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Pathologic Differentiation Between Lupus and Nonlupus Membranous Glomerulopathy

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Pathologic Differentiation Between Lupus and Nonlupus Membranous Glomerulopathy View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Kidney International, Vol. 24 (1983), pp. 377—385 Pathologic differentiation between lupus and nonlupus membranous glomerulopathy J. CHARLES JENNETTE, SAMY S. ISKANDAR, and FREDERIC G. DALLDORF Department of Pathology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Pathologic differentiation between lupus and nonlupus membranous sans lupus erythCmateux disséminé cliniquement patent. Les valeurs glomerulopathy. The following clinical and pathologic features were predictives positives/negatives de certaines des caracteristiques patho- evaluated in 170 patients with electron microscopically documented logiques étudiées sont les suivantes: depOts denses mésangiaux 63/99, membranous glomerulopathy: age, sex, race, American Rheumatism depOts denses sous-endothéliaux 77/93, inclusions tubuloréticulaires Association lupus criteria, serum ANA, serum complement, glomerular 61/96, depOts intenses de Clq 47/95, depOts dans Ia membrane basale hypercellularity, stage of subepithelial dense deposits, endothelialtubulaire 100/87, et hypercellularitC glomerulaire 26/86. tubuloreticular inclusions, tubular basement membrane deposits, tissue ANA, glomerular deposition of IgG, 1gM, IgA, C3, C4, and Clq. At the time of biopsy 148 patients had no clinical evidence for lupus, and 22 The characteristic light, immunofluorescence, and electron had a clinical diagnosis of lupus. Six additional patients eventually microscopic features of membranous glomerulopathy (MG) developed overt lupus after an average of 12 months. Incidences ofhave been described thoroughly [lii. That MG occurs as one serologic and pathologic features in lupus as compared with nonlupus membranous glomerulopathy were determined. These data were used variant of lupus nephritis is also well recognized [2]. In a patient to calculate sensitivity, specificity, positive and negative predictive with clinically diagnosed systemic lupus erythematosus (SLE), values, and overall efficiency of each parameter in differentiatingidentification of MG in a renal biopsy is presumed to indicate a between lupus and nonlupus membranous glomerulopathy. In general, common pathogenesis for the MG and SLE, thus leading to a serologic, morphologic and immunohistopathologic features are more accurate at ruling out lupus than making the diagnosis of lupus.diagnosis of lupus MG (LMG). However, a number of features are significantly more frequent in lupus Certain pathologic features are known to occur more fre- membranous glomerulopathy. Therefore, identification of these fea- quently in LMG than in nonlupus MG (NLMG) [31.However, tures, especially more than one, warrants a high suspicion of lupus when these pathologic features suggesting LMG occur in a rather than nonlupus membranous glomerulopathy even in patients patient with no clinical diagnosis of SLE, how accurately can without clinically overt systemic lupus erythematosus. The positive/ne- gative predictive values of some of the pathologic features studied are they identify those patients with unrecognized or nascent SLE? as follows: mesangial dense deposits 63/99, subendothelial dense depos- To address this question, we determined how often selected its 77/93, tubuloreticular inclusions 61/96, intense CIq deposition 47/95, serologic, morphologic or immunohistopathologic features tubular basement membrane deposits 100/87, and glomerular hypercel- were present in patients with MG who had (1) no clinical lularity 26/86. diagnosis of SLE; (2) a diagnosis of SLE made at some interval Differentiation pathologique entre glomérulopathie extra-membraneuse after biopsy or; (3) a diagnosis of SLE made during or before lupique et non lupique. Les caractCristiques cliniques et pathologiques the hospital admission when the biopsy was performed. The suivantes ont été évaluCes chez 170 malades atteints de glomerulopathie features studied were serum antinuclear antibodies (AN A), extra-membraneuse documentée par microscopic électronique: l'age, Ic sexe, Ia race, les critCres de lupus de l'American Rheumatism Associa- hypocomplementemia, glomerular hypercellularity, mesangial tion, les ANA seriques, Ic complement sérique, l'hypercellularitedense deposits, subendothelial dense deposits, endothelial tu- glomCrulaire, Ic stade des dCpôts denses sous-epithCliaux, les inclusions buloreticular inclusions, tubular basement membrane deposits, endothCliales tubuloréticulaires, les depots dans Ia membrane basalebiopsy tissue ANA reaction, and glomerular deposition of IgG, tubulaire, les ANA tissulaires, les depOts glomCrulaires d'IgG, 1gM, IgA, 1gM, C3, C4, and Clq. These data were then used to IgA, C3, C4, et Clq. Au moment de Ia biopsie, 148 malades n'avaient pas d'argument clinique pour un lupus, et 22 avaient un diagnosticcalculate the sensitivity, specificity, positive predictive value, clinique de lupus. Six malades supplémentaires ont dCveloppé un lupus negative predictive value and overall efficiency of each serolog- patent aprCs une moyenne de 12 mois. L'incidence des caractCristiques ic, morphologic, or immunohistopathologic feature in discrimi- serologiques et pathologiques dans Ia glomerulopathie extra-membran- nating between NLMG and LMG. euse lupique ou non lupique a été déterminée. Ces donnCes ont été utilisCes pour calculer Ia sensibilité, Ia spécificité, les valeurs prédic- Methods tives positives et negatives, et l'efficacité globale de chaque paramétre pour différencier entre glomerulopathie extramembraneuse lupique ou Case selection. The working definition of MG used required non lupique. D'une facon générale, les caractéristiques serologiques, the ultrastructural identification of regularly distributed sub- morphologiques et immunohistopathologiques sont plus puissantes pour éliminer le lupus que pour faire Ic diagnostic de lupus. Cependant, un certain nombre de caracteristiques sont significativement plus frequentes dans Ia glomerulopathie extra-membraneuse lupique. C'est Received for publication November 26, 1982 pourquoi Ia misc en evidence de ces caractéristiques, surtout s'il y en a and in revised form February 16, 1983 plus dune, apporte une forte suspicion de glomérulopathie extra- membraneuse plus lupique que non lupique, mCme chez des malades © 1983 by the International Society of Nephrology 377 378 Jennette et a! epithelial dense deposits (or their stage 3 or 4 intramembranoused mesangial, electron dense deposits had to be internal to a variants) without large subendothelial deposits. Unlike somerecognizable paramesangial basement membrane (Fig. I). This definitions of LMG that would relegate a MG patient with anyrequirement was to prevent mistaken identification as mesan- subendothelial deposits to a category of proliferative lupusgial deposits tangentially cut subepithelial deposits or subepi- nephritis [4], small subendothelial deposits (Fig. 1) did notthelial deposits on a majority of cases, one of the authors exclude a patient from our MG series. And, in fact, most MGevaluated contiguous capillary loops (Fig. 2). In a majority of patients with small subendothelial deposits had no glomerularcases, one of the authors evaluated the initial immunofluores- hypercellularity. Since the value of glomerular hypercellularitycence microscopic preparations, and in all other cases from in differentiating between LMG and NLMG was to be evaluat-which immunofluorescence microscopic data were used, recuts ed, this feature did not exclude a MG patient either. However,from the —70°C stored blocks were examined by the same patients with regularly distributed subepithelial deposits andauthor. The degree of immunofluorescence was quantitated conspicuous subendothelial deposits were excluded from the from 0 to 4+. study. These patients often had diffuse hypercellularity and Statistical analysis. To evaluate the diagnostic accuracy of characteristics of either diffuse proliferative, mixed membra-pathologic differentiation between LMG and NLMG the meth- nous and proliferative, or type 3 membranoproliferativeods of Galen and Gambino [7] were applied. A determination glomerulonephritis. was designated a true positive (TP) if positive in a LMG patient, A total of 170 patients were studied. Although some patientsa false positive (FP) if positive in a NLMG patient, a true had repeat biopsies, only data from the first biopsy specimennegative (TN) if negative in a NLMG patient, and a false were used for compilation. One hundred forty-eight patientsnegative (FN) if negative in a LMG patient. The sensitivity (SN) found to have MG had no clinical diagnosis of SLE made beforeof a parameter is the incidence of TP results in LMG patients or during the hospital admission when the biopsy was per- [(TP) (TP+FN)x (100)] and is therefore equivalent to the formed. We evaluated followup clinical data on 78 of these incidence of a given feature in LMG patients. The specificity patients for an average of 25 months per patient (range, 4 to 92 (SP) is the incidence of TN results in NLMG patients [(TN) months). Six of these 78 patients subsequently had SLE recog- (TN+FP)x (100)]. The positive predictive value (PPV) is the nized clinically after an average followup of 12 months. Twen-percent positive results that are true positives in the total ty-two patients had a clinical diagnosis of SLE made before orpopulation of MG patients [(TP) ÷ (TP +FP)x (100)]. The during the hospital admission when the biopsy was performed.
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