WBR0748

Author	[[PageAuthor::Rim Halaby, M.D. [1]]]
Exam Type	ExamType::USMLE Step 1
Main Category
Sub Category	SubCategory::Musculoskeletal/Rheumatology, SubCategory::Oncology
Prompt	[[Prompt::A 40 year old man presents to the physician's office for foamy urine. The patient reports he is previously healthy. He takes no medications and has no allergies. A full physical examination is unremarkable. A 24-hour urinary collection shows 6 grams of urinary proteins/24 hours. Renal biopsy is performed and the diagnosis of membranous nephropathy is made. Which of the following findings may distinguish primary from secondary forms of membranous nephropathy?]]
Answer A	AnswerA::Deposition of specific IgG subclasses on immunofluorescence
Answer A Explanation	[[AnswerAExp::IgG4 subtype is most commonly seen in idiopathic membranous nephropathy. In contrast, IgG1, 2, and 3 are more commonly seen in secondary forms of membranous nephropathy. The difference between the two may aid in the differentiation between primary (idiopathic) and secondary membranous nephropathy]]
Answer B	AnswerB::Extent of glomerular crescent formation on light microscopy
Answer B Explanation	AnswerBExp::Crescent formation are present most commonly in rapidly progressive glomerulonephritis (RPGN), but may also be present in other forms of glomerulonephritis. Extent of crescent formation characterizes a worse disease of poor prognosis.
Answer C	AnswerC::Presence of gross hematuria during clinical work-up
Answer C Explanation	[[AnswerCExp::Gross hematuria is usually unlikely in membranous nephropathy, although it might still be present. Microscopic hematuria is more common than gross hematuria. Hematuria does not help in differentiation between primary and secondary membranous nephropathies.]]
Answer D	AnswerD::Quantification of nephrotic-range proteinuria during 24-hour urinary collection
Answer D Explanation	[[AnswerDExp::The degree of proteinuria helps in identifying the patients who require intervention. Patients with sub-nephrotic range proteinuria usually have higher chances of spontaneous remission. On the other hand, patients with nephrotic range proteinuria are less likely to remis spontaneously. Proteinuria is considered the most important prognostic marker, and has a "dose-dependent" effect; where the more the proteinuria, the worse the prognosis.]]
Answer E	AnswerE::Presence of urinary IgG and IgM during clinical work-up
Answer E Explanation	AnswerEExp::Urinary IgG and IgM may be found in patients with membranous nephropathy. They may be utilized as biological biomarkers for follow-up and progression. Nonetheless, their role still needs to be validated.
Right Answer	RightAnswer::A
Explanation	[[Explanation::Up to 80% of patients with idiopathic membranous glomerulopathy (MGN) or membranous nephropathy present with nephrotic syndrome. A minority of patients have sub-nephrotic-range proteinuria at presentation. Patients may also have microscopic hematuria. The finding of gross hematuria, on the other hand, is unlikely in MGN and the finding suggests the search for alternative diagnoses. However, it might nonetheless be noted at presentation. Kidney biopsy is the gold standard for the diagnosis of MGN. On light microscopy, kidney biopsy typically shows capillary wall thickening with normal cellularity. Immunofluorescence shows IgG and C3 deposits along capillary walls. Electron microscopy shows exclusively subepithelial deposits between podocyte foot processes. Subtype of IgG present on immunofluorescence may be helpful in differentiating idiopathic vs. secondary causes of MGN. In primary idiopathic MGN, the IgG4 subtype of IgG is most commonly seen, comprising approximately 80% of all idiopathic cases. However, this is not true for secondary causes of MGN, although other features on renal biopsy are common between the 2 forms. IgG1, 2, and 3 are more commonly seen in secondary MGN. Furthermore, the location of the deposits may also provide clues on the diagnosis. While deposits in primary MGN are exclusively seen in the subepithelial region, deposits in secondary MGN may involve subepithelial and more likely subendothelial regions of the capillary wall. Educational Objective: IgG subclass on immunofluorescence may differentiate primary vs. secondary membranous nephropathy. IgG4 is associated with primary membranous nephropathy; while IgG1, 2, and 3 are more commonly associated with secondary membranous nephropathy. Reference: Jennette JC, Iskandar SS, Dalldorf FG. Pathologic differentiation between lupus and nonlupus membranous glomerulopathy. Kidney Int. 1983; 24(3):377-85 Ohtani H, Wakui H, Komatsuda A, et al. Distribution of glomerular IgG subclass deposits in malignancy-associated membranous nephropathy. Nephrol Dial Transplant. 2004; 19(3):574-9. Polanco N, Gutierrez E, Covarsi A, et al. Spontaneous remission of nephrotic syndrome in idiopathic membranous nephropathy. J Am Soc Nephrol. 2010; 21(4):697-704. Menon S, Valentini RP. Membranous nephropathy in children: clinical presentation and therapeutic approach. Pediatr Nephrol. 2010; 25(8):1419-28. Educational Objective: References: ]]
Approved	Approved::No
Keyword	WBRKeyword::membranous, WBRKeyword::nephropathy, WBRKeyword::subendothelial, WBRKeyword::subepithelial, WBRKeyword::IgG, WBRKeyword::subclass, WBRKeyword::IgG1, WBRKeyword::IgG2, WBRKeyword::IgG3, WBRKeyword::IgG4, WBRKeyword::prognosis, WBRKeyword::differentiate, WBRKeyword::differentiation, WBRKeyword::distinguish, WBRKeyword::primary, WBRKeyword::idiopathic, WBRKeyword::secondary, WBRKeyword::form, WBRKeyword::forms
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