Kidney Biopsy Teaching Case

Immune Complex Disease With a Lupus-like Pattern ofDeposition in an Antinuclear Antibody–Negative Patient

James L. Pirkle, MD,1 Barry I. Freedman, MD,1 and Agnes B. Fogo, MD2

Immune complex–mediated glomerulonephritis can be caused by a multitude of disease processes and maymanifest in a variety of histologic patterns. Lupus nephritis is an immune complex disease, the diagnosis ofwhich requires that the affected patient have systemic lupus erythematosus (SLE). In the absence of SLE, thefinding of glomerulonephritis with certain patterns of immune complex deposition characteristic of lupusnephritis has been referred to as lupus-like glomerulonephritis. Immunoglobulin G (IgG), IgA, IgM, complementC3, and C1q deposition in glomerular immune deposits is one such pattern. We report a case of immunecomplex disease in a primarily membranous distribution with mesangial, subendothelial, and tubular basementmembrane deposits with IgG, IgA, IgM, C3, and C1q deposition in a patient with proteinuria, photosensitivedermatitis, and a positive lupus anticoagulant test. The patient had 3 of the clinical criteria for SLE, thus failingto meet the diagnosis based on the American College of Rheumatology definition. In this case, a diagnosis oflupus-like glomerulonephritis was made after other causes of membranous glomerulopathy were excluded.This teaching case highlights the broad differential diagnosis of this pattern of injury and reviews similar casesin the literature.Am J Kidney Dis. 62(1):159-164. © 2013 by the National Kidney Foundation, Inc.

INDEX WORDS: Immune complex disease; antinuclear antibody (ANA) negative; full-house immunofluores-cence; lupus-like glomerulonephritis; kidney; pathology; systemic lupus erythematosus.

INTRODUCTION

Immune complex–mediated glomerulonephritis canbe caused by a multitude of disease processes andmay manifest in a variety of histologic patterns.Lupus nephritis is an immune complex disease, thediagnosis of which requires that the affected patienthave systemic lupus erythematosus (SLE). The Ameri-can College of Rheumatology currently requires thepresence of at least 4 of 11 clinical or laboratorycriteria to diagnose SLE (Box 1).1,2 In the absence ofSLE, the finding of certain patterns of immune com-plex disease characteristic of lupus nephritis has beenreferred to as lupus-like glomerulonephritis. Immuno-fluorescence staining for immunoglobulin G (IgG),IgA, IgM, complement (C3), and C1q in glomerularimmune deposits, known as a full-house stainingpattern, is one such finding characteristic of lupusnephritis.3 Other findings characteristic of lupus ne-phritis include extraglomerular immune deposits withintubular basement membranes, immune deposits withinall glomerular compartments (subendothelial, subepi-thelial, and mesangial), and tubuloretricular inclu-sions.4 We report a case of immune complex diseasein a predominant membranous pattern with mesan-gial, subendothelial, and tubular basement membranedeposits with IgG, IgA, IgM, C3, and C1q depositionin a patient with proteinuria, photosensitive dermati-tis, and a positive lupus anticoagulant test result. Thepatient had 3 of the criteria for SLE, thus failing tomeet the diagnosis based on the American College of

Rheumatology definition.

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CASE REPORT

Clinical History and Initial LaboratoryDataA 21-year-old white woman presented with a 5-year history of

proteinuria first discovered on a routine screening urinalysis at age16. Antinuclear antibody (ANA) testing was negative when protein-uria was detected, and kidney biopsy was not performed. Thepresumptive diagnosis at the time was minimal change disease,and she was managed with an angiotensin-converting enzymeinhibitor, which she had since discontinued. Additional findingsincluded occasional lower-extremity edema and an episodic rashon the arms. She otherwise felt well and had no other significantmedical history. She did not report use of nonsteroidal anti-inflammatory drugs, fever, weight loss, night sweats, diarrhea,nausea, arthritis, serositis, or miscarriage. A paternal cousin hadSLE. There was no history of illicit drug use or sexually transmit-ted disease. On examination, blood pressure was 126/72 mm Hgand a patchy erythematous rash covered the sun-exposed areas ofthe upper extremities, excluding the palms. Urinalysis showed nored blood cells, white blood cells, or casts, and 24-hour urineprotein excretion was 1.2 g. Serum creatinine level was 0.5 mg/dL(estimated glomerular filtration rate, �60 mL/min/1.73 m2 accord-ing to the 4-variable Modification of Diet in Renal Disease

From the 1Section on Nephrology, Wake Forest School ofMedicine, Winston-Salem, NC; and 2Department of Pathology,Microbiology and Immunology, Vanderbilt University MedicalCenter, Nashville, TN.

Received February 7, 2012. Accepted in revised form February14, 2013. Originally published online April 1, 2013.

Address correspondence to James L. Pirkle, MD, Section onNephrology, Wake Forest School of Medicine, Medical CenterBlvd, Winston-Salem, NC 27157-1053. E-mail jpirkle@wakehealth.edu

© 2013 by the National Kidney Foundation, Inc.0272-6386/$36.00

http://dx.doi.org/10.1053/j.ajkd.2013.02.353

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[MDRD] Study equation). Laboratory findings at presentation arelisted in Table 1. Serologic evaluation was negative for humanimmunodeficiency virus (HIV), hepatitis B, and hepatitis C andANA. Partial thromboplastin time was prolonged at 88.4 seconds,and coagulation studies were positive for lupus anticoagulantactivity.

KidneyBiopsy

Kidney biopsy revealed features of membranous glomerulopa-thy with spike appearance of the glomerular basement membraneson Jones silver stain, with mesangial expansion by numerousimmune complexes (Fig 1A). In addition, segmental sclerosis wasseen in 6 of 32 glomeruli, without endocapillary proliferation,necrosis, or crescents (Fig 1B). Immunofluorescence microscopyshowed granular capillary loop, mesangial, and tubular basementmembrane deposits staining for IgG (3� global and diffuse, on0-3� scale), IgA (trace segmental), IgM (1� segmental), C3 (3�global and diffuse), and C1q (trace segmental; Fig 2A and B).Corresponding global subepithelial and mesangial deposits, withrare small subendothelial deposits, extensive foot-process efface-

Box 1. ACR Criteria for the Diagnosis of SLE

● Malar rash● Discoid rash● Photosensitivitya

● Oral ulcers● Nonerosive arthritis● Pleuritis or pericarditis● Kidney disordera

● Neurologic disorder● Hematologic disorder● Immunologic disordera

● Positive antinuclear antibody

Sources: Tan et al1 and Hochberg.2aThis patient had 3 of 11 criteria: (1) photosensitivity, (2) renal

disorder (protein excretion �0.5 g/24 h), and (3) immunologicdisorder (positive test result for lupus anticoagulant).

Table 1. Laboratory Findings

Parameter Value

White blood cells (�103/�L) 8.4

Hemoglobin (g/dL) 16.0

Platelet count (�103/�L) 221

Serum albumin (g/dL) 3.9

Serum creatinine (mg/dL) 0.5

eGFR (mL/min/1.73 m2) �60

Partial thromboplastin time (s) 88.4

Erythrocyte sedimentation rate (mm/h) 13

Complement C3 (mg/dL)a 104

Complement C4 (mg/dL)b 10

Note: Conversion factor for serum creatinine in mg/dL to�mol/L, �88.4.

Abbreviation: eGFR, estimated glomerular filtration rate.aReference range, 90-180 mg/dL.

bReference range, 10-40 mg/dL.

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ment, and scattered tubular basement membrane deposits werefound by electron microscopy (Fig 3A and B). Tubuloretricularinclusions were not identified.

DiagnosisThe diagnosis of immune complex–mediated glomerulonephri-

tis in a predominant membranous pattern was made by kidneybiopsy. The presence of immune complexes in the mesangial andsubendothelial areas was suggestive of a secondary cause ratherthan primary, and the distribution of the immune complexes andIgG, IgA, IgM, C3, and C1q deposition suggested lupus as anunderlying cause. Given her age at initial presentation, time courseof the proteinuria, lack of other historical or laboratory evidencefor chronic infection, and histologic findings characteristic of

Figure 1. (A) The glomerular basement membrane is thick-ened with small spikes on Jones silver stain, representing areaction to the subepithelial deposits, characteristic of a membra-nous pattern process. In tangential areas of sectioning, a cork-board-type hole appearance is evident because the deposits donot stain with silver stain (original magnification, �100).(B) Usual-type segmental sclerosis and mesangial expansionwith mild increase in mesangial cellularity are evident. There isno endocapillary proliferation, necrosis, or broad-based adhe-sion to support that this sclerosis is due to past active prolifera-tive lesions. Glomerular basement membranes are prominentdue to numerous subepithelial deposits and basement mem-brane reaction, visualized on silver stain (periodic acid–Schiffstain; original magnification, �40).

lupus nephritis with 3 clinical criteria for SLE, we made the

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Lupus-like Glomerulonephritis

diagnosis of membranous glomerulopathy secondary to lupus-likeglomerulonephritis.

Clinical Follow-upGiven the patient’s clinical stability for the prior 5 years and the

absence of other high-risk clinical or histologic features, she wastreated conservatively with losartan, 100 mg daily. Serologictesting 4 months after the initial serologic tests showed a secondnegative result for ANA and negative results for anti–double-stranded DNA (anti-dsDNA), anti-Smith (anti-Sm), anti-ribonucleo-protein (anti-RNP), anti-Ro, and anti-La. Furthermore, proteinuriadecreased to protein excretion of 900 mg/24 h, serum creatininelevel remained stable at 0.6 mg/dL (estimated glomerular filtrationrate �60 mL/min/1.73 m2), and no new signs or symptoms of SLEdeveloped.

DISCUSSION

The differential diagnosis of immune complex–

Figure 2. (A) There is granular diffuse global capillary loopand mesangial staining in full-house pattern, with focal granulartubular basement membrane staining (anti–immunoglobulin G[IgG] immunofluorescence; original magnification, �40). (B) Tu-bular basement membranes show focal granular staining (anti-IgG immunofluorescence; original magnification, �80).

mediated glomerulonephritis is broad and in a case

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such as this with predominant membranous pattern ofdeposition, includes both primary and secondarycauses of membranous glomerulopathy. The immuno-genic antigens involved in the pathogenesis of pri-mary membranous glomerulopathy had long re-mained elusive, but recent research identified theM-type phospholipase A2 receptor (PLA2R) as a ma-jor target antigen in this disease.5 Circulating autoan-tibodies to PLA2R were found in 70% of patients withprimary membranous glomerulopathy compared to

Figure 3. (A) Glomerular basement membrane with evenlydistributed subepithelial deposits with intervening basement mem-brane reaction, with rare small subendothelial deposits (arrows).There also were frequent mesangial deposits (not shown) (trans-mission electron microscopy; original magnification, �11,000).(B) Tubular basement membrane deposits are evident (transmis-

sion electron microscopy; original magnification, �7,100).

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none in those with secondary causes.5 In anothercohort, some patients with primary membranous glo-merulopathy without detectable circulating antibodieshad detectable PLA2R within glomerular immunedeposits.6 In cases of membranous glomerulopathywithout features suggestive of a secondary cause orfor which primary disease appears likely, serologictesting for autoantibodies to the PLA2R is recom-mended. Immunostaining of the kidney biopsy speci-men also may be helpful to identify PLA2R within thedeposits. Identification of specific IgG subclasses ex-pressed in both primary membranous glomerulopathyand (secondary) membranous lupus nephritis demon-strated that IgG1, IgG2, and IgG3 subclasses tend tobe expressed highly in membranous lupus nephritis,whereas IgG1 and IgG4 tend to be expressed inprimary membranous glomerulopathy.7,8 Studiesevaluating IgG subclasses to distinguish between the2 diagnoses have shown variable accuracy, but accu-racy was as high as 88% when using a decision treethat incorporated the location of the subclasses withinthe glomerulus.8

In our case, the findings of immune complex depo-sition in subendothelial, mesangial, and extraglomeru-lar compartments suggested that the cause of theglomerulopathy was secondary rather than primary,9

and testing for PLA2R and IgG subclasses was notperformed.

Causes of secondary membranous glomerulopathyare many and can be divided into 3 major categories:systemic diseases, drugs and toxins, and infections.10

The systemic diseases diabetes mellitus, sickle celldisease, Guillain-Barré syndrome; cancers (includingcarcinoma, lymphoma, and chronic lymphocytic leu-kemia); and autoimmune diseases (including SLE,rheumatoid arthritis, Sjögren syndrome, sarcoidosis,and bullous pemphigoid) have all been associatedwith membranous glomerulopathy. A variety of drugsand toxins have been identified as causal agents,including the commonly used captopril, clopidogrel,and nonsteroidal anti-inflammatory drugs. Gold saltsand penicillamine, drugs historically used to treatrheumatoid arthritis, and toxins such as hydrocarbons,formaldehyde, mercury, and solvents have all beenassociated with membranous glomerulopathy. Infec-tious causes must be considered carefully before asecondary cause is attributed to an autoimmune dis-ease because treatment with immunosuppressiveagents in such cases could have catastrophic conse-quences. In developed countries, hepatitis B, hepatitisC, streptococcal infections, bacterial abscesses, andsyphilis are potential causes that should be consid-ered. In addition, malaria, schistosomiasis, tuberculo-sis, leprosy, and filariasis must be considered in devel-

oping countries.10

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Deposition of IgG, IgA, IgM, C3, and C1q inimmune deposits, as in this case, serves to narrow thedifferential diagnosis of secondary membranous glo-merulopathy. This finding, when considered by itself,whether in a primarily membranous, mesangial, orproliferative lesion, is highly characteristic of but notspecific for lupus nephritis. Such immunoglobulinand complement deposition is seen in several glomer-ular diseases, which usually present with a mesan-gioproliferative or endocapillary proliferative lesion,including HIV glomerulonephritis and parasitic infec-tions, and has been reported in glomerulonephritisassociated with cirrhotic liver disease.11 Schistosomia-sis, a parasitic infection that causes chronic illnessoften with hepatosplenomegaly, can cause membra-nous glomerulopathy with deposition of IgG, IgA,IgM, and complement components, as well as IgE.12

Two other entities are worth mentioning whenconsidering the differential diagnosis of an immunecomplex–mediated glomerulonephritis such as theone in our case: dysproteinemias and C1q nephropa-thy. Dysproteinemias typically cause readily identifi-able injury patterns in the kidney, including myelomacast nephropathy, amyloidosis, and monoclonal immu-noglobulin deposition disease.13 Less commonly, dys-proteinemias can result in glomerular deposits of IgGthat mimic immune complex glomerulonephritis. Arecent case series reported on 37 patients with primar-ily membranoproliferative and endocapillary prolifera-tive injury patterns with occasional membranous fea-tures with monoclonal IgG deposition. The depositshad the granular and nonorganized appearance ofimmune complex deposits. Mean age of the patientswas 54.5 years, with two-thirds older than 50 years.14

We did not stain for light chains in our patient due toher young age, but in middle-aged or older adults orcases with a high suspicion for dysproteinemia, thisassay would be indicated. C1q nephropathy is a pat-tern of immune complex–mediated glomerulonephri-tis that is characterized by predominant mesangialC1q deposition, but with other features resemblinglupus nephritis. In a retrospective case review, Shar-man et al15 determined that some cases of immunecomplex–mediated glomerulonephritis with IgG, IgA,IgM, C3, and C1q deposition in ANA-negative pa-tients not meeting the clinical criteria for SLE met thecriteria for C1q nephropathy. Those cases had domi-nant C1q staining, in keeping with the diagnosis ofC1q nephropathy, unlike our patient, in whom onlyminor C1q staining was present.

Although certain features of immune complex glo-merulonephritis are fairly characteristic of lupus ne-phritis, this diagnosis requires that the patient haveSLE. When SLE is absent, the findings of: (1) IgG,

IgA, IgM, C3, and C1q deposition; (2) extraglomeru-

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Lupus-like Glomerulonephritis

lar immune deposits within tubular basement mem-branes; (3) immune deposits within all glomerularcompartments (subendothelial, subepithelial, and mes-angial); and (4) tubuloretricular inclusions are sugges-tive of a lupus-like glomerulonephritis.4,9 Our casedemonstrated the first 3 findings; however, tubulore-tricular inclusions were absent. Although rare suben-dothelial deposits were present by electron micros-copy in our case, there was no endocapillaryproliferation by light microscopy to suggest the diag-nosis of an active focal proliferative glomerulonephri-tis. Furthermore, segmental scars were present, butthe sclerosis showed a not otherwise specified pheno-type, without the broad-based adhesions to specifi-cally suggest they were the result of scarring ofprevious more active proliferative lesions.16,17 Evenidiopathic membranous glomerulopathy may developsecondary segmental sclerosis lesions due to chronicinjury, and thus the presence of segmental scars in thiscase also could represent merely a chronic sequela ofthe membranous pattern injury.

It has been suggested that these lupus-like lesionsmay represent a kidney-limited form of SLE.18 Suchpatients may or may not have other signs and symp-toms of SLE, but fail to meet American College ofRheumatology criteria for the diagnosis. However,case-based evidence suggests that these patients maybe at risk of evolving into SLE in the future. Reportshave described glomerulopathies suggestive of lupusnephritis in patients lacking clinical or biochemicalevidence of SLE in whom ANAs initially were absentand became detectable after several years of follow-up.11,19 Other reports have described patients who hadimmune complex disease with IgG, IgA, IgM, C3, andC1q deposition suggestive of lupus nephritis, as wellas other clinical criteria for SLE, but with negativetest results for ANA.20,21 Nakahara et al22 reported acase of glomerulopathy in a patient without SLE whodeveloped lupus in later years. That patient lackedIgG, IgA, IgM, C3, and C1q deposition, but hadtubuloretricular inclusions. Many of these cases wereyoung women or girls, as in our case. A recent seriesdocumented 4 cases of lupus-like glomerulonephritiswith proliferative lesions in adult women with vari-able clinical presentations. Two of the 4 had negativetest results for ANA, and none had SLE based onAmerican College of Rheumatology criteria.4

The patient in this case and patients in several ofthe other reports reviewed here had negative testresults for ANA. Research involving the pathogenesisof lupus nephritis often focuses on the role of ANAsin immune complex formation, either as circulatingentities ultimately deposited in the glomerulus or within situ formation.11,19 In patients with lupus nephritis

and negative ANA results, the possibility of a false-

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negative test result must be considered. The reasonsfor this are well documented and include technicaland clinical factors.23 Furthermore, the test for ANAcan be negative while a test for specific antibodiesagainst a particular component of nuclear material,such as anti-dsDNA antibodies, may be positive.Recent attention has turned toward the nucleosome, orDNA-histone complex, as the antigenic factor in lu-pus nephritis.24 Dysfunctional apoptosis or poor clear-ing of apoptotic cells may cause release of nucleo-somes into the circulation.25 Antibodies to circulatingnucleosomes may cross-react with other componentsof the glomerular basement membrane or bind tonucleosomes deposited in the glomerular basementmembrane.26 The formation of nucleosome-specificantibodies appears to precede the appearance of anti-dsDNA and anti-histone antibodies as a result ofepitope spreading.25

In the absence of SLE, immune complex–mediatedglomerulonephritis may be suggestive of lupus nephri-tis given certain histologic features; so called lupus-like glomerulonephritis. Other causes of immune com-plex disease must be excluded before considering adiagnosis of lupus-like glomerulonephritis, especiallyinfectious causes. The reported cases suggest thatsuch patients need to be monitored for the develop-ment of frank SLE.

ACKNOWLEDGEMENTSSupport: None.Financial Disclosure: The authors declare that they have no

relevant financial interests.

REFERENCES1. Tan EM, Cohen AS, Fries JF, et al. The 1982 revised criteria

for the classification of systemic lupus erythematosus. ArthritisRheum. 1982;25:1271-1277.

2. Hochberg MC. Updating the American College of Rheuma-tology revised criteria for the classification of systemic lupuserythematosus. Arthritis Rheum. 1997;40:1725.

3. Cameron JS. Lupus nephritis. J Am Soc Nephrol. 1999;10:413-424.

4. Huerta A, Bomback AS, Liakopoulos V, et al. Renal-limited‘lupus-like’ nephritis. Nephrol Dial Transplant. 2012;27(6):2337-2342.

5. Beck LH Jr, Bonegio RGB, Lambeau G, et al. M-Typephospholipase A2 receptor as target antigen in idiopathic membra-nous nephropathy. N Engl J Med. 2009;361:11-21.

6. Debiec H, Ronco P. PLA2R autoantibodies and PLA2Rglomerular deposits in membranous nephropathy. N Engl J Med.2011;364:689-690.

7. Imai H, Hamai K, Komatsuda A, et al. IgG subclasses inpatients with membranoproliferative glomerulonephritis, membra-nous nephropathy, and lupus nephritis. Kidney Int. 1997;51:270-276.

8. Song YS, Min KW, Kim JH, et al. Differential diagnosis oflupus and primary membranous nephropathies by IgG subclass

analysis. Clin J Am Soc Nephrol. 2012;7:1947-1955.

163

Pirkle, Freedman, and Fogo

9. Jennette JC, Iskandar SS, Dalldorf FG. Pathologic differentia-tion between lupus and nonlupus membranous glomerulopathy.Kidney Int. 1983;24:377-385.

10. Ponticelli C. Membranous nephropathy. J Nephrol. 2007;20:268-287.

11. Baskin E, Agras PI, Menekse N, et al. Full-house nephropa-thy in a patient with negative serology for lupus. Rheumatol Int.2007;27:281-284.

12. van Velthuysen ML, Florquin S. Glomerulopathy associ-ated with parasitic infections. Clin Microbiol Rev. 12000;3:55-66,table.

13. Markowitz GS. Dysproteinemia and the kidney. Adv AnatPathol. 2004;11:49-63.

14. Nasr SH, Satoskar A, Markowitz GS, et al. Proliferativeglomerulonephritis with monoclonal IgG deposits. J Am Soc Neph-rol. 2009;20:2055-2064.

15. Sharman A, Furness P, Feehally J. Distinguishing C1qnephropathy from lupus nephritis. Nephrol Dial Transplant. 2004;19:1420-1426.

16. Giannico G, Fogo AB. Lupus nephritis: is the kidney biopsycurrently necessary in the management of lupus nephritis? ClinJ Am Soc Nephrol. 2013;8(1):138-145.

17. Weening JJ, D’Agati VD, Schwartz MM, et al. The classifi-cation of glomerulonephritis in systemic lupus erythematosus

revisited. J Am Soc Nephrol. 2004;15:241-250.

164

18. Jones E, Magil A. Nonsystemic mesangiopathic glomerulo-nephritis with “full house” immunofluorescence. Pathological andclinical observation in five patients. Am J Clin Pathol. 1982;78:29-34.

19. Gianviti A, Barsotti P, Barbera V, et al. Delayed onset ofsystemic lupus erythematosus in patients with “full-house” nephrop-athy. Pediatr Nephrol. 1999;13:683-687.

20. Caltik A, Demircin G, Bulbul M, et al. An unusual case ofANA negative systemic lupus erythematosus presented with vascu-litis, long-standing serositis and full-house nephropathy. Rheuma-tol Int. 2013;33(1):219-222.

21. Kim HA, Chung JW, Park HJ, et al. An antinuclear antibody-negative patient with lupus nephritis. Korean J Intern Med. 2009;24:76-79.

22. Nakahara C, Hayashi D, Kinugasa H, et al. Delayed onset ofsystemic lupus erythematosus in a child with endothelial tubulore-ticular inclusion. Clin Nephrol. 2001;56:332-335.

23. Maddison PJ. ANA-negative SLE. Clin Rheum Dis. 1982;8:105-119.

24. Burlingame RW, Cervera R. Anti-chromatin (anti-nucleo-some) autoantibodies. Autoimmun Rev. 2002;1:321-328.

25. Pisetsky DS. Anti-DNA and autoantibodies. Curr OpinRheumatol. 2000;12:364-368.

26. van Bavel CC, Fenton KA, Rekvig OP, et al. Glomerulartargets of nephritogenic autoantibodies in systemic lupus erythem-

atosus. Arthritis Rheum. 2008;58:1892-1899.

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