Pediatric Nephrology
https://doi.org/10.1007/s00467-020-04786-y
CLINICAL QUIZ
A rare complication of pauci-immune crescentic glomerulonephritis
in a child: Answers
Sidharth Kumar Sethi 1 & Abhyuday Rana 2 & Shyam Bihari Bansal 2 & Alka Rana 3 & Dinesh Kumar Yadav 2 & Kritika Soni 2 &
Marie-Agnès Dragon-Durey 4 & Rupesh Raina 5 & Vijay Kher 2
Received: 22 August 2020 / Accepted: 15 September 2020
# IPNA 2020
Keywords Child . Pauci-immune crescentic glomerulonephritis . Thrombotic microangiopathy . aHUS . Alternative complement
pathway . Anti-factor H antibodies . CFHR1 and CFHR3 duplication
Answers
1. Activation of alternative complement pathway should be
kept in mind in a selected subset of patients with ANCA-
negative pauci-immune crescentic glomerulonephritis
(PICGN) who present with hemolysis and
thrombocytopenia.
2. Investigations for evaluation of alternative complement
pathway genes, anti-factor H antibodies, and multiplex
ligation probe amplification for deletions in CFHR genes.
3. Complement blocker eculizumab or plasma exchanges
(with plasma as replacement fluid) should be initiated as
soon as possible.
Plasma exchanges were restarted in the child, but this time,
she received plasma replacement instead of albumin. A
Both Sidharth Sethi and Abhyuday Rana shall be first authors
This refers to the article that can be found at https://doi.org/10.1007/
s00467-020-04784-0.
* Sidharth Kumar Sethi
sidsdoc@gmail.com
1
Pediatric Nephrology, Kidney Institute, Medanta the Medicity,
Gurgaon, Haryana 122001, India
2
Kidney Institute, Medanta the Medicity, Gurgaon, Haryana 122001,
India
3
Department of Pathology, Medanta the Medicity,
Gurgaon, Haryana 122001, India
4
Université de Paris, Hôpital Européen Georges Pompidou, APHP,
INSERM UMRS1138, Paris, France
5
Pediatric Nephrology, Akron Children’s Hospital, Cleveland, OH,
USA
detailed complement assay yielded anti-factor H antibodies
(Table 1) with a titer of 295 A U /L. The decision to start
eculizumab therapy was withheld due to monetary constraints.
After 5 sessions of total plasma exchanges (TPE) with plasma
replacement hemolysis resolved, the patient’s condition im-
proved gradually thereafter (serum creatinine (sCr) stabilized
at 2.2 mg/dL; Hb 8.4 g/dL) (Fig. 1), and on achieving hema-
tological remission, she was discharged with advice to contin-
ue alternate day TPE, monthly intravenous cyclophospha-
mide, and daily oral steroids. Repeat anti-factor H antibodies
sent on discharge showed a rise of titer to 960 AU /L. She was
lost to follow-up and expired 2 months later at home.
The clinical exome sequencing report came back later and
showed no mutations in genes of complement H, I, B, CD46,
thrombomodulin, or DGKE. Multiplex ligation-dependent probe
amplification (MLPA) revealed homozygous duplications in
CFHR1 and CFHR3 genes with a probe ratio of 1.8–2.17. The
duplication involved the upstream region; exons 1, 2, 3, and 6 and
intron 4 of CFHR3 gene; and exons 3, 5, and 6 of CFHR1 gene.
Commentary
Complement proteins provide an important line of defense,
which on activation generates several fragments that have
pro-inflammatory and cytolytic effects. ANCA-associated
vasculitis (AAV) has a complex pathophysiology that in-
volves ANCA development (an autoimmune response) and
damage processes [1, 2], which appears to be driven by the
priming of neutrophils and their activation and interaction
with the complement system [3]. The role of the complement
system has recently regained importance in the pathogenesis
of kidney diseases. In murine models of AAV, complement
depletion of the terminal pathway component C5 or the
 Pediatr Nephrol

Table 1 Antigenic and genetic results of complement assay TMA due to aberrant complement activation. This finding
05/05/17 02/06/17 Normal values adds to growing evidence suggesting complement activation
as a pivotal step in the pathogenesis and evolution of these two
Antigenic complement analysis distinct pathologic entities.
CH50 0 < 10% 70–130% Our understanding of immune-mediated glomerular dis-
C3 Ag 469 1190 660–1250 mg/L eases is still evolving. A role for complement activation in
C4 Ag 93 381 93–380 mg/L AAV has emerged in recent understandings of AAV patho-
Factor H Ag 65 99 65–140% genesis. Until recently, it was commonly accepted that serum
Factor I Ag 41 112 70–130% C3 and C4 levels remain within normal ranges in AAV pa-
Anti-factor H Ab Positive Positive – tients, which probably led to an underestimation of the path-
Anti-factor H titer 295 960 < 100 ogenic importance of the complement system in AAV.
CD46 13.7 – Interestingly, up to one-third of patients with pauci-immune
C3 nephritic factor – – glomerulonephritis have negative ANCA serology. These pa-
Gene sequencing: normal sequencing for complement factor H, B, I, CD tients generally have less constitutional symptoms and
46, thrombomodulin, DGKE, normal clinical exome sequencing extrarenal manifestations but present with more severe kidney
Multiplex ligation-dependent probe amplification: homozygous duplica- involvement than ANCA-positive patients [2]; however, ab-
tions in CFHR1 and CFHR3 genes with a probe ratio of 1.8–2.17 errant complement activation is more commonly reported in
this subset of disease [5].
Animal studies suggest that complement activation, via the
alternative pathway (AP) component factor B prevented de- alternative pathway, is crucial for disease development, prov-
velopment of disease [4]. ing previous assumptions fallacious [9]. Xing et al. using kid-
There is growing evidence that the activation of the AP and ney biopsy specimens from patients with MPO-ANCA-
terminal pathway of complement is much more pronounced in positive PICGN showed immunofluorescence staining for
ANCA-negative patients than in PR3- and MPO-positive MAC, C3d, factor B, and factor P in glomeruli and small
cases [5]. Routine kidney biopsy examination of complement blood vessels, confirming a role of alternative complement
proteins typically involves staining for only C1q and C3; pathway activation [10]. Biopsy specimens from patients with
hence, determination of alternative pathway activation is not AAV and renal-limited PICGN show deposition of compo-
possible in all such cases. nents of the alternative complement pathway (AP) but no
There are not many reports of thrombotic microangiopathy staining for C4d, a marker of the classic and the lectin pathway
(TMA) in renal AAV patients [6–8]. Here, we present an [11].
unusual case of a young female with biopsy-proven PICGN Disease secondary to genetic abnormalities or circulating
(ANCA negative) whose clinical course was worsened by antibodies that impairs the activity of the redundant regulatory

Fig. 1 Timeline of hemolysis and

C3 levels with plasmapheresis
Pediatr Nephrol
proteins of the alternative complement pathway (AP) can
complicate the natural course of ANCA-associated glomeru-
lonephritis [12] as seen in our patient. Even though our patient
had normal complement levels at the outset, C3 levels started
showing a decreasing trend way before TMA had set in
completely. Thus, it could be inferred that alternative comple-
ment activation had begun prior to TMA development and
hence played a pivotal role in the pathogenesis of PICGN in
our patient.
As highlighted by Sethi et al., findings of paramount com-
plement activation in ANCA-negative pauci-immune GN
may be due to underlying AP abnormality [5]. Our patient
was found to have anti-factor H antibodies and homozygous
duplication in CFHR1 and CFHR3 genes. Although the du-
plication detected in our patient is a variant of unknown sig-
nificance, after correlating it with the current clinical scenario,
it seemed likely that the duplication rendered the AP over-
active and led to the development of TMA and possibly
PICGN in our patient. It is likely that the ensuing glomerular
injury due to atypical hemolytic uremic syndrome (aHUS)
may have accentuated crescent formation and worsened over-
all prognosis [13].
Although this case could be labeled under the umbrella of
C3 glomerulopathy (C3 glomerulonephritis) given the C3
staining on immunofluorescence studies in mesangium and
focally around capillary walls, the absence of immune com-
plexes on electron microscopy rules out an underlying C3
glomerulopathy.
Sathe et al. has reported the development of aHUS in a
pediatric patient 6 months after being diagnosed with
biopsy-proven ANCA [7]. The child was found to have
anti-factor H antibodies and a low serum C3 level, but no
genetic studies were undertaken. Manenti et al. conducted
a study on 46 patients with ANCA vasculitis [12]. Of
thirty patients who underwent biopsy, only eight showed
histological evidence of TMA. This subgroup had a dra-
matically worse death-censored kidney survival, caution-
ing that TMA in ANCA disease may be under-recognized
both clinically and on biopsy. No evidence of TMA was
found in our biopsy (on light microscopy or electron mi-
croscopy), and we did not undertake a second biopsy to
histologically document TMA in our case. Due to exhaus-
tion of sample, we could not get a retrospective compre-
hensive complement staining on the biopsy.
In our patient, it is noteworthy to mention that plas-
ma exchange with albumin replacement led to short-
lived clinical improvement in our patient and was
quickly followed by the development of TMA. It is
plausible that depletion of complement components due
to albumin replacement (instead of plasma) could have
accelerated the development of TMA in the context of a
predisposing genetic abnormality in our patient. So, we
switched the patient to plasma exchange with plasma
replacement and consequently noted a significant im-
provement in her clinical and laboratory parameters.
Eculizumab is the gold standard treatment for aHUS with a
good efficacy and safety profile [14]. However, when
eculizumab is unavailable in resource-poor settings such as
India, TPE may be the first treatment of choice which was
initiated in our patient, despite which she succumbed to her
illness.
The detection of antibodies to factor H and genetic variants
in complement genes in our case with both ANCA-negative
PICGN and TMA further adds evidence to the ever-increasing
resource of literature implicating complement activation in the
pathogenesis of ANCA-negative PICGN. We firmly suggest
that a detailed diagnostic work-up of the alternative comple-
ment pathway should be carried out in patients presenting with
ANCA-negative PICGN to optimize overall patient and kid-
ney outcome.
Compliance with ethical standards
Conflict of interests The authors declare that they have no competing
interests.
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