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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#44;</span></p><p class="elsevierStylePara">Anti-glomerular basement membrane &#40;GBM&#41; antibody disease accounts for 20&#37; of all rapidly progressive glomerulonephritis&#46;<span class="elsevierStyleSup">1</span> Occasionally it has been diagnosed in patients with normal renal functions and those patients have favorable renal prognosis&#46; Here&#44; we report a patient with anti-GBM antibody disease who presented with nephrotic range proteinuria&#44; normal renal function and lack of pulmonary symptoms&#46; Contrary to the previous data in literature&#59; he developed end stage renal disease &#40;ESRD&#41; within three years despite appropriate treatment&#46;</p><p class="elsevierStylePara">A 23-years-old non-smoker university student male patient presented with minimal bilateral edema in lower extremities that was present for two weeks&#46; He had no gross hematuria&#44; hemoptysis or other pulmonary symptoms&#46; His past medical history was unremarkable&#46; Laboratory evaluation revealed 7200mg&#47;day proteinuria with normal renal functions &#40;serum creatinine&#58; 1mg&#47;dL&#41;&#46; Serum albumin level was 4g&#47;dL&#46; Urinalysis showed 3&#43; proteinuria with microscopic hematuria&#46; Anti-nuclear and anti-double-stranded DNA antibodies&#44; HIV&#44; hepatitis B and hepatitis C serologies were negative&#46; Complement levels were normal&#46; Renal ultrasonography was normal&#46; Renal biopsy was consistent with anti-GBM antibody disease with diffuse linear IgG staining along the GBM&#44; diffuse endocapillary proliferation and cellular&#47;fibrocellular crescent formation in 40&#37; of glomeruli &#40;Figure 1&#41;&#46; Numerous glomeruli showed segmental scarring&#46; As soon as the diagnosis was confirmed with positive anti-GBM antibody in serum&#44; plasmapheresis and immunosuppressive treatment was started&#46; Fourteen plasmapheresis sessions were performed until antibodies disappeared&#46; After three days of intravenous pulse methylprednisolone treatment &#40;500mg&#47;day&#41;&#44; he was maintained on oral prednisolone &#40;started with 1mg&#47;kg&#47;day and tapered slowly&#41; and monthly intravenous 750mg cyclophosphamide infusions&#46; After twelve intravenous cyclophosphamide treatments&#44; serum creatinine was 1&#46;3mg&#47;dL&#44; albumin was 3&#46;1g&#47;dL and 24-h protein excretion was 4g&#47;day&#46; Thereafter he was maintained on low dose prednisolone &#40;5mg&#47;day&#41; and azathioprine &#40;100mg&#47;day&#41; combination&#46; However under this treatment his renal functions deteriorated and a second biopsy had to be performed after 18 months when creatinine level increased to 2mg&#47;dL and proteinuria to 6g&#47;day&#46; Although serum anti-GBM antibody and ANCA were negative at that time&#44; histomorphologic examination demonstrated ongoing active disease with crescents&#44; linear immunofluorescent staining for IgG on GBM&#8217;s and significant chronic injury &#40;Figure 2&#41;&#46; Pulse methylprednisolone followed by oral prednisolone&#44; cyclosporine and mycophenolate mofetil could not prevent further deterioration of renal functions&#46; Furthermore he suffered from a herpes-zoster infection and had to struggle with intracranial abscess caused by actinomyces&#46; Immunosuppressive treatment was stopped and regular hemodialysis treatment was started on the 27<span class="elsevierStyleSup">th</span> month after first diagnosis&#46;</p><p class="elsevierStylePara">This patient with anti-GBM antibody disease presented with nephrotic range proteinuria with normal renal functions&#46; In spite of normal renal function at presentation&#44; ESRD could not be prevented with intensive treatment&#46;</p><p class="elsevierStylePara">The first interesting point about the patient is the clinical and laboratory data at the time of diagnosis&#46; He had an unusual presentation with normal renal function and absence of pulmonary symptoms&#44; and the indication of the renal biopsy was nephrotic range proteinuria&#46; Isolated nephrotic syndrome is not a classical feature of anti-GBM antibody disease although it may occasionally accompany disturbed renal function&#46; The cause of nephrotic syndrome in these patients may be a co-existing glomerulopathy which is membranous glomerulonephritis in most of the cases&#46;<span class="elsevierStyleSup">2</span> Minimal change disease&#44;<span class="elsevierStyleSup">3</span> IgA nephropathy<span class="elsevierStyleSup">4</span> or membranoproliferative glomerulonephritis<span class="elsevierStyleSup">5</span> may also be associated with anti-GBM antibody disease&#46; There was no accompanying glomerular pathology in this patient based on light microscopic and immunofluorescence studies&#46; Although electron microscopy could not be performed&#44; unresponsiveness of the proteinuria to the steroid and cyclophosphamide decreases the possibility of accompanying minimal change disease&#46;</p><p class="elsevierStylePara">Another interesting point of this case is the progressive course of the disease despite normal renal function at the beginning&#46; It is known that prognosis of this disease is intimately dependent on the initial creatinine level&#46;<span class="elsevierStyleSup">6</span> Patients with anti-GBM antibody disease with normal renal function at presentation uniformly showed good renal prognosis&#46;<span class="elsevierStyleSup">7</span> This patient had progressive deterioration in renal functions despite intensive immunosuppressive treatment&#46;</p><p class="elsevierStylePara">Unusual presentation and course in this patient is difficult to explain&#46; Several hypotheses have been proposed for atypical presentations in anti-GBM antibody disease&#46; The disease is classically characterized by circulating autoantibodies against non-collageneous domain of alpha-3 chain of type-IV collagen&#46;<span class="elsevierStyleSup">8</span> It has been suggested that presence of antibodies against non-collagenous domains of alpha-1 and alpha-4 chains of type-IV collagen may result in differing presentations of anti-GBM antibody disease&#46;<span class="elsevierStyleSup">9</span> Another possible mechanism to explain the atypical presentation of anti-GBM antibody disease is involvement by the different IgG subclasses&#46; It was shown that anti-GBM antibody is most likely IgG1 or IgG4&#44; and only IgG1 can activate complement&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">In conclusion anti-GBM antibody disease may present with normal renal functions and nephrotic range proteinuria and appropriate treatment may not prevent ESRD in these patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12580&#95;19904&#95;58355&#95;en&#95;12580&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="12580_19904_58355_en_12580_f1.jpg" alt="First renal biopsy from the patient&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; First renal biopsy from the patient&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12580&#95;19904&#95;58356&#95;en&#95;12580&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="12580_19904_58356_en_12580_f2.jpg" alt="Second kidney biopsy from the patient&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Second kidney biopsy from the patient&#46;</p>"
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An atypical case of anti-GBM antibody disease with renal function deterioration from normal to end stage renal disease
Tolga Yildirima, Dilek Ertoy-Baydarb, Ercan Turkmena, Rahmi Yilmaza, Yunus Erdema
a Department of Nephrology, Faculty of Medicine. Hacettepe University, Ankara, Turkey,
b Department of Pathology, Faculty of Medicine. Hacettepe University, Ankara, Turkey,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#44;</span></p><p class="elsevierStylePara">Anti-glomerular basement membrane &#40;GBM&#41; antibody disease accounts for 20&#37; of all rapidly progressive glomerulonephritis&#46;<span class="elsevierStyleSup">1</span> Occasionally it has been diagnosed in patients with normal renal functions and those patients have favorable renal prognosis&#46; Here&#44; we report a patient with anti-GBM antibody disease who presented with nephrotic range proteinuria&#44; normal renal function and lack of pulmonary symptoms&#46; Contrary to the previous data in literature&#59; he developed end stage renal disease &#40;ESRD&#41; within three years despite appropriate treatment&#46;</p><p class="elsevierStylePara">A 23-years-old non-smoker university student male patient presented with minimal bilateral edema in lower extremities that was present for two weeks&#46; He had no gross hematuria&#44; hemoptysis or other pulmonary symptoms&#46; His past medical history was unremarkable&#46; Laboratory evaluation revealed 7200mg&#47;day proteinuria with normal renal functions &#40;serum creatinine&#58; 1mg&#47;dL&#41;&#46; Serum albumin level was 4g&#47;dL&#46; Urinalysis showed 3&#43; proteinuria with microscopic hematuria&#46; Anti-nuclear and anti-double-stranded DNA antibodies&#44; HIV&#44; hepatitis B and hepatitis C serologies were negative&#46; Complement levels were normal&#46; Renal ultrasonography was normal&#46; Renal biopsy was consistent with anti-GBM antibody disease with diffuse linear IgG staining along the GBM&#44; diffuse endocapillary proliferation and cellular&#47;fibrocellular crescent formation in 40&#37; of glomeruli &#40;Figure 1&#41;&#46; Numerous glomeruli showed segmental scarring&#46; As soon as the diagnosis was confirmed with positive anti-GBM antibody in serum&#44; plasmapheresis and immunosuppressive treatment was started&#46; Fourteen plasmapheresis sessions were performed until antibodies disappeared&#46; After three days of intravenous pulse methylprednisolone treatment &#40;500mg&#47;day&#41;&#44; he was maintained on oral prednisolone &#40;started with 1mg&#47;kg&#47;day and tapered slowly&#41; and monthly intravenous 750mg cyclophosphamide infusions&#46; After twelve intravenous cyclophosphamide treatments&#44; serum creatinine was 1&#46;3mg&#47;dL&#44; albumin was 3&#46;1g&#47;dL and 24-h protein excretion was 4g&#47;day&#46; Thereafter he was maintained on low dose prednisolone &#40;5mg&#47;day&#41; and azathioprine &#40;100mg&#47;day&#41; combination&#46; However under this treatment his renal functions deteriorated and a second biopsy had to be performed after 18 months when creatinine level increased to 2mg&#47;dL and proteinuria to 6g&#47;day&#46; Although serum anti-GBM antibody and ANCA were negative at that time&#44; histomorphologic examination demonstrated ongoing active disease with crescents&#44; linear immunofluorescent staining for IgG on GBM&#8217;s and significant chronic injury &#40;Figure 2&#41;&#46; Pulse methylprednisolone followed by oral prednisolone&#44; cyclosporine and mycophenolate mofetil could not prevent further deterioration of renal functions&#46; Furthermore he suffered from a herpes-zoster infection and had to struggle with intracranial abscess caused by actinomyces&#46; Immunosuppressive treatment was stopped and regular hemodialysis treatment was started on the 27<span class="elsevierStyleSup">th</span> month after first diagnosis&#46;</p><p class="elsevierStylePara">This patient with anti-GBM antibody disease presented with nephrotic range proteinuria with normal renal functions&#46; In spite of normal renal function at presentation&#44; ESRD could not be prevented with intensive treatment&#46;</p><p class="elsevierStylePara">The first interesting point about the patient is the clinical and laboratory data at the time of diagnosis&#46; He had an unusual presentation with normal renal function and absence of pulmonary symptoms&#44; and the indication of the renal biopsy was nephrotic range proteinuria&#46; Isolated nephrotic syndrome is not a classical feature of anti-GBM antibody disease although it may occasionally accompany disturbed renal function&#46; The cause of nephrotic syndrome in these patients may be a co-existing glomerulopathy which is membranous glomerulonephritis in most of the cases&#46;<span class="elsevierStyleSup">2</span> Minimal change disease&#44;<span class="elsevierStyleSup">3</span> IgA nephropathy<span class="elsevierStyleSup">4</span> or membranoproliferative glomerulonephritis<span class="elsevierStyleSup">5</span> may also be associated with anti-GBM antibody disease&#46; There was no accompanying glomerular pathology in this patient based on light microscopic and immunofluorescence studies&#46; Although electron microscopy could not be performed&#44; unresponsiveness of the proteinuria to the steroid and cyclophosphamide decreases the possibility of accompanying minimal change disease&#46;</p><p class="elsevierStylePara">Another interesting point of this case is the progressive course of the disease despite normal renal function at the beginning&#46; It is known that prognosis of this disease is intimately dependent on the initial creatinine level&#46;<span class="elsevierStyleSup">6</span> Patients with anti-GBM antibody disease with normal renal function at presentation uniformly showed good renal prognosis&#46;<span class="elsevierStyleSup">7</span> This patient had progressive deterioration in renal functions despite intensive immunosuppressive treatment&#46;</p><p class="elsevierStylePara">Unusual presentation and course in this patient is difficult to explain&#46; Several hypotheses have been proposed for atypical presentations in anti-GBM antibody disease&#46; The disease is classically characterized by circulating autoantibodies against non-collageneous domain of alpha-3 chain of type-IV collagen&#46;<span class="elsevierStyleSup">8</span> It has been suggested that presence of antibodies against non-collagenous domains of alpha-1 and alpha-4 chains of type-IV collagen may result in differing presentations of anti-GBM antibody disease&#46;<span class="elsevierStyleSup">9</span> Another possible mechanism to explain the atypical presentation of anti-GBM antibody disease is involvement by the different IgG subclasses&#46; It was shown that anti-GBM antibody is most likely IgG1 or IgG4&#44; and only IgG1 can activate complement&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">In conclusion anti-GBM antibody disease may present with normal renal functions and nephrotic range proteinuria and appropriate treatment may not prevent ESRD in these patients&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12580&#95;19904&#95;58355&#95;en&#95;12580&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="12580_19904_58355_en_12580_f1.jpg" alt="First renal biopsy from the patient&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; First renal biopsy from the patient&#46;</p><p class="elsevierStylePara"><a href="grande&#47;12580&#95;19904&#95;58356&#95;en&#95;12580&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="12580_19904_58356_en_12580_f2.jpg" alt="Second kidney biopsy from the patient&#46;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Second kidney biopsy from the patient&#46;</p>"
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