The differential diagnosis of crescentic glomerulonephritis. The pathology of specific lesions with prognostic implications

Rapid progressive glomerulonephritis in patients with familial Mediterranean fever

Two patients with a long-standing history of familial Mediterranean fever (FMF) presented with gross hematuria, oliguria, and acute renal failure; both required dialysis support. Kidney biopsies from both patients revealed crescentic rapid progressive glomerulonephritis (RPGN) without amyloidosis. One patient recovered renal function with methylprednisolone pulse therapy and cyclophosamide. The second patient did not improve and required regular hemodialysis. He is asymptomatic on colchicine therapy. To our knowledge, these are the first cases documenting the presence of RPGN in patients with FMF.

Circulating anti-neutrophil cytoplasm antibodies in patients with rapidly progressive glomerulonephritis and extracapillary proliferation

We investigated 39 patients with rapidly progressive glomerulonephritis and extracapillary proliferation for the presence of circulating anti-neutrophil cytoplasm antibodies (ANCA) by indirect immunofluorescence. Patients with antibodies against the glomerular basement membrane, systemic lupus erythematosus or with glomerulonephritis following infection and where renal disease could be ascribed to treatment with drugs were not included. IgG class ANCA producing diffuse cytoplasmic immunostaining were detected in 54% of the patients. With reservation for the difficulties involved in distinguishing between different forms of systemic vasculitis, these autoantibodies were present in patients with Wegener's granulomatosis (12 out of 17 patients), polyarteritis nodosa (4/6), idiopathic extracapillary glomerulonephritis (1/4), and with less distinct syndromes (4/10), but not in Henoch-Schönlein's purpura (0/2). Another 18% of the patients showed granulocyte-specific anti-nuclear antibodies' with perinuclear immunostaining. This pattern was recently reported to indicate the presence of antibody against myeloperoxidase of alcohol-fixed neutrophils. Autoimmune mechanisms, particularly those involving components of neutrophil granulocytes, could play a significant role in development of extracapillary glomerulonephritis.

Immunoperoxidase autopsy study of crescentic glomerulonephritis with extracapillary proliferation

Twenty-five cases of extracapillary crescentic glomerulonephritis were examined immunohistologically. The peroxidase-antiperoxidase (PAP) method was used, the presence of immunoglobulin, complement factors and fibrin was analysed and glomerular positivity was found in all but two cases. Two types of reaction could be discerned: linear and granular, which can be considered as evidence of the pathomechanism. Surprisingly, IgG and IgM positivity was seen most frequently. The author emphasizes the importance of immunoperoxidase examination in the renal histology. This method can be easily applied in paraffin-embedded samples and gives many useful information.

Adult hemolytic uremic syndrome associated with nonimmune deposit crescentic glomerulonephritis and alveolar hemorrhage

An 18-year-old girl presented with anuric rapidly progressive glomerulonephritis associated with hypoxemic respiratory failure due to diffuse lung hemorrhage. The course of the kidney disease terminated in end-stage renal failure. The patient had been on permanent hemodialysis since her first admission; episodes of lung hemorrhage recurred five times over a follow-up period of 8 months. Two months after her first admission, the patient manifested features suggestive of the hemolytic uremic syndrome, namely, microangiopathic hemolytic anemia, thrombocytopenia, and excessive hypertension complicated by hypertensive encephalopathy. Based on the sequence of events in the course of this patient's disease, the authors believe that the hematological abnormalities were superimposed on the glomerular disease rather than being a primary disorder. Possible mechanisms for the association of the two disorders are discussed.

Treatment of non anti-GBM-antibody mediated, rapidly progressive glomerulonephritis by plasmapheresis and immunosuppression

A retrospective study was conducted to evaluate the efficacy of plasmapheresis in combination with different immunosuppressive drugs ("pulse" therapy, azathioprine or cyclophosphamide together with steroids) in nine patients presenting with rapidly progressive glomerulonephritis (RPGN) not mediated by antibody to glomerular basement membrane. Six of these patients had to be initially dialysed. All patients underwent renal biopsy, which revealed that seven patients had a minimum of 80% crescents and five had interstitial fibrosis. Recovery of renal function was observed in seven patients (78%). All patients without interstitial fibrosis were recompensated for at least 14 months after the acute onset of RPGN. Those who presented with interstitial fibrosis declined to endstage renal failure after 13 months requiring chronic hemodialysis treatment or cadaveric kidney transplantation. On the basis of these findings interstitial fibrosis seems to be a limiting factor for the prognosis of non-anti-GBM-antibody mediated RPGN.

Rapidly progressive glomerulonephritis with glomerular crescent formation in rheumatoid arthritis

Systemic vasculitis is a well-known complication of rheumatoid arthritis (RA). Rapidly progressive glomerulonephritis is commonly associated with vasculitis syndromes but rarely found in RA. This report describes two RA patients with complicating systemic vasculitis who developed rapidly progressive glomerulonephritis with glomerular crescent formation. One recovered after treatment with corticosteroids and cytostatic drugs and the other died of severe systemic vasculitis despite similar therapy.

Prognosis after immunosuppression of patients with crescentic nephritis requiring dialysis

48 patients with rapidly progressive glomerulonephritis were treated by a regimen of intensive plasma exchange, steroids, and cytotoxic drugs. All required dialysis before immunosuppressive treatment was started, and all had 50% or more of their glomeruli affected by crescent formation. Renal function was not recovered in any of the 21 patients with anti-glomerular basement membrane antibody disease. In contrast 63% of patients without these autoantibodies recovered renal function. Plasma creatinine remained stable over prolonged follow-up (6-60 months) in all but 1 of the 10 late survivors. There was no correlation between the extent of crescent formation and recovery of renal function in those patients without circulating anti-glomerular basement membrane antibodies.

The ultrastructure of glomerular haematoxylin bodies

The ultrastructural features of haematoxylin bodies, present in a patient with active lupus glomerulonephritis, appear to include cellular elements, especially dense chromatin of probable neutrophil leucocyte origin and electron-dense, immune complex-like material. Although the participation of immune complexes in the formation of haematoxylin bodies has been previously proposed, this is the first reported demonstration of such deposits in haematoxylin bodies.

'Pulse' methylprednisolone and cyclophosphamide therapy in idiopathic rapidly progressive glomerulonephritis

The clinical report of a 31-year-old man who developed acute renal failure due to idiopathic rapidly progressive glomerulonephritis is presented. Intravenous pulse methylprednisolone therapy in combination with cyclophosphamide resulted in marked improvement in renal function. The literature dealing with pulse therapy is reviewed.

Treatment of Goodpasture's syndrome with plasmapheresis. A case report and review of the literature

A case is reported of antiglomerular basement membrane antibody-induced Goodpasture's syndrome in which the patient required hemodialysis and was treated with immunosuppressive agents and plasmapheresis. A severe (80 per cent) cresentic lesion was reversed, and creatinine was stabilized at 2.5 mg/dl at one year follow-up. Earlier reports of therapy without plasmapheresis showed that 88 per cent of the patients would either die or require long-term hemodialysis. Fifteen other reported cases of Goodpasture's syndrome in which the patients were treated with plasmapheresis are reviewed. When reported, short-term follow-up showed that nine of these patients were alive without need of dialysis, five wee receiving dialysis, and only two had died. This suggests that plasmaheresis and immunosuppressive therapy may reverse the renal lesion in some patients with Goodpasture's syndrome.

Crescentic glomerulonephritis without immune deposits: clinicopathologic features

Of 46 patients with acute crescentic glomerulonephritis involving 20 to 90% of glomeruli, 16 had no definable systemic disease and no significant glomerular immune deposits by immunofluorescent or electron microscopy. Anti-GBM antibody and circulating immune complexes were further excluded by radioimmunoassay and Raji cell assay in all patients tested. Clinical features included a 10:6 male:female ratio, mean age of 58 years (range, 13-77), disease duration of less than 3 months, rapidly deteriorating renal function, and frequent pulmonary manifestations. Nine patients had oliguria, serum creatinine concentrations over 6 mg/100 ml, and required dialysis, but three of these patients subsequently recovered renal function. These three patients and seven patients with creatinine concentrations of less than 6 mg/100 ml have not progressed to chronic renal failure. In this series, idiopathic acute crescentic glomerulonephritis without immune deposits was more common than was immune complex or anti-GBM nephritis. The clinical, laboratory, and pathologic characteristics of these patients were similar to those reported in anti-GBM and immune-complex-induced glomerulonephritis. These observations expand the spectrum of rapidly progressive crescentic glomerulonephritis. They suggest that glomerular immune deposits may be less important than other factors in determining the extent of renal injury and subsequent clinical course in crescentic glomerulonephritis.