti-GBM disease and 314 patients with IgAN underwent kidney transplantation from 1994 to 2015. The incidence of graft loss was 6.2 per 100 person-years for anti-GBM disease, which was similar to IgAN (4.08 per 100 person-years, p = .09). Patient mortality for anti-GBM was 0.03 per 100 person-years, similar to IgAN (0.02 per 100 person-years, p = .12). Disease recurrence occurred in one of the 26 anti-GBM patients. Four out of 26 patients (15%) developed malignancy, most commonly skin cancer. Long-term graft and patient survival for patients with ESKD due to anti-GBM was similar to IgAN after kidney transplantation.

Comparison of the performance of a chemiluminescence assay and an ELISA for detection of anti-GBM antibodies

Objective

Autoantibodies to the α3 chain noncollagen 1 domain of type IV collagen (α3(IV)NC1) are a serological hallmark in the diagnosis of anti-glomerular basement membrane (GBM) disease. The objective of our study was to compare the performance of anti-glomerular basement membrane (GBM) antibody detection by chemiluminescence immunoassay (CIA) and by enzyme-linked immunosorbent assays (ELISAs).

Methods

Sera from outpatients who were suspected to have anti-GBM disease and 31 patients with biopsy-proven anti-GBM disease were collected. Thirty normal controls were also included. All samples were tested for anti-GBM antibodies by CIA and commercial ELISA. The anti-GBM antibody-positive samples were confirmed by a homemade ELISA coated with recombinant human α3(IV)NC1.

Results

Compared with detection of anti-GBM antibodies with ELISA, detection of anti-GBM antibodies with CIA showed a positivity agreement of 70% and a negativity agreement of 98.6%. Among the 4 patients with different results, the anti-GBM antibody detection by CIA was in agreement with the homemade ELISA coated with recombinant human α3(IV)NC1 and the clinical diagnosis. In 31 patients with anti-GBM disease, good agreement was achieved in the detection of anti-GBM antibodies with CIA, commercial ELISA and the homemade ELISA (100%, 100%). The AUC for CIA and commercial ELISA was 0.987 and 0.966, respectively.

Conclusions

The detection of anti-GBM antibodies with CIA demonstrated good sensitivity and specificity and was in good agreement with our homemade ELISA, which seems better than the commercial ELISA in suspected anti-GBM disease patients. The three assays performed in parallel in the diagnosis of anti-GBM disease patients.

Recurrence of Goodpasture syndrome without circulating anti-glomerular basement membrane antibodies after kidney transplant, a case report

BACKGROUND

Goodpasture Syndrome (GS) is an autoimmune disease caused by the development of auto-antibodies against the Glomerular Basement Membrane (GBM). Linear deposit of immunoglobulins G on the GBM detected by immunofluorescence analysis of renal biopsies is a GS pathognomonic finding. GS is commonly monophasic and its incidence is 1.6 case per million per year.

CASE PRESENTATION

This report describes and discusses the case of a 40-year-old woman who one year after allograft kidney transplant, presented with acute pulmonary and renal symptoms of GS, leading to acute graft dysfunction, without circulating anti-GBM antibody detection in laboratory assays. She received a living donor kidney transplant 4 years after the first diagnosis of GS without circulating anti-GBM antibodies, when considered in remission.

CONCLUSIONS

In both episodes, the diagnosis of GS was based exclusively on the kidney biopsy that showed rapidly progressing glomerulonephritis with deposition of immunoglobulins G on the GBM. Although rare, the management of patients with GS without circulating anti-GBM antibodies is difficult due to the lack of standardized follow-up guidelines to reduce the risk of GS recurrence after kidney transplantation.

T cell responses to peptides of Goodpasture autoantigen in patients with anti-glomerular basement membrane disease

AIM

Cell-mediated autoimmunity, especially autoreactive T cells, is crucial in the initiation of anti-glomerular membrane (GBM) disease. Epitopes for T cells on Goodpasture autoantigen are not fully defined. This study investigated T cell epitopes in anti-GBM patients, aiming to identify the epitopes and their clinical significance.

METHODS

Peripheral blood mononuclear cells (PBMC) were collected from 13 patients with anti-GBM disease. Twenty-four overlapping linear peptides were synthesized covering the whole sequence of human α3(IV)NC1. PBMC response to each peptide was detected by proliferation assay. Their associations with clinical features were further analyzed.

RESULTS

Peripheral blood mononuclear cells proliferative responses to linear peptides on α3(IV)NC1 could be detected in all patients. Five major epitopes were identified as stimulatory in over half of the patients: α3(IV)NC1_127-148 (P14) (69.2%), α3(IV)NC1_159-178 (77.8%), α3(IV)NC1_179-198 (55.6%), α3(IV)NC1_189-208 (P19) (75.0%) and α3(IV)NC1_141-154 (57.1%). P14 and P19 were highly recognized in patients comparing with healthy controls (69.2% vs. 0.0%, P = 0.011; 75.0% vs. 0.0%, P = 0.021, respectively).

CONCLUSION

T cell proliferation to linear epitopes was detected in human anti-GBM disease. α3_127-148 was a mutual T and B cell epitope, implying its initial role in epitope spreading process.

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.

The role of HLA-DRB1 alleles on susceptibility of Chinese patients with anti-GBM disease

Anti-glomerular basement membrane (GBM) disease, a rare autoimmune disorder, is associated with HLA-DR15 genotype in Caucasian and Japanese populations. But the distribution of HLA-DRB1 alleles in Chinese patients with anti-GBM disease and their association with clinical characteristics of anti-GBM disease are to be determined. The present study analyzed the HLA-DRB1 alleles by sequence based typing in 44 Chinese patients with anti-GBM disease and 200 healthy controls. The effects of DRB1 alleles on susceptibility to anti-GBM disease were examined by a relative predispositional effects (RPEs) method. The clinical and pathological data of the patients were collected and analyzed. The DRB1*1501 allele was significantly associated with anti-GBM disease (p=1.597 x 10(-7)). The RPEs test also showed a significant increased frequency of DRB1*0404 in anti-GBM disease (p=0.037). Interestingly, the patients with DRB1*1501 or 0404 had more crescent formation in glomeruli than those without the two alleles (p=0.021). But the DRB1*0404 was rare in both patients and control groups, which indicates that the importance of the *0404 allele is limited in anti-GBM disease. We conclude that the HLA-DRB1*1501 allele is a genetic marker for susceptibility to anti-GBM disease.

Natural anti-GBM antibodies from normal human sera recognize α3(IV)NC1 restrictively and recognize the same epitopes as anti-GBM antibodies from patients with anti-GBM disease

Anti-GBM disease is a rare autoimmune condition characterized by autoantibodies targeting the alpha3 chain non-collagen 1 domain of type IV collagen (alpha3(IV)NC1). Recently, we isolated IgG reacting with alpha3(IV)NC1 from normal healthy human sera. The current study examined the antigen and epitope specificity of these natural autoantibodies (NAA) using recombinant human alpha1, 3, 5(IV)NC1 and three constructs expressing, previously defined epitope regions designated E(A), E(B) and S2, in the alpha1(IV)NC1 background. The NAA preparations reacted with recombinant human alpha3(IV)NC1 to the same extent as with purified bovine alpha(IV)NC1, but not with recombinant human alpha1 and alpha5(IV)NC1. NAA preparations recognized the three chimeric proteins (E(A), E(B) and S2) yielding similar absorbance values. We conclude that anti-GBM NAA recognize the same major epitopes as anti-GBM antibodies from patients with Goodpasture's disease.

Early recurrence of primary disease after pediatric renal transplantation: two case reports and a review of the literature

Recurrence of primary diseases such as FSGS or HUS is known to cause early graft dysfunction after pediatric renal transplantation. We report the unusual occurrence of early graft dysfunction following kidney transplant in two pediatric cases. Both subjects had biopsy proven recurrence of CGN in less than a week after transplantation. We were able to sustain the renal function in one of them following aggressive treatment. Hence, early recurrence of CGN should be considered in the differential diagnosis of early graft dysfunction.

Antigen and Epitope Specificity of Anti–Glomerular Basement Membrane Antibodies in Patients with Goodpasture Disease with or without Anti-Neutrophil Cytoplasmic Antibodies

Goodpasture disease (GP) is defined by the presence of anti-glomerular basement membrane (anti-GBM) antibodies and rapidly progressive glomerulonephritis. Besides anti-GBM, many patients with GP produce anti-neutrophil cytoplasmic antibodies (ANCA). For elucidation of the pathophysiologic significance of ANCA in this setting, epitope and antigen specificity of the anti-GBM antibodies and antigen specificity of ANCA were studied. Bovine testis alpha(IV)NC1 (tNC1); recombinant human alpha1, alpha3, alpha4, and alpha5(IV)NC1 (ralpha1 through ralpha5); and three chimeric proteins that contain previously defined epitope regions designated E(A), E(B), and S2 were used to examine the anti-GBM antibodies by ELISA in 205 Chinese patients with GP with or without ANCA. In the 205 anti-GBM antibody-positive sera, 63 (30.7%) were also ANCA positive (61 myeloperoxidase-ANCA and six proteinase 3-ANCA, four being triple positive). All 205 sera recognized tNC1 and ralpha3(IV)NC1. In the double-positive group, 54.0, 66.7, 71.4% of the sera could recognize ralpha1, ralpha4, and ralpha5, respectively, compared with 49.3, 60.6, and 55.6% for patients with anti-GBM antibodies alone. The levels of the antibodies to ralpha3, tNC1, and the alpha3/alpha1 ratio were lower in the double-positive group than that in patients with anti-GBM antibody alone (P < 0.05). Most of the sera could recognize the epitope regions E(A), E(B), and S2, but the absorbance values to E(A), E(B), and S2 were lower in double-positive group (P < 0.05). Double-positive patients had a broader spectrum of anti-GBM antibodies and lower levels of antibodies against alpha3(IV)NC1 compared with that of patients with anti-GBM antibodies alone.

Alveolar haemorrhage in anti-glomerular basement membrane disease without detectable antibodies by conventional assays

Anti-glomerular basement membrane (anti-GBM) disease represents the spectrum of disease attributable to circulating anti-GBM antibodies. While active anti-GBM disease in the absence of circulating anti-GBM antibodies has been described, it is considered rare with the use of current routinely available assays. We report four subjects with features consistent with active anti-GBM antibody disease without detectable antibodies by routinely available enzyme linked immunosorbent assay (ELISA) and immunoblot techniques. All were smokers who presented with diffuse alveolar haemorrhage, minimal renal involvement, and undetectable anti-GBM antibodies. Seronegative anti-GBM disease with predominant pulmonary involvement may be more common than previously appreciated and should be part of the differential diagnosis for otherwise unexplained diffuse alveolar haemorrhage. Renal biopsy with immunofluorescent studies should be considered in the diagnostic evaluation of such subjects, including those with idiopathic pulmonary haemosiderosis.

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.

Pathogenesis of Goodpasture syndrome: a molecular perspective

Goodpasture (GP) syndrome is a form of anti-glomerular basement membrane (GBM) disease, in which autoantibodies bind to alpha3(IV) collagen in GBM causing rapidly progressive glomerulonephritis and pulmonary hemorrhage. The conformational GP epitopes have been mapped to 2 regions within the noncollagenous (NC1) domain of the alpha3(IV) chain. Recently, we described the molecular organization of the autoantigen in the native alpha3alpha4alpha5(IV) collagen network of the GBM. The crystal structure of the NC1 domain has revealed how the GP epitopes are sequestered in the native GBM. Further insight into the pathogenesis of disease has been obtained from better animal models. These advances provide a foundation for the development of new specific therapies.

Pulmonary manifestations of Goodpasture's syndrome. Antiglomerular basement membrane disease and related disorders

Goodpasture's syndrome, or antiglomerular basement membrane disease, is a disorder in which lungs and kidneys are affected by the binding of anti-GBM antibodies, leading to pulmonary hemorrhage and glomerulonephritis with rapidly progressive renal insufficiency. Recent advances in the understanding of disease pathogenesis and diagnosis and treatment have significantly improved our ability to recognize the syndrome, distinguish it from other similar disorders, and offer successful treatment. This article focuses on the pathogenetic features, clinical manifestations, diagnostic strategies, and therapeutic principles of anti-GBM disease.

[Therapeutic plasma exchange 1996]

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique to remove large molecular weight substances. Since the late seventies TPE was used in a variety of diseases in which humoral factors may play a part in the pathogenesis. Today, accepted indications only exist for a few entities in defined situations: Anti-glomerular basement membrane antibody mediated disease, TTP/HUS, Guillain-Barré-syndrome, hyperviscosity syndrome, chronic polyneuropathy associated with IgG and IgA gammopathy, chronic inflammatory demyelinating polyneuropathy and myasthenia gravis.

Renal transplantation for patients with autoimmune diseases: single-center experience with 42 patients

BACKGROUND

In patients with autoimmune diseases such as vasculitis or systemic lupus erythematosus (SLE), end-stage renal disease develops in a high percentage of patients, and kidney transplantation has become a therapeutic option. However, only limited data about the prognosis and outcome after kidney transplantation are available.

METHODS

Long-term graft survival and graft function of renal transplant recipients with SLE, Wegener's granulomatosis, microscopic polyangiitis, Goodpasture's syndrome, and Henoch-Schonlein purpura were evaluated in a single center. In addition, the incidence of renal and extrarenal relapses and the impact of the immunosuppressive therapy on the course of the autoimmune disease were studied.

RESULTS

Renal transplant recipients with autoimmune diseases such as vasculitis and SLE had a patient survival rate (94% after 5 years) and a graft survival rate (65% after 5 years) comparable to those of patients with other causes of end-stage renal disease (patient survival 88% and graft survival 71% after 5 years). Graft losses due to the underlying disease were rare. Extrarenal relapses occurred in three patients with Wegener's granulomatosis, one patient with microscopic polyangiitis, and three patients with SLE, but were less frequent compared with the period with chronic dialysis therapy. Autoantibody levels in patients with SLE, Wegener's granulomatosis, or microscopic polyangiitis did not seem to influence the outcome.

CONCLUSIONS

Renal transplantation should be offered to patients with autoimmune diseases. Follow-up should include the short-term control of renal and extrarenal disease activity.

Recurrent Goodpasture's disease

Goodpasture's disease is usually a monophasic illness that can be successfully treated in a large proportion of patients. Recurrent disease is rare. We report a case of Goodpasture's disease in which recurrent pulmonary hemorrhage and glomerulonephritis were observed over 12 years. Antiglomerular basement membrane autoantibody was monitored throughout this period, and we demonstrate the close association of antibody levels with disease recurrence.

The clearance of heterologous antibodies in experimental antibasement membrane antibody mediated glomerulonephritis

A study of the clearance of anti GBM antibodies is important for an understanding of the pathogenesis of Goodpasture's syndrome. This paper reports a study of the sequential clearance of heterologous anti-glomerular basement membrane antibodies in the neonatal rat. A single intraperitoneal injection was followed by rapid and linear binding of injected antibodies to glomerular basement membranes, particularly to those glomeruli in the corticomedullary region. GBM bound antibodies were cleared gradually through the mesangium and significant amounts of antibodies still remained bound after 6 months. Subsequent injections of antibodies failed to provoke morphological abnormalities. These experiments have shown that the glomerular basement membrane of neonatal and adult rats possesses similar antigenic sites. The mesangium plays a major role in the clearance of injected heterologous antibodies. The slow clearance of antibodies from the GBM indicates a strong affinity of antibodies to antigenic sites and that the removal of antibodies is intimately related to the slow metabolic turnover of the glomerular basement membrane. The findings help to explain some of the observations in human antibasement membrane antibody mediated disease of the Goodpasture's type.

Goodpasture's syndrome: recurrence after a five-year remission. Case report and review of the literature

Herein is reported the case of a man who has had a recurrence of Goodpasture's syndrome following a five-year remission. The patient presented initially in 1977 at the age of 28 with Goodpasture's syndrome manifested by pulmonary hemorrhage without clinical evidence of renal disease, and positive antiglomerular basement membrane antibody. Following treatment with corticosteroids, remission occurred and the serum antiglomerular basement membrane antibody became negative. In 1983, he experienced a relapse with the reappearance of serum antiglomerular basement membrane antibody, the development of severe life-threatening intrapulmonary hemorrhage, and hematuria. This case illustrates that life-threatening relapse may occur in Goodpasture's syndrome despite a prolonged remission and the disappearance of detectable antiglomerular basement membrane antibody in the circulation.

[Recurrence of the original disease in the transplanted kidney]

Recurrence of the original disease in the transplanted kidney is observed in 5.6%-9.3% of the patients. However, the clinical significance of recurrence is often minor. Diagnosis is easy in diseases with specific renal lesions, e.g., in dense deposit disease and IgA-nephropathy, but may be difficult if such a marker is missing. Recurrence is of special clinical importance in the following conditions: Membranoproliferative GN type I (in 33%, often severe) and type II (= dense deposit disease, recurrence in 90%, often minor), focal segmental glomerulosclerosis (in 48% of patients with a rapid course (less than 3 years) and in 12% of patients with a longer duration of the original disease; often severe), membranous nephropathy (recurrence rather rare, but often serious), and primary hyperoxaluria (in 100%). Mesangial IgA deposits recur in half of the patients with IgA-nephropathy and anaphylactoid purpura, but clinical findings are often minimal. Recurrence in anti-GBM-nephritis and SLE is rare. The study of recurrence may contribute to a better understanding of many renal diseases.

Glomerular antigens in glomerulonephritis

Ideas on the immunopathogenesis of glomerulonephritis are evolving to embrace a concept of a dynamic and constantly fluctuating involvement of immune reactants in the production of glomerular inflammation. The glomerulus should be regarded as a template around which the antibody-induced inflammatory events that constitute glomerulonephritis are initiated. Such lesions may be produced by direct antibody attack on glomerular antigens of either intrinsic structural or "planted" type, as discussed in this review, or by the deposition of circulating soluble immune complexes containing extraglomerular antigens. These mechanisms are not mutually exclusive and both may play a role in some situations. Intrinsic glomerular antigens are being increasingly better defined as to site, structure, function, and experimental animal models of spontaneous and induced glomerular injury resulting from direct antibody binding to nonclassic GBM capillary wall antigens are available for study. Similar nonclassic GBM antigens are likely to be found of importance in man. Anti-GBM antibody-induced glomerulonephritis continues to be the best understood example of direct attack on the glomerulus by antibody, and its nephritogenic noncollagenous GBM antigenic constituents are being characterized. The incorporation of extraneous substances as "planted" antigens within glomerular structures is now recognized in experimental animal models, and there is suggestive evidence to support the concept in man. Emphasis needs to be placed on the continuing interplay of free antibody and antigen with deposited reactants which, together with complement components, modulate the quality and quantity of the glomerular immune deposits.