Nodular glomerulosclerosis with anti-glomerular basement membrane-like glomerulonephritis; a distinct pattern of kidney injury observed in smokers

Background. Cigarette smoking has recently been recognized as a risk factor for developing nodular glomerulosclerosis and has also been frequently encountered in patients with anti-glomerular basement membrane (anti-GBM) disease. However, the concurrent presence of both patterns of glomerular injury has not been previously reported. Material and methods. In this article, we describe three patients with non-diabetic nodular glomerulosclerosis, anti-GBM-like glomerulonephritis (GN) and a history of heavy smoking. Results. Our cohort included three patients, of which two were men (53 and 77 years old) and one a 28-year-old woman. None of the patients had a history of diabetes mellitus but all of them were heavy smokers who presented with renal insufficiency and proteinuria. Nodular glomerulosclerosis and occasional small, non-circumferential crescents in different stages of development were found on kidney biopsy. Immunofluorescence microscopy studies showed intense linear IgG staining along the glomerular basement membranes in the absence of granular immune-type deposits. Electron microscopy evaluation revealed prominent endothelial cell injury without detectable electron-dense deposits. One patient was dialysis-dependent a few months post-biopsy while the other two patients maintained their kidney function 18 and 24 months post-biopsy but without a significant improvement of serum creatinine. Conclusions. The combination of nodular glomerulosclerosis and anti-GBM-like GN appears to be a distinct pattern of injury observed in a small subset of heavy smokers. Although this pattern of glomerular injury might be less aggressive than the typical anti-GBM GN, it does not appear to carry a favorable prognosis.