Clinical and immunological evolution of oligoanuric anti-GBM nephritis treated by haemodialysis

Plasmapheresis for systemic vasculitis

Systemic vasculitides include a variety of, and numerous diseases. In 2012, the International CHAPEL HILL Consensus Conference (CHCC2012) led to a major reorganization of the classification of vasculitis, and this is still in wide use today. Although the results of plasmapheresis for individual diseases have been sometimes shown, there are few systematic reviews that discuss the effects along with vasculitis classification. Therefore, we will discuss the efficacy and the latest evidence for each vasculitis according to the CHCC 2012 classification in this review. This review provides a comprehensive overview of the estimation of plasmapheresis in each of the vasculitides, with a particular focus on small vasculitides, which have recently discussed frequently. For some time now, plasma exchange therapy (PEX) has been frequently used and is expected to be effective in some diseases, most of which are included in small vessel vasculitides. In particular, data showing efficacy have been accumulated for immune complex vasculitis, and the recommendation seems to be high. For instance, anti‐GBM nephritis, concomitant use of PEX is essential and strongly recommended. On the other hand, for ANCA‐related vasculitis among small vessel vasculitis, RCTs have recently shown negative results. In particular, the PEXIVAS trial statistically showed that PEX has no potential to reduce the mortality and renal death in AAV, but the ASFA, ACR, and KDIGO guidelines following this trial all regard PEX as salvage therapy or selective treatment for severe cases. As plasmapheresis is often performed in combination with other therapies, it is difficult to evaluate to clarify its efficacy on its own, and this predisposition may be pronounced in vasculitis, a rare disease. Although statistically significant differences are not apparent, the diseases that show a trend toward efficacy may possibly include treatment‐sensitive subgroups. Further analysis is expected in the future.

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.

Effectiveness of Plasmapheresis in a Patient with Anti-glomerular Basement Membrane Antibody Glomerulonephritis with Advanced Kidney Dysfunction

Patients with anti-glomerular basement membrane antibody glomerulonephritis (anti-GBM GN) have severe kidney dysfunction, leading to end-stage renal disease. The effect of plasmapheresis and immunosuppressive treatment in patients with severe glomerular changes is controversial. A 62-year-old man was admitted with rapidly progressive glomerulonephritis and diagnosed with anti-GBM GN. He required hemodialysis. All glomeruli in the kidney biopsy specimen had cellular crescents without fibrotic changes, suggesting reversible damage. He was treated with plasmapheresis until the anti-glomerular basement membrane antibodies disappeared. His kidney function recovered, and dialysis was able to be discontinued. Frequent plasmapheresis in patients with dialysis-dependent anti-GBM GN may improve the kidney prognosis.

Discontinuation of Hemodialysis in a Patient with Anti-GBM Disease by the Treatment with Corticosteroids and Plasmapheresis despite Several Predictors for Dialysis-Dependence

A 26-year-old man highly suspected of having antiglomerular basement membrane (GBM) disease was treated with corticosteroid pulse therapy 9 days after initial infection-like symptoms with high procalcitonin value. The patient required hemodialysis the next day of the treatment due to oliguria. In addition to corticosteroid therapy, plasmapheresis was introduced and the patient could discontinue hemodialysis 43 days after the treatment. Kidney biopsy after initiation of hemodialysis confirmed anti-GBM disease with 86.3% crescent formation. Physician should keep in mind that active anti-GBM disease shows even high procalcitonin value in the absence of infection. To pursue recovery of renal function, the challenge of the immediate and persistent treatment with high-dose corticosteroids plus plasmapheresis for highly suspected anti-GBM disease is vitally important despite the presence of reported predictors for dialysis-dependence including oliguria and requiring hemodialysis at presentation.

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.

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.

Plasmapheresis therapy for diffuse alveolar hemorrhage in patients with small-vessel vasculitis

BACKGROUND

Unlike Goodpasture's syndrome with diffuse alveolar hemorrhage (DAH), there are few studies examining therapy for patients with DAH associated with antineutrophil cytoplasmic antibody (ANCA)-associated small-vessel vasculitis (SVV).

METHODS

We performed a retrospective review of all such patients presenting to our institution between 1995 and 2001. All patients were treated with apheresis and induction immunosuppressive therapy; namely, intravenous methylprednisolone and/or intravenous cyclophosphamide.

RESULTS

DAH resolved with apheresis in 20 of 20 patients (100%) with 6.4 (average) treatments. There were no complications of therapy. Half the patients (7 of 14) who also presented with azotemia were discharged with improved renal function.

CONCLUSION

Patients with ANCA-related SVV and DAH benefit from prompt initiation of apheresis coupled with aggressive immunosuppressive therapy. Such therapy can be lifesaving with respect to the pulmonary component of this syndrome.

ANCA and anti-GBM antibodies in diagnosis and follow-up of vasculitic disease

In the last decade, serological detection of anti-neutrophil cytoplasmic antibodies (ANCA) and of anti-glomerular basement membrane (GBM) antibodies has tremendously facilitated the diagnosis of small vessel vasculitides. Once diagnosed, these diseases have proven to be treatable. However, in contrast to anti-GBM disease, ANCA-associated vasculitides are chronic diseases with a high relapse rate. Since morbidity in ANCA-associated vasculitides is dictated by the frequency and severity of relapses, much health benefit would be achieved if a relapse could be prevented or early treatment started. Increases in ANCA titers and persistently high ANCA levels indicate a high risk of relapse and warrant clinical evaluation of the patient for signs of relapse. This review will focus on the value of ANCA and anti-GBM antibody testing in diagnosis and on the importance of these tests in follow-up of disease.

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.

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

Over the last 16 years we have treated 40 patients with a renal pathological diagnosis of anti-glomerular basement membrane (anti-GBM) disease. The age of presentation ranged from 18 years to 76. Males and females were equally affected. The most common presenting symptoms were anorexia and uremia. Fifty percent of the patients were oliguric at presentation and required dialysis within 24 h, while the mean serum creatinine (Cr) at presentation was 5.1 +/- 6.8 mg/dL. Sixty-two percent of the patients demonstrated evidence of pulmonary involvement. Hematuria was universally present and was macroscopic in 35% of cases. Eight-two percent of the biopsies demonstrated greater than 80% crescents. Eight patients retained independent renal function after immunosuppression with cyclophosphamide, prednisone, and plasmapheresis. No patient who presented with a Cr greater than 5 mg/dL retained renal function. Using a logistic regression model the only clinical, biochemical, or pathological factors at presentation that significantly predicted eventual need for dialysis were the serum creatinine and percentage of glomeruli with crescents. Ten patients underwent cadaveric renal transplantation, and 7 have a functioning graft for a mean of 8.2 years. None have shown evidence of recurrence of anti-GBM disease in the graft. We conclude that anti-GBM disease is an important cause of renal failure and that its prognosis is directly related to the degree of renal failure at presentation. Efforts need to be made to diagnose this condition earlier in its natural history if its prognosis is to be improved.

Glomerulonephritis associated with antibodies to neutrophil cytoplasm and glomerular basement membrane

The prognosis for recovery of renal function of oligoanuric patients with anti-glomerular basement membrane disease is generally regarded as poor. Five patients are reported with dialysis-dependent renal failure in whom antibodies were present simultaneously both to neutrophil cytoplasm and glomerular basement membrane all of whom responded, at least initially, to immunosuppressive therapy and plasma exchange. Two of the 5 remain in clinical and immunological remission at 25 and 51 months of follow-up. We suggest that reversal of dialysis-dependent renal failure may be possible in some patients who display this dual antibody positivity.

Immunoregulation of mercuric chloride-induced autoimmunity in Brown Norway rats: a role for CD8+ T cells revealed by in vivo depletion studies

Mercuric chloride (HgCl2) induces the production of autoantibodies to glomerular basement membrane (GBM) in the Brown Norway (BN) rat. The autoimmune response is self-limiting and thereafter the animals are resistant to rechallenge with HgCl2. Resistance can be transferred to naive animals by spleen cells from HgCl2-treated rats. A similar state of resistance can be induced with a low dose of HgCl2, insufficient in itself to induce autoimmunity. We have examined the role of CD8+ T cells in the immunoregulation of this experimental model by depleting this subset in vivo. We have also used inhibition studies in a solid-phase radioimmunoassay in an attempt to demonstrate any effect of anti-idiotypic antibodies in the spontaneous resolution of the anti-GBM antibody response. The initial induction and spontaneous resolution of anti-GBM antibodies were unaffected by depletion of CD8+ T cells. However, CD8-depleted animals were no longer resistant to rechallenge with HgCl2. Cell transfer studies showed that spleen cells from CD8-depleted animals conferred less resistance to HgCl2 than those from animals which had received control antibody. CD8 depletion also reduced the resistance induced by pretreatment with low-dose HgCl2. Studies in which peak sera were pre-incubated with post-recovery sera before testing in a solid-phase anti-GBM radioimmunoassay did not support an important role for anti-idiotypic antibodies. We conclude that CD8+ T cells play an important role in the resistance to rechallenge with HgCl2 in the BN rat, although they are not required for the induction or spontaneous resolution of the initial autoimmune response. Demonstration of the reversal of a suppressive phenomenon in vivo using an anti-CD8 monoclonal antibody is unusual.

Recurrent primary disease and de novo nephritis following renal transplantation

Recurrent or de novo diseases account for only 5% of graft failure in children, but have much to teach us about mechanisms. In children, almost the only metabolic disease with recurrence is type I hyperoxaluria, in which the poor long-term results of isolated renal transplantation make combined liver and renal transplantation, or even prophylactic liver transplantation before renal failure the preferable alternatives. While many forms of nephritis may show histological recurrence in allografts, it is notable that in many patients this is accompanied by no clinical manifestations or only mild disease: this is particularly so in mesangiocapillary glomerulonephritis (MCGN) type II. IgA-associated nephropathy and Henoch-Schönlein purpura. However focal segmental glomerulosclerosis and MCGN type I recur with sufficient frequency and severity to deter the use of living donors unless there is no alternative. The same is true of haemolytic-uraemic syndromes. As many as 10% of paediatric grafts may show de novo membranous nephropathy, but in the majority this is mild or not clinically evident. In contrast, the rare anti-glomerular basement membrane nephritis affecting some patients with Alport's syndrome usually results in graft failure, but occurs in only a minority of recipients with the syndrome. For all types of disease in allografts, risk factors for recurrence are poorly worked out, and attempts at treatment generally ineffective.

Anti-glomerular basement membrane antibody-mediated glomerulonephritis due to glue sniffing

A 16-year-old girl developed rapidly progressive glomerulonephritis and renal failure. The disease was associated with high titres of antiglomerular basement membrane antibodies in serum, linear deposits of immunoglobulin G and diffuse epithelial crescents on renal biopsy. Past history revealed heavy smoking and deliberate sniffing of Pattex glue, a mixture of hydrocarbons which possibly may affect the structure of glomerular basement membrane. After treatment by repeated plasmapheresis and drug immunosuppression autoantibodies disappeared from serum but renal function was not influenced. Renal damage is a potential hazard for glue sniffing adolescents.