Membranous and crescentic glomerulonephritis in a patient with anti-nuclear and anti-neutrophil cytoplasmic antibodies

Chang, Anthony; Aneziokoro, O.; Meehan, Shane M.; Quigg, Richard J.

doi:10.1038/sj.ki.5001957

Cited by 12 publications

(10 citation statements)

References 31 publications

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“…[9] Chang et al reported membranous nephropathy and crescentic glomerulonephritis association in a patient with positive antinuclear antibody and ANCA. [10] Our case differs from these case presentations due to an absence of anti-GBM and all other auto antibodies during the first and second renal biopsies. In the last case, reported by Hall et al in 1986, crescentic transformation was observed approximate 1.5 years after MN diagnosis, and a nearly complete response to oral prednisolone and oral cyclophosphamide treatment was emphasized.…”

contrasting

confidence: 46%

A Rare Complication of Idiopathic Membranous Nephropathy: Crescentic Transformation

et al. 2008

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Introduction. In this study, the cause of rapidly deteriorating renal functions in a follow-up period of a 65-year-old female patient, who applied with nephrotic syndrome findings and diagnosed as membranous nephropathy, is presented. Case report. A 65-year-old patient with findings of nephrotic syndrome had normal kidney size and serum complement level, and was negative for autoantibodies and viral serology. In histopathologic examination, 20 glomeruli were consistent with membranous glomerulonephritis. The patient, evaluated for idiopathic membranous nephropathy, was followed-up monthly with supportive treatment. In the second month of follow-up, a re-evaluation of the patient due to nausea and urine discoloration revealed 144 mg/dL urea, 6.3 mg/dL creatinine, and 2.5 g/dL albumin. Urine sediment revealed dysmorphic erythrocytes and granular silenders. Renal re-biopsy was done. Of 11 glomeruli, three global sclerosis and eight crescentic glomeruli with fibrosis and scarce cellular component were seen. The case was accepted as crescentic glomerulonephritis, a rare complication of idiopathic MN. Before the treatment, antiGBM, pANCA, cANCA, and ANA were negative. Pulse metil prednisolone and pulse cyclophosphamide treatment protocol was administered. Hemodialysis was needed nine times.At the end of first month of the treatment, hemodialysis was no longer needed. Conclusion. Due to a risk of spontaneous remission up to 30% of membranous nephropathy, there is no consensus on specific treatment applicable to all cases. However, crescentic GN should be investigated immediately when sudden and rapid deterioration of renal functions appeared.

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confidence: 46%

A Rare Complication of Idiopathic Membranous Nephropathy: Crescentic Transformation

et al. 2008

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“…The pathogenesis of this non-immunoglobulinmediated lesion is unknown, but the patients with lupus GN, who are ANCA positive and have an identical glomerular lesion as the ANCA-negative segmental GN cases, 8,9,[32][33][34] support the notion that lupus GN with crescents may occur by a non-immune aggregate-mediated mechanism. Furthermore, the patients with pauci-immune vasculitis who are ANCA-negative show that glomerular vasculitic pathology may be caused by a non-ANCA mechanism, 35 and a similar mechanism may be operating in ANCA negative SLE patients with focal segmental necrotising GN.…”

Section: Discussionmentioning

confidence: 89%

Evidence of concurrent immunopathological mechanisms determining the pathology of severe lupus nephritis

Katz

et al. 2009

Lupus

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The purpose of this study is to determine whether two distinct histopathological-immunopathological lesions, which have been reported in severe lupus nephritis, diffuse global glomerulonephritis (GN) (WHO IV) and a segmental and necrotising GN (WHO III) can be reported to coexist in a single patient. We examine the evidence of coexistence of these disparate lesions and the prognostic significance in a group of patients with severe lupus nephritis who have been subjected to a common therapeutic regimen by protocol. The simple, reproducible parameter indicating the presence of glomerular capillary necrosis was the presence of crescents. We, therefore, reviewed 39 renal biopsies with diffuse global lupus GN (WHO IV) (Churg, J, Sobin, LH. Lupus nephritis. Renal disease, classification and atlas of glomerular diseases. New York: Igaku-Shoin; 1982. p. 127-149). and used crescents as a surrogate for glomerular necrosis. Peripheral capillary immune deposits were less prominent in WHO IV with crescents compared with those without and resembled the reduced immune deposits seen in severe segmental GN (WHO III >or= 50%). Patients with WHO IV with crescents had decreased survival without end-stage renal disease (P = 0.02), fewer remissions (P = 0.04) and more adverse outcomes (12/22 vs 3/17) (P = 0.02) than those without crescents, and this was similar to patients with WHO III >or=50%. We conclude that, on the basis of immunological and morphological features, WHO IV with crescents appears to be the result of two distinct pathogenetic mechanisms. We propose that diffuse global lupus GN, associated with crescents, is best described as WHO class IV + WHO class III.

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“…For example, although smaller studies have suggested that several histopathologic features are associated with worse outcomes in i-MN [4,5,6,7,8,9,10,11,12], a large, collaborative study from Toronto found that pathology did not influence outcomes [13]. The literature contains similar discrepancies regarding the prognostic importance of clinical and laboratory parameters.…”

Section: Introductionmentioning

confidence: 87%

“…Several studies have suggested various histopathologic features on renal biopsy at diagnosis to be associated with a worse renal outcome [4,5,6,7,8,9,10,11,12]. Histopathologic findings that have been reported as meaningful predictors of outcome in i-MN include glomerular scarring and severity of tubulointerstitial disease.…”

Section: Discussionmentioning

confidence: 99%

Idiopathic Membranous Nephropathy: Clinical and Histologic Prognostic Features and Treatment Patterns over Time at a Tertiary Referral Center

Sprangers¹,

Bomback²,

Cohen³

et al. 2012

Am J Nephrol

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Background: Idiopathic membranous nephropathy (i-MN) is a leading cause of nephrotic syndrome in adults and results in end-stage renal disease in approximately one third of patients. There are few large, long-term US studies evaluating clinical and histologic prognostic factors in i-MN. Methods: We describe 132 patients with biopsy-proven i-MN who were followed for a mean period of 68 months at our tertiary referral center from 1977 to 2009, and we analyzed clinical and histologic features that predicted renal outcomes. Results: The presence of hypertension and treating physician’s decision to institute immunosuppression were negative predictors of attaining complete or partial remission. Among clinical variables, impaired renal function (eGFR <60 ml/min/1.73 m²) at time of presentation was the only variable at presentation associated with an increased risk of reaching end-stage renal disease. The use of statins and RAAS blockers were protective. The choice of corticosteroids as the initial immunosuppressive agent by referring physicians decreased over time but even in the most recent era (2000–2008) was significant (33%). Conclusion: Renal function at presentation and non-white race were the main predictors of a worse renal outcome. Corticosteroid therapy is still being adopted as first-line therapy in a significant number of patients in this era. The development of guidelines may help clarify the treatment strategies of i-MN.

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Membranous and crescentic glomerulonephritis in a patient with anti-nuclear and anti-neutrophil cytoplasmic antibodies

Cited by 12 publications

References 31 publications

A Rare Complication of Idiopathic Membranous Nephropathy: Crescentic Transformation

A Rare Complication of Idiopathic Membranous Nephropathy: Crescentic Transformation

Evidence of concurrent immunopathological mechanisms determining the pathology of severe lupus nephritis

Idiopathic Membranous Nephropathy: Clinical and Histologic Prognostic Features and Treatment Patterns over Time at a Tertiary Referral Center

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