Acute Glomerulonephritis Immunofluorescent and Electron-microscopic Observations in Sporadic Cases ASUMAN U . M U F T U O G L U , M . D . , TtJRKAN ERBENGI, P H . D . , M. HARMANCI, M . D . , T. KARAYEL, M.D.,
E. G U R S O Y , P H . D . , AND M. T A H S I N O G L U ,
M.D.
Department of Medicine, Cerrahpasa Faculty of Medicine, Department of Histology and Embryology, U.I. Faculty of Medicine, Department of Pathology, Faculty of Dentistry of the University of Istanbul, Istanbul, Turkey
ABSTRACT
T w o TYPES of immunologically mediated renal disease have been recognized in experimental animals. T h e first is caused by deposition of circulating immune complexes on the glomerular basement membrane. T h e second is caused by antibodies
directed against the glomerular basement membrane. 3,24 On the basis of correlating the immunofluorescent and ultrastructural findings in man with those in experimental animals, glomerular disease characterized by subepithelial granular deposits of immunoglobulins and complement has
Received May 13, 1974; received revised manu-
OclobeTrS" ^ ' ^
aCCCPted
^
pubHcati n
°
been
considered
an
immune-COmplex
disease, and continuous linear staining for
Address reprint requests to Prof. Asuman U. Muftuoglu If Hastaliklari Klinigi, Cerrahpasa Hastanesi, Aksaray, Istanbul, Turkey.
Supported by the Scientific and Technical Council
of Turkey (TAG-141). A preliminary report was presented at the Fourth Congress of the Scientific and Technical Council of Turkey, Ankara, Turkey, November 5 - 8 , 1973. 300
immunoglobulins a n d c o m p l e m e n t has as d i a g n o s t i c o f a n d a c c e p t e d r °
b e e n
glomerular basement membrane (GBM)
disease. L u p u s nephritis,12,13,19 malarial _ _• »v i s «. .. _ • • nephropathy,1,8 poststreptococcal glomer2,9,11,15,17,22 ulonephritis, glomerulonephri-
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Miiftiioglu, Asuman U., Erbengi, Tiirkan, Harmanci, M., Karayel, T., Gursoy, E., and Tahsinoglu, M.: Acute glomerulonephritis. Immunofluorescent and electron-microscopic observations in sporadic cases. Am J Clin Pathol 63: 300-309, 1975. The authors studied by immunofluorescent and electron microscopy renal biopsy specimens from 29 patients with various glomerular diseases. Poststreptococcal glomerulonephritis was characterized by the presence of complement (/^C) in the mesangium and/or on the basement membrane in all cases. Immunoglobulin G (IgG) was also present in less than half of the cases in the same distribution. Electron microscopy, carried out in six cases, revealed no uniform ultrastructural change: minimal subepithelial deposits were observed in three cases, intramembranous deposits were seen in two cases, and the basement membrane was normal in one case. Glomerular abnormalities during the courses of some systemic diseases were similar. Mild renal involvement was characterized by only /JjC deposition. This finding raises the question whether a mechanism other than or in addition to that involving immune complexes is operative in the pathogenesis of acute glomerulonephritis. There is circumstantial experimental evidence that an alternate pathway of complement activation and deposition may be operative in acute glomerulonephritis. (Key words: Glomerulonephritis; Immunopathology; Electron microscopy.)
March 1975
301
ACUTE GLOMERULONEPHRITIS
Patients and Methods Of the 29 cases, 20 were classified as acute poststreptococcal glomerulonephritis by clinical and laboratory findings. Nine patients were studied because they had either symptoms and signs of glomerulonephritis or urinary abnormalities only during the courses of other diseases (Table 1). Percutaneous renal biopsies were performed with the Vim-Silverman biopsy needle modified by Franklin. The specimen for immunofluorescence microscopy was quick-frozen and cut in a Pearse-type cryostat to a 6-micron thickness. Sections were stained with fluorescein-labelled antisera, anti-IgG, anti-IgA, anti-IgM, and anti-/3jC purchased from BehringwerkeHoechst. Sections were viewed in a Zeiss fluorescent microscope. For electron microscopy, renal tissue was fixed in 1% osmium tetroxide buffered with Veronal acetate for one hour at 4 C., dehydrated, and embedded in Vestopal-W. Sections were cut on a PorterBlum (Sorwall) microtome, stained with uranyl acetate, and viewed in a Zeiss EM and EM 92S electron microscope.
Table 1. Clinical Classification of 29 Cases of Glomerulonephritis Clinical Diagnosis Acute poststreptococcal glomerulonephritis Miscellaneous Allergic purpura Sjogren's syndrome Systemic lupus erythematosus Hodgkin's disease Au-positive hepatitis TOTAL
Number of Cases
20 4 1 2 1 1 29
Results Acute Poststreptococcal Glomerulonephritis (Table 2) Light Microscopy. Of the 20 cases of acute poststreptococcal glomerulonephritis, six were considered trace acute glomerulonephritis (AGN) (minimal focal cellular proliferation), eight were considered 1 + AGN (diffuse endothelial and mesangial cell proliferation with capillary loop narrowing), two were considered 2+ AGN (1+ AGN with additional significant polymorphonuclear leukocyte infiltration), one was considered 3 + AGN (cellular proliferation, polymorphonuclear leukocyte infiltration and hypersegmentation of the glomeruli), and two were considered 4 + AGN (3+ with additional generalized glomerular swelling4). Immunofluorescent Microscopy. By immunofluorescent microscopy /3,C was seen in a finely granular or interrupted linear distribution along segments of the glomerular basement membrane and the mesangium in all cases. In eight cases immunoglobulin G (IgG) was also found deposited in a finely granular or interrupted linear fashion on the basement membrane and the mesangium (Fig. 1). No deposition of IgA or IgM was found. Electron Microscopy. Electron microscopic studies were performed in six cases. There
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
tis associated with other bacterial infections, 10,23 and glomerular diseases of unknown etiology, such as membranous nephropathy, 6 have been taken to be examples of immune-complex disease, whereas Goodpasture's syndrome has been the only true example of anti-GBM disease in man. 5,20 ' 21 We studied renal biopsy specimens from 29 patients who had glomerular disease by immunofluorescence and electron microscopy. The patients we studied encompassed a wide spectrum of glomerular diseases, from asymptomatic urinary findings during the course of other diseases to severe forms of glomerulonephritis. Our purpose was to correlate the immunofluorescent and electron microscopic findings with the renal histopathology.
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MUFTUOGLU ET Ah.
A.J.C.P.—Vol.
63
FIG. 2 (right). Patient 8. Granular deposition of IgG on the glomerular basement membrane and the mesangium in poststreptococcal glomerulonephritis. Immunofluorescent microscopy. x600.
was no uniform ultrastructural change of the basement membrane in these cases. The basement membrane was normal in one patient (Patient 7) who had trace AGN by light microscopy and only ^ C deposits by fluorescent microscopy. Thickening of the basement membrane was seen in two cases (Patients 16 and 20). Amorphic electron-dense deposits formed an irregular, interrupted line facing the foot processes or the epithelial cells in the thickened segments. There was also increased density in the foot processes near the basement membrane. These patients had mild AGN by light microscopy but granular deposits of IgG and /3iC were observed by fluorescence microscopy. Three patients (4, 8, and 9) had minimal segmental subepithelial deposits. These patients had 1+ and 2 +
AGN by light microscopy and minimal granular IgG and fi^C deposition on the basement membrane (Figs. 2 and 3). Glomerular Disease in the Courses of Systemic Diseases (Table 3) Light Microscopy. Four cases of allergic purpura were included in this series. Patient 21 had normal histology, Patient 22 had 1 + AGN, and Patients 23 and 24 had trace AGN. The patient who had Sjogren's syndrome had some proliferative changes and segmental thickening of the basement membrane, considered to be nondiagnostic. One patient (26) who had systemic lupus erythematosus had typical lupus nephritis, and the other (27) had glomerular changes of AGN 1 + . One patient with
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
FIG. 1 (left). Patient 20. Granular deposition of IgG on the glomerular basement membrane and the mesangium in poststreptococcal glomerulonephritis. Immunofluorescent microscopy. x400.
March 1975
303
ACUTE GLOMERULONEPHRITIS
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•'•,
\
E. G U R S O Y , P H . D . , AND M. T A H S I N O G L U ,
M.D.
Department of Medicine, Cerrahpasa Faculty of Medicine, Department of Histology and Embryology, U.I. Faculty of Medicine, Department of Pathology, Faculty of Dentistry of the University of Istanbul, Istanbul, Turkey
ABSTRACT
T w o TYPES of immunologically mediated renal disease have been recognized in experimental animals. T h e first is caused by deposition of circulating immune complexes on the glomerular basement membrane. T h e second is caused by antibodies
directed against the glomerular basement membrane. 3,24 On the basis of correlating the immunofluorescent and ultrastructural findings in man with those in experimental animals, glomerular disease characterized by subepithelial granular deposits of immunoglobulins and complement has
Received May 13, 1974; received revised manu-
OclobeTrS" ^ ' ^
aCCCPted
^
pubHcati n
°
been
considered
an
immune-COmplex
disease, and continuous linear staining for
Address reprint requests to Prof. Asuman U. Muftuoglu If Hastaliklari Klinigi, Cerrahpasa Hastanesi, Aksaray, Istanbul, Turkey.
Supported by the Scientific and Technical Council
of Turkey (TAG-141). A preliminary report was presented at the Fourth Congress of the Scientific and Technical Council of Turkey, Ankara, Turkey, November 5 - 8 , 1973. 300
immunoglobulins a n d c o m p l e m e n t has as d i a g n o s t i c o f a n d a c c e p t e d r °
b e e n
glomerular basement membrane (GBM)
disease. L u p u s nephritis,12,13,19 malarial _ _• »v i s «. .. _ • • nephropathy,1,8 poststreptococcal glomer2,9,11,15,17,22 ulonephritis, glomerulonephri-
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
Miiftiioglu, Asuman U., Erbengi, Tiirkan, Harmanci, M., Karayel, T., Gursoy, E., and Tahsinoglu, M.: Acute glomerulonephritis. Immunofluorescent and electron-microscopic observations in sporadic cases. Am J Clin Pathol 63: 300-309, 1975. The authors studied by immunofluorescent and electron microscopy renal biopsy specimens from 29 patients with various glomerular diseases. Poststreptococcal glomerulonephritis was characterized by the presence of complement (/^C) in the mesangium and/or on the basement membrane in all cases. Immunoglobulin G (IgG) was also present in less than half of the cases in the same distribution. Electron microscopy, carried out in six cases, revealed no uniform ultrastructural change: minimal subepithelial deposits were observed in three cases, intramembranous deposits were seen in two cases, and the basement membrane was normal in one case. Glomerular abnormalities during the courses of some systemic diseases were similar. Mild renal involvement was characterized by only /JjC deposition. This finding raises the question whether a mechanism other than or in addition to that involving immune complexes is operative in the pathogenesis of acute glomerulonephritis. There is circumstantial experimental evidence that an alternate pathway of complement activation and deposition may be operative in acute glomerulonephritis. (Key words: Glomerulonephritis; Immunopathology; Electron microscopy.)
March 1975
301
ACUTE GLOMERULONEPHRITIS
Patients and Methods Of the 29 cases, 20 were classified as acute poststreptococcal glomerulonephritis by clinical and laboratory findings. Nine patients were studied because they had either symptoms and signs of glomerulonephritis or urinary abnormalities only during the courses of other diseases (Table 1). Percutaneous renal biopsies were performed with the Vim-Silverman biopsy needle modified by Franklin. The specimen for immunofluorescence microscopy was quick-frozen and cut in a Pearse-type cryostat to a 6-micron thickness. Sections were stained with fluorescein-labelled antisera, anti-IgG, anti-IgA, anti-IgM, and anti-/3jC purchased from BehringwerkeHoechst. Sections were viewed in a Zeiss fluorescent microscope. For electron microscopy, renal tissue was fixed in 1% osmium tetroxide buffered with Veronal acetate for one hour at 4 C., dehydrated, and embedded in Vestopal-W. Sections were cut on a PorterBlum (Sorwall) microtome, stained with uranyl acetate, and viewed in a Zeiss EM and EM 92S electron microscope.
Table 1. Clinical Classification of 29 Cases of Glomerulonephritis Clinical Diagnosis Acute poststreptococcal glomerulonephritis Miscellaneous Allergic purpura Sjogren's syndrome Systemic lupus erythematosus Hodgkin's disease Au-positive hepatitis TOTAL
Number of Cases
20 4 1 2 1 1 29
Results Acute Poststreptococcal Glomerulonephritis (Table 2) Light Microscopy. Of the 20 cases of acute poststreptococcal glomerulonephritis, six were considered trace acute glomerulonephritis (AGN) (minimal focal cellular proliferation), eight were considered 1 + AGN (diffuse endothelial and mesangial cell proliferation with capillary loop narrowing), two were considered 2+ AGN (1+ AGN with additional significant polymorphonuclear leukocyte infiltration), one was considered 3 + AGN (cellular proliferation, polymorphonuclear leukocyte infiltration and hypersegmentation of the glomeruli), and two were considered 4 + AGN (3+ with additional generalized glomerular swelling4). Immunofluorescent Microscopy. By immunofluorescent microscopy /3,C was seen in a finely granular or interrupted linear distribution along segments of the glomerular basement membrane and the mesangium in all cases. In eight cases immunoglobulin G (IgG) was also found deposited in a finely granular or interrupted linear fashion on the basement membrane and the mesangium (Fig. 1). No deposition of IgA or IgM was found. Electron Microscopy. Electron microscopic studies were performed in six cases. There
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
tis associated with other bacterial infections, 10,23 and glomerular diseases of unknown etiology, such as membranous nephropathy, 6 have been taken to be examples of immune-complex disease, whereas Goodpasture's syndrome has been the only true example of anti-GBM disease in man. 5,20 ' 21 We studied renal biopsy specimens from 29 patients who had glomerular disease by immunofluorescence and electron microscopy. The patients we studied encompassed a wide spectrum of glomerular diseases, from asymptomatic urinary findings during the course of other diseases to severe forms of glomerulonephritis. Our purpose was to correlate the immunofluorescent and electron microscopic findings with the renal histopathology.
302
MUFTUOGLU ET Ah.
A.J.C.P.—Vol.
63
FIG. 2 (right). Patient 8. Granular deposition of IgG on the glomerular basement membrane and the mesangium in poststreptococcal glomerulonephritis. Immunofluorescent microscopy. x600.
was no uniform ultrastructural change of the basement membrane in these cases. The basement membrane was normal in one patient (Patient 7) who had trace AGN by light microscopy and only ^ C deposits by fluorescent microscopy. Thickening of the basement membrane was seen in two cases (Patients 16 and 20). Amorphic electron-dense deposits formed an irregular, interrupted line facing the foot processes or the epithelial cells in the thickened segments. There was also increased density in the foot processes near the basement membrane. These patients had mild AGN by light microscopy but granular deposits of IgG and /3iC were observed by fluorescence microscopy. Three patients (4, 8, and 9) had minimal segmental subepithelial deposits. These patients had 1+ and 2 +
AGN by light microscopy and minimal granular IgG and fi^C deposition on the basement membrane (Figs. 2 and 3). Glomerular Disease in the Courses of Systemic Diseases (Table 3) Light Microscopy. Four cases of allergic purpura were included in this series. Patient 21 had normal histology, Patient 22 had 1 + AGN, and Patients 23 and 24 had trace AGN. The patient who had Sjogren's syndrome had some proliferative changes and segmental thickening of the basement membrane, considered to be nondiagnostic. One patient (26) who had systemic lupus erythematosus had typical lupus nephritis, and the other (27) had glomerular changes of AGN 1 + . One patient with
Downloaded from http://ajcp.oxfordjournals.org/ by guest on June 6, 2016
FIG. 1 (left). Patient 20. Granular deposition of IgG on the glomerular basement membrane and the mesangium in poststreptococcal glomerulonephritis. Immunofluorescent microscopy. x400.
March 1975
303
ACUTE GLOMERULONEPHRITIS
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