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Gluhovschi C, Gadalean F, Velciov S, Nistor M, Petrica L. Three Diseases Mediated by Different Immunopathologic Mechanisms-ANCA-Associated Vasculitis, Anti-Glomerular Basement Membrane Disease, and Immune Complex-Mediated Glomerulonephritis-A Common Clinical and Histopathologic Picture: Rapidly Progressive Crescentic Glomerulonephritis. Biomedicines 2023; 11:2978. [PMID: 38001978 PMCID: PMC10669599 DOI: 10.3390/biomedicines11112978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 11/02/2023] [Accepted: 11/04/2023] [Indexed: 11/26/2023] Open
Abstract
Immune mechanisms play an important role in the pathogenesis of glomerulonephritis (GN), with autoimmunity being the main underlying pathogenetic process of both primary and secondary GN. We present three autoimmune diseases mediated by different autoimmune mechanisms: glomerulonephritis in vasculitis mediated by anti-neutrophil cytoplasmic antibodies (ANCAs), glomerulonephritis mediated by anti-glomerular basement membrane antibodies (anti-GBM antibodies), and immune complex-mediated glomerulonephritis. Some of these diseases represent a common clinical and histopathologic scenario, namely rapidly progressive crescentic glomerulonephritis. This is a severe illness requiring complex therapy, with the main role being played by therapy aimed at targeting immune mechanisms. In the absence of immune therapy, the crescents, the characteristic histopathologic lesions of this common presentation, progress toward fibrosis, which is accompanied by end-stage renal disease (ESRD). The fact that three diseases mediated by different immunopathologic mechanisms have a common clinical and histopathologic picture reveals the complexity of the relationship between immunopathologic mechanisms and their clinical expression. Whereas most glomerular diseases progress by a slow process of sclerosis and fibrosis, the glomerular diseases accompanied by glomerular crescent formation can progress, if untreated, in a couple of months into whole-nephron glomerulosclerosis and fibrosis. The outcome of different immune processes in a common clinical and histopathologic phenotype reveals the complexity of the relationship of the kidney with the immune system. The aim of this review is to present different immune processes that lead to a common clinical and histopathologic phenotype, such as rapidly progressive crescentic glomerulonephritis.
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Affiliation(s)
- Cristina Gluhovschi
- Division of Nephrology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (F.G.); (L.P.)
- Centre for Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
| | - Florica Gadalean
- Division of Nephrology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (F.G.); (L.P.)
- Centre for Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
- Division of Nephrology, County Emergency Hospital Timisoara, 300041 Timișoara, Romania
| | - Silvia Velciov
- Centre for Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
- Division of Nephrology, County Emergency Hospital Timisoara, 300041 Timișoara, Romania
| | - Mirabela Nistor
- Division of Nephrology, County Emergency Hospital Timisoara, 300041 Timișoara, Romania
| | - Ligia Petrica
- Division of Nephrology, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania; (F.G.); (L.P.)
- Centre for Molecular Research in Nephrology and Vascular Disease, Faculty of Medicine, “Victor Babeș” University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timișoara, Romania;
- Division of Nephrology, County Emergency Hospital Timisoara, 300041 Timișoara, Romania
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Floyd L, Bate S, Hadi Kafagi A, Brown N, Scott J, Srikantharajah M, Myslivecek M, Reid G, Aqeel F, Frausova D, Kollar M, Kieu PL, Khurshid B, Pusey CD, Dhaygude A, Tesar V, McAdoo S, Little MA, Geetha D, Brix SR. Risk Stratification to Predict Renal Survival in Anti-Glomerular Basement Membrane Disease. J Am Soc Nephrol 2023; 34:505-514. [PMID: 36446430 PMCID: PMC10103284 DOI: 10.1681/asn.2022050581] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 12/03/2022] Open
Abstract
SIGNIFICANCE STATEMENT Most patients with anti-glomerular basement membrane (GBM) disease present with rapidly progressive glomerulonephritis, and more than half develop ESKD. Currently, no tools are available to aid in the prognostication or management of this rare disease. In one of the largest assembled cohorts of patients with anti-GBM disease (with 174 patients included in the final analysis), the authors demonstrated that the renal risk score for ANCA-associated vasculitis is transferable to anti-GBM disease and the renal histology is strongly predictive of renal survival and recovery. Stratifying patients according to the percentage of normal glomeruli in the kidney biopsy and the need for RRT at the time of diagnosis improves outcome prediction. Such stratification may assist in the management of anti-GBM disease. BACKGROUND Prospective randomized trials investigating treatments and outcomes in anti-glomerular basement membrane (anti-GBM) disease are sparse, and validated tools to aid prognostication or management are lacking. METHODS In a retrospective, multicenter, international cohort study, we investigated clinical and histologic parameters predicting kidney outcome and sought to identify patients who benefit from rescue immunosuppressive therapy. We also explored applying the concept of the renal risk score (RRS), currently used to predict renal outcomes in ANCA-associated vasculitis, to anti-GBM disease. RESULTS The final analysis included 174 patients (out of a total of 191). Using Cox and Kaplan-Meier methods, we found that the RRS was a strong predictor for ESKD. The 36-month renal survival was 100%, 62.4%, and 20.7% in the low-risk, moderate-risk, and high-risk groups, respectively. The need for renal replacement therapy (RRT) at diagnosis and the percentage of normal glomeruli in the biopsy were independent predictors of ESKD. The best predictor for renal recovery was the percentage of normal glomeruli, with a cut point of 10% normal glomeruli providing good stratification. A model with the predictors RRT and normal glomeruli ( N ) achieved superior discrimination for significant differences in renal survival. Dividing patients into four risk groups led to a 36-month renal survival of 96.4% (no RRT, N ≥10%), 74.0% (no RRT, N <10%), 42.3% (RRT, N ≥10%), and 14.1% (RRT, N <10%), respectively. CONCLUSIONS These findings demonstrate that the RRS concept is transferrable to anti-GBM disease. Stratifying patients according to the need for RRT at diagnosis and renal histology improves prediction, highlighting the importance of normal glomeruli. Such stratification may assist in the management of anti-GBM disease. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/JASN/2023_02_27_JASN0000000000000060.mp3.
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Affiliation(s)
- Lauren Floyd
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Sebastian Bate
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Abdul Hadi Kafagi
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Nina Brown
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Jennifer Scott
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Dublin, Ireland
| | | | - Marek Myslivecek
- First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Nephrology, General University Hospital, Prague, Czech Republic
| | - Graeme Reid
- Renal Pathology, Adult Histopathology Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Faten Aqeel
- Department of Medicine, John Hopkins University, Baltimore, Maryland
| | - Doubravka Frausova
- First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Nephrology, General University Hospital, Prague, Czech Republic
| | - Marek Kollar
- Centre of Clinical and Transplant Pathology, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Phuong Le Kieu
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
| | - Bilal Khurshid
- Renal Department, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Charles D. Pusey
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Ajay Dhaygude
- Renal Department, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Vladimir Tesar
- First Faculty of Medicine, Charles University, Prague, Czech Republic
- Department of Nephrology, General University Hospital, Prague, Czech Republic
| | - Stephen McAdoo
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Mark A. Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Trinity College Dublin, Dublin, Ireland
- Irish Centre for Vascular Biology, Dublin, Ireland
| | - Duvuru Geetha
- Department of Medicine, John Hopkins University, Baltimore, Maryland
| | - Silke R. Brix
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester, United Kingdom
- Renal, Urology and Transplantation Unit, Manchester University NHS Foundation Trust, Manchester, United Kingdom
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Ponticelli C, Calatroni M, Moroni G. Anti-glomerular basement membrane vasculitis. Autoimmun Rev 2023; 22:103212. [PMID: 36252931 DOI: 10.1016/j.autrev.2022.103212] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/11/2022] [Indexed: 12/27/2022]
Abstract
Antiglomerular basement membrane disease (anti-GBM) is a rare life-threatening autoimmune vasculitis that involves small vessels and it is characterized by circulating autoantibodies directed against type IV collagen antigens expressed in glomerular and alveolar basement membrane. The typical clinical manifestations are the rapidly progressive glomerulonephritis and the alveolar hemorrhage. The diagnosis is usually confirmed by the detection of anti-GBM circulating antibodies. If not rapidly recognized, anti-GBM disease can lead to end stage kidney disease (ESKD). An early diagnosis and prompt treatment with immunosuppressive therapies and plasmapheresis are crucial to prevent a poor outcome. In this review, we discuss the primary form of anti-GBM (the so called Goodpasture syndrome) but also cases associated with other autoimmune diseases such as antineutrophil-cytoplasmic-antibody (ANCA) vasculitis, membranous nephropathy, IgA nephritis and systemic lupus erythematosus (SLE), as well as the few cases of anti-GBM vasculitis complicating kidney transplantation in the Alport syndrome.
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Affiliation(s)
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy; Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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Honda N, Shigehara R, Furuhashi K, Nagai Y, Yokogawa N. Anti-glomerular basement membrane diseases and thrombotic microangiopathy treated with rituximab. Mod Rheumatol Case Rep 2022:rxac091. [PMID: 36420905 DOI: 10.1093/mrcr/rxac091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 11/10/2022] [Accepted: 11/23/2022] [Indexed: 06/16/2023]
Abstract
A 68-year-old, male patient presented with a two-week history of malaise and anuria. Renal replacement therapy with hemodialysis was begun for acute kidney injury. His anti-glomerular basement membrane (anti-GBM) antibody titer was 3060 U/mL. Based on this finding, anti-GBM diseases was diagnosed. Plasmapheresis and high-dose glucocorticoid therapy were begun, but his hemolytic anemia and thrombocytopenia progressed. ADAMTS-13 activity decreased to 33%, but no inhibitor was detected. Secondary thrombotic microangiopathy (TMA) was suspected, and rituximab therapy was begun. The addition of rituximab is thought to have further reduced the anti-GBM antibodies, prevented recurrence, stabilized the platelet count, and facilitated the patient's withdrawal from plasmapheresis and glucocorticoid therapy. Rituximab may be a viable therapeutic option for anti-GBM diseases complicated with TMA.
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Affiliation(s)
- Nanase Honda
- Department of Internal Medicine Hino Municipal Hospital, Tokyo, Japan
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Rihiro Shigehara
- Department of Internal Medicine Hino Municipal Hospital, Tokyo, Japan
| | - Kazunori Furuhashi
- Department of Internal Medicine Hino Municipal Hospital, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiki Nagai
- Department of Internal Medicine Hino Municipal Hospital, Tokyo, Japan
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Naoto Yokogawa
- Department of Internal Medicine Hino Municipal Hospital, Tokyo, Japan
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
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Li Q, Cao Q, Wang C, Nguyen H, Wang XM, Zheng G, Wang YM, Hu S, Alexander SI, Harris DCH, Wang Y. Dendritic cell-targeted CD40 DNA vaccine suppresses Th17 and ameliorates progression of experimental autoimmune glomerulonephritis. J Leukoc Biol 2019; 105:809-819. [PMID: 30811635 DOI: 10.1002/jlb.5a0818-333r] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/22/2019] [Accepted: 02/07/2019] [Indexed: 01/23/2023] Open
Abstract
The CD40-CD40L costimulatory pathway is critical for T cell activation in autoimmune disease. We have previously found that blocking the CD40-CD40L pathway using a dendritic cell-targeted CD40 DNA (DEC-CD40) vaccine prevented the development of Heymann nephritis. In this study, we explored the effect of a DEC-CD40 vaccine in the treatment of experimental autoimmune glomerulonephritis (EAG), an animal model of human Goodpasture's disease induced by antigen α3IV-NC1. DEC-CD40 vaccine given at week 3 and week 6 after 3IV-NC1 injection reduced kidney structural and functional injury significantly in EAG. DEC-CD40 vaccination suppressed Th17 cell numbers and Th17 immune responses in kidney and spleen, but did not alter Th1 cells number and responses. Serum derived from rats with DEC-CD40 vaccination suppressed Th17 differentiation, but not Th1 differentiation in vitro. Furthermore, B cell activation, driven by Th17 cytokines, was suppressed by serum from rats vaccinated with DEC-CD40. A DNA vaccine encoding CD40 and targeting dendritic cell, ameliorates kidney injury in both early and late stages in EAG rats, indicating DEC-CD40 vaccination has a therapeutic role in EAG. Its effect is associated with the reduction of Th17 differentiation and Th17-mediated B cell activation.
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Affiliation(s)
- Qing Li
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
- The Central Laboratory of Medical Research Center, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Qi Cao
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
- Laboratory of Immunology and Targeted Therapy, School of Laboratory Medicine, Xinxiang Medical University, Xinxiang, China
| | - Chengshi Wang
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Hanh Nguyen
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Xin Maggie Wang
- Flow Cytometry Facility, Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Guoping Zheng
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Yuan Min Wang
- Centre for Kidney Research, Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia
| | - Shilian Hu
- Anhui Geriatrics Institute, Department of Geriatrics, Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Stephen I Alexander
- Centre for Kidney Research, Children's Hospital at Westmead, University of Sydney, Sydney, New South Wales, Australia
| | - David C H Harris
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Yiping Wang
- Centre for Transplant and Renal Research, Westmead Institute for Medical Research, The University of Sydney, Sydney, New South Wales, Australia
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Lapointe E, Moghaddam B, Barclay K, Traboulsee AL, Neufeld P. Goodpasture's Syndrome Following Alemtuzumab Therapy in Multiple Sclerosis. Can J Neurol Sci 2018; 45:712-714. [PMID: 30277178 DOI: 10.1017/cjn.2018.325] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Emmanuelle Lapointe
- Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bahar Moghaddam
- Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Krista Barclay
- Neurology, Djavad Mowafaghian Center for Brain Health, Vancouver, British Columbia, Canada
| | - Anthony L Traboulsee
- Division of Neurology, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Neufeld
- Department of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
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Parrot A, Voiriot G, Canellas A, Gibelin A, Nacacche JM, Cadranel J, Fartoukh M. Hémorragies intra-alvéolaires. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
L’hémorragie intra-alvéolaire (HIA), maladie rare, est une urgence thérapeutique, car elle peut conduire rapidement vers une insuffisance respiratoire aiguë asphyxiante avec décès. La triade, hémoptysie–anémie–infiltrat radiologique, suggère le diagnostic d’HIA, mais elle peut manquer dans deux tiers des cas, y compris chez des patients en détresse respiratoire. La tomodensitométrie thoracique peut aider dans les formes atypiques. Le diagnostic d’HIA repose sur la réalisation d’un lavage bronchoalvéolaire. Les étiologies en sont très nombreuses. Il importera de séparer, en urgence, les HIA d’origine non immune, avec un dépistage de celles d’origine septique qui doivent bénéficier d’une enquête microbiologique ciblée et cardiovasculaire avec la réalisation d’une échographie cardiaque, des HIA immunes (les vascularites liées aux anticorps anticytoplasme des polynucléaires neutrophiles, les connectivites et le syndrome de Goodpasture), avec la recherche d’autoanticorps et la réalisation de biopsies au niveau des organes facilement accessibles. La biopsie pulmonaire doit rester exceptionnelle. En cas d’HIA immune inaugurale, un traitement par stéroïdes et cyclophosphamide peut être débuté. Les indications du rituximab commencent à être mieux établies. Le bénéfice des échanges plasmatiques est débattu. En cas de réapparition d’infiltrats pulmonaires, chez un patient suivi pour une HIA immune, on s’efforcera d’écarter une infection dans un premier temps.
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Abstract
Systemic vasculitides are a group of rare diseases characterized by inflammation of the arterial or venous vessel wall, causing stenosis or thrombosis. Clinical symptoms may be limited to skin or to other organs or may include multiple manifestations as systemic conditions. The pathogenesis is related to the presence of leukocytes in the vessels and to the IC deposition, which implies the activation of the complement system (CS) and then the swelling and damage of vessel mural structures. The complement system (CS) is involved in the pathogenesis of several autoimmune diseases, including systemic vasculitides. This enzymatic system is a part of the innate immune system, and its function is linked to the modulation of the adaptive immunity and in bridging innate and adaptive responses. Its activation is also critical for the development of natural antibodies and T cell response and for the regulation of autoreactive B cells. Complement triggering contributes to inflammation-driven tissue injury, which occurs during the ischemia/reperfusion processes, vasculitides, nephritis, arthritis, and many others diseases. In systemic vasculitides, a group of uncommon diseases characterized by blood vessel inflammation, the contribution of CS in the development of inflammatory damage has been demonstrated. Treatment is mainly based on clinical manifestations and severity of organ involvement. Evidences on the efficacy of traditional immunosuppressive therapies have been collected as well as data from clinical trials that involve the modulation of the CS. In particular in small-medium-vessel vasculitides, the CS represents an attractive target. Herein, we reviewed the pathogenetic role of CS in these systemic vasculitides as urticarial vasculitis, ANCA-associated vasculitides, anti-glomerular basement membrane disease, cryoglobulinaemic vasculitides, Henoch-Schönlein purpura/IgA nephropathy, and Kawasaki disease and therefore its potential therapeutic use in this context.
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Ge YT, Liao JL, Liang W, Xiong ZY. Anti-Glomerular Basement Membrane Disease Combined with IgA Nephropathy Complicated with Reversible Posterior Leukoencephalopathy Syndrome: An Unusual Case. AMERICAN JOURNAL OF CASE REPORTS 2015; 16:849-53. [PMID: 26621456 PMCID: PMC4671450 DOI: 10.12659/ajcr.894619] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patient: Male, 24 Final Diagnosis: Crescentic glomerulonephritis (type I) with IgA nephropathy Symptoms: Headache • gross hematuria • nocturia • seizures Medication: Cyclophosphamide Clinical Procedure: Dignosis to treatment Specialty: Nephrology
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Affiliation(s)
- Ya-ting Ge
- Department of Nephrology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
| | - Jin-lan Liao
- Department of Nephrology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
| | - Wei Liang
- Department of Nephrology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
| | - Zu-ying Xiong
- Department of Nephrology, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China (mainland)
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Tan SJ, Ducharlet K, Dwyer KM, Myers D, Langham RG, Hill PA. A case of triple pathology: seronegative anti-glomerular basement membrane antibody-mediated glomerulonephritis and membranous nephropathy in a patient with underlying diabetic kidney disease. Clin Kidney J 2015; 6:322-6. [PMID: 26064494 PMCID: PMC4400487 DOI: 10.1093/ckj/sft043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 03/19/2013] [Indexed: 01/19/2023] Open
Abstract
In diabetic patients with acute kidney injury (AKI), kidney biopsy often reveals non-diabetic kidney pathology. This case describes a patient with known Type 1 diabetes who presented with AKI, nephrotic syndrome and haematuria. Combination pathology of seronegative anti-glomerular basement membrane antibody-mediated glomerulonephritis (anti-GBM GN), membranous nephropathy (MN) and diabetic nephropathy (DN) was demonstrated. Strong linear GBM IgG-staining on biopsy with crescentic GN and clinical AKI led to a diagnosis of anti-GBM GN, although serum antibodies were not detectable. Features of DN, Kimmelstiel-Wilson nodules and albumin staining were also present, along with features of MN, such as subepithelial deposits on electron microscopy. Despite treatment with immunosuppression and plasmapheresis, there was no recovery of kidney function. Coexisting anti-GBM GN and MN is well recognized, but the concurrent diagnosis with DN has not been described.
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Affiliation(s)
- Sven-Jean Tan
- Department of Nephrology , St Vincent's Hospital , Fitzroy, VIC , Australia
| | - Kathryn Ducharlet
- Department of Nephrology , St Vincent's Hospital , Fitzroy, VIC , Australia
| | - Karen M Dwyer
- Department of Nephrology , St Vincent's Hospital , Fitzroy, VIC , Australia
| | - Damian Myers
- Department of Surgery and Orthopaedics , St Vincent's Hospital , Fitzroy, VIC , Australia
| | - Robyn G Langham
- Department of Nephrology , St Vincent's Hospital , Fitzroy, VIC , Australia ; Department of Medicine , University of Melbourne , Parkville, VIC , Australia
| | - Prue A Hill
- Department of Anatomical Pathology , St Vincent's Hospital , Fitzroy, VIC , Australia
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Touzot M, Poisson J, Faguer S, Ribes D, Cohen P, Geffray L, Anguel N, François H, Karras A, Cacoub P, Durrbach A, Saadoun D. Rituximab in anti-GBM disease: A retrospective study of 8 patients. J Autoimmun 2015; 60:74-9. [PMID: 25953709 DOI: 10.1016/j.jaut.2015.04.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 04/09/2015] [Accepted: 04/12/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Anti-glomerular basement membrane (GBM) disease is a rare autoantibody-mediated disorder presenting as rapidly progressive glomerulonephritis, and often with pulmonary hemorrhage. Antibody removal with plasmapheresis and immunosuppressive drugs are the cornerstones of the treatment. Data regarding the use of specific B-cell depleting therapy such as rituximab are lacking. METHODS We conducted a retrospective observational study of 8 patients with severe and/or refractory GBM disease that received rituximab therapy. RESULTS Eight patients (2 men, 6 women) with a mean age of 26 ± 13.1 years old were included. Seven had severe renal involvement [median creatinin level was 282 μmol/l, range (65-423)] requiring high immunosuppressive or plasmapheresis dependent, and two had relapse of pulmonary hemorrhage including one with renal failure. Patients received an initial immunosuppressive treatment including steroid and cyclosphosphamide (n = 8) and plasmapheresis (n = 5). Except one late relapse, rituximab therapy was started within two months after diagnosis. All patients except one received 4 weekly dose of rituximab (375 mg(2)). Anti-GBM antibodies were still present in 6/8 patients, at rituximab initiation. Complete remission was observed in 7 out of 8 patients, mostly 3 months after rituximab therapy. After a mean follow-up of 25.6 months (range 4-93), patient and renal survival were 100% and 75% respectively, but rituximab use did not improve GFR. Anti-GBM antibodies remained negative for all patients during follow-up. Only one patient developed a severe bacterial infection but no opportunistic or viral infections were reported. CONCLUSION Rituximab may represent an additional and/or alternative therapy in the induction treatment of anti-GBM disease.
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Affiliation(s)
- Maxime Touzot
- Service de néphrologie, IFRNT, Le Kremlin-Bicêtre, France.
| | - Johanne Poisson
- Département de Médecine Interne et d'Immunologie clinique, Groupe Hospitalier Pitié-Salpêtrière, 84, boulevard de l'Hôpital, Paris 75013, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalo-Universitaire de Rangueil, Toulouse, France
| | - David Ribes
- Département de Néphrologie et Transplantation d'Organes, Centre Hospitalo-Universitaire de Rangueil, Toulouse, France
| | - Pascal Cohen
- Service de Médecine interne, groupe hospitalier Cochin, Paris, France
| | | | - Nadia Anguel
- Service de réanimation médicale, CHU Bicêtre, Le Kremlin-Bicêtre, France
| | - Helene François
- Service de néphrologie, IFRNT, Le Kremlin-Bicêtre, France; Institut National de la Santé et de la Recherche Médicale INSERM U1014 Villejuif, France
| | - Alexandre Karras
- Service de néphrologie, hôpital européen Georges-Pompidou, Paris, France
| | - Patrice Cacoub
- Département de Médecine Interne et d'Immunologie clinique, Groupe Hospitalier Pitié-Salpêtrière, 84, boulevard de l'Hôpital, Paris 75013, France; Centre national de référence maladies systémiques et autoimmunes rares, DHU Inflammation, Immunopathologie, Biothérapie, Université Paris VI-Pierre et Marie Curie, Paris, France
| | - Antoine Durrbach
- Service de néphrologie, IFRNT, Le Kremlin-Bicêtre, France; Institut National de la Santé et de la Recherche Médicale INSERM U1014 Villejuif, France
| | - David Saadoun
- Département de Médecine Interne et d'Immunologie clinique, Groupe Hospitalier Pitié-Salpêtrière, 84, boulevard de l'Hôpital, Paris 75013, France; Centre national de référence maladies systémiques et autoimmunes rares, DHU Inflammation, Immunopathologie, Biothérapie, Université Paris VI-Pierre et Marie Curie, Paris, France.
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12
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Parrot A, Fartoukh M, Cadranel J. Hémorragie intra-alvéolaire. Rev Mal Respir 2015; 32:394-412. [DOI: 10.1016/j.rmr.2014.11.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 06/06/2014] [Indexed: 10/24/2022]
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13
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Hopfer H, Hünemörder S, Treder J, Turner JE, Paust HJ, Meyer-Schwesinger C, Hopfer U, Sachs M, Peters A, Bucher-Kocaoglu B, Ahrens S, Panzer U, Mittrücker HW. Glomerulopathy induced by immunization with a peptide derived from the goodpasture antigen α3IV-NC1. THE JOURNAL OF IMMUNOLOGY 2015; 194:3646-55. [PMID: 25769923 DOI: 10.4049/jimmunol.1401267] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 02/13/2015] [Indexed: 01/08/2023]
Abstract
Mouse experimental autoimmune glomerulonephritis, a model of human antiglomerular basement membrane disease, depends on both Ab and T cell responses to the Goodpasture Ag noncollagenous domain 1 of the α3-chain of type IV collagen (α3IV-NC1). The aim of our study was to further characterize the T cell-mediated immune response. Repeated immunization with mouse α3IV-NC1 caused fatal glomerulonephritis in DBA/1 mice. Although two immunizations were sufficient to generate high α3IV-NC1-specific IgG titers, Ab and complement deposition along the glomerular basement membranes, and a nephrotic syndrome, two additional immunizations were needed to induce a necrotizing/crescentic glomerulonephritis. Ten days after the first immunization, α3IV-NC1-specific CD4(+) cells producing TNF-α, IFN-γ, or IL-17A were detected in the spleen. With the emergence of necrotizing/crescentic glomerulonephritis, ∼0.15% of renal CD4(+) cells were specific for α3IV-NC1. Using peptides spanning the whole α3IV-NC1 domain, three immunodominant T cell epitopes were identified. Immunization with these peptides did not lead to clinical signs of experimental autoimmune glomerulonephritis or necrotizing/crescentic glomerulonephritis. However, mice immunized with one of the peptides (STVKAGDLEKIISRC) developed circulating Abs against mouse α3IV-NC1 first detected at 8 wk, and 50% of the mice showed mild proteinuria at 18-24 wk due to membranous glomerulopathy. Taken together, our results suggest that autoreactive T cells are able to induce the formation of pathologic autoantibodies. The quality and quantity of α3IV-NC1-specific Ab and T cell responses are critical for the phenotype of the glomerulonephritis.
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Affiliation(s)
- Helmut Hopfer
- Institute of Pathology, University Hospital Basel, 4031 Basel, Switzerland; Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany;
| | - Stefanie Hünemörder
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; and
| | - Julia Treder
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; and
| | - Jan-Eric Turner
- Department of Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Hans-Joachim Paust
- Department of Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | | | - Ulrike Hopfer
- Department of Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Marlies Sachs
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; Department of Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Anett Peters
- Department of Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | | | - Stefanie Ahrens
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; and
| | - Ulf Panzer
- Department of Medicine, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Hans-Willi Mittrücker
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; and
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14
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Goodpasture's syndrome: A clinical update. Autoimmun Rev 2015; 14:246-53. [DOI: 10.1016/j.autrev.2014.11.006] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 11/09/2014] [Indexed: 11/22/2022]
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15
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Alchi B, Griffiths M, Sivalingam M, Jayne D, Farrington K. Predictors of renal and patient outcomes in anti-GBM disease: clinicopathologic analysis of a two-centre cohort. Nephrol Dial Transplant 2015; 30:814-21. [DOI: 10.1093/ndt/gfu399] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 12/02/2014] [Indexed: 11/13/2022] Open
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16
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Biology and immunopathogenesis of vasculitis. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00154-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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17
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Mao M, Alavi MV, Labelle-Dumais C, Gould DB. Type IV Collagens and Basement Membrane Diseases. CURRENT TOPICS IN MEMBRANES 2015; 76:61-116. [DOI: 10.1016/bs.ctm.2015.09.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
The vasculitides are a large group of heterogeneous diseases for which it has been assumed that pathogenesis is largely autoimmune. As clinicians, we distinguish one form of vasculitis from another on the basis of observed patterns of organ injury, the size of the vessels affected and histopathological findings. The terms 'small-vessel', 'medium-vessel' and 'large-vessel' vasculitis are useful clinical descriptors, but fail to inform us about why vessels of a certain calibre are favoured by one disease and not another. Classification based on vessel size also fails to consider that vessels of a specific calibre are not equally prone to injury. Distinct vulnerabilities undoubtedly relate to the fact that same-size vessels in different tissues may not be identical conduits. In fact, vessels become specialized, from the earliest stages of embryonic development, to suit the needs of different anatomical locations. Vessels of the same calibre in different locations and organs are as different as the organ parenchymal cells through which they travel. The dialogue between developing vessels and the tissues they perfuse is designed to meet special local needs. Added to the story of vascular diversity and vulnerability are changes that occur during growth, development and ageing. An improved understanding of the unique territorial vulnerabilities of vessels could form the basis of new hypotheses for the aetiopathogenesis of the vasculitides. This Review considers how certain antigens, including infectious agents, might become disease-relevant and how vascular diversity could influence disease phenotypes and the spectrum of vascular inflammatory diseases.
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Affiliation(s)
- Gary S Hoffman
- Department of Rheumatic and Immunologic Diseases, A50, 9500 Euclid Avenue, Lerner College of Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Leonard H Calabrese
- Department of Rheumatic and Immunologic Diseases, A50, 9500 Euclid Avenue, Lerner College of Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
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Dammacco F, Battaglia S, Gesualdo L, Racanelli V. Goodpasture's disease: A report of ten cases and a review of the literature. Autoimmun Rev 2013; 12:1101-8. [DOI: 10.1016/j.autrev.2013.06.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 06/06/2013] [Indexed: 12/31/2022]
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Syeda UA, Singer NG, Magrey M. Anti-glomerular basement membrane antibody disease treated with rituximab: A case-based review. Semin Arthritis Rheum 2013; 42:567-72. [DOI: 10.1016/j.semarthrit.2012.10.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 09/30/2012] [Accepted: 10/30/2012] [Indexed: 11/30/2022]
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21
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Tang W, McDonald SP, Hawley CM, Badve SV, Boudville NC, Brown FG, Clayton PA, Campbell SB, de Zoysa JR, Johnson DW. Anti-glomerular basement membrane antibody disease is an uncommon cause of end-stage renal disease. Kidney Int 2012; 83:503-10. [PMID: 23254902 DOI: 10.1038/ki.2012.375] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
There are few reports regarding outcomes of anti-glomerular basement membrane (GBM) disease in patients who underwent renal replacement therapy. To help define this we studied all patients with anti-GBM disease who started renal replacement therapy for end-stage renal disease (ESRD) in Australia and New Zealand (ANZDATA Registry) between 1963 and 2010 encompassing 449 individuals (0.8 percent of all ESRD patients). The median survival on dialysis was 5.93 years with death predicted by older age and a history of pulmonary hemorrhage. Thirteen patients recovered renal function, although 10 subsequently experienced renal death after a median period of 1.05 years. Of the 224 patients who received their first renal allograft, the 10-year median patient and renal allograft survival rates were 86% and 63%, respectively. Six patients experienced anti-GBM disease recurrence in their allograft, which led to graft failure in two. Using multivariable Cox regression analysis, patients with anti-GBM disease had comparable survival on dialysis or following renal transplantation (hazard ratios of 0.86 and 1.03, respectively) compared to those with ESRD due to other causes. Also, renal allograft survival (hazard ratio of 1.03) was not altered compared to other diseases requiring a renal transplant. Thus, anti-GBM disease was an uncommon cause of ESRD, and not associated with altered risks of dialysis, transplant or first renal allograft survival. Death on dialysis was predicted by older age and a history of pulmonary hemorrhage.
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Affiliation(s)
- Wen Tang
- ANZDATA Registry, Adelaide, South Australia, Australia
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22
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Hopfer H, Holzer J, Hünemörder S, Paust HJ, Sachs M, Meyer-Schwesinger C, Turner JE, Panzer U, Mittrücker HW. Characterization of the renal CD4+ T-cell response in experimental autoimmune glomerulonephritis. Kidney Int 2012; 82:60-71. [PMID: 22437418 DOI: 10.1038/ki.2012.73] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Autoimmunity against the Goodpasture antigen α3IV-NC1 results in antiglomerular basement membrane glomerulonephritis. Although antibodies are central to the pathogenesis, there is good evidence for the participation of T cells in this disease. To define the contribution of T cells, we used the model of experimental autoimmune glomerulonephritis. Immunization of DBA/1 mice with α3IV-NC1 resulted in proteinuria, a biphasic course of the disease, and an eventual loss of kidney function. In the initial phase, the mice developed an α3IV-NC1-specific IgG response, had IgG deposition along the glomerular basement membrane, and steadily increased proteinuria, but only marginal signs of inflammation with limited leukocyte infiltration. After 9-13 weeks, mice proceeded to develop crescentic glomerulonephritis, extensive tubulointerstitial damage, and massive macrophage infiltration. T-cell infiltration was less pronounced, mostly confined to the interstitium, and T cells displayed an activated phenotype with a significant fraction of Th1 or Th17 CD4(+) T cells. Close examination revealed the presence of autoreactive T cells producing IFNγ upon restimulation with α3IV-NC1. Thus, our results suggest that accumulation of effector T cells, including autoreactive T cells, represents a critical step in the progression from mild glomerulonephritis, with limited glomerular damage, to severe crescentic glomerulonephritis accompanied by tubulointerstitial inflammation and loss of kidney function.
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Affiliation(s)
- Helmut Hopfer
- Institute of Pathology, University Hospital Basel, Basel, Switzerland
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Abstract
This review summarizes the clinical evidence and practical details for the use of plasmapheresis and other apheresis modalities for each indication in nephrology. Updated information on the molecular biology and immunology of each renal disease is discussed in relation to the rationale for apheresis therapy and its place amid other available treatments. Autoantibody-mediated diseases, such as anti-GBM (anti-glomerular basement membrane) glomerulonephritis (GN), ANCA (antineutrophil cytoplasmic antibody)-related GN and the antibody-mediated type of TTP (thrombotic thrombocytopenic purpura), and alloantibody-mediated diseases such as kidney transplant sensitization and humoral rejection, can be treated by various plasmapheresis methods. These include standard plasmapheresis with a replacement volume, or plasmapheresis with online plasma purification using adsorption columns or secondary filtration. However, it should be noted that the pathogenic molecules implicated in FSGS (focal segmental glomerulosclerosis), myeloma cast nephropathy, and perhaps other diseases are too small to be removed by most online purification methods. A great majority of controlled trials and series on which evidence-based treatment recommendations are made were performed using centrifugal plasmapheresis; it is presumed that membrane-separation plasmapheresis is equally efficacious. For some rarer diseases, such as MPGN (membranoproliferative GN) type 2 with factor H abnormalities or C3Nef (C3 nephritic factor) autoantibodies, there are only a few case reports, but enough scientific understanding to warrant a trial of plasmapheresis in severe cases. Photopheresis, which is effective for cell-mediated rejection in heart and lung transplantation, has not yet found a place in the routine treatment of kidney transplant rejection.
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Affiliation(s)
- Amber P Sanchez
- Department of Medicine, Division of Nephrology, University of California, and Therapeutic Apheresis Program, UCSD Medical Center, San Diego, California 92103-8781, USA
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Goodpasture's disease: molecular architecture of the autoantigen provides clues to etiology and pathogenesis. Curr Opin Nephrol Hypertens 2011; 20:290-6. [PMID: 21378566 DOI: 10.1097/mnh.0b013e328344ff20] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Goodpasture's disease is an autoimmune disorder characterized by the deposition of pathogenic autoantibodies in basement membranes of kidney and lung, which induces rapidly progressive glomerulonephritis and pulmonary hemorrhage. The target antigen is the α3NC1 domain of collagen IV, which is expressed in target organs as an α345 network. Recent studies of specificity and epitopes of Goodpasture's autoantibodies and discovery of novel posttranslational modification of the antigen, a sulfilimine bond, provide further insight into mechanisms of initiation and progression of Goodpasture's disease. RECENT FINDINGS Analysis of the specificity of Goodpasture's autoantibodies revealed a distinct subset of circulating and kidney-bound antiα5NC1 antibody, which is associated with loss of kidney function. Structural integrity of the α345NC1 hexamer is stabilized by the novel sulfilimine crosslinks conferring immune privilege to the Goodpasture's autoantigen. Native antibodies may contribute to establishment of immune tolerance to autoantigen. Structural analysis of epitopes for autoantibodies and alloantibodies indicates a critical role of conformational change in the α345NC1 hexamer in eliciting an autoimmune response in Goodpasture's disease. SUMMARY Understanding of the quaternary structure of the Goodpasture's autoantigen continues to provide insights into autoimmune mechanisms that serve as a basis for development of novel diagnostic tools and therapies for Goodpasture's disease.
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