Membranoproliferative glomerulonephritis differential diagnosis
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2], Mehrian Jafarizade, M.D [3]
Overview
There are some differential diagnosis mentioned for MPGN as they have some symptoms and signs in shared, the most relevant diseases are acute glomerulonephritis, IgA Nephropathy, LupusNephritis, poststreptococcal glomerulonephritis, and rapidly progressive Glomerulonephritis (RPGN).
Differentiating Membranoproliferative Glomerulonephritis From Other Diseases
According to the pathophysiology of Membranoproliferative Glomerulonephritis (MPGN) various differential diagnosis include :[1]
Differential dignosis for MPGN | ||
---|---|---|
Type | Disease | Pattern of injury |
Immune-complex GN |
|
|
Anti-GBM GN | Anti-GBM GN |
|
Pauci-Immune GN |
|
|
Monoclonal Ig GN |
|
|
C3 glomerulopathy |
|
Various types of glomerular diseases should be differentiated from each other based on associations, presence of pitting edema, hematuria, hypertension, hemoptysis, oliguria, peri-orbital edema, hyperlipidemia, type of antibodies, light and electron microscopic features. The above table differentiates between various types of glomerular diseases:
Glomerular diseases | Disease | History and Symtoms | Laboratory Findings | Pathology | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
History | Systemic symptoms | Hemeturia | Proteinuria | Hypertension | Pitting edema | Oliguria | Nephrotic features | Nephritic features | Hyperlipidemia and hypercholesterolemia | Auto-antibodies,
Complements |
Light microscope | Electron microscope | Immunoflourescence pattern | |||
Acute Nephritic Syndromes | Poststreptococcal Glomerulonephritis[2][3][4] |
|
+/- | + | +/- | +/- | +/- | +/- | +/- | +/- |
|
|
| |||
Renal disease due to Subacute Bacterial Endocarditis, or cardiac shunt (Atrioventricular)[5][6] |
|
+/- | + | +/- | +/- | +/- | +/- | +/- | +/- |
|
|
|
| |||
Lupus Nephritis[7] |
|
|
+/- | + | +/- | +/- | +/- | +/- | +/- | +/- |
|
|
|
| ||
Goodpasture syndrome|Antiglomerular Basement Membrane Disease Goodpasture syndrome|(Goodpasture's syndrome)]][8][9] |
|
|
+ | + | + | + | + | + | - | - | Diffuse thickening of the glomerular basement membrane with absence of sub-epithelial and sub-endothelial deposits |
| ||||
IgA Nephropathy[10][11] |
|
|
+ | +/- | + | +/- | + | - | + | - |
|
|
|
| ||
Disease | History | Systemic symptoms | Hemeturia | Proteinuria | Hypertension | Pitting edema | Oliguria | Nephrotic features | Nephritic features | Hyperlipidemia and hypercholesterolemia | Auto-antibodies,
Complements |
Light microscope | Electron microscope | Immunoflourescence pattern | ||
ANCA Small-Vessel Vasculitis[12][13] | Granulomatosis with Polyangiitis (Wegener's)[14][15][16] |
|
|
+ | + | + | +/- | + | - | + | - |
|
|
| ||
Microscopic Polyangiitis[17] | +/- |
|
+ | + | + | + | + | + | - |
| ||||||
Churg-Strauss Syndrome[18] | +/- | + | + | + | + | + | + | - |
| |||||||
Membranoproliferative Glomerulonephritis[19][20] |
|
+ | + | + | +/- | + | + | - | - | - |
|
| ||||
Henoch-Schönlein purpura [21] |
|
|
+ | + | + | +/- | + | + | - | - | - |
|
|
| ||
Disease | History | Systemic symptoms | Hemeturia | Proteinuria | Hypertension | Pitting edema | Oliguria | Nephrotic features | Nephritic features | Hyperlipidemia and hypercholesterolemia | Auto-antibodies,
Complements |
Light microscope | Electron microscope | Immunoflourescence pattern | ||
Cryoglobulinemia[22] | Patients having cryoglobulinemia may have positive history of:
|
Pulmonary symptoms:
Cutaneous symptoms: Gastrointestinal symptoms:
General symptoms:
|
+/- | + | +/- | + | +/- | +/- | +/- | +/- | +/- |
|
| |||
Nephrotic Syndrome | Minimal Change Disease[23][24] |
|
- | + | - | + | +/- | + | - | + |
|
|
- | |||
Focal Segmental Glomerulosclerosis[25][26][27] |
|
- | + | - | + | +/- | + | - | + |
|
|
- | ||||
Membranous Glomerulonephritis[28][29] |
|
- | + | - | + | +/- | + | - | + | Immune complex deposition |
|
Immune complex GN, granular deposite | ||||
Diabetic Nephropathy[30][31][32][33][34][35][36][37][38][39] | For more information on diabetes click here. | - | + | - | + | +/- | + | - | + |
|
|
- | ||||
Disease | History | Systemic symptoms | Hemeturia | Proteinuria | Hypertension | Pitting edema | Oliguria | Nephrotic features | Nephritic features | Hyperlipidemia and hypercholesterolemia | Auto-antibodies,
Complements |
Light microscope | Electron microscope | Immunoflourescence pattern | ||
Glomerular Deposition Diseases | Light Chain Deposition Disease[40] |
|
- | - | + | - | + | +/- | + | - | + | - |
|
|
| |
Renal Amyloidosis[41][42][43][44] |
|
- | + | - | + | +/- | + | - | + | - |
|
|
| |||
Fibrillary-Immunotactoid Glomerulopathy[45] | - | +/- | + | +/- | +/- | +/- | + | +/- | +/- | - |
|
|
| |||
Fabry's Disease[46][47][48] |
|
|
- | + | - | + | +/- | + | - | + | - |
|
|
- | ||
Basement Membrane Syndrome | Alport's Syndrome[49][50][51][52][53][54] |
|
Auditary:
Occular problems:
|
- | + | - | + | +/- | + | - | + | - |
|
|
| |
Disease | History | Systemic symptoms | Hemeturia | Proteinuria | Hypertension | Pitting edema | Oliguria | Nephrotic features | Nephritic features | Hyperlipidemia and hypercholesterolemia | Auto-antibodies,
Complements |
Light microscope | Electron microscope | Immunoflourescence pattern | ||
Thin Basement Membrane Disease[55][56] |
|
- | - | + | -/+ | - | -/+ | - | -/+ | - | - | - | Diffuse thinning of the glomerular basement membranes (GBM) | - | ||
Nail-Patella Syndrome[57][58] |
|
|
+ | + | - | - | - | - | - | - | - |
|
|
| ||
Glomerular-Vascular Syndromes | Hypertensive Nephrosclerosis[59] | Chronic hypertension |
|
+/- | +/- | + | +/- | +/- | +/- | - | +/- | - | ||||
Cholesterol Emboli[60] |
|
|
+/- | +/- | + | +/- | +/- | +/- | - | +/- | - |
|
|
| ||
Disease | History | Systemic symptoms | Hemeturia | Proteinuria | Hypertension | Pitting edema | Oliguria | Nephrotic features | Nephritic features | Hyperlipidemia and hypercholesterolemia | Auto-antibodies,
Complements |
Light microscope | Electron microscope | Immunoflourescence pattern | ||
Sickle Cell Disease[61] |
|
|
+/- | +/- | +/- | - | - | - | - | - | - |
| ||||
Thrombotic Microangiopathies[62] | Click for more information on Thrombotic Microangiopathies. | + | +/- | + | +/- | +/- | +/- | - | - | - |
|
|
| |||
Antiphospholipid Antibody Syndrome [63][64][65] |
|
|
+ | +/- | + | +/- | +/- | +/- | - | - | - |
|
|
|
Some infectious diseases such as HIV, HBV, HCV, syphilis, leprosy, malaria, and schistosomiasis may cause glomerular diseases.
References
- ↑ D'Amico, Giuseppe; Fornasieri, Alessandro (1995). "Cryoglobulinemic glomerulonephritis: A membranoproliferative glomerulonephritis induced by hepatitis C virus". American Journal of Kidney Diseases. 25 (3): 361–369. doi:10.1016/0272-6386(95)90095-0. ISSN 0272-6386.
- ↑ GERMUTH FG (1953). "A comparative histologic and immunologic study in rabbits of induced hypersensitivity of the serum sickness type". J Exp Med. 97 (2): 257–82. PMC 2136196. PMID 13022878.
- ↑ Germuth FG, Senterfit LB, Dreesman GR (1972). "Immune complex disease. V. The nature of the circulating complexes associated with glomerular alterations in the chronic BSA-rabbit system". Johns Hopkins Med J. 130 (6): 344–57. PMID 5031005.
- ↑ Radhakrishnan J, Cattran DC (2012). "The KDIGO practice guideline on glomerulonephritis: reading between the (guide)lines--application to the individual patient". Kidney Int. 82 (8): 840–56. doi:10.1038/ki.2012.280. PMID 22895519.
- ↑ Neugarten J, Baldwin DS (August 1984). "Glomerulonephritis in bacterial endocarditis". Am. J. Med. 77 (2): 297–304. PMID 6380288.
- ↑ Arze RS, Rashid H, Morley R, Ward MK, Kerr DN (January 1983). "Shunt nephritis: report of two cases and review of the literature". Clin. Nephrol. 19 (1): 48–53. PMID 6831779.
- ↑ Weening JJ, D'Agati VD, Schwartz MM, Seshan SV, Alpers CE, Appel GB, Balow JE, Bruijn JA, Cook T, Ferrario F, Fogo AB, Ginzler EM, Hebert L, Hill G, Hill P, Jennette JC, Kong NC, Lesavre P, Lockshin M, Looi LM, Makino H, Moura LA, Nagata M (February 2004). "The classification of glomerulonephritis in systemic lupus erythematosus revisited". Kidney Int. 65 (2): 521–30. doi:10.1111/j.1523-1755.2004.00443.x. PMID 14717922.
- ↑ Bolton WK (November 1996). "Goodpasture's syndrome". Kidney Int. 50 (5): 1753–66. PMID 8914046.
- ↑ Mathew TH, Hobbs JB, Kalowski S, Sutherland PW, Kincaid-Smith P (February 1975). "Goodpasture's syndrome: normal renal diagnostic findings". Ann. Intern. Med. 82 (2): 215–8. PMID 1090223.
- ↑ Suzuki H, Kiryluk K, Novak J, Moldoveanu Z, Herr AB, Renfrow MB, Wyatt RJ, Scolari F, Mestecky J, Gharavi AG, Julian BA (October 2011). "The pathophysiology of IgA nephropathy". J. Am. Soc. Nephrol. 22 (10): 1795–803. doi:10.1681/ASN.2011050464. PMC 3892742. PMID 21949093.
- ↑ Wyatt RJ, Julian BA (June 2013). "IgA nephropathy". N. Engl. J. Med. 368 (25): 2402–14. doi:10.1056/NEJMra1206793. PMID 23782179.
- ↑ Higgins RM, Goldsmith DJ, Connolly J, Scoble JE, Hendry BM, Ackrill P, Venning MC (January 1996). "Vasculitis and rapidly progressive glomerulonephritis in the elderly". Postgrad Med J. 72 (843): 41–4. PMC 2398323. PMID 8746284.
- ↑ Jennette JC (March 2003). "Rapidly progressive crescentic glomerulonephritis". Kidney Int. 63 (3): 1164–77. doi:10.1046/j.1523-1755.2003.00843.x. PMID 12631105.
- ↑ Renaudineau Y, Le Meur Y (October 2008). "Renal involvement in Wegener's granulomatosis". Clin Rev Allergy Immunol. 35 (1–2): 22–9. doi:10.1007/s12016-007-8066-6. PMID 18172777.
- ↑ Weiss MA, Crissman JD (October 1984). "Renal biopsy findings in Wegener's granulomatosis: segmental necrotizing glomerulonephritis with glomerular thrombosis". Hum. Pathol. 15 (10): 943–56. PMID 6384024.
- ↑ Pagnoux C (March 2008). "[Wegener's granulomatosis and microscopic polyangiitis]". Rev Prat (in French). 58 (5): 522–32. PMID 18524109.
- ↑ Chung SA, Seo P (August 2010). "Microscopic polyangiitis". Rheum. Dis. Clin. North Am. 36 (3): 545–58. doi:10.1016/j.rdc.2010.04.003. PMC 2917831. PMID 20688249.
- ↑ Sinico RA, Di Toma L, Maggiore U, Tosoni C, Bottero P, Sabadini E, Giammarresi G, Tumiati B, Gregorini G, Pesci A, Monti S, Balestrieri G, Garini G, Vecchio F, Buzio C (May 2006). "Renal involvement in Churg-Strauss syndrome". Am. J. Kidney Dis. 47 (5): 770–9. doi:10.1053/j.ajkd.2006.01.026. PMID 16632015.
- ↑ Alchi B, Jayne D (August 2010). "Membranoproliferative glomerulonephritis". Pediatr. Nephrol. 25 (8): 1409–18. doi:10.1007/s00467-009-1322-7. PMC 2887509. PMID 19908070.
- ↑ Davis AE, Schneeberger EE, Grupe WE, McCluskey RT (May 1978). "Membranoproliferative glomerulonephritis (MPGN type I) and dense deposit disease (DDD) in children". Clin. Nephrol. 9 (5): 184–93. PMID 657595.
- ↑ Jennette JC, Falk RJ (July 1994). "The pathology of vasculitis involving the kidney". Am. J. Kidney Dis. 24 (1): 130–41. PMID 8023818.
- ↑ Fogo AB, Lusco MA, Najafian B, Alpers CE (February 2016). "AJKD Atlas of Renal Pathology: Cryoglobulinemic Glomerulonephritis". Am. J. Kidney Dis. 67 (2): e5–7. doi:10.1053/j.ajkd.2015.12.007. PMID 26802335.
- ↑ Saha TC, Singh H (November 2006). "Minimal change disease: a review". South. Med. J. 99 (11): 1264–70. doi:10.1097/01.smj.0000243183.87381.c2. PMID 17195422.
- ↑ Saleem MA, Kobayashi Y (2016). "Cell biology and genetics of minimal change disease". F1000Res. 5. doi:10.12688/f1000research.7300.1. PMC 4821284. PMID 27092244.
- ↑ Rosenberg AZ, Kopp JB (March 2017). "Focal Segmental Glomerulosclerosis". Clin J Am Soc Nephrol. 12 (3): 502–517. doi:10.2215/CJN.05960616. PMC 5338705. PMID 28242845.
- ↑ Jefferson JA, Shankland SJ (September 2014). "The pathogenesis of focal segmental glomerulosclerosis". Adv Chronic Kidney Dis. 21 (5): 408–16. doi:10.1053/j.ackd.2014.05.009. PMC 4149756. PMID 25168829.
- ↑ Gephardt GN, Tubbs RR, Popowniak KL, McMahon JT (October 1986). "Focal and segmental glomerulosclerosis. Immunohistologic study of 20 renal biopsy specimens". Arch. Pathol. Lab. Med. 110 (10): 902–5. PMID 2429634.
- ↑ Lai WL, Yeh TH, Chen PM, Chan CK, Chiang WC, Chen YM, Wu KD, Tsai TJ (February 2015). "Membranous nephropathy: a review on the pathogenesis, diagnosis, and treatment". J. Formos. Med. Assoc. 114 (2): 102–11. doi:10.1016/j.jfma.2014.11.002. PMID 25558821.
- ↑ Wasserstein AG (April 1997). "Membranous glomerulonephritis". J. Am. Soc. Nephrol. 8 (4): 664–74. PMID 10495797.
- ↑ Drummond K, Mauer M, International Diabetic Nephropathy Study Group (2002). "The early natural history of nephropathy in type 1 diabetes: II. Early renal structural changes in type 1 diabetes". Diabetes. 51 (5): 1580–7. PMID 11978659.
- ↑ Hørlyck A, Gundersen HJ, Osterby R (1986). "The cortical distribution pattern of diabetic glomerulopathy". Diabetologia. 29 (3): 146–50. PMID 3699305.
- ↑ Alpers CE, Hudkins KL (2011). "Mouse models of diabetic nephropathy". Curr Opin Nephrol Hypertens. 20 (3): 278–84. doi:10.1097/MNH.0b013e3283451901. PMC 3658822. PMID 21422926.
- ↑ Kimmelstiel P, Wilson C (1936). "Intercapillary Lesions in the Glomeruli of the Kidney". Am J Pathol. 12 (1): 83–98.7. PMC 1911022. PMID 19970254.
- ↑ Alpers CE, Biava CG (1989). "Idiopathic lobular glomerulonephritis (nodular mesangial sclerosis): a distinct diagnostic entity". Clin Nephrol. 32 (2): 68–74. PMID 2766585.
- ↑ Toyoda M, Najafian B, Kim Y, Caramori ML, Mauer M (2007). "Podocyte detachment and reduced glomerular capillary endothelial fenestration in human type 1 diabetic nephropathy". Diabetes. 56 (8): 2155–60. doi:10.2337/db07-0019. PMID 17536064.
- ↑ Najafian B, Crosson JT, Kim Y, Mauer M (2006). "Glomerulotubular junction abnormalities are associated with proteinuria in type 1 diabetes". J Am Soc Nephrol. 17 (4 Suppl 2): S53–60. doi:10.1681/ASN.2005121342. PMID 16565248.
- ↑ Najafian B, Kim Y, Crosson JT, Mauer M (2003). "Atubular glomeruli and glomerulotubular junction abnormalities in diabetic nephropathy". J Am Soc Nephrol. 14 (4): 908–17. PMID 12660325.
- ↑ Najafian B, Alpers CE, Fogo AB (2011). "Pathology of human diabetic nephropathy". Contrib Nephrol. 170: 36–47. doi:10.1159/000324942. PMID 21659756.
- ↑ Najafian B, Alpers CE, Fogo AB (2011). "Pathology of human diabetic nephropathy". Contrib Nephrol. 170: 36–47. doi:10.1159/000324942. PMID 21659756.
- ↑ Hutchison CA, Cockwell P, Stringer S, Bradwell A, Cook M, Gertz MA, Dispenzieri A, Winters JL, Kumar S, Rajkumar SV, Kyle RA, Leung N (June 2011). "Early reduction of serum-free light chains associates with renal recovery in myeloma kidney". J. Am. Soc. Nephrol. 22 (6): 1129–36. doi:10.1681/ASN.2010080857. PMC 3103732. PMID 21511832.
- ↑ Baker KR, Rice L (2012). "The amyloidoses: clinical features, diagnosis and treatment". Methodist Debakey Cardiovasc J. 8 (3): 3–7. PMC 3487569. PMID 23227278.
- ↑ Gillmore JD, Hawkins PN (October 2013). "Pathophysiology and treatment of systemic amyloidosis". Nat Rev Nephrol. 9 (10): 574–86. doi:10.1038/nrneph.2013.171. PMID 23979488.
- ↑ Jerzykowska S, Cymerys M, Gil LA, Balcerzak A, Pupek-Musialik D, Komarnicki MA (2014). "Primary systemic amyloidosis as a real diagnostic challenge - case study". Cent Eur J Immunol. 39 (1): 61–6. doi:10.5114/ceji.2014.42126. PMC 4439975. PMID 26155101.
- ↑ Pepys MB (2006). "Amyloidosis". Annu. Rev. Med. 57: 223–41. doi:10.1146/annurev.med.57.121304.131243. PMID 16409147.
- ↑ Korbet SM, Schwartz MM, Lewis EJ (March 1991). "Immunotactoid glomerulopathy". Am. J. Kidney Dis. 17 (3): 247–57. PMID 1996564.
- ↑ Alroy J, Sabnis S, Kopp JB (June 2002). "Renal pathology in Fabry disease". J. Am. Soc. Nephrol. 13 Suppl 2: S134–8. PMID 12068025.
- ↑ Meikle PJ, Hopwood JJ, Clague AE, Carey WF (1999). "Prevalence of lysosomal storage disorders". JAMA : the Journal of the American Medical Association. 281 (3): 249–54. PMID 9918480. Unknown parameter
|month=
ignored (help) - ↑ Branton MH, Schiffmann R, Sabnis SG; et al. (2002). "Natural history of Fabry renal disease: influence of alpha-galactosidase A activity and genetic mutations on clinical course". Medicine. 81 (2): 122–38. PMID 11889412. Unknown parameter
|month=
ignored (help) - ↑ McCarthy PA, Maino DM (2000). "Alport syndrome: a review". Clin Eye Vis Care. 12 (3–4): 139–150. PMID 11137428.
- ↑ Chugh KS, Sakhuja V, Agarwal A, Jha V, Joshi K, Datta BN; et al. (1993). "Hereditary nephritis (Alport's syndrome)--clinical profile and inheritance in 28 kindreds". Nephrol Dial Transplant. 8 (8): 690–5. PMID 8414153.
- ↑ Chugh KS, Sakhuja V, Agarwal A, Jha V, Joshi K, Datta BN; et al. (1993). "Hereditary nephritis (Alport's syndrome)--clinical profile and inheritance in 28 kindreds". Nephrol Dial Transplant. 8 (8): 690–5. PMID 8414153.
- ↑ McCarthy PA, Maino DM (2000). "Alport syndrome: a review". Clin Eye Vis Care. 12 (3–4): 139–150. PMID 11137428.
- ↑ Amari F, Segawa K, Ando F (1994). "Lens coloboma and Alport-like glomerulonephritis". Eur J Ophthalmol. 4 (3): 181–3. PMID 7819734.
- ↑ Govan JA (1983). "Ocular manifestations of Alport's syndrome: a hereditary disorder of basement membranes?". Br J Ophthalmol. 67 (8): 493–503. PMC 1040106. PMID 6871140.
- ↑ Savige J, Rana K, Tonna S, Buzza M, Dagher H, Wang YY (2003). "Thin basement membrane nephropathy". Kidney Int. 64 (4): 1169–78. doi:10.1046/j.1523-1755.2003.00234.x. PMID 12969134. Unknown parameter
|month=
ignored (help) - ↑ Hou P, Chen Y, Ding J, Li G, Zhang H (2007). "A novel mutation of COL4A3 presents a different contribution to Alport syndrome and thin basement membrane nephropathy". Am. J. Nephrol. 27 (5): 538–44. doi:10.1159/000107666. PMID 17726307.
- ↑ Najafian B, Smith K, Lusco MA, Alpers CE, Fogo AB (October 2017). "AJKD Atlas of Renal Pathology: Nail-Patella Syndrome-Associated Nephropathy". Am. J. Kidney Dis. 70 (4): e19–e20. doi:10.1053/j.ajkd.2017.08.001. PMID 28941488.
- ↑ Guidera KJ, Satterwhite Y, Ogden JA, Pugh L, Ganey T (1991). "Nail patella syndrome: a review of 44 orthopaedic patients". J Pediatr Orthop. 11 (6): 737–42. PMID 1960197.
- ↑ Hughson MD, Puelles VG, Hoy WE, Douglas-Denton RN, Mott SA, Bertram JF (July 2014). "Hypertension, glomerular hypertrophy and nephrosclerosis: the effect of race". Nephrol. Dial. Transplant. 29 (7): 1399–409. doi:10.1093/ndt/gft480. PMC 4071048. PMID 24327566.
- ↑ Lusco MA, Najafian B, Alpers CE, Fogo AB (April 2016). "AJKD Atlas of Renal Pathology: Cholesterol Emboli". Am. J. Kidney Dis. 67 (4): e23–4. doi:10.1053/j.ajkd.2016.02.034. PMID 27012950.
- ↑ Wesson DE (June 2002). "The initiation and progression of sickle cell nephropathy". Kidney Int. 61 (6): 2277–86. doi:10.1046/j.1523-1755.2002.00363.x. PMID 12028473.
- ↑ Lusco MA, Fogo AB, Najafian B, Alpers CE (December 2016). "AJKD Atlas of Renal Pathology: Thrombotic Microangiopathy". Am. J. Kidney Dis. 68 (6): e33–e34. doi:10.1053/j.ajkd.2016.10.006. PMID 27884283.
- ↑ Jayakody Arachchillage D, Greaves M (2014). "The chequered history of the antiphospholipid syndrome". Br J Haematol. 165 (5): 609–17. doi:10.1111/bjh.12848. PMID 24684307.
- ↑ Jayakody Arachchillage D, Greaves M (2014). "The chequered history of the antiphospholipid syndrome". Br J Haematol. 165 (5): 609–17. doi:10.1111/bjh.12848. PMID 24684307.
- ↑ Popa A, Voinea L, Pop M, Stana D, Dascalu AM, Alexandrescu C; et al. (2008). "[Primary antiphospholipid syndrome]". Oftalmologia. 52 (1): 13–7. PMID 18714484.