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Membranous glomerulonephritis with crescents

  • Nephrology - Original Paper
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Abstract

Purpose

The coexistence of membranous glomerulonephritis (MGN) and necrotizing and crescentic glomerulonephritis (NCGN) is an unusual finding in a renal biopsy except in lupus nephritis. Little is known about whether these lesions are causally related in any clinical setting.

Methods

We reviewed the pathology, presentation, and clinical course of 13 non-lupus patients with combined MGN and NCGN in native kidney biopsies (nine females, four males; median age 69 years), with particular attention to evidence of secondary MGN. Additional IgG subclass and phospholipase A2 receptor (PLA2R) immunofluorescence studies were conducted in seven cases.

Results

Eight biopsies were pauci-immune other than the capillary wall deposits of MGN; one patient had a non-lupus immune complex disease, and four had mesangial deposits, including one with rare subendothelial deposits. None had anti-glomerular basement membrane disease. IgG4 was dominant or codominant in the capillary wall deposits in three cases and virtually absent in four; PLA2R was positive in two cases, and negative in five. Seven patients were judged to have secondary MGN, including five of eight ANCA+ patients. Twelve patients were treated with combinations of steroids, cyclophosphamide, rituximab, followed by durable response in seven and relentless progression to end stage renal disease in four.

Conclusions

Secondary MGN occurs with higher frequency in ANCA-positive NCGN than in the general MGN population. A causal relationship between MGN and NCGN was not established in any patient, but circumstances suggest a common cause in several, including immune complex disease, drug reaction and paraneoplastic syndrome.

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References

  1. Nasr SH, Said SM, Valeri AM, Stokes MB, Masani NN, D’Agati VD, Markowitz GS (2009) Membranous glomerulonephritis with ANCA-associated necrotizing and crescentic glomerulonephritis. Clin J Am Soc Nephrol 4:299–308

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  2. Basford AW, Lewis J, Dwyer JP, Fogo AB (2011) Membranous nephropathy with crescents. J Am Soc Nephrol 22:1804–1808

    Article  CAS  PubMed  Google Scholar 

  3. Glassock RJ (1992) Secondary membranous glomerulonephritis. Nephrol Dial Transplant Suppl 1:64–71

    Google Scholar 

  4. Beck LH, Bonegio RGB, Lambeau G, Beck DM, Powell DW, Cummins TD, Klein JB, Salant DJ (2009) M-type phospholipase A2 receptor as target antigen in idiopathic membranous glomerulonephritis. N Eng J Med 361:11–21

    Article  CAS  Google Scholar 

  5. Qin W, Beck LH, Zeng C, Chen Z, Li S, Zuo K, Salant DJ, Liu Z (2011) Anti-phospholipase A2 receptor antibody in membranous nephropathy. J Am Soc Nephrol 22:1137–1143

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  6. Ohtani H, Wakui H, Komatsuda A, Okuyama S, Masai R, Maki N, Kigawa A, Sawada K, Imai H (2004) Distribution of glomerular IgG subclass deposits in malignancy-associated membranous nephropathy. Nephrol Dial Transplant 19:574–579

    Article  CAS  PubMed  Google Scholar 

  7. Qu Z, Liu G, Li J, Wu LH, Tan Y, Zheng X, Ao J, Zhao MH (2012) Absence of glomerular IgG4 deposition in patients with membranous nephropathy may indicate malignancy. Nephrol Dial Transplant 27:1931–1937

    Article  CAS  PubMed  Google Scholar 

  8. Larsen CP, Messias NC, Silva FG, Messias E, Walker PD (2013) Determination of primary versus secondary membranous glomerulopathy utilizing phospholipase A2 receptor staining in renal biopsies. Mod Pathol 26:709–715

    Article  CAS  PubMed  Google Scholar 

  9. Alberts B, Bray D, Lewis J, Raff M, Roberts K, Watson JD (1994) Cancer. In: Molecular biology of the cell, 3rd edn. Garland Publishing, Inc, New York, pp 1261–1263

  10. Kearney N, Podolak J, Matsumura L, Houghton D, Troxell M (2011) Patterns of IgG subclass deposits in membranous glomerulonephritis in renal allografts. Transplant Proc 43:3743–3746

    Article  CAS  PubMed  Google Scholar 

  11. Yokogawa N, Vivino FB (2009) Hydralazine-induced autoimmune disease: comparison to idiopathic lupus and ANCA-positive vasculitis. Mod Rheumatol 19:338–347

    Article  PubMed  Google Scholar 

  12. Sheikh TK, Charron RC, Katz A (1981) Renal manifestations of drug-induced systemic lupus erythematosus. Am J Clin Pathol 75:755–762

    CAS  PubMed  Google Scholar 

  13. Haas M, Eustace JA (2004) Immune complex deposits in ANCA-associated crescentic glomerulonephritis: a study of 126 cases. Kidney Int 65:2145–2152

    Article  CAS  PubMed  Google Scholar 

  14. Hofstra JM, Debiec H, Short CD et al (2012) Antiphospholipase A2 receptor antibody titer and subclass in idiopathic membranous nephropathy. J Am Soc Nephrol 23:1735–1743

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  15. Hoxha E, Harendza S, Zahner G, Panzer U, Steinmetz O, Fechner K, Helmchen U, Stahl RA (2012) An immunofluorescence test for phospholipase antibodies and its clinical usefulness in patients with membranous glomerulonephritis. Nephrol Dial Transplant 26:2526–2532

    Article  Google Scholar 

  16. Glassock RJ (2012) Attending rounds: an older patient with nephrotic syndrome. Clin J Am Soc Nephrol 7:665–670

    Article  PubMed  Google Scholar 

  17. Brouer E, Tervaert JW, Horst G, Huitema MG, van der Giessen M, Limburg PC, Kallenberg CG (1991) Predominance of IgG1 and IgG4 subclasses of anti-neutrophil cytoplasmic autoantibodies (ANCA) in patients with Wegener’s granulomatosis and clinically related disorders. Clin Exp Immunol 83:379–386

    Article  Google Scholar 

  18. Holland M, Hewins P, Goodall M, Adu D, Jefferis R, Savage COS (2004) Anti-neutrophil cytoplasmic antibody IgG subclasses in Wegner’s granulomatosis: a possible pathogenic role for the IgG4 subclass. Clin Exp Immunol 138:183–192

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  19. Hussain A, Pankhurst T, Goddall M, Colman R, Jefferis R, Savage CO, Williams JM (2009) Chimeric IgG4 PR3-ANCA induces selective inflammatory responses from neutrophils through engagement of Fcγ receptors. Immunology 128:236–244

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  20. Surindran S, Ayalon R, Hasan N, Beck LH Jr, Salant DJ, Barisoni L, Skolnik EY, Beara-Lasic L (2012) Coexistence of ANCA-associated glomerulonephritis and anti-phospholipase A2 receptor antibody-positive membranous nephropathy. Clin Kidney J 5:162–165

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  21. Chemouny JM, Pagnoux C, Caudwell V, Karras A, Borie R, Guillevin L, Vrtovsnik F, Daugas E (2012) ANCA-associated diseases and lung carcinomas: a five-case series. Clin Nephrol. doi:10.5414/CN107407

  22. Hamidou MA, El Kouri D, Audrain M, Groulleau J-Y (2001) Systemic antineutrophil cytoplasmic antibody vasculitis associated with lymphoid neoplasia. Ann Rheum Dis 60:293–295

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  23. Schwartz MM (2007) Membranous glomerulonephritis. In: Jennette JC, Olson JL, Schwartz MM, Silva FG (eds) Heptinstall’s pathology of the kidney, 6th edn. Lippincott Williams and Wilkins, Philadelphia, pp 219–222

    Google Scholar 

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Acknowledgments

We thank our Nephrology colleagues who provided detailed clinical and follow-up data: Doctors Pei-Li Wang, Leah Swetnam, Richard Kebler, Julie Raggio, Hem Deodhar, David Rozansky, Kendal Michaels, Jeanne Mowry, Kenneth Stringer, Dean Raniele, Clayton Smiley, and Shukri Osman. Part of this work was presented at the 2012 meeting of the United States and Canadian Academy of Pathology.

Conflict of interest

The authors declare that they have no conflict of interest.

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Authors and Affiliations

  1. Department of Pathology, Oregon Health and Science University, L471, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA

    Caroline M. F. Barrett, Megan L. Troxell & Donald C. Houghton

  2. Nephropath, Little Rock, AR, USA

    Christopher P. Larsen

  3. Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA

    Christopher P. Larsen

Authors
  1. Caroline M. F. Barrett
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  2. Megan L. Troxell
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  3. Christopher P. Larsen
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  4. Donald C. Houghton
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Corresponding author

Correspondence to Megan L. Troxell.

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Barrett, C.M.F., Troxell, M.L., Larsen, C.P. et al. Membranous glomerulonephritis with crescents. Int Urol Nephrol 46, 963–971 (2014). https://doi.org/10.1007/s11255-013-0593-x

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  • DOI: https://doi.org/10.1007/s11255-013-0593-x

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