Anti-glomerular basement membrane disease superimposed on membranous nephropathy: a case report and review of the literature

Abstract

Introduction: Anti-glomerular basement membrane disease is a rare autoimmune disorder characterized by pulmonary hemorrhage, crescentic glomerulonephritis and the presence of circulating anti-glomerular basement membrane antibodies. The simultaneous occurrence of both anti-glomerular basement membrane disease and membranous nephropathy is rare.

Case presentation: A 59-year-old Hispanic man presented with acute onset of nausea and vomiting and was found to have renal insufficiency. Work-up included a kidney biopsy, which revealed anti-glomerular basement membrane disease with underlying membranous nephropathy. He was treated with emergent hemodialysis, intravenous corticosteroids, plasmapheresis, and cyclophosphamide without improvement in his renal function.

Conclusion: Simultaneous anti-glomerular basement membrane disease and membranous nephropathy is very rare. There have been 16 previous case reports in the English language literature that have been associated with a high mortality and morbidity, and a very high rate of renal failure resulting in hemodialysis. Co-existence of membranous nephropathy and anti-glomerular basement membrane disease may be immune-mediated, although the exact mechanism is not clear.

Figure 1

Light microscopy revealed cellular crescents in all sampled 20 glomeruli with extensive fibrinoid necrosis and neutrophil margination.

Figure 2

Immunofluorescence findings of linear glomerular capillary wall positivity of 3 + intensity for IgG with 1-2+ C3, 3+ kappa and 2+ lambda support the diagnosis of anti GBM disease.

Figure 3

Electron microscopy showed global subepithelial deposits which is diagnostic for underlying membranous glomerulopathy stage 3.