Clinical Investigation

Kidney International (1974) 5, 57–71; doi:10.1038/ki.1974.7

Change from diffuse proliferative to membranous glomerulonephritis: Serial biopsies in four cases

Gabriel Richet1, Jean-Paul Fillastre1, Liliane Morel-Maroger1 and Jean Bariety1

1Unité de Recherche de Néphrologie Normale et Pathologique de l'INSERM (U 64), and Groupe de Recherches sur l'Hypertension artérielle de l'INSERM (U 28), Paris, France

Correspondence: Prof G Richet, Service de Néphrologie, Hôital Tenon, 4 rue de la Chine, 75970 Paris Cedex 20, France.

Received 9 July 1973; Revised 1 October 1973.

Top

Abstract

Change from diffuse proliferative to membranous glomerulonephritis: Serial biopsies in four cases. Serial renal biopsies (light microscopy and immunofluorescence) disclosed the transformation into membranous nephritis of four cases of diffuse proliferative glomerulonephritis (three exudative and one proliferative). In three of these cases electron microscopy was performed on deparaffinized light microscopic material. In two patients the glomerular basement membranes (GBM) on the initial specimens were regular and normal in every aspect. No spike-like expansions were revealed next to the base of the numerous subepithelial deposits. On the subsequent biopsy specimens spike-like expansions of GBM appeared. On the last biopsy, deposits were encircled between two layers of GBM. Such an unusual anatomical evolution could not be predicted initially on histological grounds. In one patient, early membranous changes were present in association with exudative lesions. In this patient one cannot exclude the presence of combined lesions from the very beginning of the disease instead of a transformation from proliferative to membranous glomerulonephritis. Clinical and biological features were initially those of acute glomerulonephritis. Later, the nephrotic syndrome appeared in three patients, subsiding after months in two and persisting in one. Findings in these patients provide yet another link between two types of human nephritis which have thus far been considered unrelated; moreover, the findings confirm the existence of a relationship between human nephritis and experimental glomerulonephritis, serum sickness types.

Transformation d'une glomerulonephrite diffuse proliferative en glomerulite extramembraneuse. Des biopsies sériées (en microscopie optique et immunofluorescence) ont montré la transformation de quatre cas de glomérulonéphrite (GN) proliférative diffuse (comprenant trois cas de GN exsudatives et un cas de GN proliférative) en glomérulite extramembraneuse. Dans trois cas sur les quatre, un examen en microscopie électronique a été effectué sur les tissus destinés à la microscopie optique, dé paraffinés. Initialement, dans deux cas, la membrane basale était normale et régulière, et les nombreux dépôts sous épithéliaux visibles n'étaient pas enchâssés par des expansions de la membrane basale. Sur les biopsies suivantes, des expansions de la membrane basale sont apparues entre les dépôts. Une telle évolution ne pouvait être prévue compte tenu de l'aspect de la GN à la fois en microscopie optique. Dans le troisième cas, en revanche, des expansions membranoïdes étaient précocément associées aux lésions dites exsudatives. Dans ce cas, il est difficile d'exclure une association de deux lésions différentes dès le début, plutôt qu'une transformation des lésions. Dans tous les cas, cliniquement et histologiquement, les symptômes étaient ceux d'une glomérulonéphrite aiguë. La protéinurie a persisté, assez importante dans trois cas pour provoquer un syndrome néphrotique qui régressé au bout de plusieurs mois. Ces cas montrent le lien entre deux groupes de glomérulonéphrites humaines jusqu'ici considérées comme totalement distinctes. En outre, il convient de rapprocher ces constatations de celles qui ont été faites dans les GN expérimentales de la maladie sérique.

Top

References

  1. Dixon FJ: The pathogenesis of glomerulonephritis, editorial. Am J Med 1968 44:493
  2. Dixon FJ: The role of antigen-antibody complexes in disease. Harvey Lect 58:21–63, 1962
  3. Germuth FG, Senterfit LB, Pollack AD: Immune complex disease : I. Experimental acute and chronic glomerulonephritis. Johns Hopkins Med J 120:225, 1967
  4. Freedman P, Meister MP, Co BS, Markowitz AS, Dubin A: The subclinical renal response to streptococcal infection. N Engl J Med 275:795, 1966
  5. Higgins PM, Abbott BA, James PM, Dillon S, Mac-Monagle PJ: Acute nephritis and streptococcal sore throat: A prospective study in general practice. Br Med J 2:1156, 1965
  6. Stetson CA, Rammelkamp CH Jr, Krause RM, Kohen RJ, Perry WD: Epidemic acute nephritis: Studies on etiology, natural history and prevention. Medicine (Baltimore) 34:431, 1955
  7. Kimmelstiel P, On Ja Kim, Beres J: Studies on renal biopsy specimens, with the aid of the electron microscope: II. Glomerulonephritis and glomerulosclerosis. Am J Clin Pathol 38:280, 1962
  8. Herdson PB, Jennings RB, Earle DP: Glomerular fine structure in post streptococcal acute glomerulonephritis. Arch Pathol 81:117, 1966
  9. Movat HZ, Steiner JW, Huhn D: The fine structure of the glomerulus in acute glomerulonephritis. J Lab Invest 11:117, 1962
  10. Hinglais N, de Montera H: Aspect ultrastructural de la paroi des capillaires glomerulaires au cours de six glomerulonéphrites aiguës. Pathol Biol 10:587, 1962
  11. Faith GC, Trump BF: The glomerular capillary wall in human kidney disease: Acute glomerulonephritis, systemic lupus erythematosus and preeclampsia, comparative electrom microscopic observations and a review. Lab Invest 15:1682, 1966 | PubMed |
  12. Andres GA, Accinni L, Hsu KC, Zabriskie JB, Segal BC: Electron microscopic studies of human glomerulonephritis with ferritin-conjugated antibody: Localization of antigen-antibody complexes in glomerular structures of patients with acute glomerulonephritis. J Exp Med 123:399, 1966 | Article | PubMed | ChemPort |
  13. Jennings RB, Earle DP: Post streptococcal glomerulonephritis: Histopathologic and clinical studies of the acute, subsiding acute, and early chronic latent phases. J Clin Invest 40:1525, 1961
  14. Lawrence JR, Pollak VE, Pirani CL, Kark RM: Histologic and clinical evidence of post streptococcal glomerulonephritis in patients with the nephrotic syndrome. Medicine (Baltimore) 42:1, 1963
  15. McCluskey RT, Baldwin DS: Natural history of acute glomerulonephritis. Am J Med 35:213, 1963
  16. Osawa G, Beres J, Kimmelstiel P: Glomerulonephritis: Observations by light and electron microscopy. Am J Clin Pathol 46:295, 1966
  17. Ehrenreitch T, Churg J: Pathology of membranous nephropathy, in Pathology Annual, edited by Sommers SC, New Tork, Appleton, 1969, pp. 145–186
  18. Rosen S: Membranous glomerulonephritis: Current status. Human Pathol 2:209, 1971
  19. Bariety J, Druet Ph, Lagrue G, Samarco P, Milliez P: Les glomérulopéthies "extramembraneuses": Etude morphologique en microscopie optique, électronique et en immunofluorescence. Pathol Biol 18:5, 1970
  20. Sugisaki T, Klassen J, Andres GA, Milgrom F, Mc-Cluskey RT: Passive transfer of Heymann nephritis with serum. Kidney Int 3:66, 1973 | PubMed |
  21. Alousi A, Post RS, Heymann W: Experimental autoimmune nephrosis in Rats : Morphogenesis of the glomerular lesion: Immunohistochemical and electron microscopic studies. Am J Pathol 54:47, 1969
  22. Berger J: Démembrement de la glomérulonéphrite membraneuse. Bull Soc Méd Hôp Paris 77:597, 1961
  23. Berger J, Galle P, Méry J Ph: Etude critique de la notion de glomérulonéphrite extramembraneuse, in Actualités Néphrologiques de l'Hôpital Necker 1963. Paris, Ed. méd. Flammarion, 1963, vol. 1, p. 193.
  24. Burkholder PM, Bradford WD: Proliferative glomerulonephritis in children. Am J Pathol 56:423, 1969
  25. Burkholder PM, Marchand A, Krueger RP: Mixed membranous and proliferative glomerulonephritis. Lab Invest 23:459, 1970
  26. Churg J: Pathology of glomerulonephritis. Bull NY Acad Med 46:761, 1970
  27. Churg J, Grishman E, Goldstein MH, Yunis SL, Porush JG: Idiopathic nephrotic syndrome in adults: A study and classification based on renal biopsies. N Engl J Med 272:165, 1965
  28. Forland M, Spargo BH: Clinicopathological correlations in idiopathic nephrotic syndrome with membranous nephropathy. Nephron 6:498, 1969.
  29. Pollak VE, Rosen S, Pirani CL, Muehrcke RC, Kark RM: Natural history of lipoid nephrosis and of membranous glomerulonephritis. Ann Intern Med 69:1171, 1968
  30. Heptinstall RM: Pathology of end stage kidney disease. Am J Med 44:656, 1968
  31. Chaptal J, Jean R, Habib R, Bonnet H, Pages A, Dumas R: Glomérulonéphrites post infectieuses de l'enfant : Confrontations anatomocliniques au cours de l'évolution. Arch Fr Pédiâtr 24:907, 1967
  32. Greifer I: Clinicopathology and natural history of acute glomerulonephritis, in Acute Glomerulonephritis, edited by Metcoff J, Boston, Little Brown and Co., 1967, vol. 1, p. 165
  33. Kushner DS, Armstrong SH Jr, Dubin A, Szanto PB, Markowitz A, Maduros BP, Levine JM, River GL, Gynn TN, Pendras JP: Acute glomerulonephritis in the adult: Longitudinal, clinical, functional and morphologic studies of rates of healing and progression to chronicity. Medicine (Baltimore) 40:203, 1961
  34. Liebermann E: Critical analysis of therapy of acute glomerulonephritis, exclusive of immunosuppressive drugs, in Acute Glomerulonephritis, edited by Metcoff J, Boston, Little Brown and Co., 1967, vol. 1, p. 371
  35. McCrory WW, Shibuya M: Acute glomerulonephritis in childhood: Long-term follow-up. NY State J Med 68:2416, 1968
  36. Roy S, Wall HP, Etteldore JN: Second attacks of acute glomerulonephritis. J Pediatr 75:758, 1969
  37. Royer P, Habib R, Corby C: Les glomérulonéphrites postinfectieuses de l'enfant, in Actualités Néphrologiques de l'Hôpital Necker 1965, Paris, Ed. méd. Flammarion, 1965, vol. 1, p. 207
  38. Salle B, Mamelle JC, Ladreyt JP: Etude évolutive des lésions histologiques au cours des glomérulonéphrites aiguës post infectieuses de l'enfant. Schweiz Med Wochenschr 98:917, 1968.
  39. Wasserman E, Treser G, Ehrenreich T, Ores R, Lange K: Glomerular changes in clinically healed acute glomerulonephritis: Correlation of light microscopy and immunohistology (abstract). Am Pediatr Soc April 1966, Atlantic City.
  40. Parrish AE, Watt MF, Howe JS: Membranous glomerulonephritis. Arch Intern Med 100:620, 1957
  41. Hayslett JP, Kashgarian M, Cook C, Spargo BH: The effect of azathioprine on lupus glomerulonephritis. Medicine (Baltimore) 51:393, 1972
  42. Arakawa M, Kimmelstiel P: The glomerulonephritis of acute serum sickness. Am J Clin Pathol 54:60, 1970
  43. Valdes AJ, Sonterfit LB, Pollack AD, Germuth FG: The effect of antigen excess on chronic immune glomerulonephritis. Johns Hopkins Med J 129:9, 1969

Extra navigation

.
ADVERTISEMENT