IgA肾病合并膜性肾病1例

患者男性,52岁,因发现小便起泡沫半年,无水肿及其他不适入院。尿常规：潜血（＋＋）,蛋白（＋＋＋）,院外按“慢性肾炎”治疗1个月,尿蛋白无减少。体检：BP120/75mmHg,下肢无水肿,尿常规：蛋白（＋＋＋）,潜血（＋＋＋）,镜检可铜陵大量颗粒管型,24h尿蛋白排泄量2.95g,尿沉渣;红细胞123个μl,变形率85%,芽孢状;     

膜性肾病伴乙肝病毒感染的病理学改变

目的探讨肾穿刺确诊膜性肾病(membranous nephropathy,MN)合并HBV感染的病理特点及肾组织HBV抗原检测的意义。方法回顾性分析147例MN患者的临床和肾脏病理资料,根据HBV血清学结果分为A组(HBV抗原阳性)、B组(仅HBV抗体阳性)、C组(HBV阴性的原发MN),比较其肾脏病理、临床表现及实验室检测结果。肾组织HBsAg/HBcAg检测采用EnVision方法。结果 A组肾小球基膜假双轨、肾小球节段硬化、节段内皮细胞肿胀增生、内皮下和系膜区电子致密物及IgM、C4、C1q沉积的比率显著高于C组。A组的发病年龄较低,肝功能异常和低补体血症发生率明显高于B、C两组(P0.05)。A组肾组织HBsAg和(或)HBcAg阳性患者在病理及临床表现方面与阴性患者比较无明显差异(P0.05)。结论不同于原发性MN,伴HBV感染的MN常伴肾小球节段硬化、内皮细胞肿胀增生、假双轨和多种免疫球蛋白及补体多部位沉积。免疫组化未发现肾组织HBsAg和(或)HBcAg沉积不能完全排除MN与HBV感染不相关,还需结合光镜、荧光和电镜的改变综合判断。     

青年人特发性膜性肾病临床病理特征

目的探讨青年特发性膜性肾病(idiopathic membranous nephropathy, IMN)患者的临床病理特征。方法将232例IMN患者按照年龄划分为青年组(≥18岁,45岁)和中老年组(≥45岁),收集一般资料和临床资料及其病理结果,并统计分析两组临床病理差异。结果青年组和老年组IMN患者男女比分别为45∶33和73∶81。与中老年组相比,青年组白细胞、血红蛋白、淋巴细胞和估计肾小球滤过率相对较高(P0.05),收缩压、尿素氮较低(P0.05)。两组在血肌酐、血白蛋白、24 h尿蛋白定量、血浆抗PLA2R抗体等指标差异均无统计学意义(P0.05)。青年组以Ⅰ～Ⅱ期和Ⅱ期为主,中老年组以Ⅱ期为主,两组总体分期差异无统计学意义(P0.05)。另外,青年组患者肾小球硬化积分、小动脉管壁增厚发生率、玻璃样变性发生率和肾小管萎缩积分较低(P0.05)。两组IgG、IgG4和C3沉积均以阳性为主,其差异无统计学意义(P0.05)。两组肾组织PLA2R定性差异有统计学意义(P=0.008),青年组阳性率低于中老年组。结论青年与中老年IMN患者有其共性,但两者也存在差异。临床病理特征提示青年人IMN预后可能会优于中老年人。     

甲泼尼龙联合羟基脲治疗原发性膜性肾病的疗效

目的 探讨甲泼尼龙联合羟基脲治疗原发性膜性肾病的临床效果。方法 选取2016年1月~2018年12月我院经肾穿刺活检病理确诊为原发性膜性肾病患者42例,按照随机数字表法分成观察组（20例）和对照组（22例）。观察组给予甲泼尼龙联合羟基脲治疗,对照组接受甲泼尼龙联合环磷酰胺治疗,比较两组24h尿总蛋白、血浆白蛋白、临床疗效及并发症发生率。结果 两组治疗前后24h尿总蛋白、血浆白蛋白比较,差异无统计学意义（P＞0.05）;观察组总有效率为80.00%,低于对照组的86.36%,但差异无统计学意义（P＞0.05）。观察组并发症总发生率为35.00%,低于对照组的40.91%,但差异无统计学意义（P＞0.05）。结论 甲泼尼龙联合环磷酰胺治疗原发性膜性肾病较甲泼尼龙联合羟基脲降尿蛋白效果具有非劣效性,且无严重并发症发生,可作为治疗的备选方案。     

原发性膜性肾病尿液差异蛋白筛选及分析

目的 对原发性膜性肾病患者和健康对照组尿液中的差异表达蛋白进行筛选、鉴定和初步分析,为进一步筛选诊断原发性膜性肾病的尿液生物学标志物提供依据。方法 采用蛋白质组学-Label-free分析技术对尿液蛋白进行筛选、鉴定和分析,差异蛋白使用Uniprot-Homo sapiens数据库进行信息分析。结果 通过蛋白质组学-Label-free分析,共鉴定出1 342个尿液蛋白,9 284个肽段,以差异系数大于1.5倍及以上、差异有统计学意义(P<0.05)为筛选标准,与健康对照组相比,在原发性膜性肾病患者中上调差异蛋白156个,下调差异蛋白共793个。结论 本研究筛选了原发性膜性肾病患者与健康对照尿液中的20个主要差异蛋白,为原发性膜性肾病尿液标志物的后续研究提供实验依据和基础。     

膜性肾病小鼠模型的建立与鉴定

目的 建立小鼠膜性肾病模型.方法 取6周龄健康雄性BALB/c小鼠20只,分为对照组和模型组.模型组小鼠皮下注射0.2 mg阳离子牛血清白蛋白(C-BSA)和等体积的完全弗氏佐剂,对照组皮下注射生理盐水和完全弗氏佐剂.2周后,模型组小鼠尾静脉注射阳离子牛血清白蛋白,每周3次,隔日注射,对照组使用生理盐水代替.模型的鉴定则采用血液生化检查和病理检查(PASM染色、IgG免疫荧光染色、透射电镜)等方法.结果 8周后12只模型组小鼠出现高蛋白尿、低蛋白血症和高胆固醇血症;PASM染色显示出类似于早期膜性肾病,IgG免疫荧光染色显示出沿毛细血管壁呈颗粒状物沉积,透射电镜下有足突的广泛融合.结论 C-BSA尾静脉注射小鼠可成功构建小鼠膜性肾病模型.     

超声鉴别诊断乳腺典型髓样癌与不典型髓样癌的价值分析

目的分析病理证实的乳腺髓样癌及不典型髓样癌的超声及病理资料,证明超声诊断乳腺髓样癌价值。方法回顾性分析114例乳腺髓样癌病灶病理资料,将其分为髓样癌组及不典型髓样癌组,分析其超声声像图中病灶的形态、大小、边缘、边界、内部回声、血流情况等,探讨两组超声声像图的差异。结果乳腺典型髓样癌病灶93例,不典型髓样癌病灶21例,两组的超声声像图上各特征均无明显统计学差异。超声诊断典型髓样癌和不典型髓样癌良恶性的准确性分别为83.87%、85.71%。结论超声对鉴别乳腺髓样癌良恶性方面具有诊断价值,但在鉴别髓样癌与不典型髓样癌方面价值有限。     

足细胞抗原在人类膜性肾病治疗中的研究进展

膜性肾病(membranous nephropathy,MN)是一种器官特异性自身免疫病,发病机制是自身抗体结合足细胞靶抗原后激活补体导致肾小球滤过屏障损伤和蛋白尿.近年研究已发现中性肽链内切酶、M型磷脂酶A2受体(phospholipase A2 receptor,PLA2R)、醛糖还原酶、超氧化物歧化酶2、α烯醇化酶、1型血小板反应蛋白7A域等足细胞靶抗原.抗PLA2R抗体和肾组织PLA2R抗原是诊断和治疗MN的新兴生物标志物.     

血清抗-PLA_2R抗体对特发性膜性肾病诊断价值的meta分析北大核心CSCD

目的：探讨血清抗-PLA2R抗体（anti-PLA2R）在特发性膜性肾病（IMN）诊断中的价值。方法：检索Pub Med、Elsevier、Springer、中国期刊全文数据库、中国科技期刊数据库、万方数字化期刊全文数据库等数据库中2009年1月至2013年12月国内外公开发表的关于血清anti-PLA2R诊断特发性膜性肾病的相关文献,根据纳入和排除标准筛选文献并提取数据,采用诊断精确性研究的质量评估方法（QUADAS）评价文献质量,通过Meta-Disc和Stata软件进行Meta分析。通过汇总后的敏感度、特异度、似然比及汇总受试者工作曲线（ROC）综合评价血清anti-PLA2R对IMN的诊断价值。采用依次减少一篇文献的方法进行敏感性分析,通过Egger漏斗图检验文献发表偏倚。结果：共筛选出7篇文献。累计病例967例,其中IMN患者454例,对照组513例。异质性检验提示不存在阈值效应引起的异质性（Spearman相关系数为0.107,P=0.819）,但存在非阈值效应引起的异质性（Cochrane-Q为16.89,P=0.009 7）。采用随机效应模型合并诊断指标。合并后的灵敏度为69%,95%CI：0.65-0.73,特异度为98%,95%CI：0.96-0.99。汇总阳性似然比16.37,95%CI：4.06-65.95,汇总阴性似然比0.32,95%CI：0.24-0.43。SROC曲线显示AUC为0.854 0,Q＊指数为0.785 0。敏感性分析显示本研究稳定可信,Egger漏斗图显示无明显发表偏倚。结论：血清anti-PLA2R对诊断IMN具有重要的临床价值。     

Circulating antibodies against alpha-enolase in patients with primary membranous nephropathy (MN)

MN is characterized by the glomerular deposition of IgG4 immune complexes. This suggests that nephritogenic immune responses in MN are of the Th2 T helper cell type; however, the pathogenesis of MN is still unknown. In this study we examined sera from patients with primary MN for antibodies to renal proteins. A 47-kD protein in both human and porcine renal extracts was found by immunoblotting to react specifically with serum IgG from some patients. This protein was purified from porcine kidney and identified as alpha-enolase on the basis of its partial amino acid sequences. Sera from 87 patients with primary MN, 24 patients with secondary MN (15 rheumatoid arthritis patients, nine systemic lupus erythematosus patients), and 16 healthy subjects were examined by ELISA using purified alpha-enolase. In 60 (69%) patients with primary MN and 14 (58%) patients with secondary MN, the measured optical density values, and hence serum anti-alpha-enolase antibody levels, were greater than the mean + 2 s.d. of healthy subjects. Immunoblot analysis showed that IgG1 or IgG3 was the predominant subclass (Th1 T helper cell type subclass) of antibodies against alpha-enolase in patients with primary and secondary MN. Since circulating antibodies against alpha-enolase have recently been reported in patients with various autoimmune disorders, our results suggest that a number of patients with presumed primary MN may also have abnormalities in Th1 T helper cell-mediated immune responses.     

Interferon-gamma (IFN-gamma) and IL-4 expressed during mercury-induced membranous nephropathy are toxic for cultured podocytes.

The subepithelial immune deposits of Dorus Zadel Black (DZB) rats with mercury-induced membranous nephropathy consist of autoantibodies directed to laminin P1 and of complement. The animals develop massive proteinuria within 10-14 days which is associated with obliteration of foot processes of glomerular visceral epithelial cells (GVEC), or podocytes. Previous studies indicate that these autoantibodies are probably not the sole mediator of proteinuria and GVEC damage. In this study we investigated whether circulating or macrophage-derived cytokines can contribute to the GVEC changes as detected in vivo. In vivo at the height of the proteinuria, increased intraglomerular IFN-gamma immunoreactivity was found. In diseased rats a five-fold increase in intraglomerular macrophages was found, but we could not detect intraglomerular IFN-alpha, IFN-beta, IL-1 beta or tumour necrosis factor-alpha (TNF-alpha) by using immunohistology. Subsequently, we exposed cultured GVEC to these cytokines to investigate their cytotoxic effects on several physiological and structural parameters. IFN-gamma and IL-4 were the only cytokines that exerted toxic effects, resulting in a rapidly decreased transepithelial resistance of confluent monolayers, which was closely associated with altered immunoreactivity of the tight junction protein ZO-1. IL-4 also affected vimentin and laminin immunoreactivity. IFN-gamma and IL-4 only interfered with monolayer integrity when added to the basolateral side of the GVEC, indicating specific (receptor-mediated) effects. Only IL-4 decreased the viability of the cells, and treated monolayers demonstrated an increased passage of the 44-kD protein horseradish peroxidase. From our experiments we concluded that IFN-gamma subtly affected monolayer integrity at the level of the tight junctions, and that IL-4 additionally induced cell death. We hypothesize that the toxic effects of the cytokines IFN-gamma and IL-4 as seen with cultured podocytes are necessary together with the autoantibodies, for the ultimate induction of proteinuria in mercury nephropathy in the DZB rat.     

Characterization of autoantibodies in primary membranous nephropathy and their clinical significance

Introduction: Membranous nephropathy (MN) is the most common cause of a nephrotic syndrome in Caucasian adults. The identification of target antigens in MN in the last decade has had a major impact on the clinical approach to these patients.

Areas covered: Since the discoveries in animal models in the 1980s that circulating autoantibodies induce disease upon in situ binding to glomerular podocytes, many attempts have been undertaken to define the human antigens responsible for disease induction. Only in 2009 was Phospholipase A₂ Receptor 1 described as the major antigen responsible for MN onset in about 70% of patients. Subsequently, in 2014, Thrombospondin Type-1 Domain-Containing 7A was identified as a second antigen, accounting for 2–3% of patients with MN. The knowledge of the role of these antibodies in MN has improved the diagnosis and management of patients and helped to better define the need for immunosuppressive treatment.

Expert commentary: These discoveries over the last 10 years in the discipline of nephrology have clearly shown the improvements a better understanding of disease pathogenesis can bring for patient care.     

Higher frequencies of circulating ICOS+, IL-21+ T follicular helper cells and plasma cells in patients with new-onset membranous nephropathy

Background: T follicular helper (TFH) cells and B cells are known to regulate humoral immune responses. This study is aimed at examining the putative contribution of different subsets of circulating of TFH cells and B cells to membranous nephropathy (MN).

Methods: A total of 45?MN patients and 19 healthy controls (HCs) were examined for the number of TFH cells and B cells by flow cytometry. The level of 24-h urinary protein and eGFR were calculated, and the level of serum cytokines was examined. The potential association among these measures was analyzed.

Results: Compared to the HCs, MN patients had significantly higher numbers of circulating CD4⁺CXCR5⁺, CD4⁺CXCR5⁺ICOS⁺, CD4⁺CXCR5⁺CD154⁺, CD4⁺CXCR5⁺IL-21⁺, and CD4⁺CXCR5⁺CD28⁺ TFH cells, as well as IgD⁺CD27^?CD19⁺ and CD138⁺CD19⁺ B cells. However, the number of IgD⁺CD27⁺CD19⁺ B cells was significantly lower in MN patients than in the HC. The levels of serum IL-21, IL-2, IL-4, IL-10, IL-17A, and IFN-γ were significantly higher in MN patients than in the HC. Furthermore, the numbers of CD4⁺CXCR5⁺, CD4⁺CXCR5⁺ICOS⁺, CD4⁺CXCR5⁺CD154⁺, CD4⁺CXCR5⁺IL-21⁺, CD4⁺CXCR5⁺CD28⁺ TFH cells, CD138⁺CD19⁺ B cells, and the level of sera IL-21 were negatively correlated with the values of eGFR, but positively correlated with the levels of 24-h urinary proteins. Following treatment, the numbers of CD4⁺CXCR5⁺, CD4⁺CXCR5⁺ICOS⁺, CD4⁺CXCR5⁺CD154⁺, CD4⁺CXCR5⁺IL-21⁺, CD4⁺CXCR5⁺CD28⁺ TFH cells, CD138⁺CD19⁺ B cells, and the levels of IL-21 were significantly reduced. In contrast, IL-4 and IL-10 levels were noticeably increased after treatment.

Conclusions: Data suggest that activated TFH and plasma cells may contribute to the pathogenesis of MN.     

Compared staining of the phospholipase A2 receptor in the glomeruli of Chinese adults and children with idiopathic membranous nephropathy

Background

The identification of the M-type phospholipase A2 receptor (PLA2R) is a breakthrough recognized as a major target for adults with idiopathic membranous nephropathy (IMN). However, the role PLA2R played in pediatric patients with IMN, particularly in Chinese, has yet to be determined.

The molecular and structural bases for the association of complement C3 mutations with atypical hemolytic uremic syndrome

Atypical hemolytic uremic syndrome (aHUS) associates with complement dysregulation caused by mutations and polymorphisms in complement activators and regulators. However, the reasons why some mutations in complement proteins predispose to aHUS are poorly understood. Here, we have investigated the functional consequences of three aHUS-associated mutations in C3, R592W, R161W and I1157T. First, we provide evidence that penetrance and disease severity for these mutations is modulated by inheritance of documented “risk” haplotypes as has been observed with mutations in other complement genes. Next, we show that all three mutations markedly reduce the efficiency of factor I-mediated C3b cleavage when catalyzed by membrane cofactor protein (MCP), but not when catalyzed by factor H. Biacore analysis showed that each mutant C3b bound sMCP (recombinant soluble MCP; CD46) at reduced affinity, providing a molecular basis for its reduced cofactor activity. Lastly, we show by electron microscopy structural analysis a displacement of the TED domain from the MG ring in C3b in two of the C3 mutants that explains these defects in regulation. As a whole our data suggest that aHUS-associated mutations in C3 selectively affect regulation of complement on surfaces and provide a structural framework to predict the functional consequences of the C3 genetic variants found in patients.     

THSD7A-associated membranous nephropathy in a patient with neurofibromatosis type 1

Target antigens in idiopathic membranous nephropathy (MN) include the phospholipase A2 receptor (PLA₂R), and in some cases, the thrombospondin type 1 domain-containing 7A (THSD7A). A notable phenomenon is the high rate of cancer (reported to be as high as 20%) in patients with THSD7A-associated MN. Neurofibromatosis type 1 (NF1) is an autosomal dominant disease caused by NF1 gene mutation, and clinically characterized by multiple cutaneous neurofibromas and café-au-lait spots. In this article, we report a patient with NF1 who developed THSD7A-associated MN when the NF1 skin lesions deteriorated. The patient, a 62-year-old male, was referred to us for nephrotic syndrome for 6 months. Physical examination revealed multiple cutaneous nodules throughout the entire body, and the patient noted recent increase in the numbers of these skin lesions. Cutaneous nodules excisional biopsy suggested NF1 and Sanger sequencing using genomic DNA extracted from peripheral blood revealed a previously reported heterozygous frameshift NF1 mutation (c.1541_1542delAG, p. Gln514fs). Renal biopsy revealed MN and immunohistochemistry (IHC) showed enhanced staining of THSD7A as well as PLA₂R along the glomerular basement membrane whereas the serum level of THSD7A and PLA₂R were both within normal range. The neurofibroma tissues were positive for THSD7A but not for PLA₂R on IHC. The patient did not respond to 6-month treatment with glucocorticosteroid and cyclophosphamide. In this exceptional case, strong positive staining of THSD7A in both skin and renal biopsy samples, together with the temporal association between nephrotic syndrome and skin lesions and lack of treatment response, suggested the possibility that MN could be the result of immune response to THSD7A in NF1. This report may improve understanding of the mechanistic link between MN and cancer.     

Schistosoma mansoni circulating anodic antigen but not circulating cathodic antigen interacts with complement component C1q

Adult schistosome parasites, living in the blood vessels of their mammalian hosts, protect themselves against immune damage in a variety of ways. In addition to the tegument, the intestinal epithelium of the blood-feeding worms is permanently exposed to both the innate and the acquired immune system. In this study, we investigated whether the Schistosoma gut-associated antigens CAA and CCA (circulating anodic antigen and circulating cathodic antigen, respectively), which are excreted in relatively large quantities into the host's circulation, might play a role in evading complement attack. Of several complement components tested, only purified C1q showed significant binding to CAA, a negatively charged highly glycosylated glycoprotein. CCA, also highly glycosylated, but neutral or slightly positively charged, did not bind to C1q. CAA bound only to the collagen-like stalks of C1q and not to the globular heads. No detectable interaction of CAA with precursor human CI was found and CAA did not induce activation of CI in whole human serum as assessed by consumption of hemolytic C4 activity. Also CAA could not induce activation of precursor CI in vitro. These results suggest that CAA behaves like a receptor for C1q, and might be involved in protecting the vulnerable schistosome gut against complement-mediated attack.     

电镜在心脏疾病中的研究及诊断意义

心脏疾病的病因及发病机制复杂.随着生物医学研究手段的拓展,研究者需要将分子改变与表型建立联系,电子显微镜作为观察超微结构的成熟技术,在医学领域重新成为研究者们认识疾病的重要工具.