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Kuang H, Jiang N, Jia XY, Cui Z, Zhao MH. Epidemiology, clinical features, risk factors, and outcomes in anti-glomerular basement membrane disease: A systematic review and meta-analysis. Autoimmun Rev 2024; 23:103531. [PMID: 38493958 DOI: 10.1016/j.autrev.2024.103531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 03/15/2024] [Accepted: 03/15/2024] [Indexed: 03/19/2024]
Abstract
Anti-glomerular basement membrane (GBM) disease is a small-vessel vasculitis that represents the most aggressive form of autoimmune glomerulonephritis. The study aimed to investigate the prevalence, clinical characteristics, risk factors, and outcomes of anti-GBM disease through a systematic review and meta-analysis involving 47 studies with 2830 patients. The overall incidence of anti-GBM disease ranged from 0.60 to 1.79 per million population per annum. In rapidly progressive glomerulonephritis and crescentic glomerulonephritis, the pooled incidence rates were 8.0% and 12.8%, respectively. The pooled prevalence rates of anti-GBM antibodies, antineutrophil cytoplasmic antibodies (ANCA), and lung hemorrhage were 88.8%, 27.4%, and 32.6%, respectively. Patients with combined ANCA positivity demonstrated a prognosis comparable to those patients with only anti-GBM antibodies, though with differing clinical features. The pooled one-year patient and kidney survival rates were 76.2% and 30.2%, respectively. Kidney function on diagnosis and normal glomeruli percentage were identified as strong prognostic factors. This study represents the first comprehensive meta-analysis on anti-GBM disease, providing insights into its management. However, caution is warranted in interpreting some results due to the observational nature of the included studies and high heterogeneity.
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Affiliation(s)
- Huang Kuang
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Nan Jiang
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Yu Jia
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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2
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Kipgen D, Crosby J, Dey V, Kelly M, McQuarrie E, Geddes C. The relationship between histopathological features, immunosuppression and outcome in patients undergoing native kidney biopsies. Histopathology 2024; 84:671-682. [PMID: 38084646 DOI: 10.1111/his.15115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/22/2023] [Accepted: 11/26/2023] [Indexed: 02/07/2024]
Abstract
AIMS To assess retrospectively the association between histopathological lesions on renal biopsy and subsequent impairment of renal function across the spectrum of kidney diseases and to explore the influence of immunosuppressive therapy within the first 6 months after biopsy on this association. METHODS AND RESULTS Clinical data from 488 adult patients having a renal biopsy reported at a single centre from 2017 to 2019 were obtained during a median follow-up period of 786 days. Seventeen semi-quantitative histology parameters were recorded at the time of biopsy, 14 of which were suitable for assessment of association with loss of eGFR by multivariable Cox regression analysis, measurement of eGFR slope and measurement of eGFR 12 months after biopsy. A widely used histopathological chronicity score was also assessed. Clinical baseline variables including prescription of immunosuppression were recorded. Seven of 14 histology parameters: mesangial matrix expansion, global glomerulosclerosis, tubular atrophy, interstitial fibrosis, arteriolosclerosis, mesangial hypercellularity and acute tubular injury; and the chronicity score, predicted loss of kidney function by all three measures. Prescription of immunosuppression was more likely in patients with active inflammatory pathology and less likely in patients with chronic fibrotic pathology, and was associated with reduced risk of loss of eGFR. CONCLUSIONS This retrospective study demonstrates the prognostic significance and complex relationship with immunosuppression of routinely reported histopathological variables in patients having native kidney biopsies, across the spectrum of kidney diseases. It provides useful information for renal biopsy prognostication and design of retrospective studies, including machine learning models.
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Affiliation(s)
- David Kipgen
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jana Crosby
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Vishal Dey
- John Lynch Renal Unit, University Hospital Crosshouse, Crosshouse, UK
| | - Michael Kelly
- Dumfries and Galloway Royal Infirmary Renal Unit, Dumfries, UK
| | - Emily McQuarrie
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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3
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Nelveg-Kristensen KE, Madsen B, McClure M, Bruun N, Lyngsø C, Dieperink H, Gregersen JW, Krarup E, Ivarsen P, Torp-Pedersen C, Egfjord M, Szpirt W, Carlson N. Age- and time-dependent increases in incident anti-glomerular basement membrane disease: a nationwide cohort study. Clin Kidney J 2024; 17:sfad261. [PMID: 38186880 PMCID: PMC10768786 DOI: 10.1093/ckj/sfad261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Indexed: 01/09/2024] Open
Abstract
Background Epidemiologic assessments of anti-glomerular basement membrane (GBM) disease have been challenging due to its rare occurrence. We examined changes in the incidence and outcomes from 1998 to 2018 using nationwide healthcare registries. Methods All patients with incident anti-GBM disease were identified using the International Classification of Diseases, 10th Revision code DM31.0A. Controls were matched 4:1 on birthyear and sex using exposure density sampling. Log link regression adjusted for time, age and sex was applied to model survival. Results We identified 97 patients with incident anti-GBM disease, corresponding to an incidence of 0.91 cases/million/year [standard deviation (SD) 0.6]. The incidence increased over time [1998-2004: 0.50 (SD 0.2), 2005-2011: 0.80 (SD 0.4), 2012-2018: 1.4 (SD 0.5); P = .02] and with age [0.76 (SD 0.4), 1.5 (SD 1.04) and 4.9 (SD 2.6) for patients <45, 45-75 and >75 years]. The median age was 56 years (interquartile range 46) and 51.6% were female. Dialysis was required in 58.4%, 61.9% and 62.9% of patients at day 30, 180 and 360, respectively. The 1-year kidney survival probability was 0.38 (SD 0.05) and exhibited time-dependent changes [1998-2004: 0.47 (SD 0.13), 2005-2011: 0.16 (SD 0.07), 2012-2018: 0.46 (SD 0.07); P = .035]. The 5-year mortality was 26.8% and mortality remained stable over time (P = .228). The risk of death was greater than that of the matched background population {absolute risk ratio [ARR] 5.27 [confidence interval (CI) 2.45-11.3], P < .001}, however, it was comparable to that of patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) requiring renal dialysis at presentation [ARR 0.82 (CI 0.48-1.41), P = .50]. Conclusion The incidence of anti-GBM disease increased over time, possibly related to temporal demographic changes. Mortality remained high and was comparable with an age- and sex-matched cohort of dialysis-dependent AAV patients.
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Affiliation(s)
| | - Bo Madsen
- Department of Nephrology, SLE and Vasculitis Clinic, Aalborg University Hospital, Aalborg, Denmark
| | - Mark McClure
- Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Nanna Bruun
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Cecilie Lyngsø
- Department of Nephrology, Zealand University Hospital, Roskilde, Denmark
| | - Hans Dieperink
- Department of Nephrology, Odense University Hospital, Odense, Denmark
| | - Jon Waarst Gregersen
- Department of Nephrology, SLE and Vasculitis Clinic, Aalborg University Hospital, Aalborg, Denmark
| | - Elizabeth Krarup
- Department of Nephrology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Per Ivarsen
- Department of Nephrology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Nordsjaellands Hospital, Hillerød, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Martin Egfjord
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Wladimir Szpirt
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Nicholas Carlson
- Department of Nephrology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Aomura D, Harada M, Nakajima T, Nimura T, Yamaka K, Yamada Y, Hashimoto K, Tanaka N, Kamijo Y. Serum sulfatide level is associated with severe systemic vasculitis with kidney involvement. Front Immunol 2023; 14:1271741. [PMID: 38111574 PMCID: PMC10726124 DOI: 10.3389/fimmu.2023.1271741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/17/2023] [Indexed: 12/20/2023] Open
Abstract
Sulfatides are a type of sulfated glycosphingolipid that are secreted with lipoproteins into the serum. These molecules are involved in the inflammatory pathway of vessels in addition to coagulation and platelet aggregation. Previous studies have proposed that sulfatides play a pivotal role in regulating inflammation-related disorders. Systemic vasculitis (SV) diseases are generally caused by autoimmune diseases and often involve kidney vasculitis, which may lead to rapidly progressive kidney dysfunction and end-stage kidney disease. Our earlier pilot study revealed that the level of serum sulfatides (SSs) was significantly decreased in patients with anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV), a representative disease-causing SV with kidney involvement (SVKI), especially in patients exhibiting active crescentic findings on kidney biopsy. To further explore the clinical significance of an association between SS and SVKI, we analyzed and compared the SS level of patients with various SVKI diseases in this retrospective cohort study. Among patients admitted to our hospital between 2008 and 2021, we ultimately enrolled 26 patients with IgA vasculitis (IgAV), 62 patients with AAV, and 10 patients with anti-glomerular basement membrane disease (GBM) as examples of SVKI diseases, as well as 50 patients with IgA nephropathy (IgAN) and 23 donors for living kidney transplantation as controls. The mean ± standard deviation SS level in the donor, IgAN, IgAV, AAV, and GBM groups was 8.26 ± 1.72, 8.01 ± 2.21, 6.01 ± 1.73, 5.37 ± 1.97, and 2.73 ± 0.99 nmol/mL, respectively. Analysis of patients in the SVKI disease group showed that those with the crescentic class kidney biopsy finding exhibited a significantly lower SS level than did those with other class biopsy features. Additionally, the SS level had a higher detection ability for SVKI patients with crescentic class kidney biopsy findings (area under the receiver operating characteristic curve 0.90, 95% confidence interval 0.82-0.99) than did several other predictor candidates. Our results indicate that the SS level is decreased in more severe SVKI diseases and may be associated with active glomerular lesions in SVKI kidney biopsy samples.
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Affiliation(s)
- Daiki Aomura
- Department of Nephrology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Makoto Harada
- Department of Nephrology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takero Nakajima
- Department of Metabolic Regulation, Shinshu University School of Medicine, Matsumoto, Japan
- Center for Medical Education and Training, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takayuki Nimura
- Department of Nephrology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kosuke Yamaka
- Department of Nephrology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yosuke Yamada
- Department of Nephrology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Koji Hashimoto
- Department of Nephrology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Naoki Tanaka
- Department of Global Medical Research Promotion, Shinshu University Graduate School of Medicine, Matsumoto, Japan
- International Relations Office, Shinshu University School of Medicine, Matsumoto, Japan
- Research Center for Social Systems, Shinshu University, Matsumoto, Japan
| | - Yuji Kamijo
- Department of Nephrology, Shinshu University School of Medicine, Matsumoto, Japan
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5
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Petr V, Thurman JM. The role of complement in kidney disease. Nat Rev Nephrol 2023; 19:771-787. [PMID: 37735215 DOI: 10.1038/s41581-023-00766-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 09/23/2023]
Abstract
The complement cascade comprises soluble and cell surface proteins and is an important arm of the innate immune system. Once activated, the complement system rapidly generates large quantities of protein fragments that are potent mediators of inflammatory, vasoactive and metabolic responses. Although complement is crucial to host defence and homeostasis, its inappropriate or uncontrolled activation can also drive tissue injury. For example, the complement system has been known for more than 50 years to be activated by glomerular immune complexes and to contribute to autoimmune kidney disease. Notably, the latest research shows that complement is also activated in kidney diseases that are not traditionally thought of as immune-mediated, including haemolytic-uraemic syndrome, diabetic kidney disease and focal segmental glomerulosclerosis. Several complement-targeted drugs have been approved for the treatment of kidney disease, and additional anti-complement agents are being investigated in clinical trials. These drugs are categorically different from other immunosuppressive agents and target pathological processes that are not effectively inhibited by other classes of immunosuppressants. The development of these new drugs might therefore have considerable benefits in the treatment of kidney disease.
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Affiliation(s)
- Vojtech Petr
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joshua M Thurman
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
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Yamashita M, Takayasu M, Maruyama H, Hirayama K. The Immunobiological Agents for Treatment of Antiglomerular Basement Membrane Disease. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2014. [PMID: 38004064 PMCID: PMC10673378 DOI: 10.3390/medicina59112014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023]
Abstract
Combination therapy with glucocorticoids, cyclophosphamide, and plasmapheresis is recommended as the standard treatment for anti-glomerular basement membrane (anti-GBM) disease, but the prognosis of this disease remains poor. Several immunobiological agents have been administered or are expected to be useful for anti-GBM disease in light of refractory disease or the standard treatments' tolerability. Many data regarding the use of biologic agents for anti-GBM disease have accumulated, verifying the effectiveness and potential of biologic agents as a new treatment option for anti-GBM disease. Tumor necrosis factor (TNF) inhibitors were shown to be useful in animal studies, but these agents have no clinical use and were even shown to induce anti-GBM disease in several cases. Although the efficacy of the TNF-receptor antagonist has been observed in animal models, there are no published case reports of its clinical use. There are also no published reports of animal or clinical studies of anti-B-cell-activating factor, which is a member of the TNF family of agents. Anti-interleukin (IL)-6 antibodies have been demonstrated to have no effect on or to exacerbate nephritis in animal models. Anti-C5 inhibitor was observed to be useful in a few anti-GBM disease cases. Among the several immunobiological agents, only rituximab has been demonstrated to be useful in refractory or poor-tolerance patients or small uncontrolled studies. Rituximab is usually used in combination with steroids and plasma exchange and is used primarily as an alternative to cyclophosphamide, but there is insufficient evidence regarding the efficacy of rituximab for anti-GBM disease, and thus, randomized controlled studies are required.
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Affiliation(s)
| | | | | | - Kouichi Hirayama
- Department of Nephrology, Tokyo Medical University Ibaraki Medical Center, Ami 300-0395, Ibaraki, Japan; (M.Y.); (M.T.); (H.M.)
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7
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Ounhasuttiyanon A, Tantranont N, Srithongkul T. Atypical Antiglomerular Basement Membrane Disease in a Pregnant Patient with Systemic Lupus Erythematosus. Case Rep Nephrol 2023; 2023:6963543. [PMID: 38028131 PMCID: PMC10657238 DOI: 10.1155/2023/6963543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 12/01/2023] Open
Abstract
Antiglomerular basement membrane disease (anti-GBM) is an unusual cause of glomerulonephritis. Patients usually present with rapidly progressive glomerulonephritis with or without pulmonary hemorrhage. The diagnosis is based on linear deposits of IgG along the GBM and the presence of anti-GBM antibodies. However, cases with atypical anti-GBM disease in which an anti-GBM antibody was not detected have been reported. We report a 29-year-old pregnant woman with underlying systemic lupus erythematosus (SLE) who presented with severe glomerulonephritis due to atypical antiglomerular basement membrane disease. She was initially diagnosed with active lupus nephritis and her renal function gradually worsened after steroid treatment, so the pregnancy was terminated due to the high maternal and fetal risks. A kidney biopsy showed linear capillary wall staining with fibrous crescents without endocapillary proliferation. The anti-GBM antibody showed negative results two times, so she was diagnosed with atypical anti-GBM disease. Treatment began with intravenous pulse methylprednisolone and continued with mycophenolate mofetil and prednisolone. Due to the intolerability of side effects, the treatment regimen was subsequently changed to intravenous cyclophosphamide. Although she had a significant improvement in clinical edema, serum albumin, and hematuria, her renal function gradually decreased during the 12 months of treatment. A review of the literature showed that the atypical anti-GBM is less aggressive than the typical anti-GBM disease. However, several patients had persistent renal dysfunction and 20-30% of patients had progression to ERSD. To the best of our knowledge, this is the first case of atypical anti-GBM disease in pregnant patients with suspected SLE reported in the literature.
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Affiliation(s)
- Areerat Ounhasuttiyanon
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Salaya, Thailand
| | - Ngoentra Tantranont
- Department of Pathology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Salaya, Thailand
| | - Thatsaphan Srithongkul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Siriraj Hospital, Mahidol University, Salaya, Thailand
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8
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Rivedal M, Haaskjold YL, Berge H, Knoop T. Antiglomerular Basement Membrane Disease Possibly Triggered by Undiagnosed Renal Cell Carcinoma: A Case Report. Kidney Med 2023; 5:100709. [PMID: 37693652 PMCID: PMC10485625 DOI: 10.1016/j.xkme.2023.100709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023] Open
Abstract
Antiglomerular basement membrane (anti-GBM) disease is a rare, small-vessel vasculitis that affects the capillary beds of the kidneys and lungs. Although exceedingly rare, several case reports have described anti-GBM disease with a concurrent cancer diagnosis, suggesting a possible correlation between these 2 conditions. Herein, we describe the first known case to our knowledge of a woman in her early 60s with simultaneous anti-GBM disease and clear cell renal cell carcinoma, in which the tumor was thought to have been the substrate for anti-GBM disease. We believe that renal cell carcinoma may have contributed to the production of anti-GBM autoantibodies and, thus, anti-GBM disease. The concurrence of these 2 conditions complicated the treatment of the patient, who was hemodialysis-dependent at the time of hospital discharge. This report highlights the importance of considering anti-GBM disease as a potential diagnosis in patients with acute kidney failure, and how important it is to identify both clear cell renal cell carcinoma and anti-GBM disease at an early stage to improve outcomes.
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Affiliation(s)
- Mariell Rivedal
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Yngvar Lunde Haaskjold
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Hedda Berge
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Thomas Knoop
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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9
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Tang A, Zhao X, Tao T, Xie D, Xu B, Huang Y, Li M. Unleashing the power of complement activation: unraveling renal damage in human anti-glomerular basement membrane disease. Front Immunol 2023; 14:1229806. [PMID: 37781380 PMCID: PMC10540768 DOI: 10.3389/fimmu.2023.1229806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 08/31/2023] [Indexed: 10/03/2023] Open
Abstract
Anti-glomerular basement membrane (GBM) disease is a rare but life-threatening autoimmune disorder characterized by rapidly progressive glomerulonephritis with or without pulmonary hemorrhage. Renal biopsies of anti-GBM patients predominantly show linear deposition of IgG and complement component 3 (C3), indicating a close association between antigen-antibody reactions and subsequent complement activation in the pathogenesis of the disease. All three major pathways of complement activation, including the classical, lectin, and alternative pathways, are involved in human anti-GBM disease. Several complement factors, such as C3, C5b-9, and factor B, show a positive correlation with the severity of the renal injury and act as risk factors for renal outcomes. Furthermore, compared to patients with single positivity for anti-GBM antibodies, individuals who are double-seropositive for anti-neutrophil cytoplasmic antibody (ANCA) and anti-GBM antibodies exhibit a unique clinical phenotype that lies between ANCA-associated vasculitis (AAV) and anti-GBM disease. Complement activation may serve as a potential "bridge" for triggering both AAV and anti-GBM conditions. The aim of this article is to provide a comprehensive review of the latest clinical evidence regarding the role of complement activation in anti-GBM disease. Furthermore, potential therapeutic strategies targeting complement components and associated precautions are discussed, to establish a theoretical basis for complement-targeted therapies.
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Affiliation(s)
- Anqi Tang
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Xin Zhao
- Clinical Medical College, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Tian Tao
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Dengpiao Xie
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Bojun Xu
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Youqun Huang
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Mingquan Li
- Department of Nephrology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
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10
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Kazemzadeh K, Kabiri Naeini E, Moeinzadeh F, Naimi A. Anti-GBM disease with positive serum anti-GBM antibodies but negative IgG deposition: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231189767. [PMID: 37533486 PMCID: PMC10392201 DOI: 10.1177/2050313x231189767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 07/07/2023] [Indexed: 08/04/2023] Open
Abstract
Anti-glomerular basement membrane antibodies are significantly specific for detecting anti-glomerular basement membrane disease. These antibodies are typically targeted against the non-collagenous (NC1) domain of the alpha 3 chain of type IV collagen and, to a lesser extent, the α4(IV) or α5(IV) chains, which create a triple-helical structure in the glomerular basement membrane. The modification of the hexameric structure of NC1 (α3(IV)) results in the exposure of new epitopes, leading to an immune reaction and the subsequent deposition of linear antibodies along the glomerular basement membrane, culminating in crescentic glomerulonephritis. Anti-glomerular basement membrane antibodies that are positive are believed to be pathogenic and capable of binding to the glomerular basement membrane in vivo, particularly in the context of rapidly progressive glomerulonephritis. Herein, we present a patient with positive serum anti-glomerular basement membrane antibodies but negative IgG deposition. The current findings are significant for raising physicians' awareness of the probable errors in detecting anti-glomerular basement membrane antibody disease as a possible cause of irreversible kidney failure.
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Affiliation(s)
- Kimia Kazemzadeh
- Students’ Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
- Interest Group Department, Universal Scientific Education and Research Network, Tehran, Iran
| | - Elham Kabiri Naeini
- Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Firouzeh Moeinzadeh
- Isfahan Kidney Diseases Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
- Department of Internal Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azar Naimi
- Department of Pathology, Isfahan University of Medical Sciences, Isfahan, Iran
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11
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Caillard P, Vigneau C, Halimi JM, Hazzan M, Thervet E, Heitz M, Juillard L, Audard V, Rabant M, Hertig A, Subra JF, Vuiblet V, Guerrot D, Tamain M, Essig M, Lobbedez T, Quemeneur T, Legendre M, Ganea A, Peraldi MN, Vrtovsnik F, Daroux M, Makdassi R, Choukroun G, Titeca-Beauport D. Prognostic value of complement serum C3 level and glomerular C3 deposits in anti-glomerular basement membrane disease. Front Immunol 2023; 14:1190394. [PMID: 37475859 PMCID: PMC10354545 DOI: 10.3389/fimmu.2023.1190394] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/20/2023] [Indexed: 07/22/2023] Open
Abstract
Background and objectives Activation of the complement system is involved in the pathogenesis of anti-glomerular basement membrane (anti-GBM) disease. Glomerular deposits of complement 3 (C3) are often detected on kidney biopsies. The primary objective of this study was to analyze the prognostic value of the serum C3 level and the presence of C3 glomerular deposits in patients with anti-GBM disease. Methods We conducted a retrospective cohort study of 150 single-positive patients with anti-GBM disease diagnosed between 1997 and 2017. Patients were categorized according to the serum C3 level (forming a low C3 (C3<1.23 g/L) and a high C3 (C3≥1.23 g/L) groups) and positivity for C3 glomerular staining (forming the C3+ and C3- groups). The main outcomes were kidney survival and patient survival. Results Of the 150 patients included, 89 (65%) were men. The median [interquartile range (IQR)] age was 45 [26-64]. At diagnosis, kidney involvement was characterized by a median [IQR] peak serum creatinine (SCr) level of 578 [298-977] µmol/L, and 106 (71%) patients required dialysis. Patients in the low C3 group (72 patients) had more severe kidney disease at presentation, as characterized by higher prevalences of oligoanuria, peak SCr ≥500 µmol/L (69%, vs. 53% in the high C3 group; p=0.03), nephrotic syndrome (42%, vs. 24%, respectively; p=0.02) and fibrous forms on the kidney biopsy (21%, vs. 8%, respectively; p=0.04). Similarly, we observed a negative association between the presence of C3 glomerular deposits (in 52 (41%) patients) and the prevalence of cellular forms (83%, vs. 58% in the C3- group; p=0.003) and acute tubulo-interstitial lesions (60%, vs. 36% in the C3- group; p=0.007). When considering patients not on dialysis at diagnosis, the kidney survival rate at 12 months was poorer in the C3+ group (50% [25-76], vs. 91% [78-100] in the C3- group; p=0.01), with a hazard ratio [95% confidence interval] of 5.71 [1.13-28.85] (p=0.04, after adjusting for SCr). Conclusion In patients with anti-GBM disease, a low serum C3 level and the presence of C3 glomerular deposits were associated with more severe disease and histological kidney involvement at diagnosis. In patients not on dialysis at diagnosis, the presence of C3 deposits was associated with worse kidney survival.
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Affiliation(s)
- Pauline Caillard
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
- Mécanismes Physiopathologiques et Conséquences des Calcifications Cardiovasculaires (MP3CV) laboratory, Centre de Recherche en Santé (CURS), Amiens, France
| | - Cécile Vigneau
- Rennes University Hospital, Inserm, Ecole des hautes études en santé publique (EHESP), Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, Rennes, France
| | - Jean-Michel Halimi
- Department of Nephrology, Tours University Hospital and EA4245, University of Tours, Tours, France
| | - Marc Hazzan
- Nephrology Department, Lille University Hospital, University of Lille, UMR 995, Lille, France
| | - Eric Thervet
- Department of Nephrology, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Paris and INSERM UMRS970, Boulogne-Billancourt, France
| | - Morgane Heitz
- Department of Nephrology and Dialysis, Annecy Genevois Hospital, Pringy, France
| | - Laurent Juillard
- Department of Nephrology, Edouard Herriot Hospital, Hospices Civils de Lyon, Carmen INSERM 1060 and Univ Lyon, Lyon, France
| | - Vincent Audard
- Department of Nephrology and Renal Transplantation, Reference Center-Idiopathic Nephrotic Syndrome, Henri-Mondor Hospital/Albert-Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP) Créteil, INSERMU955, Paris Est Créteil University, Créteil, France
| | - Marion Rabant
- Pathology Department, Necker University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre-Université de Paris, Paris, France
| | - Alexandre Hertig
- Department of Nephrology, Dialysis and Transplantation, Foch Hospital, Paris-Saclay University, Suresnes, France
| | - Jean-François Subra
- Department of Nephrology, Dialysis and Transplantation, University Hospital, Angers and Centre de Recherche en Cancérologie et Immunologie Nantes-Angers (CRCINA), INSERM, Nantes University, Angers University, Angers, France
| | - Vincent Vuiblet
- Department of Nephrology and Renal Transplantation, Reims University Hospital, Reims, France
| | - Dominique Guerrot
- Department of Nephrology, Rouen University Hospital, Rouen and INSERM, U1096 Rouen, France
| | - Mathilde Tamain
- Department of Nephrology and Dialysis, Vichy Hospital, Vichy, France
| | - Marie Essig
- Department of Nephrology, Dialysis, and Renal Transplantation, Ambroise-Paré Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris-Saclay University, Boulogne-Billancourt, France
| | - Thierry Lobbedez
- Department of Nephrology, Caen University Hospital, Caen, France and the French Registry of Peritoneal Dialysis, Langue Française, Pontoise, France
| | - Thomas Quemeneur
- Department of Nephrology and Internal Medicine, Valenciennes General Hospital, Valenciennes, France
| | - Mathieu Legendre
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital, Dijon, France
| | | | - Marie-Noëlle Peraldi
- Department of Nephrology, Dialysis and Renal Transplantation, Necker University Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Centre-Université de Paris, Paris, France
| | - François Vrtovsnik
- Nephrology Department, Bichat-Claude Bernard Hospital, APHP, Paris, France. Faculty of Medicine, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Maïté Daroux
- Department of Nephrology, Duchenne Hospital, Boulogne-Sur-Mer, France
| | - Raïfah Makdassi
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
| | - Gabriel Choukroun
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
- Mécanismes Physiopathologiques et Conséquences des Calcifications Cardiovasculaires (MP3CV) laboratory, Centre de Recherche en Santé (CURS), Amiens, France
| | - Dimitri Titeca-Beauport
- Department of Nephrology, Dialysis, and Transplantation, University of Picardie Jules Verne, Amiens University Hospital, Amiens, France
- Mécanismes Physiopathologiques et Conséquences des Calcifications Cardiovasculaires (MP3CV) laboratory, Centre de Recherche en Santé (CURS), Amiens, France
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12
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Kanaoka K, Ihara S, Nakatani T, Minami S. Rituximab for the Treatment of Anti-glomerular Basement Membrane Disease with Isolated Diffuse Alveolar Hemorrhage. Intern Med 2023; 62:1971-1975. [PMID: 36261370 PMCID: PMC10372275 DOI: 10.2169/internalmedicine.0166-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 09/05/2022] [Indexed: 04/07/2023] Open
Abstract
Anti-glomerular basement membrane (GBM) disease with isolated diffuse alveolar hemorrhage (DAH) is rare. We herein report a 91-year-old man admitted with hypoxia and diagnosed with anti-GBM disease with DAH based on positive bronchoalveolar lavage and serum antibody test results. There was no renal involvement. Although remission was achieved using glucocorticoids and plasmapheresis, the patient experienced DAH relapse one week after the last plasmapheresis. Rituximab 375 mg/m2 was administered 4 times weekly; thereafter, DAH relapse was not observed, and the glucocorticoid dosage was tapered. Rituximab was thus effective in treating anti-GBM disease with isolated DAH in an extremely elderly patient.
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Affiliation(s)
- Kensuke Kanaoka
- Department of Respiratory Medicine, Osaka Police Hospital, Japan
| | - Shoichi Ihara
- Department of Respiratory Medicine, Osaka Police Hospital, Japan
| | - Takeshi Nakatani
- Department of Respiratory Medicine, Osaka Police Hospital, Japan
| | - Seigo Minami
- Department of Respiratory Medicine, Osaka Police Hospital, Japan
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13
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Windpessl M, Odler B, Bajema IM, Geetha D, Säemann M, Lee JM, Vaglio A, Kronbichler A. Glomerular Diseases Across Lifespan: Key Differences in Diagnostic and Therapeutic Approaches. Semin Nephrol 2023; 43:151435. [PMID: 37945450 DOI: 10.1016/j.semnephrol.2023.151435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Glomerular diseases are common causes of chronic kidney disease in childhood, adolescence, and adulthood. The epidemiology of glomerular diseases differs between different age groups, with minimal change disease being the leading cause of nephrotic syndrome in childhood, while membranous nephropathy and focal segmental glomerulosclerosis are more common in adulthood. IgA vasculitis is also more common in childhood. Moreover, there is a difference in disease severity with more children presenting with a relapsing form of nephrotic syndrome and a more acute presentation of antineutrophil cytoplasmic antibody-associated vasculitis and concomitant glomerulonephritis, as highlighted by the higher percentage of cellular crescents on kidney biopsy specimens in comparison with older patients. There is also a female preponderance in antineutrophil cytoplasmic antibody-associated vasculitis and more children present with tracheobroncholaryngeal disease. This article aims to summarize differences in the presentation of different glomerular diseases that are encountered commonly by pediatric and adult nephrologists and potential differences in the management.
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Affiliation(s)
- Martin Windpessl
- Section of Nephrology, Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria; Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Balazs Odler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ingeborg M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands; Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria; Sigmund Freud University, Medical School, Vienna, Austria
| | - Jiwon M Lee
- Division of Rare Disease Management, Korea Disease Control and Prevention Agency, Cheongju-si, Republic of Korea
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Firenze, Nephrology Unit, Meyer Children's Hospital, Firenze, Italy
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria.
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14
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Chalkia A, Koutsianas C, Stampolliou E, Giannou P, Gakiopoulou H, Vassilopoulos D, Petras D. Pulmonary-Renal Syndrome During COVID-19 Pandemic Revealed a Rare Case of Anti-GBM Disease. Mediterr J Rheumatol 2023; 34:252-256. [PMID: 37654641 PMCID: PMC10466353 DOI: 10.31138/mjr.34.2.256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 02/16/2023] [Accepted: 02/21/2023] [Indexed: 09/02/2023] Open
Abstract
Anti-GBM disease is a rare, life-threatening small vessel vasculitis caused by circulating anti-GBM antibodies resulting to rapidly progressive glomerulonephritis and/or pulmonary haemorrhage. The gold standard for the diagnosis is the renal biopsy with the pathognomonic finding of linear deposition of IgG along the glomerular capillaries. Early diagnosis and intervention are key determinants of the response to therapy and long-term prognosis of these patients. However, during COVID-19 pandemic recognizing a pulmonary-renal syndrome caused by autoimmune diseases has become challenging. Herein, we aimed to describe a rare case of anti-GBM disease with pulmonary haemorrhage and rapidly progressive glomerulonephritis in a young man in a tertiary referral hospital in Greece, while COVID-19 pandemic was at its peak. Although the patient presented high level of creatinine and crescents, the early diagnosis and start of treatment resulted to favourable renal prognosis.
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Affiliation(s)
- Aglaia Chalkia
- Nephrology Department, Hippokration General Hospital, Athens, Greece
| | - Christos Koutsianas
- 2nd Department of Medicine and Laboratory, Clinical Immunology - Rheumatology Unit, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | | | - Panagiota Giannou
- Nephrology Department, Hippokration General Hospital, Athens, Greece
| | - Harikleia Gakiopoulou
- 1st Department of Pathology, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Clinical Immunology - Rheumatology Unit, National and Kapodistrian University of Athens School of Medicine, Hippokration General Hospital, Athens, Greece
| | - Dimitrios Petras
- Nephrology Department, Hippokration General Hospital, Athens, Greece
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15
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Conte C, Antonelli G, Melica ME, Tarocchi M, Romagnani P, Peired AJ. Role of Sex Hormones in Prevalent Kidney Diseases. Int J Mol Sci 2023; 24:ijms24098244. [PMID: 37175947 PMCID: PMC10179191 DOI: 10.3390/ijms24098244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/29/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
Chronic kidney disease (CKD) is a constantly growing global health burden, with more than 840 million people affected worldwide. CKD presents sex disparities in the pathophysiology of the disease, as well as in the epidemiology, clinical manifestations, and disease progression. Overall, while CKD is more frequent in females, males have a higher risk to progress to end-stage kidney disease. In recent years, numerous studies have highlighted the role of sex hormones in the health and diseases of several organs, including the kidney. In this review, we present a clinical overview of the sex-differences in CKD and a selection of prominent kidney diseases causing CKD: lupus nephritis, diabetic kidney disease, IgA nephropathy, and autosomal dominant polycystic kidney disease. We report clinical and experimental findings on the role of sex hormones in the development of the disease and its progression to end-stage kidney disease.
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Affiliation(s)
- Carolina Conte
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Giulia Antonelli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Maria Elena Melica
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
| | - Mirko Tarocchi
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
| | - Paola Romagnani
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, 50139 Florence, Italy
| | - Anna Julie Peired
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, 50134 Florence, Italy
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16
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Matsuno T, Okumura T. Anti-glomerular Basement Membrane Disease After Diagnosis of Immunoglobulin A Nephropathy: A Case Report. Cureus 2023; 15:e39737. [PMID: 37398717 PMCID: PMC10310401 DOI: 10.7759/cureus.39737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Anti-glomerular basement membrane (anti-GBM) disease has one of the worst prognoses of nephritis and is rarely associated with other forms of glomerulonephritis. In this report, we present the case of a 76-year-old man who developed anti-GBM disease four months after being diagnosed with IgA nephropathy (IgAN). To our knowledge, although there have been several reports of IgAN combined with anti-GBM disease, there have been no cases in which we were able to confirm that the anti-GBM antibody titer changed from negative to positive over the disease course. This case suggests that even patients with previously diagnosed chronic glomerulonephritis, including IgAN, and an unusually rapid clinical course should be evaluated for the presence of autoantibodies to exclude overlapping autoimmune diseases.
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17
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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: 5] [Impact Index Per Article: 5.0] [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: 1] [Impact Index Per Article: 1.0] [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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Ge Y, Liu K, Yang G, Yu X, Sun B, Zhang B, Yuan Y, Zeng M, Wang N, Xing C, Mao H. Clinicopathological characteristics and outcome predictors of anti-glomerular basement membrane glomerulonephritis. Ren Fail 2022; 44:2037-2045. [PMID: 36408940 PMCID: PMC9683053 DOI: 10.1080/0886022x.2022.2147673] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To explore the clinicopathological features of anti-glomerular basement membrane (anti-GBM) glomerulonephritis (anti-GBM-GN) and the prognostic values of clinical and laboratory indicators at diagnosis on renal and patient survival. Methods A total of 76 patients (34 males and 42 females) with anti-GBM-GN who were hospitalized in the First Affiliated Hospital of Nanjing Medical University between January 2010 and June 2021 were included in this study. The baseline clinical features, histopathological data from renal biopsies, and predictors of renal and patient survival were retrospectively analyzed. Results Among the 76 patients, the median serum creatinine at diagnosis was 618.0 (350.98, 888.25) μmol/L and the median estimated glomerular filtration rate (eGFR) was 6.62 (4.39, 14.41) mL/min. Of these 76 patients, 55 (72.4%) received initial kidney replacement therapy (KRT) and 39 (51.3%) received plasma exchange or double-filtered plasmapheresis (DFPP). During a median follow-up duration of 28.5 (6.0, 71.8) months, 53 (69.7%) patients progressed to kidney failure with replacement therapy (KFRT) and received maintenance dialysis. Initial KRT (HR = 3.48, 95% CI = 1.22–9.97, p = 0.020) was a significant risk factor for renal survival. During the follow-up, 49 (64.5%) of 76 patients survived. Age (≥60 years, HR = 4.13, 95% CI = 1.65–10.38, p = 0.003) and initial KRT (HR = 2.87, 95% CI = 1.01–8.14, p = 0.047) were predictive of patient survival. Conclusions Among patients with anti-GBM-GN, initial KRT at presentation was predictive of KFRT while older age and initial KRT were associated with higher all-cause mortality.
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Affiliation(s)
- Yifei Ge
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kang Liu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Guang Yang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiangbao Yu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bin Sun
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bo Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yanggang Yuan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ningning Wang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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20
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Kronbichler A, Bajema I, Geetha D, Säemann M. Novel aspects in the pathophysiology and diagnosis of glomerular diseases. Ann Rheum Dis 2022; 82:585-593. [PMID: 36535746 DOI: 10.1136/ard-2022-222495] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Immune deposits/complexes are detected in a multitude of tissues in autoimmune disorders, but no organ has attracted as much attention as the kidney. Several kidney diseases are characterised by the presence of specific configurations of such deposits, and many of them are under a 'shared care' between rheumatologists and nephrologists. This review focuses on five different diseases commonly encountered in rheumatological and nephrological practice, namely IgA vasculitis, lupus nephritis, cryoglobulinaemia, anti-glomerular basement membrane disease and anti-neutrophil cytoplasm-antibody glomerulonephritis. They differ in disease aetiopathogenesis, but also the potential speed of kidney function decline, the responsiveness to immunosuppression/immunomodulation and the deposition of immune deposits/complexes. To date, it remains unclear if deposits are causing a specific disease or aim to abrogate inflammatory cascades responsible for tissue damage, such as neutrophil extracellular traps or the complement system. In principle, immunosuppressive therapies have not been developed to tackle immune deposits/complexes, and repeated kidney biopsy studies found persistence of deposits despite reduction of active inflammation, again highlighting the uncertainty about their involvement in tissue damage. In these studies, a progression of active lesions to chronic changes such as glomerulosclerosis was frequently reported. Novel therapeutic approaches aim to mitigate these changes more efficiently and rapidly. Several new agents, such as avacopan, an oral C5aR1 inhibitor, or imlifidase, that dissolves IgG within minutes, are more specifically reducing inflammatory cascades in the kidney and repeat tissue sampling might help to understand their impact on immune cell deposition and finally kidney function recovery and potential impact of immune complexes/deposits.
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Affiliation(s)
- Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK .,Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden and Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
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21
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Zhu M, Wang J, Le W, Xu F, Jin Y, Jiao C, Zhang H. Relationship between anti-GBM antibodies and kidney outcomes in patients with anti-GBM disease. J Nephrol 2022; 36:789-797. [PMID: 36427163 DOI: 10.1007/s40620-022-01508-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 10/19/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Animal experiments have shown that anti-GBM antibodies play a pathogenic role in anti-GBM disease. However, the relationship between anti-GBM antibody levels and kidney outcomes in patients with anti-GBM disease is unclear. METHODS We performed a retrospective analysis of 110 patients diagnosed with anti-GBM disease. We compared their baseline characteristics stratifying on different anti-GBM antibody levels, and used Cox regression analysis to analyze the correlation between antibody levels and kidney survival. We further selected 69 patients to evaluate the modification of antibody titers over 14 days of treatment, then compared kidney survival of patients in the group with antibody level decrease < 48% to those with antibody decrease ≥ 48%. RESULTS The 110 patients had a median follow-up of 27.1 (Q1-Q3: 7.9-80.1) months, and among them 90 (81.8%) developed kidney failure. Multivariate analysis suggested that anti-GBM antibody level was an independent risk factor for progression to kidney failure in patients with anti-GBM disease (HR 1.08, 95% CI 1.01-1.16). The patients who reduced the antibodies levels quickly had better kidney survival than those who did not, and multivariate analysis also indicated that antibody decrease rate was related to kidney outcomes. CONCLUSIONS Anti-GBM antibody level is closely related to kidney outcomes in patients with anti-GBM disease, and short-term reduction of antibodies can be beneficial to improving kidney outcomes.
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Affiliation(s)
- Mengyue Zhu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210016, China
| | - Jingjing Wang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210016, China
| | - Weibo Le
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210016, China
| | - Feng Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210016, China
| | - Ying Jin
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210016, China
| | - Chenfeng Jiao
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210016, China
| | - Haitao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Medical School of Nanjing University, 305 East Zhongshan Road, Nanjing, 210016, China.
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22
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Shaojie F, Sensen S, Jingda H, Luyu W, Fei Z, Jinyu Y, Zhonggao X, Hao W. Great prognosis of concurrent anti-GBM disease and IgA nephropathy in a young woman: A case report. Medicine (Baltimore) 2022; 101:e30686. [PMID: 36123857 PMCID: PMC9478285 DOI: 10.1097/md.0000000000030686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE The causal relationship between anti-glomerular basement membrane (anti-GBM) disease and immunoglobulin A (IgA) nephropathy is still unclear and cases of concurrent anti-GBM disease and IgA nephropathy are very rare, especially with a good prognosis and long-term follow-up. Here, we report a case of concurrent anti-GBM disease and IgA nephropathy. By using corticosteroids and cyclophosphamide in combination with plasmapheresis, the patient achieved a very good prognosis with complete normalization of renal function and complete disappearance of hematuria and proteinuria at the subsequent follow-up. To our knowledge, no previous case with such a long follow-up and such a good prognosis have been reported. PATIENT CONCERNS This case report describes a 26-year-old Chinese woman who presented with fever as the initial symptom, followed by dysmorphic hematuria, overt proteinuria and rapidly worsening renal function. Before admission, the patient received symptomatic supportive treatment such as intravenous albumin infusion, improvement of circulation, but the symptoms were not significantly improved. DIAGNOSIS Per the results of kidney biopsy, the patient was diagnosed with crescentic glomerulonephritis and anti-GBM disease with IgA nephropathy. INTERVENTIONS The key to obtain a good prognosis was the early application of corticosteroids and cyclophosphamide in combination with plasmapheresis to make the anti-GBM antibody turn negative quickly. OUTCOMES After 2 weeks of therapy, the patients' anti-GBM antibody turned negative and serum creatinine improved to a normal range. After 10 months, the patient's proteinuria level reached complete remission. After 12 months, the patient's hematuria had disappeared completely. LESSONS This case provides experience in the treatment of concurrent anti-GBM disease and IgA nephropathy and highlights the importance of early application of plasmapheresis and immunosuppressive therapy to obtain a good prognosis.
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Affiliation(s)
- Fu Shaojie
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Su Sensen
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Huang Jingda
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Wang Luyu
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Zhang Fei
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Yu Jinyu
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Xu Zhonggao
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Wu Hao
- Department of Nephrology, The First Hospital of Jilin University, Changchun, China
- *Correspondence: Hao Wu, Department of Nephrology, The First Hospital of Jilin University, Changchun, China (e-mail: )
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23
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Martin K, Deleveaux S, Cunningham M, Ramaswamy K, Thomas B, Lerma E, Madariaga H. The presentation, etiologies, pathophysiology, and treatment of pulmonary renal syndrome: A review of the literature. Dis Mon 2022; 68:101465. [PMID: 36008166 DOI: 10.1016/j.disamonth.2022.101465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Pulmonary renal syndrome (PRS) is a constellation of different disorders that cause both rapidly progressive glomerulonephritis and diffuse alveolar hemorrhage. While antineutrophil cytoplasmic antibody associated vasculitis and anti-glomerular basement membrane disease are the predominant causes of PRS, numerous other mechanisms have been shown to cause this syndrome, including thrombotic microangiopathies, drug exposures, and infections, among others. This syndrome has high morbidity and mortality, and early diagnosis and treatment is imperative to improve outcomes. Treatment generally involves glucocorticoids and immunosuppressive agents, but treatment targeted to the underlying disorder can improve outcomes and mitigate side effects. Familiarity with the wide range of possible causes of PRS can aid the clinician in workup, diagnosis and early initiation of treatment. This review provides a summary of the clinical presentation, etiologies, pathophysiology, and treatment of PRS.
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Affiliation(s)
| | | | | | | | - Beje Thomas
- Medstar Georgetown University Hospital, United States
| | - Edgar Lerma
- Advocate Christ Medical Center, United States
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24
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Sánchez-Agesta M, Rabasco C, Soler MJ, Shabaka A, Canllavi E, Fernández SJ, Cazorla JM, López-Rubio E, Romera A, Barroso S, Huerta A, Calle L, Sierra M, Domínguez-Torres P, Moreno-Ramírez M, Afonso S, Mascarós V, Coca A, Espinosa M. Anti-glomerular Basement Membrane Glomerulonephritis: A Study in Real Life. Front Med (Lausanne) 2022; 9:889185. [PMID: 35865174 PMCID: PMC9295717 DOI: 10.3389/fmed.2022.889185] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Anti-glomerular basement membrane (anti-GBM) disease is a severe entity with few therapeutic options including plasma exchange and immunosuppressive agents. The aim of this study was to analyze the clinical and pathological features that predict the evolution of end-stage kidney disease (ESKD) and the kidney survival in a cohort of patients with anti-GBM disease with renal involvement in real life. Methods A retrospective multicentre observational study including 72 patients from 18 nephrology departments with biopsy-proven anti-GBM disease from 1999 to 2019 was performed. Progression to ESKD in relation to clinical and histological variables was evaluated. Results Creatinine at admission was 8.6 (± 4) mg/dL and 61 patients (84.7%) required dialysis. Sixty-five patients (90.3%) underwent plasma exchange. Twenty-two patients (30.6%) presented pulmonary hemorrhage. Kidney survival was worse in patients with creatinine levels > 4.7 mg/dL (3 vs. 44% p < 0.01) and in patients with > 50% crescents (6 vs. 49%; p = 0.03). Dialysis dependence at admission and creatinine levels > 4.7 mg/dL remained independent significant predictors of ESKD in the multivariable analysis [HR (hazard ratio) 3.13 (1.25–7.84); HR 3 (1.01–9.14); p < 0.01]. The discrimination value for a creatinine level > 4.7 mg/dL and 50.5% crescents had an area under the curve (AUC) of 0.9 (95% CI 0.82–0.97; p < 0.001) and 0.77 (95% CI 0.56–0.98; p = 0.008), respectively. Kidney survival at 1 and 2 years was 13.5 and 11%, respectively. Patient survival at 5 years was 81%. Conclusion In real life, patients with severe anti-GBM disease (creatinine > 4.7 mg/dL and > 50% crescents) remained with devastating renal prognosis despite plasma exchange and immunosuppressive treatment. New therapies for the treatment of this rare renal disease are urgently needed.
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Affiliation(s)
- Marina Sánchez-Agesta
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
- *Correspondence: Marina Sánchez-Agesta,
| | - Cristina Rabasco
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - María J. Soler
- Department of Nephrology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Amir Shabaka
- Department of Nephrology, Hospital Clínico San Carlos, Madrid, Spain
| | | | - Saulo J. Fernández
- Department of Nephrology, Hospital Universitario Insular de Gran Canaria, Las Palmas, Spain
| | - Juan M. Cazorla
- Department of Nephrology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | - Ana Romera
- Department of Nephrology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Sergio Barroso
- Department of Nephrology, Hospital Universitario de Badajoz, Badajoz, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
- RedinRen ISCIII RETYC 16/009, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Leonardo Calle
- Department of Nephrology, Complejo Asistencial de Segovia, Segovia, Spain
| | - Milagros Sierra
- Department of Nephrology, Hospital San Pedro, Logroño, Spain
| | | | | | - Sara Afonso
- Department of Nephrology, Hospital Universitario La Paz, Madrid, Spain
| | - Victoria Mascarós
- Department of Nephrology, Hospital Francesc Borja de Gandía, Valencia, Spain
| | - Armando Coca
- Department of Nephrology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
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25
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Qu W, Liu N, Xu T, Tian B, Wang M, Li Y, Ma J, Yao L. Case Report: Coexistence of Anti-Glomerular Basement Membrane Disease, Membranous Nephropathy, and IgA Nephropathy in a Female PatientWith Preserved Renal Function. Front Pharmacol 2022; 13:876512. [PMID: 35721146 PMCID: PMC9198400 DOI: 10.3389/fphar.2022.876512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/28/2022] [Indexed: 11/24/2022] Open
Abstract
The coexistence of anti-glomerular basement membrane (GBM) disease, idiopathic membranous nephropathy (IMN), and IgA nephropathy in one patient is a very rare case, which has not yet been reported. Whether the three diseases are correlated and the underlying mechanism remain unknown. Herein, we report a 48-year-old female patient that was admitted because of proteinuria and abnormal renal function, which was diagnosed as anti-GBM disease, idiopathic membranous nephropathy, and IgA nephropathy by renal biopsy. The patient received treatment including high-dose methylprednisolone pulse therapy, plasma exchange, and intravenous infusion of both cyclophosphamide (CTX) and rituximab. In the follow-up, the titer of the anti-GBM antibody gradually decreased, renal function was restored, and urinary protein was reduced, without significant adverse effects.
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Affiliation(s)
- Wei Qu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Nan Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Tianhua Xu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Binyao Tian
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Meng Wang
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Yanqiu Li
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Jianfei Ma
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
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26
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Asim M, Akhtar M. Epidemiology, Impact, and Management Strategies of Anti-Glomerular Basement Membrane Disease. Int J Nephrol Renovasc Dis 2022; 15:129-138. [PMID: 35418771 PMCID: PMC8999706 DOI: 10.2147/ijnrd.s326427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/15/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Muhammad Asim
- Division of Nephrology, Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- Correspondence: Muhammad Asim, Division of Nephrology, Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar, Tel +97455838342, Email
| | - Mohammed Akhtar
- Department of Laboratory Medicine and Pathology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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27
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Uhlin F, Szpirt W, Kronbichler A, Bruchfeld A, Soveri I, Rostaing L, Daugas E, Lionet A, Kamar N, Rafat C, Mysliveček M, Tesař V, Fernström A, Kjellman C, Elfving C, McAdoo S, Mölne J, Bajema I, Sonesson E, Segelmark M. Endopeptidase Cleavage of Anti-Glomerular Basement Membrane Antibodies in vivo in Severe Kidney Disease: An Open-Label Phase 2a Study. J Am Soc Nephrol 2022; 33:829-838. [PMID: 35260419 PMCID: PMC8970456 DOI: 10.1681/asn.2021111460] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/01/2022] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The prognosis for kidney survival is poor in patients presenting with circulating anti-glomerular basement membrane (GBM) antibodies and severe kidney injury. It is unknown if treatment with an endopeptidase that cleaves circulating and kidney bound IgG can alter the prognosis. METHODS An investigator-driven phase 2a one-arm study (EudraCT 2016-004082-39) was performed in 17 hospitals in five European countries. A single dose of 0.25 mg/kg of imlifidase was given to 15 adults with circulating anti-GBM antibodies and an eGFR <15 ml/min per 1.73m2. All patients received standard treatment with cyclophosphamide and corticosteroids, but plasma exchange only if autoantibodies rebounded. The primary outcomes were safety and dialysis independency at 6 months. RESULTS At inclusion, ten patients were dialysis dependent and the other five had eGFR levels between 7 and 14 ml/min per 1.73m2. The median age was 61 years (range 19-77), six were women, and six were also positive for anti-neutrophil cytoplasmic antibodies. Then 6 hours after imlifidase infusion, all patients had anti-GBM antibodies levels below the reference range of a prespecified assay. At 6 months 67% (ten out of 15) were dialysis independent. This is significantly higher compared with 18% (nine out of 50) in a historical control cohort (P<0.001, Fisher's exact test). Eight serious adverse events (including one death) were reported, none assessed as probably or possibly related to the study drug. CONCLUSIONS In this pilot study, the use of imlifidase was associated with a better outcome compared with earlier publications, without major safety issues, but the findings need to be confirmed in a randomized controlled trial.Clinical Trial registration number: EUDRACT 2016-004082-39 https://www.clinicaltrialsregister.eu/ctr-search/trial/2007-001377-28/results.
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Affiliation(s)
- Fredrik Uhlin
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
| | - Wladimir Szpirt
- Department of Nephrology P, Københavns universitet, Copenhagen, Denmark
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Annette Bruchfeld
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden,Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
| | - Inga Soveri
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lionel Rostaing
- Department of Nephrology, Hemodialysis, Apheresis, and Kidney Transplantation, EriCHU Grenoble-Alpes, Grenoble, France
| | - Eric Daugas
- Nephrology Service, Hôpital Bichat, Université de Paris, Paris, France
| | - Arnaud Lionet
- Neohrology service, Centre Hospitalier Regional, Lille University, Lille, France
| | - Nassim Kamar
- Department of Nephrology and Organ Transplantation, Université Paul Sabatier, Toulouse, France
| | - Cédric Rafat
- Urgences Néphrologiques et Transplantation Rénale, Paris, France
| | - Marek Mysliveček
- Department of Nephrology, Charles University and General University Hospital, Prague, Czech Republic
| | - Vladimír Tesař
- Department of Nephrology, Charles University and General University Hospital, Prague, Czech Republic
| | - Anders Fernström
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | | | | | - Stephen McAdoo
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Johan Mölne
- Department of Laboratory Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Mårten Segelmark
- Department of Nephrology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden .,Department of Clinical Sciences, Lund University, Lund, Sweden
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28
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Abstract
There is increasing understanding that a multifaceted interplay of sex-dependent genetic and immune dysregulation underpins the development of glomerular disorders. Regional and ethnic variations in glomerular disease incidence make delineating the effects of sex and gender on disease pathophysiology more complex, but there is a marked paucity of research in this area. This review article presents a summary of the current understanding of sex and gender in glomerular disease, highlighting the broader effects of sex and gender on autoimmunity, clinical presentations, and pathophysiology of individual glomerular diseases, as well as exploring sex, gender, and glomerular disease within a wider socioenvironmental context. It is important to specifically consider the effects of sex and gender when presenting and analyzing clinical and scientific studies on glomerular disease. Failure to do so risks promoting disparities within health care provision, neglecting opportunities to identify sex-specific biomarkers, and potentially hindering the development of sex-specific therapies.
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Affiliation(s)
- Hannah Beckwith
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK.
| | - Liz Lightstone
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
| | - Steve McAdoo
- Department of Renal Medicine, Imperial College London, London, UK; Imperial College Healthcare NHS Trust, London, UK
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29
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Nalcacioglu H, Tekcan D, Meydan BC, Onal HG, Aydog O. Macroscopic hematuria, facing an uncommon disease: Answers. Pediatr Nephrol 2022; 37:339-343. [PMID: 34668062 DOI: 10.1007/s00467-021-05285-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Hulya Nalcacioglu
- Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, Kurupelit, Samsun, Turkey.
| | - Demet Tekcan
- Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, Kurupelit, Samsun, Turkey
| | - Bilge Can Meydan
- Pathology Department, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Hulya Gozde Onal
- Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, Kurupelit, Samsun, Turkey
| | - Ozlem Aydog
- Pediatric Nephrology Department, Ondokuz Mayis University Faculty of Medicine, Kurupelit, Samsun, Turkey
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30
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LIU J, ZENG X, LIN Q, HE W, YE W, YANG Q. The benefits and harms of Chinese medicinal herbs for the treatment of rapidly progressive glomerulonephritis in adult patients. FOOD SCIENCE AND TECHNOLOGY 2021. [DOI: 10.1590/fst.23620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Jialing LIU
- Guangzhou University of Chinese Medicine, China; Guangdong Provincial Hospital of Chinese Medicine, China
| | - Xiaoxi ZENG
- Sichuan University, China; Sichuan University, China
| | - Qizhan LIN
- Guangdong Provincial Hospital of Chinese Medicine, China; Guangzhou University of Chinese Medicine, China
| | - Weifeng HE
- The Second People's Hospital of Hunan Province, China
| | - Wei YE
- Renmin Hospital of Wuhan University, China
| | - Qianchun YANG
- Guangzhou University of Chinese Medicine, China; Guangzhou University of Chinese Medicine, China
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31
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Kaneko S, Yamagata K, Usui J, Tsuboi N, Sugiyama H, Maruyama S, Narita I. Epidemiology and temporal changes in the prognosis of rapidly progressive glomerulonephritis in Japan: a nationwide 1989-2015 survey. Clin Exp Nephrol 2021; 26:234-246. [PMID: 34643841 DOI: 10.1007/s10157-021-02148-y] [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: 08/18/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Rapidly progressive glomerulonephritis (RPGN) can progress to end-stage kidney disease within a short period. This study is a continuation of the chronological nationwide survey conducted by the Japan-RPGN working group. METHODS We examined a total of 2793 RPGN cases registered during four periods (1989-1998, 1999-2001, 2002-2008, 2009-2011) plus 1386 cases in 2012-2015. As potential prognostic determinants, we investigated the onset period, the clinical severity (CS) grade [classified according to age, serum creatinine (sCr) and C-reactive protein levels, and presence/absence of lung lesions], and causative disease. RESULTS The cumulative overall RPGN patient survival at 24 months kept improving over the five periods (72.0%, 72.9%, 77.7%, 83.0%, 84.9%, p < 0.001 for trend). The cumulative renal survival also improved in the latest period (68.7%, 75.4%, 76.7%, 73.4%, 78.2%, p < 0.001 for trend). The CS grade was well stratified to predict both life and renal prognoses. Anti-glomerular basement membrane disease (aGBMD)-RPGN had a poorer renal prognosis than other diseases. In anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV-RPGN, accounting for > 70% of the overall RPGN), the prognostic results were similar to that for overall RPGN. There was a much better renal prognosis for the latest period under the condition of sCr < 3 mg/dL (the 24-month cumulative renal survival: 97.9%), but not for sCr ≥ 3 mg/dL (61.5%). CONCLUSIONS In overall RPGN as well as AAV-RPGN, both life and renal prognoses tended to improve, but the favorable renal result was substantially limited to mild cases. There was no improvement of the renal prognosis in aGBMD-RPGN.
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Affiliation(s)
- Shuzo Kaneko
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan.,Department of Nephrology, Itabashi Chuo Medical Center, Itabashi, Tokyo, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan.
| | - Joichi Usui
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8577, Japan
| | - Naotake Tsuboi
- Department of Nephrology, Fujita Health University Graduate School of Medicine, Toyoake, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Internal Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 640] [Impact Index Per Article: 213.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Kant S, Kronbichler A, Sharma P, Geetha D. Advances in Understanding of Pathogenesis and Treatment of Immune-Mediated Kidney Disease: A Review. Am J Kidney Dis 2021; 79:582-600. [PMID: 34508831 DOI: 10.1053/j.ajkd.2021.07.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/25/2021] [Indexed: 12/21/2022]
Abstract
There continues to be rapid advancement in our understanding of the pathogenesis of immune-mediated kidney disease. This progress has culminated in the development of multiple therapeutic agents that have consistently improved renal and patient outcomes. The focus of this review is to discuss these recent advancements in immune-mediated kidney disease via the lens of direct and indirect immune-mediated mechanisms. In the direct immune-mediated disease, recently described antigens in anti-glomerular basement membrane (GBM) disease and membranous nephropathy are discussed, along with new therapeutic regimens in membranous nephropathy and focal segmental glomerulosclerosis. From an indirect immune-mediated disease standpoint, recent pivotal trials in antineutrophil cytoplasmic antibody vasculitis, lupus nephritis, and IgA nephropathy are examined from a real-world practice perspective. New molecular pathways in various disorders of alternate complement pathway are described, which in turn have led to development of various experimental therapies. In addition, pivotal and ongoing therapeutic trials in the aforementioned diseases are presented.
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Affiliation(s)
- Sam Kant
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Purva Sharma
- Division of Kidney Diseases and Hypertension, Zucker School of Medicine, Hofstra University/Northwell Health, Hempstead, New York
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
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Zahir Z, Wani AS, Prasad N, Jain M. Clinicopathological characteristics and predictors of poor outcome in anti-glomerular basement membrane disease - a fifteen year single center experience. Ren Fail 2021; 43:79-89. [PMID: 33334228 PMCID: PMC7751384 DOI: 10.1080/0886022x.2020.1854301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction Anti-glomerular basement membrane (anti-GBM) disease is a small vessel vasculitis affecting the renal and lung capillary beds. We aim to study the clinicopathological characteristics and predictors of poor outcome of this disease in our population. Materials and methods This is a 15 year retrospective, single center observational study of Indian cohort. Patients with biopsy proven anti-GBM disease were studied. Results Anti-GBM disease was found in 0.5% of the total cases. The mean age at presentation was 46.7 years. Compared to renal limited disease those with pulmonary-renal syndrome had a higher frequency of hypertension, oliguria, percentage of crescents, interstitial inflammation and glomerulosclerosis. Double positive (anti-GBM and ANCA antibodies) patients showed more of glomerulosclerosis, tubular atrophy/interstitial fibrosis (IFTA) as well as periglomerular granulomas on biopsy. Patient survival at one year was 40.4% and death censored renal survival was 9.7%. Factors affecting the dialysis dependency at presentation were oligoanuria (p = .04), creatinine levels >5.7 mg/dl (p = .003), and high mean anti-GBM titers (p = .008). Atypical cases accounted for 8.3% of these patients. Oligoanuria (HR = 5.0, p = .05), high serum creatinine (HR = 1.55, p = .05), severe glomerulosclerosis (HR = 1.09, p = .03), and IFTA (HR = 2, p = .04) were associated with poor renal outcome. Advanced age (HR = 1.92, p = .03), high serum creatinine (HR = 1.9, p = .04) and high anti-GBM titers (HR = 1.01, p = .03) were associated with poor patient survival. Conclusions Anti-GBM is a rare disease with poor prognosis and varied presentations. Patients with pulmonary-renal syndrome showed severe disease whereas double positive had more of chronic changes. The predictors of poor prognosis include advanced age, oliguria, serum anti-GBM levels, serum creatinine levels, degree of glomerulosclerosis and IFTA. Atypical anti-GBM cases should be kept in mind while evaluating renal biopsies.
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Affiliation(s)
- Zafirah Zahir
- PDCC Renal Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Asif Sadiq Wani
- Department of Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.,Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Narayan Prasad
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Manoj Jain
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
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Garcia GE, Lu YJ, Truong LD, Roncal-Jiménez CA, Miyazaki M, Miyazaki-Anzai S, Cara-Fuentes G, Andres-Hernando A, Lanaspa M, Johnson RJ, Leamon CP. A Novel Treatment for Glomerular Disease: Targeting the Activated Macrophage Folate Receptor with a Trojan Horse Therapy in Rats. Cells 2021; 10:2113. [PMID: 34440885 PMCID: PMC8393837 DOI: 10.3390/cells10082113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 02/07/2023] Open
Abstract
Since activated macrophages express a functional folate receptor β (FRβ), targeting this macrophage population with folate-linked drugs could increase selectivity to treat inflammatory diseases. Using a macrophage-mediated anti-glomerular basement membrane (anti-GBM) glomerulonephritis (GN) in WKY rats, we investigated the effect of a novel folic acid-aminopterin (AMT) conjugate (EC2319) designed to intracellularly deliver AMT via the FR. We found that treatment with EC2319 significantly attenuated kidney injury and preserved renal function. Kidney protection with EC2319 was blocked by a folate competitor, indicating that its mechanism of action was specifically FRβ-mediated. Notably, treatment with methotrexate (MTX), another folic acid antagonist related to AMT, did not protect from kidney damage. EC2319 reduced glomerular and interstitial macrophage infiltration and decreased M1 macrophage recruitment but not M2 macrophages. The expression of CCL2 and the pro-fibrotic cytokine TGF-β were also reduced in nephritic glomeruli with EC2319 treatment. In EC2319-treated rats, there was a significant decrease in the deposition of collagens. In nephritic kidneys, FRβ was expressed on periglomerular macrophages and macrophages present in the crescents, but its expression was not observed in normal kidneys. These data indicate that selectively targeting the activated macrophage population could represent a novel means for treating anti-GBM GN and other acute crescentic glomerulonephritis.
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Affiliation(s)
- Gabriela E. Garcia
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Yingjuan J. Lu
- Endocyte, Inc., Novartis Institutes for Biomedical Research, West Lafayette, IN 47906, USA; (Y.J.L.); (C.P.L.)
| | - Luan D. Truong
- Department of Pathology, The Houston Methodist Hospital, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Carlos A. Roncal-Jiménez
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Makoto Miyazaki
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Shinobu Miyazaki-Anzai
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Gabriel Cara-Fuentes
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Ana Andres-Hernando
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Miguel Lanaspa
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Richard J. Johnson
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; (C.A.R.-J.); (M.M.); (S.M.-A.); (G.C.-F.); (A.A.-H.); (M.L.); (R.J.J.)
| | - Christopher P. Leamon
- Endocyte, Inc., Novartis Institutes for Biomedical Research, West Lafayette, IN 47906, USA; (Y.J.L.); (C.P.L.)
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Shin JI, Geetha D, Szpirt WM, Windpessl M, Kronbichler A. Anti-glomerular basement membrane disease (Goodpasture disease): From pathogenesis to plasma exchange to IdeS. Ther Apher Dial 2021; 26:24-31. [PMID: 34339589 DOI: 10.1111/1744-9987.13718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/28/2021] [Accepted: 07/30/2021] [Indexed: 12/28/2022]
Abstract
Anti-glomerular basement membrane (GBM) disease (Goodpasture disease) often presents with severe kidney failure and pulmonary hemorrhage. Anti-GBM antibodies are pathogenic, and other autoantibodies such as laminin-521 have been identified recently, potentially indicating a subset with a more severe disease phenotype and poor prognosis. Around 30%-40% of patients are also anti-neutrophil cytoplasmatic antibody (ANCA)-positive and this subset combines features of anti-GBM disease and ANCA-associated vasculitis, with particular impact on long-term treatment. A combination of therapeutic plasma exchange (or immunoadsorption), cyclophosphamide, and glucocorticoids is considered standard of care management, but despite early initiation, patients with poor prognostic factors often remain dialysis dependent. Imlifidase (IdeS), capable to cleave IgG within hours, has been tested in a phase II trial. Among 15 patients, 10 with poor prognosis at baseline (eGFR <15 ml/min/1.73 m2 ) were dialysis independent at 6 months. Further developments are needed to refine treatment approaches in anti-GBM disease.
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Affiliation(s)
- Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Wladimir M Szpirt
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Martin Windpessl
- Section of Nephrology, Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria.,Medical Faculty, Johannes Kepler University Linz, Linz, Austria
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Zou G, Lu H, Zhuo L, Zou W, Li W. Anti-glomerular basement membrane disease mediated by IgG and IgA: a case report. Ren Fail 2021; 43:774-778. [PMID: 33913397 PMCID: PMC8901282 DOI: 10.1080/0886022x.2021.1914658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Anti-glomerular basement membrane (anti-GBM) disease is a rare autoimmune condition responsible for rapidly progressive glomerulonephritis. This disease is usually mediated by IgG autoantibodies against the noncollagenous domain of the α3(IV) collagen chain. In rare cases, IgA or IgM anti-GBM antibodies are involved. This raises the question of whether there are different types of antibody-mediated anti-GBM disease at the same time. Case report A 37-year-old woman with anti-GBM disease mediated by IgG and IgA. The patient developed rapidly progressive glomerulonephritis with nephrotic syndrome. Indirect immunofluorescence analysis indicated the presence of IgG and IgA antibodies reactive with a basement membrane component, identified by enzyme-linked immunoadsorbent assay and Western blotting as the α3(IV) collagen chain. After plasmapheresis and immunotherapy (steroids and cyclophosphamide), much improved the massive proteinuria and renal function. Follow up to date, she had normal renal function without proteinuria. Conclusions This is the first case report of anti-GBM disease mediated by IgG and IgA. If the clinical presentation and histopathological findings are suggestive of atypical anti-GBM disease, alternative laboratory tests such as Western blotting analysis can be used to confirm the diagnosis.
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Affiliation(s)
- Guming Zou
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Haitao Lu
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Li Zhuo
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Wanzhong Zou
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, People's Republic of China
| | - Wenge Li
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, People's Republic of China
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Shimamura Y, Maeda T, Abe K, Ogawa Y, Takizawa H. Clinical and immunologic characteristics of Japanese patients with anti-glomerular basement membrane disease: case reports and literature review. RENAL REPLACEMENT THERAPY 2021. [DOI: 10.1186/s41100-021-00317-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Clinical studies of anti-glomerular basement membrane (GBM) disease were limited because of the low incidence. We aimed to report the characteristics, treatments, and outcomes of patients with anti-GBM disease at a tertiary reference medical center in Japan and review the literature of mortality in patients with anti-GBM disease.
Case presentation
Case 1 was a 72-year-old Japanese man that was referred with worsening of the serum creatinine (from 1.1 to 27.3 mg/dL). Anti-GBM disease was confirmed by renal biopsy, and treatments with oral prednisolone and plasmapheresis were initiated. Although his anti-GBM antibody decreased (from 476 to 18 units/mL) after the treatments, the patient died from lung abscess. Case 2 was a 32-year-old Japanese man that presented with fever and macroscopic hematuria. At presentation, his serum creatinine was 4.2 mg/dL, and anti-GBM antibody was 265 units/mL. Renal biopsy confirmed the diagnosis of anti-GBM disease, and intensive treatments with plasmapheresis and methyl prednisolone were started, followed by oral prednisolone. Living-donor kidney transplantation was performed because his anti-GBM antibody had remained undetectable for 1 year after diagnosis. In the main text, clinicopathological characteristics of 12 patients with anti-GBM disease at our institution were summarized.
Conclusions
We found that the 1-year survival rate of patients with anti-GBM disease was 88% in our cohort, which was comparable to previous studies. Multicenter, nationwide studies are expected to evaluate prognosis of Japanese patients with this rare entity.
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Ahmad SB, Santoriello D, Canetta P, Bomback AS, D'Agati VD, Markowitz G, Ahn W, Radhakrishnan J, Appel GB. Concurrent Anti-Glomerular Basement Membrane Antibody Disease and Membranous Nephropathy: A Case Series. Am J Kidney Dis 2021; 78:219-225.e1. [PMID: 33421452 DOI: 10.1053/j.ajkd.2020.11.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 11/29/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Anti-glomerular basement membrane (GBM) disease is a rapidly progressive glomerulonephritis which, in some instances, occurs concurrently with other diseases such as antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Rarely, it also occurs with membranous nephropathy (MN). We report a series of such patients, characterizing their long-term follow up. STUDY DESIGN Case series. SETTING & PARTICIPANTS Twelve patients referred to 1 medical center between 2001 and 2019 with anti-GBM disease and MN whose clinical characteristics and course were described. RESULTS Patients' ages ranged from 20 to 81 years old, and all presented with severe acute kidney injury requiring dialysis on presentation or shortly thereafter. Only 1 patient had pulmonary findings on presentation. The predominant pathology was crescentic and necrotizing glomerulonephritis with linear staining for immunoglobulin G along the GBM associated with epimembranous electron-dense immune-type deposits. All 11 patients who were tested had significant titers of anti-GBM antibodies, but only 1 of the 5 tested for phospholipase A2 receptor (PLA2R) on biopsy was positive. Eight patients received therapy with cyclophosphamide, prednisone, and plasmapheresis; 2 patients with prednisone and plasmapheresis; and 2 with rituximab-based regimens. Progression to a requirement for kidney replacement therapy occurred in all 12 patients, but 2 patients later recovered kidney function. Recurrence of anti-GBM disease did not occur for any of the patients studied. LIMITATIONS Incomplete testing for PLA2R in biopsy and serum, limited sample size, and lack of uniform treatment regimen. CONCLUSIONS In this case series, the presentation of concurrent anti-GBM disease and MN was characterized by rapidly progressive glomerulonephritis and poor kidney outcomes. These findings suggest possible value from earlier diagnosis and the need for identification of more effective treatment regimens.
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Affiliation(s)
- Syeda B Ahmad
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Dominick Santoriello
- Department of Pathology, Columbia College of Physicians and Surgeons, New York, NY
| | - Pietro Canetta
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Vivette D D'Agati
- Department of Pathology, Columbia College of Physicians and Surgeons, New York, NY
| | - Glen Markowitz
- Department of Pathology, Columbia College of Physicians and Surgeons, New York, NY
| | - Wooin Ahn
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Jai Radhakrishnan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Gerald B Appel
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY.
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Abstract
Since the first clinicopathologic description by Ernest Goodpasture of a patient whom he considered to have died of influenza in 1919, substantial progress has been made in our knowledge of anti-glomerular basement membrane disease. This has led to a significant decrease in the morbidity and mortality associated with this disease. In this paper, we aim to review the literature that has enhanced our understanding of classic anti-glomerular basement membrane disease and its clinic-pathologic variants in the key areas of immunopathogenesis and histopathology. We also summarize varied clinical presentations and therapeutic strategies.
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Peyton N, Rastogi P. Educational Case: Necrotizing and Crescentic Glomerulonephritis With Anti-Glomerular Basement Membrane Antibodies (Anti-Gbm). Acad Pathol 2020; 7:2374289520975166. [PMID: 33330742 PMCID: PMC7720308 DOI: 10.1177/2374289520975166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/09/2020] [Accepted: 10/19/2020] [Indexed: 12/02/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.1
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Affiliation(s)
- Nicole Peyton
- Department of Pathology, University of Iowa, Iowa City, IA, USA
| | - Prerna Rastogi
- Department of Pathology, University of Iowa, Iowa City, IA, USA
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Harrigan AM, West ML, Geldenhuys L, Poyah P. Renal-Limited Antiglomerular Basement Membrane Disease Related To Alemtuzumab: A Case Report. Can J Kidney Health Dis 2020; 7:2054358120962680. [PMID: 33117548 PMCID: PMC7573726 DOI: 10.1177/2054358120962680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 08/17/2020] [Indexed: 11/30/2022] Open
Abstract
Rationale: Alemtuzumab is a monoclonal antibody approved for the treatment of relapsing-remitting multiple sclerosis (RRMS). Many autoimmune-mediated adverse events have been associated with alemtuzumab, including renal-limited anti-glomerular basement membrane (GBM) disease. Presenting concern: A 52-year-old female with RRMS presented with acute kidney injury 39 months after receiving 1 cycle of alemtuzumab. She had a history of alemtuzumab-associated hypothyroidism and thrombocytopenia, urinary tract infections, and chronically abnormal urinalyses. Diagnosis: A diagnosis of renal-limited anti-GBM disease was made based on renal biopsy and positive anti-GBM serology. Alemtuzumab was thought to be the trigger of the anti-GBM disease as there were no other exposures or serologic findings suggesting other causes. Interventions: She was treated with corticosteroids, cyclophosphamide, and plasmapheresis. She required hemodialysis for acute renal failure. Outcomes: Despite treatment, the patient’s renal function did not recover. She remained dialysis-dependent and anti-GBM antibody titers remained elevated 6 months after presentation. Teaching points: Anti-GBM disease is a life-altering adverse event that can be associated with alemtuzumab. Our case highlights the limitations of monitoring urinalyses as a trigger for anti-GBM antibody testing in patients who have received alemtuzumab and have baseline abnormal urinalyses; such patients may require further protocolized anti-GBM antibody testing, although the optimal frequency of such antibody screening remains unclear.
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Affiliation(s)
- Amye M Harrigan
- Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Michael L West
- Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada.,Division of Nephrology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Laurette Geldenhuys
- Division of Pathology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Penelope Poyah
- Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada.,Division of Nephrology, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
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Moiseev S, Cohen Tervaert JW, Arimura Y, Bogdanos DP, Csernok E, Damoiseaux J, Ferrante M, Flores-Suárez LF, Fritzler MJ, Invernizzi P, Jayne D, Jennette JC, Little MA, McAdoo SP, Novikov P, Pusey CD, Radice A, Salama AD, Savige JA, Segelmark M, Shoenfeld Y, Sinico RA, Sousa MJ, Specks U, Terrier B, Tzioufas AG, Vermeire S, Zhao MH, Bossuyt X. 2020 international consensus on ANCA testing beyond systemic vasculitis. Autoimmun Rev 2020; 19:102618. [PMID: 32663621 DOI: 10.1016/j.autrev.2020.102618] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 03/08/2020] [Indexed: 02/07/2023]
Abstract
This document follows up on a 2017 revised international consensus on anti-neutrophil cytoplasm antibodies (ANCA) testing in granulomatosis with polyangiitis and microscopic polyangiitis and focuses on the clinical and diagnostic value of ANCA detection in patients with connective tissue diseases, idiopathic interstitial pneumonia, autoimmune liver diseases, inflammatory bowel diseases, anti-glomerular basement membrane (GBM) disease, infections, malignancy, and during drug treatment. Current evidence suggests that in certain settings beyond systemic vasculitis, ANCA may have clinical, pathogenic and/or diagnostic relevance. Antigen-specific ANCA targeting proteinase-3 and myeloperoxidase should be tested by solid phase immunoassays in any patient with clinical features suggesting ANCA-associated vasculitis and in all patients with anti-GBM disease, idiopathic interstitial pneumonia, and infective endocarditis associated with nephritis, whereas in patients with other aforementioned disorders routine ANCA testing is not recommended. Among patients with autoimmune liver diseases or inflammatory bowel diseases, ANCA testing may be justified in patients with suspected autoimmune hepatitis type 1 who do not have conventional autoantibodies or in case of diagnostic uncertainty to discriminate ulcerative colitis from Crohn's disease. In these cases, ANCA should be tested by indirect immunofluorescence as the target antigens are not yet well characterized. Many questions concerning the optimal use of ANCA testing in patients without ANCA-associated vasculitis remain to be answered.
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Affiliation(s)
- Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia.
| | - Jan Willem Cohen Tervaert
- Department of Medicine, Division of Rheumatology, University of Alberta, Edmonton, Canada and Maastricht University, Maastricht, The Netherlands
| | - Yoshihiro Arimura
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo, Japan
| | - Dimitrios P Bogdanos
- Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, Larissa, Greece
| | - Elena Csernok
- Department of Internal Medicine, Rheumatology and Immunology, Vasculitis-Center Tübingen-Kirchheim, Medius Klinik Kirchheim, University of Tübingen, Kirchheim-Teck, Germany
| | - Jan Damoiseaux
- Central Diagnostic Laboratory, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marc Ferrante
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Luis Felipe Flores-Suárez
- Primary Systemic Vasculitides Clinic, Instituto Nacional de Enfermedades Respiratorias, Mexico City, Mexico
| | - Marvin J Fritzler
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pietro Invernizzi
- Division Gastroenterology and Center for Autoimmune Liver Diseases, University of Milano-Bicocca School of Medicine, Monza, Italy
| | - David Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - J Charles Jennette
- Division of Nephropathology, School of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Mark A Little
- Trinity Health Kidney Centre, Trinity Translational Medicine Institute, Dublin, Ireland
| | - Stephen P McAdoo
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Pavel Novikov
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Charles D Pusey
- Centre for Inflammatory Disease, Department of Medicine, Imperial College London, London, UK
| | - Antonella Radice
- Microbiology and Virology Institute, ASST Santi Paolo e Carlo, San Carlo Borromeo Hospital, Milan, Italy
| | - Alan D Salama
- UCL Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Judith A Savige
- Department of Medicine, Melbourne Health, University of Melbourne, Melbourne, Australia
| | - Mårten Segelmark
- Department of Clinical Sciences, Lund University, Department of Nephrology and Rheumatology, Skane University Hospital, Lund, Sweden
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Renato A Sinico
- Department of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Maria-José Sousa
- Immunopathology and Autoimmunity Department, Centro de Medicina Laboratorial Germano de Sousa, Lisbon, Portugal
| | - Ulrich Specks
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Benjamin Terrier
- Department of Internal Medicine, National Referral Center for Rare Systemic and Autoimmune Diseases, Hôpital Cochin, Paris, France
| | - Athanasios G Tzioufas
- Department of Pathophysiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Severine Vermeire
- University Hospitals Leuven, Department of Gastroenterology and Hepatology, KU Leuven, Leuven, Belgium
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking-Tsinghua Centre for Life Sciences, Beijing, China
| | - Xavier Bossuyt
- Laboratory Medicine, University Hospitals Leuven, Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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Turner M, Crawford A, Winterbottom C, Flossmann O, Alchi B, Soares M, Bhandary U. Heavy chain deposition disease presenting with raised anti-GBM antibody levels; a case report. BMC Nephrol 2020; 21:175. [PMID: 32398029 PMCID: PMC7216388 DOI: 10.1186/s12882-020-01837-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background Monoclonal immunoglobulin deposition disease (MIDD) is a rare condition accounting for < 1% of histopathological diagnoses made on kidney biopsy1. The best outcomes are seen in those diagnosed and treated promptly, but delay to diagnosis is common with the largest series reporting a median time from onset of renal impairment to diagnosis of 12 months2. Here, we report a case of the heavy chain subset of MIDD presenting with positive anti-glomerular basement membrane (anti-GBM) antibodies obscuring the true diagnosis. Case presentation Here, we present a challenging case presenting with oedema, haematoproteiuria, and new renal impairment. Anti-GBM antibodies were positive and prompted treatment as atypical anti-GBM disease. However, they were ultimately proven to be monoclonal and secondary to myeloma. The final diagnosis facilitated effective myeloma treatment which led to complete remission and independence from renal replacement therapy. Conclusions This case reinforces the importance of comprehensive histopathological and haematological assessment in making the correct diagnosis. Here it facilitated effective treatment and recovery of renal function.
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Affiliation(s)
- Michael Turner
- Renal Unit, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK.
| | - Anna Crawford
- Renal Unit, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK
| | | | - Oliver Flossmann
- Renal Unit, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK
| | - Bassam Alchi
- Renal Unit, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK
| | - Maria Soares
- Department of Cellular Pathology, John Radcliffe Hospital, Headley Way, Oxford, UK
| | - Umanath Bhandary
- Renal Unit, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK
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Elshirbeny M, Alkadi MM, Mujeeb I, Fituri O. Atypical Anti-Glomerular Basement Membrane Disease With Diffuse Crescentic Membranoproliferative Glomerulonephritis: Case Report and Review of Literature. Qatar Med J 2020; 2020:16. [PMID: 32391252 PMCID: PMC7199789 DOI: 10.5339/qmj.2020.16] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 01/05/2020] [Indexed: 12/28/2022] Open
Abstract
Anti-glomerular basement membrane (anti-GBM) disease occurs in fewer than two cases per million population. Patients usually present with features of rapidly progressive glomerulonephritis (RPGN) with or without pulmonary involvement. Anti-GBM disease is classically diagnosed by both demonstrating GBM linear immunofluorescence staining on kidney biopsy and detecting anti-GBM antibodies in serum. More than 90% of patients with anti-GBM disease either become dialysis-dependent or die if left untreated. Here, we report a 37-year-old man who presented with bilateral lower limb edema, hypertension, acute kidney injury (creatinine of 212 μmol/L), microscopic hematuria, and nephrotic range proteinuria (15 g/day). His kidney biopsy showed diffuse crescentic membranoproliferative glomerulonephritis and bright linear staining of GBM by immunoglobulin G consistent with anti-GBM disease; however, serum anti-GBM antibodies were negative. The patient was diagnosed with atypical anti-GBM disease and treated aggressively with intravenous pulse steroids, plasmapheresis, oral cyclophosphamide, and oral prednisolone with significant improvement in kidney function and proteinuria. Atypical anti-GBM disease should be considered in patients presenting with RPGN, even in the absence of serum anti-GBM antibodies. Early diagnosis and aggressive treatment in such cases are warranted to prevent irreversible kidney damage as the course of the disease might not be as benign as previously thought.
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Affiliation(s)
- Mostafa Elshirbeny
- Division of Nephrology, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Mohamad M Alkadi
- Division of Nephrology, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Imaad Mujeeb
- Division of Nephrology, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Omar Fituri
- Division of Nephrology, Department of Medicine, Hamad Medical Corporation, Doha, Qatar
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Chittka D, Lennartz L, Jung B, Banas B, Bergler T. [Successful rituximab treatment of recurrent glomerulonephritis associated with antibodies against the glomerular basement membrane]. Internist (Berl) 2020; 61:416-423. [PMID: 32179970 DOI: 10.1007/s00108-020-00773-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This article presents a case of recurrent anti-GBM disease (with antibodies against the glomerular basement membrane [GBM]) in a 17-year-old patient successfully treated with rituximab. Kidney biopsy with detection of linear deposition of immunoglobulin G (IgG) along the basement membrane is the diagnostic gold standard, which should be accompanied by serological testing. However, standard assays for the detection of anti-GBM antibodies have a high rate of false-negative results. In this particular case, an increase in proteinuria despite standard therapy (plasmapheresis, steroids, cyclophosphamide) was the clinical correlate of relapsing disease. The use of rituximab completely resolved the recurrent anti-GBM disease.
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Affiliation(s)
- D Chittka
- Abteilung Nephrologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - L Lennartz
- Abteilung Nephrologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - B Jung
- Abteilung Nephrologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - B Banas
- Abteilung Nephrologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - T Bergler
- Abteilung Nephrologie, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
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47
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Segelmark M, Hellmark T. Anti-glomerular basement membrane disease: an update on subgroups, pathogenesis and therapies. Nephrol Dial Transplant 2020; 34:1826-1832. [PMID: 30371823 DOI: 10.1093/ndt/gfy327] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 09/20/2018] [Indexed: 12/12/2022] Open
Abstract
Most patients with anti-glomerular basement membrane (anti-GBM) disease present with rapidly progressive glomerulonephritis with or without pulmonary haemorrhage; however, there are several variants and vigilance is necessary to make a correct diagnosis. Such variants include overlap with anti-neutrophil cytoplasm antibodies-associated vasculitis and membranous nephropathy as well as anti-GBM occurring de novo after renal transplantation. Moreover, patients can present with isolated pulmonary haemorrhage as well as with negative tests for circulating anti-GBM. Virtually all patients with anti-GBM disease have autoantibodies that react with two discrete epitopes on the α3 chain of type IV collagen. Recent evidence suggests that healthy persons have low-affinity natural antibodies reacting with the same epitopes, but most people are protected from developing disease-causing high-affinity autoantibodies by human leukocyte antigen-dependent regulatory T-cells (Tregs). The α3 chain-derived peptides presented by the HLA-DR15 antigen lack the ability to promote the development of such Tregs. The detection of anti-GBM in circulation using the rapid assay test has led to early diagnosis and improved prognosis. However, our present tools to curb the inflammation and to eliminate the assaulting antibodies are insufficient. Only about one-third of all patients survive with functioning native kidneys. More effective therapies need to be developed; agents that inhibit neutrophil recruitment, deplete B cells and cleave immunoglobulin G (IgG) in vivo may become new weapons in the arsenal to combat anti-GBM disease.
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Affiliation(s)
- Mårten Segelmark
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
| | - Thomas Hellmark
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Nephrology, Lund, Sweden
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Severe Infection in Anti-Glomerular Basement Membrane Disease: A Retrospective Multicenter French Study. J Clin Med 2020; 9:jcm9030698. [PMID: 32143501 PMCID: PMC7141378 DOI: 10.3390/jcm9030698] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 12/23/2022] Open
Abstract
In patients presenting with anti-glomerular basement membrane (GBM) disease with advanced isolated kidney involvement, the benefit of intensive therapy remains controversial due to adverse events, particularly infection. We aim to describe the burden of severe infections (SI) (requiring hospitalization or intravenous antibiotics) and identify predictive factors of SI in a large cohort of patients with anti-GBM disease. Among the 201 patients (median [IQR] age, 53 [30–71] years) included, 74 had pulmonary involvement and 127 isolated glomerulonephritis. A total of 161 SI occurred in 116 patients during the first year after diagnosis. These infections occurred during the early stage of care (median [IQR] time, 13 [8–19] days after diagnosis) with mainly pulmonary (45%), catheter-associated bacteremia (22%) and urinary tract (21%) infections. In multivariable analysis, positive ANCA (HR [95% CI] 1.62 [1.07−2.44]; p = 0.02) and age at diagnosis (HR [95% CI] 1.10 [1.00–1.21]; p = 0.047) remained independently associated with SI. Age-adjusted severe infection during the first three months was associated with an increased three-year mortality rate (HR [95% CI] 3.13 [1.24–7.88]; p = 0.01). Thus, SI is a common early complication in anti-GBM disease, particularly in the elderly and those with positive anti-neutrophil cytoplasmic antibodies (ANCA). No significant association was observed between immunosuppressive strategy and occurrence of SI.
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Impact of ANCA-Associated Vasculitis on Outcomes of Hospitalizations for Goodpasture's Syndrome in the United States: Nationwide Inpatient Sample 2003-2014. ACTA ACUST UNITED AC 2020; 56:medicina56030103. [PMID: 32121573 PMCID: PMC7142422 DOI: 10.3390/medicina56030103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 12/27/2022]
Abstract
Background and objectives: Goodpasture’s syndrome (GS) is a rare, life-threatening autoimmune disease. Although the coexistence of anti-neutrophil cytoplasmic antibody (ANCA) with Goodpasture’s syndrome has been recognized, the impacts of ANCA vasculitis on mortality and resource utilization among patients with GS are unclear. Materials and Methods: We used the National Inpatient Sample to identify hospitalized patients with a principal diagnosis of GS from 2003 to 2014 in the database. The predictor of interest was the presence of ANCA-associated vasculitis. We tested the differences concerning in-hospital treatment and outcomes between GS patients with and without ANCA-associated vasculitis using logistic regression analysis with adjustment for other clinical characteristics. Results: A total of 964 patients were primarily admitted to hospital for GS. Of these, 84 (8.7%) had a concurrent diagnosis of ANCA-associated vasculitis. Hemoptysis was more prevalent in GS patients with ANCA-associated vasculitis. During hospitalization, GS patients with ANCA-associated required non-significantly more mechanical ventilation and non-invasive ventilation support, but non-significantly less renal replacement therapy and plasmapheresis than those with GS alone. There was no significant difference in in-hospital outcomes, including organ failure and mortality, between GS patients with and without ANCA-associated vasculitis. Conclusions: Our study demonstrated no significant differences between resource utilization and in-hospital mortality among hospitalized patients with coexistence of ANCA vasculitis and GS, compared to those with GS alone.
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Kaewput W, Thongprayoon C, Boonpheng B, Ungprasert P, Bathini T, Chewcharat A, Srivali N, Vallabhajosyula S, Cheungpasitporn W. Inpatient Burden and Mortality of Goodpasture's Syndrome in the United States: Nationwide Inpatient Sample 2003-2014. J Clin Med 2020; 9:jcm9020455. [PMID: 32041346 PMCID: PMC7074028 DOI: 10.3390/jcm9020455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/02/2020] [Accepted: 02/05/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Goodpasture’s syndrome is a rare, life-threatening, small vessel vasculitis. Given its rarity, data on its inpatient burden and resource utilization are lacking. We conducted this study aiming to assess inpatient prevalence, mortality, and resource utilization of Goodpasture’s syndrome in the United States. Methods: The 2003–2014 National Inpatient Sample was used to identify patients with a principal diagnosis of Goodpasture’s syndrome. The inpatient prevalence, clinical characteristics, in-hospital treatment, end-organ failure, mortality, length of hospital stay, and hospitalization cost were studied. Multivariable logistic regression was performed to identify independent factors associated with in-hospital mortality. Results: A total of 964 patients were admitted in hospital with Goodpasture’s syndrome as the principal diagnosis, accounting for an overall inpatient prevalence of Goodpasture’s syndrome among hospitalized patients in the United States of 10.3 cases per 1,000,000 admissions. The mean age of patients was 54 ± 21 years, and 47% were female; 52% required renal replacement therapy, whereas 39% received plasmapheresis during hospitalization. Furthermore, 78% had end-organ failure, with renal failure and respiratory failure being the two most common end-organ failures. The in-hospital mortality rate was 7.7 per 100 admissions. The factors associated with increased in-hospital mortality were age older than 70 years, sepsis, the development of respiratory failure, circulatory failure, renal failure, and liver failure, whereas the factors associated with decreased in-hospital mortality were more recent year of hospitalization and the use of therapeutic plasmapheresis. The median length of hospital stay was 10 days. The median hospitalization cost was $75,831. Conclusion: The inpatient prevalence of Goodpasture’s syndrome in the United States is 10.3 cases per 1,000,000 admissions. Hospitalization of patients with Goodpasture’s syndrome was associated with high hospital inpatient utilization and costs.
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Affiliation(s)
- Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand
- Correspondence: ; Tel.: +66-235-4760093613; Fax: +6623547733
| | - Charat Thongprayoon
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (C.T.); (A.C.)
| | - Boonphiphop Boonpheng
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA;
| | - Patompong Ungprasert
- Clinical Epidemiology Unit, Department of Research and Development, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, 10700, Thailand;
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, USA;
| | - Api Chewcharat
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (C.T.); (A.C.)
| | - Narat Srivali
- Department of Internal Medicine, St. Agnes Hospital, Baltimore, MD 21229, USA;
| | | | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
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