Yumura Wako, Suganuma Shinya, Nitta Kosaku, Sano Yoshie, Uchida Keiko, Nihei Hiroshi
Department of Medicine, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan.
Clin Exp Nephrol. 2004 Dec;8(4):363-8. doi: 10.1007/s10157-004-0306-y.
We report a case of a 44-year-old woman with nephrotic syndrome who underwent renal biopsy three times. On each occasion, light microscopy showed membranous nephropathy with mild to moderate thickening of the glomerular capillary walls. Immunofluorescence microscopy showed predominant deposition of immunoglobulin (Ig) G, IgG1, IgG2, IgG3, and IgG4; C3; and C1q along the glomerular capillary walls and deposition of IgM and IgA in some parts of the walls. Electron microscopy revealed the accumulation of electron-dense deposits in the mesangium and the subepithelial area of the glomerular basement membrane. Virus-like particles were detected in the subendothelial cells in all three biopsy specimens. A definitive diagnosis of systemic lupus erythematosus (SLE) was made at the time of the second admission, when she was 31 years old. A diagnosis of membranous lupus nephritis was then made on the basis of the pathological and clinical findings. A change in anti-single-stranded (ss)DNA antibody titers was of particular interest in this patient. Occasional small increases in anti-double-stranded (ds)DNA antibody were found, but increased anti-ssDNA antibody titers occurred before there was any elevation of urinary protein during renal relapse, and a sustained increase in the titers was shown subsequently. Hypocomplementemia occurred in parallel with the increase of anti-ssDNA antibody. Immunosuppressive therapy with steroid promptly eliminated anti-dsDNA antibody, but anti-ssDNA antibody remained positive. The patient had normocomplementemia and proteinuria was absent. Later, anti-ssDNA antibody decreased. Renal function has remained in the normal range for 20 years.
我们报告一例44岁患有肾病综合征的女性，该患者接受了三次肾活检。每次光镜检查均显示为膜性肾病，肾小球毛细血管壁有轻度至中度增厚。免疫荧光显微镜检查显示免疫球蛋白（Ig）G、IgG1、IgG2、IgG3和IgG4、C3以及C1q沿肾小球毛细血管壁呈主要沉积，IgM和IgA在壁的某些部位也有沉积。电子显微镜检查发现系膜和肾小球基底膜上皮下区域有电子致密沉积物积聚。在所有三份活检标本的内皮下细胞中均检测到病毒样颗粒。该患者在31岁第二次入院时确诊为系统性红斑狼疮（SLE）。随后根据病理和临床 findings 诊断为膜性狼疮性肾炎。抗单链（ss）DNA抗体滴度的变化在该患者中尤为引人关注。偶尔发现抗双链（ds）DNA抗体有小幅升高，但在肾脏复发期间尿蛋白升高之前抗ssDNA抗体滴度就已升高，随后滴度持续升高。低补体血症与抗ssDNA抗体的增加同时出现。使用类固醇进行免疫抑制治疗迅速消除了抗dsDNA抗体，但抗ssDNA抗体仍呈阳性。患者补体正常，蛋白尿消失。后来，抗ssDNA抗体下降。肾功能在20年内一直保持在正常范围内。 （注：原文中“findings”未翻译完整，推测可能是“发现”之类的意思，可根据完整准确的原文进行调整）
