J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website http://www.jocmr.org

Case Report

Volume 7, Number 7, July 2015, pages 575-581

An Overlapping Case of Lupus Nephritis and IgG4-Related Kidney Disease

Figure 1. Light microscopy (A, B) shows: (A) mildly thickened glomerular basement membrane and (B) diffuse acute tubular injury with epithelial simplification consistent with acute tubular necrosis (ATN). Immunoperoxidase staining (C, D): immunostaining for IgG4 shows IgG4 positive plasma cells in the interstitium.

Figure 2. Immunofluorescence (IF) showing (A) granular glomerular capillary wall staining 2+ for IgG and (B) granular diffuse tubular basement membranes staining 2+ for IgG.

**Table 1.** Evolution of BUN and Creatinine Over Days
Day	Admission	Day 2	Day 3	Day 4	Day 5	Day 6
BUN (mg/dL)	88	100	100	105	82	40
Creatinine (mg/dL)	9.65	9.27	9.20	9.70	9.0	5.80

Table 1. Evolution of BUN and Creatinine Over Days

Day

Admission

Day 2

Day 3

Day 4

Day 5

Day 6

BUN (mg/dL)

100

105

Creatinine (mg/dL)

9.65

9.27

9.20

9.70

9.0

5.80

**Table 2.** Laboratory Findings
Parameter	Value
Creatinine (mg/dL)	9.65
BUN (mg/dL)	88
Total protein (g/dL)	6.10
Albumin (g/dL)	2
Thyroid stimulating hormone (TSH) (µIU/mL)	0.81
Hepatitis B surface antigen (HbsAg)	Reactive
IgM hepatitis B core antibody	Non-reactive
Hepatitis B viral DNA (copies)	22576
Urinary protein (g/day)	2.60
ESR (mm/h)	61
Antinuclear antibody (ANA)	1:320, homogeneous
Antineutrophil cytoplasmic antibody (ANCA)	Negative
Complement C3 (mg/dL)	100 (reference range 80 - 180)
Complement C4 (mg/dL)	11 (reference range 10 - 45)
Anti-SSA antibody	Negative
Anti-SSB antibody	Negative
Anti-RNP antibody	Negative
Anti-dsDNA antibody	Negative
Smith antibody (anti-Sm)	Negative
IgG1 (mg/dL)	1230 (reference range 382 - 929)
IgG2 (mg/dL)	735 (reference range 241 - 700)
IgG3 (mg/dL)	418 (reference range 22 - 178)
IgG4 (mg/dL)	37.10 (reference range 4 - 86)
Serum protein electrophoresis (SPEP)	Normal
Glomerular basement membrane antibody (anti-GBM)	Negative
Cryoglobulin	Negative

Table 2. Laboratory Findings

Parameter

Value

Creatinine (mg/dL)

9.65

BUN (mg/dL)

Total protein (g/dL)

6.10

Albumin (g/dL)

Thyroid stimulating hormone (TSH) (µIU/mL)

0.81

Hepatitis B surface antigen (HbsAg)

Reactive

IgM hepatitis B core antibody

Non-reactive

Hepatitis B viral DNA (copies)

22576

Urinary protein (g/day)

2.60

ESR (mm/h)

Antinuclear antibody (ANA)

1:320, homogeneous

Antineutrophil cytoplasmic antibody (ANCA)

Negative

Complement C3 (mg/dL)

100 (reference range 80 - 180)

Complement C4 (mg/dL)

11 (reference range 10 - 45)

Anti-SSA antibody

Negative

Anti-SSB antibody

Negative

Anti-RNP antibody

Negative

Anti-dsDNA antibody

Negative

Smith antibody (anti-Sm)

Negative

IgG1 (mg/dL)

1230 (reference range 382 - 929)

IgG2 (mg/dL)

735 (reference range 241 - 700)

IgG3 (mg/dL)

418 (reference range 22 - 178)

IgG4 (mg/dL)

37.10 (reference range 4 - 86)

Serum protein electrophoresis (SPEP)

Normal

Glomerular basement membrane antibody (anti-GBM)

Negative

Cryoglobulin

Negative

**Table 3.** Immunofluorescence Results
	Glomeruli	Tubules	Interstitium	Vessels
Immunofluorescence results showing granular global mesangial and irregular capillary wall, as well as abundant tubular basement membrane granular deposits staining for a “full-house” of immune reactants (deposits containing IgM, IgA, IgG, Kappa, Lamda, C3 and C1). gloms: glomeruli; Gran: granular; mes: mesangial; GCW: glomerular capillary wall; TBM: tubular basement membrane; Neg: negative; FBGN: fibrinogen; ALB: albumin.
IgG	3 gloms 2+ Gran global mes Gran diffuse	TBM’s 2+ Sparse GCW	Neg	Neg
IgM	3 gloms 1+ Gran global mes Sparse GCW	TBM’s 1+ Gran focal	Plasma cells +1 cytoplasm	Neg
IgA	3 gloms 1+ Gran global mes Sparse GCW	TBM’s 1+ Gran focal	Plasma cells +1 cytoplasm	Neg
C3	3 gloms 1+ Gran global mes Sparse GCW	TBM’s 1+ Gran diffuse	Neg	Neg
C1	3 gloms neg	TBM’s 1+ Gran focal	Neg	Neg
FBGN	3 gloms neg	Neg	2+	Neg
ALB	3 gloms neg	Neg	Neg	Neg
KAPPA	3 gloms 2+ Gran global mes Sparse GCW	TBM’s 2+ Gran diffuse	Plasma cells +1 cytoplasm	Neg
LAMDA	3 gloms 2+ Gran global mes Sparse GCW	TBM’s 2+ Gran diffuse	Plasma cells +1 cytoplasm	Neg

Table 3. Immunofluorescence Results

Glomeruli

Tubules

Interstitium

Vessels

Immunofluorescence results showing granular global mesangial and irregular capillary wall, as well as abundant tubular basement membrane granular deposits staining for a “full-house” of immune reactants (deposits containing IgM, IgA, IgG, Kappa, Lamda, C3 and C1). gloms: glomeruli; Gran: granular; mes: mesangial; GCW: glomerular capillary wall; TBM: tubular basement membrane; Neg: negative; FBGN: fibrinogen; ALB: albumin.

IgG

3 gloms 2+
Gran global mes
Gran diffuse

TBM’s 2+
Sparse GCW

Neg

IgM

3 gloms 1+
Gran global mes
Sparse GCW

TBM’s 1+
Gran focal

Plasma cells +1
cytoplasm

Neg

IgA

3 gloms 1+
Gran global mes
Sparse GCW

TBM’s 1+
Gran focal

Plasma cells +1
cytoplasm

Neg

3 gloms 1+
Gran global mes
Sparse GCW

TBM’s 1+
Gran diffuse

Neg

3 gloms neg

TBM’s 1+
Gran focal

Neg

FBGN

3 gloms neg

Neg

ALB

3 gloms neg

Neg

KAPPA

3 gloms 2+
Gran global mes
Sparse GCW

TBM’s 2+
Gran diffuse

Plasma cells
+1
cytoplasm

Neg

LAMDA

3 gloms 2+
Gran global mes
Sparse GCW

TBM’s 2+
Gran diffuse

Plasma cells +1
cytoplasm

Neg