n engl j med

348;25

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19, 2003

The

new england journal

of

medicine

2543

review article

mechanisms of disease

Alports Syndrome, Goodpastures Syndrome,
and Type IV Collagen

Billy G. Hudson, Ph.D., Karl Tryggvason, M.D., Ph.D.,
Munirathinam Sundaramoorthy, Ph.D., and Eric G. Neilson, M.D.

From the Departments of Medicine (B.H.,
M.S., E.G.N.), Biochemistry (B.H., M.S.),
and Cell and Developmental Biology
(E.G.N.), Vanderbilt University School of
Medicine, Nashville; and the Department
of Medical Biochemistry and Biophysics,
Karolinska Institute, Stockholm, Sweden
(K.T.). Address reprint requests to Dr. Neil-
son at the Department of Medicine, D-3100
MCN, Vanderbilt University Medical Cen-
ter, Nashville, TN 37232-2358, or at eric.
neilson@vanderbilt.edu.
N Engl J Med 2003;348:2543-56.

Copyright 2003 Massachusetts Medical Society.

asement membranes form a complex surface on which epithe-

lial cells reside. These membranes provide morphogenic cues that determine
the fate of cells, the polarization of subcellular constituents, and the location of
cell receptors and transporters.

1-3

Basement membranes are assembled through an in-
terweaving of type IV collagen (collagen IV) with laminins, nidogen, and sulfated prote-
oglycans.

4,5

Collagen IV belongs to a family of collagenous proteins that has at least 25
distinct members. The

COL4A1, COL4A2, COL4A3, COL4A4, COL4A5,

and

COL4A6

genes

6-13

encoding the six chains of collagen IV

a

1(IV) through

a

6(IV) are selec-
tively expressed in different membranes at various stages of embryonic development.

14

This selectivity accounts for the location of disease and the clinical consequences of in-
jury to collagen IV. Damage to collagen IV due to mutation (in Alports syndrome) or an
immune attack (in Goodpastures syndrome) disrupts the function of attached epithe-
lia and leads to organ impairment.
In 1927, Alport reported that deafness was a feature of a previously described fa-
milial nephropathy that caused uremia in males but spared females.

15

Splitting of the
glomerular basement membrane, hematuria, interstitial nephritis, and progressive kid-
ney failure explain the renal aspects of the disorder.

16

The cause of Alports syndrome
was unknown

17

until mutations were discovered in the

COL4A3, COL4A4,

and

COL4A5

collagen genes.

18-20

Some carriers of a mutant collagen IV gene are thought to have a
variant of Alports syndrome termed benign familial hematuria or thin glomerular base-
ment membrane disease.

18,21-24

In 1958, Stanton and Tange

25

described nine patients with a pulmonaryrenal disor-
der they called Goodpastures syndrome after an earlier report by Ernest Goodpas-
ture.

26

The classic presentation of Goodpastures syndrome is explosive lung hem-
orrhage with nephritis that is often crescentic; the syndrome is rapidly fatal if left
untreated.

27,28

It is an immune disorder with serum antibodies directed against par-
ticular regions of the

a

3(IV) chain of collagen IV in lung and kidney.

29-33

For many years, a connection between the two syndromes was suspected, because
most glomeruli from the kidneys of patients with Alports syndrome do not stain by
the immunofluorescent method with antibodies from patients with Goodpastures
syndrome.

34

This curiosity focused attention on collagen IV, and today we know that
the pathogenesis of both diseases is linked to the same

a

3.

a

4.

a

5(IV) collagen pro-
tomer.

14,35-37

Collagen IV was first isolated by Kefalides from glomerular basement membrane in
1966,

38

and during the past 35 years, the structures of the six chains that assemble into
collagen IV molecules have been elucidated by numerous investigators.

4,6-14,39-44

Each
b
structure and distribution of type iv collagen
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,

2003

The

new england journal

of

medicine

2544

of the six chains of collagen IV has three domains:
there is a short 7S domain at the N-terminal; a
long, collagenous domain occupies the midsec-
tion of the molecule; and a noncollagenous domain
(NC1) is positioned at the C-terminal (Fig. 1). In spite
of many potential permutations, the six chains of
collagen IV apparently form only three sets of
triple helical molecules called protomers, which
are designated as

a

1.

a

1.

a

2(IV),

a

3.

a

4.

a

5(IV),
and

a

5.

a

5.

a

6(IV).

35-37,39

These protomers create
collagenous networks by uniting two NC1 trimers
to form hexamers and uniting four 7S domains to
form tetramers with other protomers, as shown
in the

a

3.

a

4.

a

5(IV) network in Figure 2A. Only
three canonical sets of hexamers form networks:

a

1.

a

1.

a

2(IV)

a

1.

a

1.

a

2(IV),

a

3.

a

4.

a

5(IV)

a

3.

a

4.

a

5(IV), and

a

1.

a

1.

a

2(IV)

a

5.

a

5.

a

6(IV). The x-ray
crystallographic structure of the

a

1.

a

1.

a

2(IV) NC1
hexamer provides novel insight into the molecular
interactions that govern chain assembly and the
pathophysiological mechanisms underlying Good-
pastures and Alports syndromes.

48,49

A computer-
generated, space-filling model of the

a

3.

a

4.

a

5(IV)
hexamer (Fig. 2B) shows how three NC1 domains
fold and associate as a trimeric cap for each pro-
tomer, which, in turn, interacts with the trimeric
cap of an adjoining protomer.

36,48

Assembly of collagen IV networks is regulated
developmentally. The

a

1.

a

1.

a

2(IV)

a

1.

a

1.

a

2(IV)
network is a component of all basement membranes
of all animal phyla,

50-53

whereas the

a

3.

a

4.

a

5(IV)

a

3.

a

4.

a

5(IV) and

a

1.

a

1.

a

2(IV)

a

5.

a

5.

a

6(IV) net-
works have a restricted distribution in mammalian
tissues. The

a

3.

a

4.

a

5(IV) network occurs in the
kidney (in glomerular basement membrane and
some tubular basement membranes), lung, testis,
cochlea, and eye,

47,54,55

and the

a

5.

a

5.

a

6(IV) net-
work is a feature of skin, smooth muscle, esopha-
gus, and kidney (Bowmans capsule).

36,37,44,56,57

During embryonic development of human glomer-
ular basement membrane, the

a

1.

a

1.

a

2(IV) net-
work appears at the start of early capillary-loop
formation (by embryonic day 75 [E75]) but is gradu-
ally replaced by the

a

3.

a

4.

a

5(IV) network in the
mature glomerular capillary (by day E150)

47,58,59

or by the

a

5.

a

5.

a

6(IV) network in Bowmans cap-
sule.

37,44,59

This developmental switch is a critical
step in the maturation of the kidney (Fig. 3A) and
perhaps other specialized tissues.
Classically, Alports syndrome consists of hematu-
ria, proteinuria (less than 1 to 2 g of protein excreted
per day), progressive renal failure, and sensorineu-
ral deafness.

60

Lenticonus of the anterior lens cap-
sule (positive oil droplet sign), retinopathy (dot
and fleck reflections), and rarely, mental retardation
or leiomyomatosis occur in some patients.

61,62

Clin-
ical variability among kindreds with Alports syn-
drome reflects the complexity of collagen genetics
(involving one of three loci with multiple sites for
mutation), inconsistency in the assembly of col-
lagen IV protomers in selected tissues, and uneven
alport s syndrome

Figure 1. Triple Helical Organization of the Type IV Collagen Family.

Six genetically distinct

a

chains are arranged into three triple helical protomers that differ in their chain composition. Each protomer has a 7S
triple helical domain at the N-terminal; a long, triple helical, collagenous domain in the middle of the molecule; and a noncollagenous (NC1)
trimer at the C-terminal. Interruptions in the GlyXaaYaa amino acid sequence at multiple sites along the collagenous domain (white rings)
confer flexibility, allowing for looping and supercoiling of protomers into networks. The selection of

a

chains for association into trimeric pro-
tomers is governed by molecular recognition sequences encoded within the hypervariable regions of NC1 domains.

35,37
Type IV collagen chains Protomers
NC1 monomer 7S
2
1
1
4
3
5
6
5
5
3
2
1
4
5
6
a1.a1.a2
a3.a4.a5
a5.a5.a6
NC1 trimer
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n engl j med

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mechanisms of disease

2545

expression of these defects.

18,19

New pedigrees usu-
ally come to attention after clinical evaluation of a
patient for progressive deafness or hematuria.

genetics

In approximately 85 percent of patients with Alports
syndrome there is X-linked inheritance of muta-
tions in the

COL4A5

gene encoding the

a

5(IV) col-
lagen chain on chromosome Xq2648.

20,63

In fe-
male carriers, penetrance is variable and depends
on the type of mutation or degree of mosaicism fol-
lowing lyonization of the X chromosome. Patients
with autosomal recessive disease are either com-
pound heterozygotes or have homozygous muta-
tions in the

COL4A3 or COL4A4 gene encoding the
a3(IV) or a4(IV) chain, respectively, on chromo-
some 2q3537.
64,65
Rarely, some kindreds have an
autosomal dominant inheritance of dominant neg-
ative mutations in the COL4A3 or COL4A4 gene.
18
The types of mutations in these genes include mis-
sense mutations, premature stop codons, splice mu-
tations, and in-frame deletions. Concomitant mu-
tations in the COL4A6 gene encoding the a6(IV)
chain are associated with leiomyomatosis.
66-68
Figure 2. Assembly and Network Organization of Collagen IV Protomers.
Protomers create basement-membrane networks with other protomers by uniting two NC1 trimers to form an interface hexamer at the C-ter-
minal and by uniting four triple helical 7S domains at the N-terminal (Panel A). A network composed of a3.a4.a5(IV) protomers is illustrated,
showing end-to-end connections of individual protomer units, supercoiling and looping of the triple helixes, and disulfide cross-links between
triple helical domains.
35-37,39
The structure of the NC1 hexamer is determined by the particular a chains that form a triple helical protomer
and by the particular canonical protomers that can connect to adjoining protomers (NC1 box). Molecular recognition sequences encoded
within NC1 domains govern the selection of partner chains for both protomer and network assembly. The 7S domains also play a key part in
determining the specificity, affinity, and geometry of the tetramer formed through the connection of four protomers (7S box).
39,45,46
Two other
networks are composed of pairs of a1.a1.a2(IV) hexamers or a1.a1.a2(IV)a5.a5.a6(IV) NC1 hexamers.
35-37,39
The a3.a4.a5(IV)
a3.a4.a5(IV) network differs from the others in that it has a greater number of disulfide cross-links between triple helical domains, which in-
creases its resistance to proteolysis.
47
Panel B shows the three-dimensional model of the a3.a4.a5(IV) NC1 hexamer that is depicted in the NC1 box in Panel A. The three-dimen-
sional structure and the location of epitopes were determined by computer modeling of the crystal structure of the a1.a1.a2(IV)
a1.a1.a2(IV) hexamer
48
and the apparent quaternary structure of the a3.a4.a5(IV) hexamer.
36
The hexamer is composed of two trimeric
caps, each derived from adjacent protomers. Each trimer consists of an a3 monomer (red), an a4 monomer (blue), and an a5 monomer
(green). The monomers have a novel tertiary structure with two homologous subdomains, each of which is characterized by b-sheet motifs.
The model depicts the location of the E
A
(yellow) and E
B
(gold) regions that encompass two dominant epitopes for Goodpasture antibodies.
The epitopes reside in the a3(IV) NC1 domain, near the triple helical junction, and they are partially sequestered by interactions with the
a5(IV) and a4(IV) NC1 domains, respectively.
A B
7S
4
3
5
4
5
3
a4
a4
a5
E
A
E
B
a5
a3
a3
NC1
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The new england journal of medicine
2546
Figure 3. Distribution and Switches of Collagen IV Networks in Glomerular Development.
During early embryonic development (Panel A, left), the a1.a1.a2(IV) network is present at all stages. In the mature glomerulus (Panel A,
right), this network is a component of Bowmans capsule, mesangial matrix, and glomerular basement membrane. In contrast, the a3.a4.a5(IV)
and a5.a5.a6(IV) networks first appear at the early capillary-loop stage. They appear to replace (dotted line) most of the a1.a1.a2(IV) net-
work within the glomerular basement membrane and Bowmans capsule, respectively, and they persist in the mature glomerulus. In the
X-linked form of Alports syndrome (Panel B), the switch in networks is arrested (red Xs), as a result of mutations in the a5(IV) chain. These
mutations result in the persistence of the a1.a1.a2(IV) network and the absence of the a3.a4.a5(IV) and a5.a5.a6(IV) networks.
Embryonic
A
Developmental
switch
3
5
4
5
5
6
1
1
2
1
1
2
3
5
4
5
3
4
1
1
2
5
5
6
Immature Mature
Embryonic
Developmental
switch
Childhood Adulthood
1
1
2
1
1
2
Immature Mature
3
5
4
5
5
6
B
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mechanisms of disease
2547
Most evidence suggests that chain mutations
produce a post-translational defect in protomer as-
sembly. The COL4A3 and COL4A4 genes
69
and genes
that encode for nephrin, podocin, and CD2-asso-
ciated protein, forming the glomerular slit dia-
phragm and allowing filtration,
70
are regulated by
a transcription factor called LMX1B, which is mu-
tated in patients with the nailpatella syndrome.
Carriers of a mutant LMX1B gene have a renal le-
sion of variable severity, which is consistent with a
reduction in the a3.a4.a5(IV) network in glomer-
ular basement membrane
71,72
and loss of the glo-
merular filtration barrier.
70
pathogenesis
Mutations present in Alports syndrome that pro-
duce post-translational defects in a3(IV), a4(IV),
or a5(IV) chains may result in incorrect folding or
assembly of monomers; such defective monomers
are rapidly degraded. These mutations, therefore,
arrest the normal developmental switch (Fig. 3A)
and cause the persistence of a1.a1.a2(IV) networks
in glomerular basement membrane (Fig. 3B).
47
In
patients with X-linked Alports syndrome, a3(IV),
a4(IV), and a5(IV) collagens in most glomeruli, tu-
bules, and Bowmans capsules are undetectable by
immunostaining (female carriers can be mosaics).
In patients with autosomal recessive Alports syn-
drome, there is a5(IV) collagen in Bowmans cap-
sule but no detectable a3(IV) or a4(IV) collagens in
glomerular or tubular basement membranes.
73
The
reason for this difference is that the a5(IV) chain is
shared by two different protomers one in the glo-
merular basement membrane and the other in Bow-
mans capsule.
36,57
Some a5(IV) mutations that al-
low for partial formation of a3.a4.a5(IV) networks
may produce less severe phenotypes.
19
The replacement of the a1.a1.a2(IV) network
by the a3.a4.a5(IV) network during fetal develop-
ment may be related to oxidative and physical stress
in renal basement membranes
74
(and perhaps also
in the cochlea
75
and the lens capsule
76
). In the kid-
ney, as plasma traverses glomerular capillaries, the
protein content, including the levels of serum pro-
teases, increases. The embryonic a1.a1.a2(IV) net-
work is more susceptible to endoproteolysis than
the more heavily cross-linked a3.a4.a5(IV) net-
work.
47,74
It seems, then, that basement mem-
branes that are more exposed to proteases or oxi-
dants need the protection of a resistant collagen IV
network. Over time, patients with Alports syndrome
probably become more sensitive to selective base-
ment-membrane proteolysis, which may explain
why their glomerular membranes thicken unevenly,
split, and ultimately deteriorate.
47
The primary filtration barrier of the glomerular
capillary consists of the glomerular basement mem-
brane and the outer slit diaphragm formed between
adjacent podocytes. Deterioration of the glomeru-
lar basement membrane produces mild proteinuria,
whereas loss of the slit diaphragm leads to massive
proteinuria.
70
Proteinuria in Alports syndrome is
associated with damage to the glomerular basement
membrane that leads to sclerosis, rather than pri-
mary loss of the slit pore. In pedigrees with a history
of renal failure, disease usually progresses from con-
comitant interstitial nephritis and the renal fibrosis
that accompanies sclerosis of the glomerular base-
ment membrane.
78,79
Macrophages and lympho-
cytes are found in areas of disrupted tubular base-
ment membrane,
80,81
and fibroblasts are formed
by epithelialmesenchymal transition.
82,83
This fi-
brogenic response destroys the renal architecture.
clinical presentation
Pedigrees with Alports syndrome vary in the ra-
pidity of onset of organ failure (Table 1). In pa-
tients with nonsense or missense mutations, read-
ing-frame shifts, or large deletions, renal failure
and sensorineural deafness generally develop by
30 years of age (in the juvenile form). In patients
with splice variants, exon-skipping mutations, or
missense mutations of glycines in the collagen
helix, health usually begins to deteriorate after 30
years of age (in the adult form), and these patients
have mild or late-onset deafness.
19,84,85
A family
history of early, severe deafness or lenticonus por-
tends a poor prognosis in young progeny at risk.
86
The presenting sign of Alports syndrome is of-
ten hematuria. Members of kindreds with a strong
history of renal failure and deafness do not need to
undergo kidney biopsy. These patients usually re-
quire only an imaging study of the genitourinary
tract to rule out a tumor or other defect that could
cause hematuria. The mutations in families with
X-linked, recessive, or dominant Alports syndrome
are not confined to a few regions of the COL4A3,
COL4A4, or COL4A5 gene. Rather, they are scattered
throughout many exons, making it difficult to de-
velop predictive genetic tests.
findings on kidney biopsy
When examined by electron microscopy, the le-
sions in kidney-biopsy specimens from patients
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n engl j med 348;25 www.nejm.org june 19, 2003
The new england journal of medicine
2548
* ANCA denotes antineutrophil cytoplasmic autoantibody.
Table 1. Clinical Pathophysiology of Alports and Goodpastures Syndromes.
Disease Mechanism Clinical Description
Alports syndromes
X-linked
Adult
Juvenile
Some missense mutations or splice vari-
ants in the COL4A5 gene, producing a
reduction or distortion in a3.a4.a5(IV)
and a5.a5.a6(IV) networks
Deletions, nonsense mutations, or mis-
sense mutations in the COL4A5 gene,
producing a loss of a3.a4.a5(IV) and
a5.a5.a6(IV) networks
Delayed onset of renal failure (>30 yr of age),
with mild deafness in men; less severe
in female carriers
Early onset of renal failure (<30 yr of age)
in men, with frank deafness and often
lenticonus
Leiomyomatosis Deletions from the COL4A5 gene through
to the second exon of the COL4A6 gene,
producing a loss of a3.a4.a5(IV) and
a5.a5.a6(IV) networks and smooth-
muscle tumors
Early onset of renal failure, with esophageal
dysfunction, genital leiomyomas, and
occasional posterior cataract
Recessive Homozygous or compound heterozygous
nonsense mutations, missense muta-
tions, frame shifts, small deletions, or
splice variants in COL4A3 or COL4A4
gene, producing a loss of the
a3.a4.a5(IV) network
Early onset of renal failure (<30 yr of age)
in both sexes
Dominant Missense mutation in the COL4A4 gene;
splice variants or short in-frame dele-
tions of the collagenous region; or
shortened signal-peptide sequences in
the COL4A3 gene; defects produce ab-
errations in the a3.a4.a5(IV) network
Renal failure of varying severity
Benign familial hematuria Missense mutations in the COL4A3 gene
or splice variants, frame shifts, or mis-
sense mutations in the COL4A4 gene,
inherited in an autosomal dominant
fashion, producing a subtle decrease
in the a3.a4.a5(IV) network
Mild hematuria with thin basement mem-
branes and rare hypertension or protein-
uria that is nonprogressive; findings on
kidney biopsy have been relatively normal
Nailpatella syndrome Autosomal dominant mutation in the
LMX1B transcription factor, which regu-
lates the COL4A3 or COL4A4 gene as
well as the genes encoding nephrin,
podocin, and CD2-associated protein
Variable penetrance, but some children have
nephrotic syndrome and skeletal and nail
dysplasias
Goodpastures syndromes*
ANCA-negative (75%) Autoantibodies to a3(IV) NC1 domain Anemia, pulmonary infiltrates, focal necrosis,
or crescentic glomerulonephritis, with
or without hemoptysis; variable progres-
sion; prognosis better with early diagno-
sis and treatment
ANCA-positive (25%) Autoantibodies to a3(IV) NC1 domain
plus antibodies to myeloperoxidase
May resemble ANCA-negative syndrome but
responds better to treatment and may be
a vasculitis-associated variant
Post-transplantation
Alports syndrome
Alloantibodies to a3(IV), a4(IV),
and a5(IV) NC1 domains
Seen in all patients with Alports syndrome
(except female carriers of the X-linked
syndrome) after transplantation; varying
degrees of nephritis
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n engl j med 348;25 www.nejm.org june 19, 2003
mechanisms of disease
2549
with Alports syndrome are variable. The typically
thin glomerular basement membranes thicken over
time into multilamellations surrounding lucent ar-
eas that often contain granules of varying density
the so-called split basement membrane (Fig.
4A).
16,87
In any one kidney from a patient with
Alports syndrome, there are areas of thinning and
splitting glomerular basement membrane. Tubules
drop out, segmental glomerular scars progress, and
the kidneys eventually fail because of interstitial fi-
brosis. Thin basement membranes are also found
in 5 to 10 percent of the normal population.
88
In
these cases, the blood pressure is normal, there is
little proteinuria, and progression to renal failure
is rare. When such patients present with hematuria,
they often receive a diagnosis of benign familial he-
maturia.
62
Many of these patients have mutations
in the same genetic loci that encode for the a3(IV)
or a4(IV) chains associated with autosomal reces-
sive or dominant Alports syndrome,
21,22
but thin
glomerular basement membranes are occasionally
seen in other forms of glomerulopathy.
22
In kin-
dreds with Alports syndrome, the carriers have thin
glomerular basement membranes and a phenotype
similar to that in patients with benign familial he-
maturia.
24
For this reason, the boundary between
Alports syndrome and benign familial hematuria
has become increasingly vague.
18,24
treatment
Patients with Alports syndrome who have early
renal failure can be treated conservatively with an-
tihypertensive drugs and angiotensin-converting
enzyme inhibitors to attenuate proteinuria and slow
progression, although the indications for treatment
in children are still unclear.
89
Patients who require
dialysis are candidates for renal transplantation. Al-
though the development of nephritis with antiglo-
merular basement membrane alloantibodies in the
transplanted kidney is not very common,
90
sensi-
tive assays can detect these antibodies in the serum
of most transplant recipients, and they are nearly
always directed against multiple epitopes along the
a3(IV), a4(IV), or a5(IV) chain of collagen (Fig. 5
and Table 1).
91,92
Female patients who are hetero-
A
B
C
Figure 4. Histopathological Features of Kidneys
in Alports and Goodpastures Syndromes.
An electron micrograph of a glomerular capillary from a
patient with Alports syndrome and proteinuria (Panel A)
demonstrates the multilamellations and lucent spaces
resulting in the split appearance of the basement mem-
brane (arrows). Panel B (hematoxylin and eosin) shows
focal, segmental necrosis of the glomerular tuft in a kid-
ney from a patient with Goodpastures syndrome. Panel C
(hematoxylin and eosin) shows the crescent formation of
the glomerular tuft in such a kidney.
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n engl j med 348;25 www.nejm.org june 19, 2003
The new england journal of medicine
2550
zygous for mutations in the COL4A5 gene occasion-
ally have progression to renal failure. When they un-
dergo transplantation, the donor kidney does not
develop antiglomerular basement membrane al-
loantibodies. Patients with Alports syndrome gen-
erally do no worse after renal transplantation than
patients with other forms of progressive renal fail-
ure.
93
Lenticonus can be treated with lens implants,
as in cataract surgery.
94
Patients with antiglomerular basement mem-
brane antibodies in whom glomerulonephritis and
lung hemorrhage develop have Goodpastures syn-
drome.
95
In the differential diagnosis of pulmo-
naryrenal syndromes, antiglomerular basement
membrane disease can be distinguished from un-
derlying immune-complex nephritis or antineu-
trophil cytoplasmic autoantibody (ANCA)associ-
ated nephritis by the presence of antiglomerular
basement membrane antibodies, which, on stain-
ing of a renal-biopsy specimen, appear in a linear
pattern in inflamed glomeruli along the glomeru-
lar basement membrane.
27
genetics
Goodpastures syndrome is a multigenic disorder.
Hudson and coworkers identified the a3(IV) NC1
domain as the Goodpasture autoantigen.
29,96
This
target antigen must be present as a component of
the native a3.a4.a5(IV) network (Fig. 2 and 5) of se-
lected basement membranes in order for pulmonary
and renal disease to develop. Consequently, there
are no reported cases in patients with Alports syn-
drome. In mice, the induction of antiglomerular
goodpasture s syndrome
Figure 5. Goodpasture Autoantibodies and Alport Alloantibodies, Which Target Different Epitopes of the a3.a4.a5(IV)
NC1 Hexamer.
Antiglomerular basement membrane antibodies derive from an antigen-specific T-cell and B-cell response (T+B). The
epitopes for the Goodpasture autoantibodies are inaccessible to antiglomerular basement membrane antibodies un-
less there is a dissociation of the hexamer, which may be caused by oxidative stress. These epitopes reside in the a3(IV)
NC1 domain and are partially sequestered by the adjacent a5(IV) NC1 and a4(IV) NC1 domains. In contrast, the
epitopes for the Alport alloantibodies are accessible on the hexamer surface and reside on the a3(IV), a4(IV), and a5(IV)
NC1 domains.
Goodpasture
autoantibodies
Immune reaction T+B
Oxidant
Antiglomerular basement
membrane antibodies
3
5
4
5
3
4
3
5
4
5
3
4
3
5
4
5
3
4
3
5
4
5
3
4
Alport alloantibodies
after transplantation
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n engl j med 348;25 www.nejm.org june 19, 2003
mechanisms of disease
2551
basement membrane disease is limited to selected
strains that express susceptibility genes in the ma-
jor histocompatibility complex (MHC).
97
Goodpastures syndrome in humans is restrict-
ed by the MHC; HLA-DRB1*1501 and DRB1*1502
alleles increase susceptibility, whereas HLA-DR7
and DR1 are protective.
98
The thymus expresses
a3(IV) NC1 peptides that can cause elimination
of autoreactive CD4+ helper T cells,
99
but a few
such T cells escape deletion and can subsequently
engage in the production of antiglomerular base-
ment membrane antibodies.
100
The immunologic
specificity of the antibodies is notable, since anti-
bodies against a1.a1.a2(IV) NC1 domains do not
cause antiglomerular basement membrane ne-
phritis.
101-103
pathogenesis
Human antiglomerular basement membrane an-
tibodies can initiate glomerulonephritis when in-
fused into primates
104
or when human allografts
are transplanted into patients with active Goodpas-
tures syndrome.
105
In genetically engineered mice
that produce human IgG antibodies, immunization
with a3(IV) NC1 domains results in the production
of human antiglomerular basement membrane
antibodies and proliferative glomerulonephritis.
106
Human antiglomerular basement membrane an-
tibodies, usually of the IgG class (or, rarely, IgA), are
of particularly high affinity and remain attached to
glomerular basement membrane for prolonged
periods
107
; the antiglomerular basement mem-
brane antibodies eluted from tissues faithfully rep-
resent the antiglomerular basement membrane
antibodies found in serum.
33
Two dominant epitopes (E
A
and E
B
) have been
identified in the a3(IV) NC1 domain.
108-112
Both
are inaccessible for antibody binding unless disso-
ciation of the hexamer occurs (Fig. 5). The E
A
and E
B
epitopes are located in close proximity to each oth-
er, near the triple helical junction (Fig. 2B),
36
and
they are sequestered at the interface between NC1
domains within a triple helical protomer, rather than
between adjacent protomers.
36,48
Although there
are several subpopulations of antiglomerular base-
ment membrane antibodies in the serum of patients
with Goodpastures syndrome,
109,113,114
immuno-
logic specificity for the two dominant epitopes is
most important.
109,110
Since the a3(IV) NC1 epitope is hidden with-
in the a3.a4.a5(IV) protomer,
110,114,115
it is pre-
sumed that an environmental factor, such as ex-
posure to hydrocarbons
116
or tobacco smoke,
117
is required in order to reveal cryptic epitopes to the
immune system (Fig. 5). Endogenous oxidants can
open this privileged site,
74
as can certain subpop-
ulations of antiglomerular basement membrane
antibodies.
110
Anti-a3(IV) NC1 antibodies are structurally
similar
118
and are highly regulated by T cells.
119
Lymphocytes and macrophages are present in the
kidneys of mice with antiglomerular basement
membrane disease,
120,121
and in rats, T cells can
transfer disease in the absence of antibody.
122,123
Moreover, the antiglomerular basement membrane
alloantibodies produced after renal transplantation
in patients with Alports syndrome
91
or the anti
glomerular basement membrane antibodies pro-
duced in patients with Goodpastures syndrome
124
may not always be sufficient for the development of
nephritis.

In this regard, transfer of antiglomeru-
lar basement membrane antibodies into mice that
are deficient in ab T-cell receptors fails to produce
glomerulonephritis, suggesting that T cells are
also effectors of the inflammatory response.
97
The mechanism of renal injury in Goodpastures
syndrome is complex. When antiglomerular base-
ment membrane antibodies bind glomerular base-
ment membrane, they activate complement
125
and
proteases
126
; such activation disrupts the filtration
barrier and Bowmans capsule, causing protein-
uria and facilitating crescent formation. CD4+ and
CD8+ T cells and intrinsic renal epithelium induce
the migration of macrophages and neutrophils
into the kidney.
121,123,127-129
Interleukin-12 and
interferon-g mediate crescent formation.
130,131
The initial inflammatory reaction in the glomerulus
produces proteinuria with attendant downstream
consequences for tubular epithelium,
132
the devel-
opment of interstitial nephritis, and the subsequent
appearance of fibrosis.
79
clinical presentation
Goodpastures syndrome occurs primarily in young
men in their late 20s and in men and women over
60 years of age.
28
In the younger age group, the
disease is usually eruptive, with hemoptysis, a sud-
den decrease in the hemoglobin level, pallor, cough,
fever, dyspnea, hematuria, non-nephrotic protein-
uria, and red-cell casts. Chest radiography shows
diffuse alveolar infiltrates. Hemoptysis is largely
confined to smokers.
117
Goodpastures syndrome is
generally detected earlier in patients who present
with lung hemorrhage, and such patients may do
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n engl j med 348;25 www.nejm.org june 19, 2003
The new england journal of medicine
2552
better than those who present with silent renal in-
jury alone. Presentation with oliguria is a particu-
larly bad sign.
133,134
antiglomerular basement membrane
antibodies
Almost all antiglomerular basement membrane
antibodies from patients with Goodpastures syn-
drome are directed against the a3(IV) NC1 domain;
a few patients also produce antibodies against the
a1(IV) or a4(IV) NC1 domain (Table 1).
30
Com-
mercial assays for antiglomerular basement mem-
brane antibodies have varying degrees of sensitivity
and specificity; often, immunofluorescent staining
of a kidney-biopsy specimen for antiglomerular
basement membrane antibody and C3 complement
is needed for confirmation. Kidney-biopsy speci-
mens from 2 to 3 percent of patients with Good-
pastures syndrome that appear on standard assays
to contain no circulating antiglomerular basement
membrane antibodies show linear staining for anti-
a3(IV) NC1 antibody along the glomerular base-
ment membrane; circulating antibodies in these
patients are detectable only with the use of a highly
sensitive biosensor.
135
In testing serum in antiglomerular basement
membrane assays, it is important that the a3(IV)
NC1 domain be used as the sole target, because as-
says that use all collagen IV fragments cannot dis-
tinguish Goodpasture antibodies from antibodies
against the a1(IV) NC1 domain in patients with a
paraneoplastic syndrome.
102
Approximately 25 per-
cent of patients with Goodpastures syndrome also
produce ANCA, mainly against myeloperoxidase
(Table 1).
136
Patients in this subgroup probably have
a vasculitis-associated variant for which the prog-
nosis is surprisingly good with treatment.
137
findings on kidney biopsy
The performance of an urgent kidney biopsy rather
than a lung biopsy (lung tissue can have a great
deal of autofluorescence) is important in suspected
cases of Goodpastures syndrome in order to estab-
lish the diagnosis and the degree of irreversible
damage. Renal biopsies typically show focal or seg-
mental glomerular necrosis (Fig. 4B), which later,
with destruction of the glomerular basement mem-
brane and cellular proliferation, leads to crescent
formation (Fig. 4C). Breakdown of the Bowmans
capsule by periglomerular inflammation is of con-
cern, and vasculitis on renal biopsy suggests the si-
multaneous presence of ANCA-related disease.
136
As these lesions progress, there is concomitant in-
terstitial nephritis with fibrosis and tubular atrophy.
treatment
The prognosis at presentation is worse if there is
oliguria, advanced fibrosis or more than 50 per-
cent crescents on renal biopsy, a serum creatinine
concentration of more than 5.7 mg per deciliter
(500 mol per liter), or a need for dialysis.
134
Most
patients with advanced disease do not have a re-
sponse to plasmapheresis or immunosuppression.
Patients with end-stage kidney disease who present
with hemoptysis, however, should be treated for
lung hemorrhage, which does respond to plasma-
pheresis.
133
Patients who have the fewest features
known to predict a poor outcome typically have a
response when given 8 to 10 treatments with plas-
mapheresis during the first two weeks, accompa-
nied by oral prednisone and cyclophosphamide
therapy. Although the evidence is largely experien-
tial, those who have a response to treatment involv-
ing an enduring absence of antiglomerular base-
ment membrane antibodies can have their dose of
prednisone tapered after a few months, while con-
tinuing to receive cyclophosphamide for varying
periods of up to a year. Kidney transplantation is
possible, but because there is a risk of recurrence,
experience has suggested that patients should wait
for six months and certainly until antiglomeru-
lar basement membrane antibodies are undetect-
able in serum.
124
The family of type IV collagens continues to provide
an important source of new information about base-
ment-membrane molecules in epithelial tissues.
Given the additional knowledge available today, we
propose renaming the a3.a4.a5(IV) protomer the
Goodpasture protomer. This change honors the
cornerstone role of the Goodpasture antigen in en-
larging our knowledge of collagen IV biochemistry
and relates the molecular understanding of pro-
tomer assembly to the pathogenesis of Goodpas-
tures and Alports syndromes.
The insights provided by the work completed
to date suggest that a number of therapeutic ad-
vances may be forthcoming. Recognition that base-
ment membranes in patients with Alports syn-
drome are particularly susceptible to proteolysis
47
may eventually lead to the prophylactic use of spe-
cific protease inhibitors or even gene-replacement
summary
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n engl j med 348;25 www.nejm.org june 19, 2003
mechanisms of disease
2553
therapy.
138
Work with experimental models of
antiglomerular basement membrane disease al-
ready predicts a role for costimulatory blockade of
T-cell activation,
139
immune modulation with in-
terleukin-4 and interleukin-10,
121
or inhibition of
macrophage migration.
140
If nothing else, the fu-
ture will be interesting, and work in this area will
undoubtedly provide a new understanding of col-
lagen-related diseases.
Supported in part by grants (DK-46282 and DK-55926, to Dr.
Neilson; DK-18381 and DK-53763, to Dr. Hudson; and DK-62524,
to Dr. Sundaramoorthy) from the National Institutes of Health and
a grant (to Dr. Tryggvason) from the Swedish Medical Research
Council.
We are indebted to Larry Howell for assistance in the preparation
of the figures.
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