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Three months before admission&#44; he was diagnosed as having AIP based on the findings of pancreatic tail enlargement&#44; irregular narrowing of the main pancreatic duct&#44; and infiltration of lymphocytes and IgG4-positive plasma cells&#44; together with storiform fibrosis by a pancreatic biopsy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; in accordance with the Japanese diagnostic criteria for AIP&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> He had been followed up without any medication&#46; He had no history of smoking&#46; His physical examination results were unremarkable except for a fever with a body temperature of 38&#46;0<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; Laboratory studies showed worsening of his renal function &#40;increased serum creatinine &#91;Cr&#93; level to 1&#46;77<span class="elsevierStyleHsp" style=""></span>mg&#47;dL from a baseline of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; proteinuria &#40;2&#46;07<span class="elsevierStyleHsp" style=""></span>g&#47;gCr&#41;&#44; hematuria &#40;30&#8211;49 red blood cells per high-power field&#41;&#44; and a C-reactive protein level of 30&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; His serological test results were positive for anti-GBM antibodies &#40;1500<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#41; but negative for anti-neutrophil cytoplasmic antibodies &#40;ANCAs&#41;&#46; Plain computed tomography revealed no signs of alveolar hemorrhage or acute pancreatitis&#46; Renal biopsy revealed 8 glomeruli&#44; all of which had a cellular crescent formation&#46; No signs of IgG4-related tubulointerstitial nephritis &#40;TIN&#41; were found&#46; Immunofluorescence microscopy revealed positive linear staining for IgG &#40;IgG1<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>IgG4&#41; and C3 along the GBM &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; On the basis of these findings&#44; the patient was diagnosed as having anti-GBM glomerulonephritis&#46; He received intravenous pulse methylprednisolone &#40;500<span class="elsevierStyleHsp" style=""></span>mg daily for 3 days&#41; followed by prednisolone &#40;30<span class="elsevierStyleHsp" style=""></span>mg daily&#41; and plasma exchange &#40;three times weekly for 25 occurrences&#41;&#46; Five months later&#44; his anti-GBM antibody level was undetectable&#44; so the prednisolone dosage was tapered to 5<span class="elsevierStyleHsp" style=""></span>mg daily with a stable serum Cr level of 2&#46;42<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; One year after treatment initiation&#44; his serum Cr level increased to 7&#46;40<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and he tested positive for anti-GBM antibodies &#40;681<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#41;&#46; He was diagnosed as having relapsed anti-GBM glomerulonephritis and underwent hemodialysis&#46; He was treated with intravenous pulse methylprednisolone followed by prednisolone and plasma exchange&#46; Nine weeks later&#44; his anti-GBM antibody level was successfully reduced to 8&#46;3<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#44; but he remained dialysis dependent&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">We report a rare case of relapsed anti-GBM glomerulonephritis complicated by AIP&#46; Our case highlights two important clinical issues&#58; anti-GBM glomerulonephritis can relapse after remission and can be complicated by IgG4-RD&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In typical anti-GBM disease&#44; the risk of relapse is thought to be quite low &#40;1&#46;2&#8211;2&#46;3&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a> Although a case of relapse triggered by smoking has been reported&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> our patient had no history of smoking&#46; Recently&#44; two atypical variants of anti-GBM disease have been reported&#46; One is anti-GBM disease with double seropositivity&#44; for ANCAs and anti-GBM antibodies&#44; with a relapse risk of 22&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The other variant is anti-GBM disease with a predominance of subclass IgG4&#44; with a relapse risk of 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> We ruled out these atypical types&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To our knowledge&#44; no previous reports have described cases of anti-GBM glomerulonephritis complicated by AIP&#46; One report described two cases of anti-GBM disease complicated by IgG4-related TIN&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Both cases presented with acute kidney injury and were diagnosed as anti-GBM glomerulonephritis and IgG4-related TIN based on the findings of seropositivity for anti-GBM antibodies and IgG linear deposition in the GBM and infiltration of IgG4-positive plasma cells by renal biopsy&#46; Both cases were serologically double-positive for anti-GBM antibodies and ANCAs&#44; and had a poor prognosis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is important to distinguish IgG4-RD from Castleman disease &#40;CD&#41; because both show plasma cell infiltration&#46; CD is characterized by lymph node proliferation and systemic inflammation&#46; A case series study reported three cases of anti-GBM disease complicated by CD&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> The authors detected plasma cells secreting anti-&#945;3&#40;IV&#41;NC1 antibodies in lymph nodes&#46; One of the three patients experienced a relapse&#46; Therefore&#44; they suggested a causal relationship between plasma cell infiltration and anti-GBM antibody production&#46; In our case&#44; plasma cell infiltration was observed in the pancreas&#59; therefore&#44; our patient may be at high risk of relapse and require careful follow-up&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; anti-GBM glomerulonephritis can be complicated by IgG4-RD and relapse after remission&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Compliance with ethical standards</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46; This research did not receive any specific grant from funding agencies&#46; All procedures performed were in accordance with the ethical standards of the institutional research committee &#40;IRB approval number&#58; 3-019068-00&#41; and with the Helsinki declaration&#46; Informed consent was obtained from the patient&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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Letter to the Editor
A case of relapsed anti-glomerular basement membrane glomerulonephritis complicated by IgG4-related disease
Un caso de glomerulonefritis recidivante de la membrana basal antiglomerular complicada por una enfermedad relacionada con la IgG4
Koki Abea,
Autor para correspondencia
a.abe@sapmed.ac.jp

Corresponding author.
, Yoshinosuke Shimamuraa, Keitaro Nishizawaa, Takuto Maedaa, Kei Yaneb, Toshiya Shinoharac, Yayoi Ogawad, Hideki Takizawaa
a Department of Nephrology, Teine Keijinkai Medical Center, Sapporo, Japan
b Department of Gastroenterology, Teine Keijinkai Medical Center, Sapporo, Japan
c Department of Pathology, Teine Keijinkai Medical Center, Sapporo, Japan
d Hokkaido Renal Pathology Center, Sapporo, Japan
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Three months before admission&#44; he was diagnosed as having AIP based on the findings of pancreatic tail enlargement&#44; irregular narrowing of the main pancreatic duct&#44; and infiltration of lymphocytes and IgG4-positive plasma cells&#44; together with storiform fibrosis by a pancreatic biopsy &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; in accordance with the Japanese diagnostic criteria for AIP&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> He had been followed up without any medication&#46; He had no history of smoking&#46; His physical examination results were unremarkable except for a fever with a body temperature of 38&#46;0<span class="elsevierStyleHsp" style=""></span>&#176;C&#46; Laboratory studies showed worsening of his renal function &#40;increased serum creatinine &#91;Cr&#93; level to 1&#46;77<span class="elsevierStyleHsp" style=""></span>mg&#47;dL from a baseline of 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#44; proteinuria &#40;2&#46;07<span class="elsevierStyleHsp" style=""></span>g&#47;gCr&#41;&#44; hematuria &#40;30&#8211;49 red blood cells per high-power field&#41;&#44; and a C-reactive protein level of 30&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; His serological test results were positive for anti-GBM antibodies &#40;1500<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#41; but negative for anti-neutrophil cytoplasmic antibodies &#40;ANCAs&#41;&#46; Plain computed tomography revealed no signs of alveolar hemorrhage or acute pancreatitis&#46; Renal biopsy revealed 8 glomeruli&#44; all of which had a cellular crescent formation&#46; No signs of IgG4-related tubulointerstitial nephritis &#40;TIN&#41; were found&#46; Immunofluorescence microscopy revealed positive linear staining for IgG &#40;IgG1<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>IgG4&#41; and C3 along the GBM &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; On the basis of these findings&#44; the patient was diagnosed as having anti-GBM glomerulonephritis&#46; He received intravenous pulse methylprednisolone &#40;500<span class="elsevierStyleHsp" style=""></span>mg daily for 3 days&#41; followed by prednisolone &#40;30<span class="elsevierStyleHsp" style=""></span>mg daily&#41; and plasma exchange &#40;three times weekly for 25 occurrences&#41;&#46; Five months later&#44; his anti-GBM antibody level was undetectable&#44; so the prednisolone dosage was tapered to 5<span class="elsevierStyleHsp" style=""></span>mg daily with a stable serum Cr level of 2&#46;42<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; One year after treatment initiation&#44; his serum Cr level increased to 7&#46;40<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and he tested positive for anti-GBM antibodies &#40;681<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#41;&#46; He was diagnosed as having relapsed anti-GBM glomerulonephritis and underwent hemodialysis&#46; He was treated with intravenous pulse methylprednisolone followed by prednisolone and plasma exchange&#46; Nine weeks later&#44; his anti-GBM antibody level was successfully reduced to 8&#46;3<span class="elsevierStyleHsp" style=""></span>U&#47;mL&#44; but he remained dialysis dependent&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">We report a rare case of relapsed anti-GBM glomerulonephritis complicated by AIP&#46; Our case highlights two important clinical issues&#58; anti-GBM glomerulonephritis can relapse after remission and can be complicated by IgG4-RD&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In typical anti-GBM disease&#44; the risk of relapse is thought to be quite low &#40;1&#46;2&#8211;2&#46;3&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a> Although a case of relapse triggered by smoking has been reported&#44;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a> our patient had no history of smoking&#46; Recently&#44; two atypical variants of anti-GBM disease have been reported&#46; One is anti-GBM disease with double seropositivity&#44; for ANCAs and anti-GBM antibodies&#44; with a relapse risk of 22&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> The other variant is anti-GBM disease with a predominance of subclass IgG4&#44; with a relapse risk of 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a> We ruled out these atypical types&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To our knowledge&#44; no previous reports have described cases of anti-GBM glomerulonephritis complicated by AIP&#46; One report described two cases of anti-GBM disease complicated by IgG4-related TIN&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> Both cases presented with acute kidney injury and were diagnosed as anti-GBM glomerulonephritis and IgG4-related TIN based on the findings of seropositivity for anti-GBM antibodies and IgG linear deposition in the GBM and infiltration of IgG4-positive plasma cells by renal biopsy&#46; Both cases were serologically double-positive for anti-GBM antibodies and ANCAs&#44; and had a poor prognosis&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">It is important to distinguish IgG4-RD from Castleman disease &#40;CD&#41; because both show plasma cell infiltration&#46; CD is characterized by lymph node proliferation and systemic inflammation&#46; A case series study reported three cases of anti-GBM disease complicated by CD&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> The authors detected plasma cells secreting anti-&#945;3&#40;IV&#41;NC1 antibodies in lymph nodes&#46; One of the three patients experienced a relapse&#46; Therefore&#44; they suggested a causal relationship between plasma cell infiltration and anti-GBM antibody production&#46; In our case&#44; plasma cell infiltration was observed in the pancreas&#59; therefore&#44; our patient may be at high risk of relapse and require careful follow-up&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; anti-GBM glomerulonephritis can be complicated by IgG4-RD and relapse after remission&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Compliance with ethical standards</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46; This research did not receive any specific grant from funding agencies&#46; All procedures performed were in accordance with the ethical standards of the institutional research committee &#40;IRB approval number&#58; 3-019068-00&#41; and with the Helsinki declaration&#46; Informed consent was obtained from the patient&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">None&#46;</p></span></span>"
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