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Fig. 5. Cytoplasmic localization of HBs antigen in degenerating hepatic cell cytoplasm. x 200. Fig. 6. HBs antigen is demonstrated along glomerular capillary loops in beaded fashion. x 200.
antinuclear antibody was occasionally noted in the patient’s clinical course as described above, it could be justified that DNA and anti-nuclear antibody complex would not be the components of granular deposits along GBM.
4) Electron Microscopic Emmination Small portions of the liver and kidney tissue obtained at autopsy were immediately processed for electron microscopic investigation after double fixation in glutaraldehyde and osmic acid. In some hepatic cells, structure of intracytoplasmic inclusion body was present containing numerous spherical particles of various sizes and degenerating organelles. The particles were measured 200 to 400 A in diameter and considered to be compatible with HBsAg, of which larger ones were superior in amount and were identified as Dane
__
Fig. 1. Active liver cirrhosis with distorted liver cell cords, proliferation of hepatic and bile duct epithelial cells, interstitial fibrosis and round cell infiltration. H & E. x 200. Fig. 2. Kidney. Note diffuse thickening of basement membrane. Cellular proliferation is not prominent and only minimal damage is present in vas afferens. H & E. x 200. Fig. 3. Mesangial region is enlarged and basement membrane is thickened with occasional splitting. Periodic acid methenamine silver impregnation. x 200. Fig. 4. HBs antigen stained on paraffin section. Five positive inclusions are noted in hepatic cell cytoplasm. Orscein. x 400.
242
MEMBRANOUS QLOMERULONEPHRITIS AND RBB ANTIQEN
Acta Path. Jap.
26(2): 1976
M. MORIYAMA e l at.
Fig. 11. Degenerating hepatocytes filled with swollen distorted mitochondrias. cytoplasmic inclusion-like structure (arrow).
243
Note a
particles with the presence of electron dense inner cores. Besides these particles, two more different morphological structures were noted, namely tubules of about 200 A in width and thin filamentous structures which were also considered to be the variants of HBsAg (Figs. 11, 12). Electron microscopy of the glomeruli confirmed extensive thickening of GBM, increased mesangial matrix, deposits of electron dense substance scattered in subendothelial regions containing particulated structure and irregular black particles or “moth-eaten” appearance in subendothelial area (Fig. 13), the latter was indicated by SAKAGUCHI as considerably specific features in hepatic glomerulosclerosis22. The most interesting &ding was the presence of particles in subendothelial and subepithelial regions which were identical in contour to those seen in the hepatic cells (Figs. 13, 14). Most of them appeared to be Dane particles having inner cores and they were codrmed as HBsAg by immunoelectron microscopic examination18 using peroxidase-labelled anti-rabbit gamma globulin after treatment of section with anti-HBsAg rabbit antibody (Fig. 15). Some mesangial cells also contained spherical particles in lysosomal structure Fig. Fig. Fig. Fig.
7. IgM is deposited along glomerular basement membrane. x 200. 8. Third component of complement is demonstrated. x 200. 9. Localization of fibrin. x 200. 10. Deposition of IgG is also noted after 2M NaCl treatment. x 200.
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M. MORIYAYA
Fig. 14. Higher magnification of Fig, 13. many of them having outer capsid.
#f
at.
Numerous spherical particles are present and
which were specifically stained by the same immunoultrastructural procedure and thus they were consistent with HBsAg (Fig. 16). The particular localization of this particles in lysosome would be result of phagocytosis of immune complex by mesangial cells rather than primary “infection” of HBsAg to this area. Furthermore, the particles and ilamentous structures in the previously described inclusion of thin-sectioned hepatic cells were positively stained by methenamine silver, which was considered to have specific a f i t y to polysaccharide moiety of viral outer coatae.
5) Serological Findings The blood drained from the heart at autopsy was provided for examination of HBsAg and HBsAb. For this purpose, the most sensitive methods known so far, i.e. immune adherence hemagglutination and radioimmunoassay for the antigen and passive hemagglutination and radioimmunoassay for the antibody were used, but both Fig. 12. Higher magnification of inner aspect of the inclusion shown in Fig. 11. Numerous particles are noted and many of them are seen to be surrounded by outer capsid (Dane particles). Tubular structure is also noted in distended cisterna (arrow). Fig. 13. Glomerular capillary loop. The basement membrane is markedly thickened having amorphous, electron dense deposits (single arrow), small blaak particles and “moth-eaten” appearance (double arrow). Besides, subepithelial accumulation of round particles is also noted. EP - epithelial cell.
246
MEMBRANOUS OLOMIRULONEPHRITIS AND EBB ANTIGEN
Acta Path. Jap.
Fig. 16. Part of glomerular capillary loop. Basement membrane (GBM)is markedly thickened having rather obscure particulated substances which m e identified a8 HBe antigen using indirect peroxidase method (insert). Fig. 16. Dane particles in lysosomal structure of mesangial cell (MC). Insert shows HBs antigen demonstrated by the same procedure a8 Fig. 16.
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M. MORIYAMA e t a l .
247
Ag and Ab could not be detected. Efforts to demonstrate circulatory soluble immune complexes in the same serum were made using sucrose density gradient ultracentrifugationll. However, no macromolecular components sedimentable faster than 19s globulin was found. The elution study of immunoglobulin from the autopsy kidney was unfortunately not done, because of the shortage of frozen fresh kidney material. 6) Control Study
Fifteen other autopsy cases of liver cirrhosis were chosen a t random for detection of HBsAg in kidneys, four of them were HBsAg positive and eleven were negative in liver specimen by immunofluorescence technique, but none of them showed deposition of HBsAg in renal GBM. Furthermore, 40 kidney biopsy cases of variable renal diseases mostly in younger age group have been studied for the presence of HBsAg in the glomeruli also by immunofluorescence. But none of them were positive. Discussion
Glomerulonephritis is known to develop by deposition of anti-GBM antibodies or antigen-antibody complexes to the GBM in experimental animal models. In human cases, although hemolytic streptococcus is thought to be one of the potent nephritogenic antigens, most of the other causative agents have remained obscure. While there have been many reported cases of glomerulonephritis in association with HBs antigenemia and/or hepatic disordersV, it was COMBES and his coworkers who presented the fist case of glomerulonephritis developed during the course of post-transfusion hepatitis with positive circulating HBsAg5. Subsequently several reports of similar cases were accumulated having immunohistological deposits of HBsAg, immunoglobulins and C, of serum complement in GBM and electron microscopic deposits in subepithelium or mesangial matrix of glomeruli1,3,1211'1*'. KNIESERand associates demonstrated not only electron dense deposits but also clusters of spherical particles in GBM and mesangium and identifled them as HBsAg by immunoelectron microscopic technique, postulating that the HBsAg immune complex was the causative agent of this type of glomerulonephritiP2. The present case was thought to fall in this entity from the immunofluorescent and immunoelectron microscopic findings of the granular deposits of HBsAg and a t the same time immunoglobulins and C, along the GBM, despite the biological nature of immunoglobulins deposited along the GBM was not immunologically determined. This pattern of distribution of multiple immune reactant along the GBM would generally be thought as representative of typical chronic serum sickness type glomerulonephritis due to deposition of preformed circulating immune complex to glomeruli4,a6. As a matter of fact, all reported cases so far were said to have either positive circulating HBsAg or Ab, whereas the case of the present study had neither serum HBsAg nor Ab in circulating or necropsy blood. As to the absence of serum HBsAg, there have been cases with
248
MXMBRANOUS OLOMERULONEPFIRITIS AND HB8 ANTIGEN
A d a Path. Jap.
diminishing or disappearance of HBsAg in circulation from unknown reason at acute exacerbation during the course of viral hepatitisls. Furthermore, if complex was made by equivalent state of antigen and antibody in serum, it was reasonable not to find either free antigen or antibody in the circulating blood. Furthermore, although macromolecular complex larger than 19s in the serum was not found in the necropsy blood of this case, the possibility of presence of much smaller complex made by antibody of low avidity and low precipitability could remain in this case. The membranous type glomerulonephritis was said to be caused by such type of soluble immune complex in the circulation14,1~. Alternatively, the complex in circulation might be completely eliminated from the blood by glomeruli through deposition. In any way, the possibility of the presence of soluble HBsAg-Ab complex in circulation of this case could not be completely ruled out. BRZOSKO et al. reported on glomerulonephritis of various forms associated with HBsAg immune complexes in children indicating HBs antigenemia and deposition of the antigen on glomeruli in significant percentages. However, the statistical and immunological background of the relationship between HBs antigenemia and glomerulonephritis in their country, Poland, is rather exceptional, because transfusion of plasma or whole blood to patients with nephritis was said to be not unusual and test for HBsAg has not been mandatory before 19723. Therefore, the possibility of contamination with HBsAg during the course of nephritis could not be excluded. The kidney of 15 other autopsy liver cirrhosis cases and 40 renal biopsy cases examined so far showed no evidence of HBsAg in the GBM. It is suspected that the HBsAg possibly propagated in the hepatic cells on one hand injured liver cells and might have developed liver cirrhosis in a certain pathway. On the other hand, possible preformed circulating HBsAg-Ab complex might have a capacity to deposit on GBM and cause membranous type glomerulonephritis. The HBs antigenemia or HBsAg positive liver cirrhosis cases are not uncommon conditions among the population studied, however, the occurrence of HBsAg associated immune complex type membranous glomerulonephritis is thought to be quite rare. The future direction of investigation should be aimed to find out the immunobiological characteristics of HBsAg-Ab complex in the circulation, and the mechanism of deposition of this particular complex to the GBM in certain cases. Acknowledgement: The authors express their appreciation to Dr. K. KOZIBSA,Niigata Tokyo University, for their help in detecting HBsAg University, and Miss N. YOSEIHABA, and Ab in necropsy blood of this case; to Dr. T. OKAZAIU,Department of Biochemistry, Nippon Medical School, for his guidance of sucrose gradient ultracentrifugation; and finally to all colleagues of the authors’ department who supplied the liver and kidney specimens of autopsy case8 for this study.
References S.K., BRAOKETT, N.C. JR., HENNIQAR, G.R. and GIVENS, L.B.: Glomeru1. AINSWORTTH, lonephritis with deposition of Australia antigen-antibody complexes in the glomerular basement membrane. Lab. Invest. 30: 369, 1974 (abstract).
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P.W., BRACKETT,N.C. JR., STILL, W.J.S. and SPORN, I.N.: 2. BRIDI, G.S., FALCON, Glomerulonephritis and renal tubular acidosis in a case of chronic active hepatitis with hyperimmunoglobulinemia. Am. J. Med. 52: 267-278, 1972. 3. BRZOSKO, W.J., KRAWCZYNSKI, K., NAZAREWICZ, T., MORZYCKA, M. and NOWOSLAWSKI, A. : Glomerulonephritis associated with hepatitis-B surface antigen immune complexes in children. Lancet 2: 477-482, 1974. 4. COCHRANE, C.G. and KOFFLER,D. : Immune complex disease in experimental animals and man. Adv. Immunol. 16: 185-264, 1973. 5. COMBES,B., STASTNY, P., SHOREY,J., EIQENBRODT, E.H., BARRERA, A., HULL, A.R. and CARTER,N.W. : Glomerulonephritis with deposition of Australia antigen-antibody complexes in glomerular basement membrane. Lancet 2 : 234-237, 1971. 6. COYNE (ZAVATONE), V.E., MILLMAN, I., CERDA,J., GERSTLEY,B.J.S., LONDON,T., SUTNICK,A. and BLUMBERQ,B.S.: The localization of Australia antigen by immunofluorescence. J. Exp. Med. 131: 307-319, 1970. S., CAQUET, R. and LAROCHE,CI. : Australia antigen in 7. DESCHE-LABARTHE, rheumatoid arthritis. Br. Med. J. 4: 548-549, 1972. 8. DOLLERY,C.T. and HARRISON,C.V. : Essential malignant hypertension with renal failure and persistent Australia-antigenaemia. Br. Med. J. 1 : 216-223, 1973. 9. GOCKE,D.J., Hsu, K., MORGAN, C., BOMBARDIERI, S., LOCKSHIN,M. and CHRISTIAN, C.L. : Association between polyarteritis and Australia antigen. Lancet 2 : 1149-1153, 1970. 10. HEATHCOTE, J., CAMERON, C.H. and DANE,D.S.: Hepatitis-B antigen in saliva and semen. Lancet 1: 71-73, 1974. 11. HEDFORS,E. and NORBERQ,R.: Evidence for circulating immune complexes in sarcoidosis. Clin. Exp. Immunol. 16 : 493-496, 1974. D.T., BANCROFT,W.H., BURNS,W. and 12. KNIESER,M.R., JENIS, E.H., LOWENTHAL, SHALHOUB, R. : Pathogenesis of renal disease associated with viral hepatitis. Arch. Path. 97: 193-200, 1974. 13. KOJIMA,K. : Personal communication. T. : Chronic glomerulonephritis induced by prolonged immunization in the 14. KURIYAMA, rabbit. Lab. Invest. 28: 224-235, 1973. 15. LIQHTFOOT, R.W. JR., DRUSIN,R.E. and CHRISTIAN,C.L.: Properties of soluble immune complexes. J. Immunol. 105: 1493-1500, 1970. V., BABES,V.T., SANDU, L. and CAJAL,S. : Australia antibodies in patients with 16. MILCOV, acute renal insufficiency undergoing haemodialysis. Lancet 2 : 101, 1973. T. and KLAJMAN, A.: Mem17. MYERS,B.D., GRIFFEL, B., NAVEH,D., JANKIELOWITZ, brano-proliferative glomerulonephritis associated with persistent viral hepatitis. Am. J. Clin. Path. 60: 222-228, 1973. 18. NAKANE,P.K. and KAWAOI,A.: Peroxidase-labelled antibody. A new method of conjugation. J. Histochem. Cytochem. 22: 1084-1091, 1974. M.B.A. and DIXON,F.J.: Immune complex disease in chronic viral infec19. OLDSTONE, tions. J. Exp. Med. 134: 32-405, 1971. 20. OLDSTONE,M.B.A. and DIXON, F.J. : Virus-antiviral antibody complexes. Progr. Immunol. 1: 763-777, 1971. 21. PRINCE,A.M. and TREPO, C.: Role of immune complexes involving SH antigen in pathogenesis of chronic active hepatitis and polyarteritis nodosa. Lancet 1 : 13091312, 1971. 22. SAKAQUCJII,H., DACHS,S., GRISHMAN, E., PARONETTO, F., SALOMON, M. and CHURQ, J. : Hepatic glomerulosclerosis. An electron microscopic study of renal biopsies in liver diseases. Lab. Invest. 14: 533-545, 1965. T., YOSHIWARA, N., AKATSUKA, 23. SHIKATA,T., UZAWA, T. and YAMAZAKI, S.: Staining methods of Australia antigen in paraffin section - Detection of cytoplasmic inclusion Jap. J. Exp. Med. 44: 25-36, 1974. bodies-. 24. TREPO,C.G., ZUCKERMAN, A.J., BIRD, R.C. and PRINCE, A.M.: The role of circulating hepatitis B antigen/antibody immune complexes in the pathogenesis of vascular and hepatic manifestations in polyarteritis nodosa. J. Clin. Path. 27 : 863-868, 1974. 25. TSUJI, T.: An immunological study of Australia antigen in tissues. Jap. J. Clin. Med.
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MEMBRANOUS QLOMERULONEPHRITIS AND HE8 ANTIQEN
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30: 1139-1146, 1972 (in Japanese).
UNANUE,E.R. and DIXON, F.J. : Experimental glomerulonephritis: Immunological events and pathogenetic mechanisms. Adv. Immunol. 6: 1-90, 1907. S. and KRAWCZYNSKI, K. : Glomerulonephritis with 27. VERTIJN,B., BROMBERQ-SZNEK, depositis of immune complexes containing Australia antigen in the glomeruli. Pol. Arch. Med. Wewn. 50: 1107-1111, 1973 (in Polish). 28. WENZEL,R.P., MCCORMICK,D.P., BUSCH,H.J. and BEAM,W.E. JR.: Arthritis and viral hepatitis. A patient with transient serum hepatitis-associated antigen, skin nodules, rash, and low serum complement. Arch. Intern. Med. 130: 770-771, 1972. 29. YAJIMA,G. and AIHARA,K. : Electronmicroscopical observation of mucopolysacchride by periodic acid methenamine silver staining. In “Applied electron microscopy for medical and biological studies”, ed. by Yamada, E. et al. Ishiyaku Shuppan, Tokyo, pp. 301-315 1973 (in Japaneee). 26.
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Fig. 5. Cytoplasmic localization of HBs antigen in degenerating hepatic cell cytoplasm. x 200. Fig. 6. HBs antigen is demonstrated along glomerular capillary loops in beaded fashion. x 200.
antinuclear antibody was occasionally noted in the patient’s clinical course as described above, it could be justified that DNA and anti-nuclear antibody complex would not be the components of granular deposits along GBM.
4) Electron Microscopic Emmination Small portions of the liver and kidney tissue obtained at autopsy were immediately processed for electron microscopic investigation after double fixation in glutaraldehyde and osmic acid. In some hepatic cells, structure of intracytoplasmic inclusion body was present containing numerous spherical particles of various sizes and degenerating organelles. The particles were measured 200 to 400 A in diameter and considered to be compatible with HBsAg, of which larger ones were superior in amount and were identified as Dane
__
Fig. 1. Active liver cirrhosis with distorted liver cell cords, proliferation of hepatic and bile duct epithelial cells, interstitial fibrosis and round cell infiltration. H & E. x 200. Fig. 2. Kidney. Note diffuse thickening of basement membrane. Cellular proliferation is not prominent and only minimal damage is present in vas afferens. H & E. x 200. Fig. 3. Mesangial region is enlarged and basement membrane is thickened with occasional splitting. Periodic acid methenamine silver impregnation. x 200. Fig. 4. HBs antigen stained on paraffin section. Five positive inclusions are noted in hepatic cell cytoplasm. Orscein. x 400.
242
MEMBRANOUS QLOMERULONEPHRITIS AND RBB ANTIQEN
Acta Path. Jap.
26(2): 1976
M. MORIYAMA e l at.
Fig. 11. Degenerating hepatocytes filled with swollen distorted mitochondrias. cytoplasmic inclusion-like structure (arrow).
243
Note a
particles with the presence of electron dense inner cores. Besides these particles, two more different morphological structures were noted, namely tubules of about 200 A in width and thin filamentous structures which were also considered to be the variants of HBsAg (Figs. 11, 12). Electron microscopy of the glomeruli confirmed extensive thickening of GBM, increased mesangial matrix, deposits of electron dense substance scattered in subendothelial regions containing particulated structure and irregular black particles or “moth-eaten” appearance in subendothelial area (Fig. 13), the latter was indicated by SAKAGUCHI as considerably specific features in hepatic glomerulosclerosis22. The most interesting &ding was the presence of particles in subendothelial and subepithelial regions which were identical in contour to those seen in the hepatic cells (Figs. 13, 14). Most of them appeared to be Dane particles having inner cores and they were codrmed as HBsAg by immunoelectron microscopic examination18 using peroxidase-labelled anti-rabbit gamma globulin after treatment of section with anti-HBsAg rabbit antibody (Fig. 15). Some mesangial cells also contained spherical particles in lysosomal structure Fig. Fig. Fig. Fig.
7. IgM is deposited along glomerular basement membrane. x 200. 8. Third component of complement is demonstrated. x 200. 9. Localization of fibrin. x 200. 10. Deposition of IgG is also noted after 2M NaCl treatment. x 200.
244
MIMBRANOUS OLOMERULONEPHRITIS AND HBB ANTIGEN
Acta Path. Jap.
M. MORIYAYA
Fig. 14. Higher magnification of Fig, 13. many of them having outer capsid.
#f
at.
Numerous spherical particles are present and
which were specifically stained by the same immunoultrastructural procedure and thus they were consistent with HBsAg (Fig. 16). The particular localization of this particles in lysosome would be result of phagocytosis of immune complex by mesangial cells rather than primary “infection” of HBsAg to this area. Furthermore, the particles and ilamentous structures in the previously described inclusion of thin-sectioned hepatic cells were positively stained by methenamine silver, which was considered to have specific a f i t y to polysaccharide moiety of viral outer coatae.
5) Serological Findings The blood drained from the heart at autopsy was provided for examination of HBsAg and HBsAb. For this purpose, the most sensitive methods known so far, i.e. immune adherence hemagglutination and radioimmunoassay for the antigen and passive hemagglutination and radioimmunoassay for the antibody were used, but both Fig. 12. Higher magnification of inner aspect of the inclusion shown in Fig. 11. Numerous particles are noted and many of them are seen to be surrounded by outer capsid (Dane particles). Tubular structure is also noted in distended cisterna (arrow). Fig. 13. Glomerular capillary loop. The basement membrane is markedly thickened having amorphous, electron dense deposits (single arrow), small blaak particles and “moth-eaten” appearance (double arrow). Besides, subepithelial accumulation of round particles is also noted. EP - epithelial cell.
246
MEMBRANOUS OLOMIRULONEPHRITIS AND EBB ANTIGEN
Acta Path. Jap.
Fig. 16. Part of glomerular capillary loop. Basement membrane (GBM)is markedly thickened having rather obscure particulated substances which m e identified a8 HBe antigen using indirect peroxidase method (insert). Fig. 16. Dane particles in lysosomal structure of mesangial cell (MC). Insert shows HBs antigen demonstrated by the same procedure a8 Fig. 16.
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Ag and Ab could not be detected. Efforts to demonstrate circulatory soluble immune complexes in the same serum were made using sucrose density gradient ultracentrifugationll. However, no macromolecular components sedimentable faster than 19s globulin was found. The elution study of immunoglobulin from the autopsy kidney was unfortunately not done, because of the shortage of frozen fresh kidney material. 6) Control Study
Fifteen other autopsy cases of liver cirrhosis were chosen a t random for detection of HBsAg in kidneys, four of them were HBsAg positive and eleven were negative in liver specimen by immunofluorescence technique, but none of them showed deposition of HBsAg in renal GBM. Furthermore, 40 kidney biopsy cases of variable renal diseases mostly in younger age group have been studied for the presence of HBsAg in the glomeruli also by immunofluorescence. But none of them were positive. Discussion
Glomerulonephritis is known to develop by deposition of anti-GBM antibodies or antigen-antibody complexes to the GBM in experimental animal models. In human cases, although hemolytic streptococcus is thought to be one of the potent nephritogenic antigens, most of the other causative agents have remained obscure. While there have been many reported cases of glomerulonephritis in association with HBs antigenemia and/or hepatic disordersV, it was COMBES and his coworkers who presented the fist case of glomerulonephritis developed during the course of post-transfusion hepatitis with positive circulating HBsAg5. Subsequently several reports of similar cases were accumulated having immunohistological deposits of HBsAg, immunoglobulins and C, of serum complement in GBM and electron microscopic deposits in subepithelium or mesangial matrix of glomeruli1,3,1211'1*'. KNIESERand associates demonstrated not only electron dense deposits but also clusters of spherical particles in GBM and mesangium and identifled them as HBsAg by immunoelectron microscopic technique, postulating that the HBsAg immune complex was the causative agent of this type of glomerulonephritiP2. The present case was thought to fall in this entity from the immunofluorescent and immunoelectron microscopic findings of the granular deposits of HBsAg and a t the same time immunoglobulins and C, along the GBM, despite the biological nature of immunoglobulins deposited along the GBM was not immunologically determined. This pattern of distribution of multiple immune reactant along the GBM would generally be thought as representative of typical chronic serum sickness type glomerulonephritis due to deposition of preformed circulating immune complex to glomeruli4,a6. As a matter of fact, all reported cases so far were said to have either positive circulating HBsAg or Ab, whereas the case of the present study had neither serum HBsAg nor Ab in circulating or necropsy blood. As to the absence of serum HBsAg, there have been cases with
248
MXMBRANOUS OLOMERULONEPFIRITIS AND HB8 ANTIGEN
A d a Path. Jap.
diminishing or disappearance of HBsAg in circulation from unknown reason at acute exacerbation during the course of viral hepatitisls. Furthermore, if complex was made by equivalent state of antigen and antibody in serum, it was reasonable not to find either free antigen or antibody in the circulating blood. Furthermore, although macromolecular complex larger than 19s in the serum was not found in the necropsy blood of this case, the possibility of presence of much smaller complex made by antibody of low avidity and low precipitability could remain in this case. The membranous type glomerulonephritis was said to be caused by such type of soluble immune complex in the circulation14,1~. Alternatively, the complex in circulation might be completely eliminated from the blood by glomeruli through deposition. In any way, the possibility of the presence of soluble HBsAg-Ab complex in circulation of this case could not be completely ruled out. BRZOSKO et al. reported on glomerulonephritis of various forms associated with HBsAg immune complexes in children indicating HBs antigenemia and deposition of the antigen on glomeruli in significant percentages. However, the statistical and immunological background of the relationship between HBs antigenemia and glomerulonephritis in their country, Poland, is rather exceptional, because transfusion of plasma or whole blood to patients with nephritis was said to be not unusual and test for HBsAg has not been mandatory before 19723. Therefore, the possibility of contamination with HBsAg during the course of nephritis could not be excluded. The kidney of 15 other autopsy liver cirrhosis cases and 40 renal biopsy cases examined so far showed no evidence of HBsAg in the GBM. It is suspected that the HBsAg possibly propagated in the hepatic cells on one hand injured liver cells and might have developed liver cirrhosis in a certain pathway. On the other hand, possible preformed circulating HBsAg-Ab complex might have a capacity to deposit on GBM and cause membranous type glomerulonephritis. The HBs antigenemia or HBsAg positive liver cirrhosis cases are not uncommon conditions among the population studied, however, the occurrence of HBsAg associated immune complex type membranous glomerulonephritis is thought to be quite rare. The future direction of investigation should be aimed to find out the immunobiological characteristics of HBsAg-Ab complex in the circulation, and the mechanism of deposition of this particular complex to the GBM in certain cases. Acknowledgement: The authors express their appreciation to Dr. K. KOZIBSA,Niigata Tokyo University, for their help in detecting HBsAg University, and Miss N. YOSEIHABA, and Ab in necropsy blood of this case; to Dr. T. OKAZAIU,Department of Biochemistry, Nippon Medical School, for his guidance of sucrose gradient ultracentrifugation; and finally to all colleagues of the authors’ department who supplied the liver and kidney specimens of autopsy case8 for this study.
References S.K., BRAOKETT, N.C. JR., HENNIQAR, G.R. and GIVENS, L.B.: Glomeru1. AINSWORTTH, lonephritis with deposition of Australia antigen-antibody complexes in the glomerular basement membrane. Lab. Invest. 30: 369, 1974 (abstract).
!-
26(2): 1976
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