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A case of triple pathology: seronegative anti-glomerular basement membrane antibody-mediated glomerulonephritis and membranous nephropathy in a patient with underlying diabetic kidney disease.

Tan SJ, Ducharlet K, Dwyer KM, Myers D, Langham RG, Hill PA - Clin Kidney J (2013)

Bottom Line: Strong linear GBM IgG-staining on biopsy with crescentic GN and clinical AKI led to a diagnosis of anti-GBM GN, although serum antibodies were not detectable.Features of DN, Kimmelstiel-Wilson nodules and albumin staining were also present, along with features of MN, such as subepithelial deposits on electron microscopy.Coexisting anti-GBM GN and MN is well recognized, but the concurrent diagnosis with DN has not been described.

View Article: PubMed Central - PubMed

Affiliation: Department of Nephrology , St Vincent's Hospital , Fitzroy, VIC , Australia.

ABSTRACT
In diabetic patients with acute kidney injury (AKI), kidney biopsy often reveals non-diabetic kidney pathology. This case describes a patient with known Type 1 diabetes who presented with AKI, nephrotic syndrome and haematuria. Combination pathology of seronegative anti-glomerular basement membrane antibody-mediated glomerulonephritis (anti-GBM GN), membranous nephropathy (MN) and diabetic nephropathy (DN) was demonstrated. Strong linear GBM IgG-staining on biopsy with crescentic GN and clinical AKI led to a diagnosis of anti-GBM GN, although serum antibodies were not detectable. Features of DN, Kimmelstiel-Wilson nodules and albumin staining were also present, along with features of MN, such as subepithelial deposits on electron microscopy. Despite treatment with immunosuppression and plasmapheresis, there was no recovery of kidney function. Coexisting anti-GBM GN and MN is well recognized, but the concurrent diagnosis with DN has not been described.

No MeSH data available.


Related in: MedlinePlus

(A) This glomerulus shows a Kimmelstiel–Wilson nodule (arrow). (B) This glomerulus shows a large cellular crescent (arrows). Periodic acid Silver stain. Original magnification ×400.
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SFT043F2: (A) This glomerulus shows a Kimmelstiel–Wilson nodule (arrow). (B) This glomerulus shows a large cellular crescent (arrows). Periodic acid Silver stain. Original magnification ×400.

Mentions: The kidney biopsy demonstrated a focal segmental necrotizing GN with cellular and fibrocellular crescents involving 29 of 40 glomeruli; another 6 glomeruli were sclerosed. Glomeruli had moderate nodular mesangial expansion and hypercellularity with several showing Kimmelstiel–Wilson nodules. Numerous tubular red blood cell casts were present. There was moderate interstitial fibrosis and tubular atrophy with a patchy interstitial mixed chronic inflammatory cell infiltrate (see Figures 1A and B and 2A and B). Immunofluorescence showed strong linear GBM staining for IgG. Weaker anti-albumin staining localized in a linear fashion to the GBM, Bowman's capsule (BC) and tubular basement membrane (TBM) staining (Figure 3A and B). Under oil immersion (×1000 magnification), a dual pattern of linear and granular glomerular peripheral capillary wall staining was seen. This was confirmed by confocal microscopy (Figure 4A–C). Electron microscopy showed Stage 1 MN with small subepithelial electron-dense ‘immune-type’ deposits with early GBM spike formation (Figure 5A and B). The overall diagnosis was that of anti-GBM GN and Stage 1 MN superimposed on Class III DN with Kimmelstiel–Wilson lesions.Fig. 1.


A case of triple pathology: seronegative anti-glomerular basement membrane antibody-mediated glomerulonephritis and membranous nephropathy in a patient with underlying diabetic kidney disease.

Tan SJ, Ducharlet K, Dwyer KM, Myers D, Langham RG, Hill PA - Clin Kidney J (2013)

(A) This glomerulus shows a Kimmelstiel–Wilson nodule (arrow). (B) This glomerulus shows a large cellular crescent (arrows). Periodic acid Silver stain. Original magnification ×400.
© Copyright Policy - creative-commons
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4400487&req=5

SFT043F2: (A) This glomerulus shows a Kimmelstiel–Wilson nodule (arrow). (B) This glomerulus shows a large cellular crescent (arrows). Periodic acid Silver stain. Original magnification ×400.
Mentions: The kidney biopsy demonstrated a focal segmental necrotizing GN with cellular and fibrocellular crescents involving 29 of 40 glomeruli; another 6 glomeruli were sclerosed. Glomeruli had moderate nodular mesangial expansion and hypercellularity with several showing Kimmelstiel–Wilson nodules. Numerous tubular red blood cell casts were present. There was moderate interstitial fibrosis and tubular atrophy with a patchy interstitial mixed chronic inflammatory cell infiltrate (see Figures 1A and B and 2A and B). Immunofluorescence showed strong linear GBM staining for IgG. Weaker anti-albumin staining localized in a linear fashion to the GBM, Bowman's capsule (BC) and tubular basement membrane (TBM) staining (Figure 3A and B). Under oil immersion (×1000 magnification), a dual pattern of linear and granular glomerular peripheral capillary wall staining was seen. This was confirmed by confocal microscopy (Figure 4A–C). Electron microscopy showed Stage 1 MN with small subepithelial electron-dense ‘immune-type’ deposits with early GBM spike formation (Figure 5A and B). The overall diagnosis was that of anti-GBM GN and Stage 1 MN superimposed on Class III DN with Kimmelstiel–Wilson lesions.Fig. 1.

Bottom Line: Strong linear GBM IgG-staining on biopsy with crescentic GN and clinical AKI led to a diagnosis of anti-GBM GN, although serum antibodies were not detectable.Features of DN, Kimmelstiel-Wilson nodules and albumin staining were also present, along with features of MN, such as subepithelial deposits on electron microscopy.Coexisting anti-GBM GN and MN is well recognized, but the concurrent diagnosis with DN has not been described.

View Article: PubMed Central - PubMed

Affiliation: Department of Nephrology , St Vincent's Hospital , Fitzroy, VIC , Australia.

ABSTRACT
In diabetic patients with acute kidney injury (AKI), kidney biopsy often reveals non-diabetic kidney pathology. This case describes a patient with known Type 1 diabetes who presented with AKI, nephrotic syndrome and haematuria. Combination pathology of seronegative anti-glomerular basement membrane antibody-mediated glomerulonephritis (anti-GBM GN), membranous nephropathy (MN) and diabetic nephropathy (DN) was demonstrated. Strong linear GBM IgG-staining on biopsy with crescentic GN and clinical AKI led to a diagnosis of anti-GBM GN, although serum antibodies were not detectable. Features of DN, Kimmelstiel-Wilson nodules and albumin staining were also present, along with features of MN, such as subepithelial deposits on electron microscopy. Despite treatment with immunosuppression and plasmapheresis, there was no recovery of kidney function. Coexisting anti-GBM GN and MN is well recognized, but the concurrent diagnosis with DN has not been described.

No MeSH data available.


Related in: MedlinePlus