Pediatric IgA nephropathy: clinical features at presentation and outcome for African-Americans and Caucasians

AIM

To determine the disease severity at onset and outcome for African-American and Caucasian pediatric patients with IgA nephropathy diagnosed at the Le Bonheur Children's Medical Center since 1990.

DESIGN/METHODS

The study population included all patients diagnosed with IgA nephropathy at the Le Bonheur Children's Medical Center from January 1990 through February 2004. All were below age 18 at biopsy. Clinical features assessed at diagnosis were age, gender, presence of hypertension, history of macroscopic hematuria, degree of proteinuria, severity of renal histology and pattern for immunofluorescent reactants.

STATISTICS

Student's t-test was used to compare age at biopsy and length of follow-up between the 2 groups. Fisher's exact test was used to compare features at presentation and patterns of immunofluorescence. Kidney survival was predicted by the Kaplan-Meier method.

RESULTS

Forty-seven patients (17 African-American, 29 Caucasian) were studied. Clinical features at diagnosis and pattern for all immunofluorescent reactants did not differ significantly between the 2 groups. Mesangial deposition of C1q occurred in 4/17 African-Americans as compared to 1/27 Caucasians (p = 0.06). Four patients (2 African-Americans, 2 Caucasians) progressed to end-stage renal disease. Predicted kidney survival was 96% (94% in African-Americans and 97% in Caucasians) at 1 year and 91% (94% in African-Americans and 89% in Caucasians) at 5 years from diagnosis. Mean time from diagnosis to end-stage renal disease or last follow-up was 3.3 years (3.8 for African-Americans, 3.0 for Caucasians). Macroscopic hematuria occurred prior to diagnosis for 90% of the Caucasian as compared to 61% of the African-American patients (p = 0.03). Urinalysis was normal at last follow-up visit for 24% of African-American patients and 32% of Caucasian patients.

CONCLUSION

In a relatively small sample from a single center, except for the difference in macroscopic hematuria, clinical features at diagnosis and outcome of IgA nephropathy appear similar for African-American and Caucasian pediatric patients.

Maternal autoantibodies from preeclamptic patients activate angiotensin receptors on human mesangial cells and induce interleukin-6 and plasminogen activator inhibitor-1 secretion

BACKGROUND

Preeclampsia affects 3-5% of all pregnancies. It is a major cause of maternal and fetal morbidity and mortality. Recent studies demonstrate that autoantibodies against the angiotensin II type 1 (AT(1)) receptor are present in the serum of preeclamptic patients. In this study, we investigated the role of AT(1) receptor-agonistic autoantibody (AT1-AA) regarding interleukin-6 (IL-6) and plasminogen activator inhibitor-1 (Pai-1) secretion in human mesangial cells.

METHODS

The study included ten patients: five severely preeclamptic and five normotensive pregnant women. Immunoglobulin-G (IgG) was purified from each individual. The presence of AT1-AA was determined based on its ability to stimulate an increase in the contraction rate of rat neonatal cardiomyocytes. Primary human mesangial cells were chosen to study IgG-induced secretion of IL-6 and Pai-1. Losartan and epitope peptides were used to determine whether AT1-AA interaction with AT(1) receptor was associated with stimulation of IL-6 and Pai-1 secretion and was mediated through AT(1) receptor activation.

RESULTS

The IgG from preeclamptic patients stimulated an increased contraction rate in rat neonatal cardiomyocytes. The IgG from preeclamptic patients induced the AT(1) receptor-specific secretion of IL-6 and Pai-1 from human mesangial cells at a significantly higher level than that achieved with IgG from normotensive patients. Competition with an epitope peptide suggested that the AT(1) receptor was stimulated by AT1-AA.

CONCLUSIONS

Our findings suggest that a maternal autoantibody with the ability to activate AT(1) receptors may account for the development of renal damage seen in preeclamptic patients.

Development of immune-complex glomerulonephritis in athymic mice: T cells are not required for the genesis of glomerular injury

Chronic injection of dextran into normal mice elicits a glomerulonephritis (GN) that models IgA nephropathy (IgAN) in humans. Since athymic mice lack T cells but nonetheless develop antibodies to polysaccharide antigens such as dextran (DEX), we used athymic mice to study the role of T lymphocytes in the induction of this form of GN, independent of the role of T cells in antibody synthesis. Both mice given injections of diethylaminoethyl (DEAE)-DEX and uninjected mice had circulating IgM and IgA anti-DEX antibodies, which apparently arise as 'natural antibodies', but immune complex GN was observed only in the injected mice. All of 15 injected mice exhibited capillary staining for IgA and IgM; none of 12 control mice contained such IgA deposits and only one had capillary staining for IgM (both P<0.001). In addition, IgG and C3 were detected in injected but not control animals. By light microscopy, injected mice exhibited marked expansion of mesangial matrix relative to controls. Electron microscopy showed no glomerular abnormalities in control mice, whereas injected mice showed large organized fibrillar deposits principally in the mesangium. Hematuria and proteinuria were present in all 15 injected mice, but only one of 11 control mice showed hematuria or proteinuria (both P<0.001). These results indicate that chronic injection of DEAE-DEX into athymic mice generates the same clinical and histologic features of GN as in euthymic mice, suggesting that T cells are not necessary to promote GN in this model.

Role of macromolecular IgA in IgA nephropathy

Primary IgA nephropathy (IgAN) is the most common form of primary glomerulonephritis, leading to progressive renal failure in almost one third of the patients. The disease is characterized by mesangial deposits of IgA. The pathogenesis of IgAN remains incompletely understood. The basic abnormality of this disorder lies within the IgA immune system rather than in the kidney. Elevated levels of IgA and IgA-containing complexes are found in sera of most patients with IgAN, but increased levels alone are not sufficient to develop IgAN. Therefore abnormal physicochemical properties of circulating IgA, such as size, charge, and glycosylation may play a role. This is supported by the presence of altered glycosylation of serum and mesangial IgA in patients with IgAN. Although the precise origin and nature of the mesangial IgA deposits are still uncertain, they contain at least in part macromolecular IgA, which may be derived from circulating IgA-containing complexes. Recently, novel insights have been obtained in the molecular composition of circulating high-molecular-weight IgA, which might include complexes with underglycosylated IgA1 and IgA-CD89 complexes. In this review various aspects of macromolecular IgA in relation to IgAN will be discussed.

Mycophenolate mofetil and roscovitine decrease cyclin expression and increase p27(kip1) expression in anti Thy1 mesangial proliferative nephritis

The response of mesangial cells to a phlogistic challenge includes cell proliferation and mesangial matrix expansion. Cell proliferation is a highly regulated process which includes enhancing factors such as cyclins, cyclin dependent kinases, and inhibitory proteins, such as p27(kip1). The aim of the study was to evaluate the effects of Mycophenolate mofetil (MMF), and roscovitine (R), on the cell cycle regulatory system when administered in the florid phase of the experimental model of mesangial proliferative nephritis induced by the anti Thy-1 antigen monoclonal antibody. Three days after nephritis induction, different groups were given MMF and R. Rats treated with MMF or R showed a slight decrease in mesangial proliferation and matrix expansion. Samples of cortical tissue were tested by 'real time' RT-PCR in order to study gene expression of cyclins B, D1, D2, D3, E, and the cyclin inhibitor p27(kip1). Localization of mRNA was evaluated by in situ hybridization. Real time RT-PCR analysis showed a significant decrease in cyclins B, D1, D2, and D3 in rats treated with either MMF or R as compared to controls. Both MMF and R treatment induced a significant increase in p27(kip1) mRNA expression. In situ hybridization showed a mesangial-endothelial expression pattern in glomeruli. The number of labelled cells per glomerulus, the number of positive glomeruli in each examined slide as well as cyclin D2 and D3 signal intensity was significantly lower in rats treated with MMF or R as compared to controls, whereas MMF or R treatment up-regulated p27(kip1) mRNA expression. Immunohistochemical evaluation of p27(kip1) aimed to examine the influence of MMF or R on protein expression confirmed up-regulation.

New insights in the pathogenesis of IgA nephropathy

IgA nephropathy (N) or Berger's disease is the most common form of primary glomerulonephritis worldwide and one of the first cause of end-stage renal failure. The disease is characterized by the accumulation in mesangial areas of complexes containing polymeric IgA1. The mechanisms involved in the pathogenesis of IgAN is only now emerging. We discussed here three essential points: (i) the generation of abnormal IgA1 and formation of IgA1 complexes; (ii) the generation of mesangial injury mediated by interaction of IgA1 complexes with mesangial IgA1 receptors, and (iii) the progression of IgA-mediated mesangial injury towards renal failure. In summary, our data reveal that quantitative and structural changes of IgA1 play a key role on the onset of the disease due to functional abnormalities of two IgA receptors: the Fc alphaRI (CD89) expressed by blood myeloid cells and the transferrin receptor (CD71) on mesangial cells. Abnormal IgA induces release of soluble CD89 soluble leading to the formation of circulating IgA complexes, which in turn may be trapped by CD71 that is overexpressed on mesangial cells in IgAN patients allowing formation of IgA1 deposits. The elucidation of IgA-receptor interactions may open new avenues for drug design and treatment of IgAN.

The fate of glomerular mesangial IgA deposition in the donated kidney after allograft transplantation

OBJECTIVE

To investigate the fate of the mesangial IgA deposits in the donor kidney after allograft transplantation.

METHODOLOGY

Routine pre-transplant cadaveric donor kidney biopsy and repeated renal biopsies were performed at months 1, 3, and 6 after renal transplantation. The patients, 342 in number, were divided into IgA positive deposition kidney group (group A, n = 83) and non-IgA deposition kidney group (group B, n = 259). There were no significant differences between the two groups' sex, age, time of hemodialysis, warm ischemia time, cold ischemia time, complement-dependent cytotoxicity, level of panel-reactive assay, and the distribution of original disease.

RESULTS

Recipients in group A received donor kidney with glomerular mesangial proliferation and marked diffuse granular IgA deposition. All of them showed edema, nephrotic range protienuria, microhematuria, hypoalbuminemia, hypertension, and delayed graft function. Borderline change was higher in group A than in group B, 37.3 and 16.2% (p < 0.001), respectively. Acute allograft rejection was higher in group A than in group B, 31.3 and 19.3% (p < 0.001), respectively. The glomerular mesangial IgA deposits gradually disappeared from the mesangial regions in grafts of acute rejection. Graft survival in both groups was not significant, being 93.8 and 95.6% in 1 yr, and 86.7 and 88.3% in 3 yr.

CONCLUSION

Clinical features of the recipients which received from donor kidney with glomerular mesangial proliferation and marked diffuse granular IgA deposition: edema, proteinuria, microhematuria, hypoalbuminemia, hypertension, and delayed graft function. The presence of IgA deposits on donated kidney, by a possible increase of the immunogenicity of these kidneys, might be a cause of increased rejection. There were no significant differences between the two groups on long-term allograft survival.

The characterization of a specific Thy-1 molecular epitope expressed on rat mesangial cells

BACKGROUND

An Experimental model of proliferative glomerulonephritis induced by an antibody against Thy-1 antigen has been established. However, the pathophysiologic role and the critical epitope of Thy-1 molecule for induction of mesangial cell dysfunction remain unknown. We have reported that monoclonal antibody 1-22-3 recognizes specific epitope which could transduce highly effective activation in mesangial cells. Identification of functional domains on cell surfaces is indispensable for understanding the molecular mechanisms of mesangial cell function. This study was undertaken to determine the functional domain containing the specific epitope recognized by monoclonal antibody 1-22-3.

METHODS

A series of glutathione-S-transferase (GST)-truncated-Thy-1 proteins were generated using pGEX 4T-1 vector. COS cells were transiently transfected with plasmid vectors which could express the rat Thy-1 and mutant-Thy-1.

RESULTS

Western blot analysis using recombinant GST-truncated-Thy-1 revealed that 1-22-3 bound to epitope at amino acids 15-23 (LRLDCRHEN). Enzyme-linked immunosorbent assay (ELISA) revealed that synthetic LRLDCRHEN peptides could inhibit the binding of 1-22-3 to rat mesangial cells and GST-Thy-1 protein. Using peptides as antigens, ELISA showed that 1-22-3 bound to the LRLDCRHEN but not to the RVNLFSDRF, which was corresponding to at amino acids 59-67 of rat Thy-1. 1-22-3 could bind the COS cells which express rat Thy-1 proteins, but could not bind rat truncated-Thy-1 which lacks residues 15-23.

CONCLUSION

Critical epitope detected by 1-22-3 in this study may play an important role in mesangial function and injury.

Stimulation of soluble guanylyl cyclase inhibits mesangial cell proliferation and matrix accumulation in experimental glomerulonephritis

To date, no specific treatment is established in mesangial proliferative glomerulonephritis in humans. Specific stimulation of soluble guanylyl cyclase (sGC), an enzyme catalyzing the synthesis of cGMP from GTP, can be achieved by the novel pyrazolopyridine derivative BAY 41-2272. The effect of sGC stimulation via BAY 41-2272 on mesangial proliferation was assessed in vivo using a mesangial proliferative glomerulonephritis model in rats (anti-Thy1 model). Renal biopsies, as well as glomerular isolates, urine samples, and blood samples were compared in BAY 41-2272- and placebo-treated groups during anti-Thy1 nephritis. The sGC beta(1)-subunit is upregulated during anti-Thy1 nephritis and mainly confined to mesangial areas by immunohistochemistry. Specific therapeutic sGC stimulation during anti-Thy1 nephritis in vivo was achieved via BAY 41-2272 treatment as demonstrated by increased glomerular cGMP levels causing inhibition of mesangial proliferation, glomerular matrix accumulation, and proteinuria compared with placebo-treated animals. sGC is tightly regulated in glomeruli during experimental glomerulonephritis. Considering its beneficial antiproliferative, antifibrotic, and antiproteinuric effect in experimental glomerulonephritis, the therapeutic stimulation of sGC could become a promising future goal in mesangial proliferative glomerulonephritis in humans.

Accelerated Glomerular Injury in Hemi-Nephrectomized Transgenic Mice of Mesangial Cell-Predominant Serpin, Megsin

Mesangial cells play a critical role in the maintenance of normal glomerular functions such as matrix remodeling and immune complex disposal. We recently identified a novel human mesangium-predominant gene, megsin, which is a new member of the serine protease inhibitor (serpin) superfamily. While our previous studies demonstrated progressive mesangial matrix expansion and an increase in the number of mesangial cells in megsin transgenic mice, it took 40 weeks to develop these manifestations. Here we performed hemi-nephrectomy to accelerate glomerular injury in megsin transgenic mice. Hemi-nephrectomized transgenic mice developed focal segmental mesangial expansion, which was associated with proteinuria. Megsin has thus a biologically relevant influence on the development of glomerular damage. The hemi-nephrectomized model of this transgenic mouse might serve as a tool to investigate the mechanisms of glomerular disease.

Modulation of renal disease in MRL/lpr mice by suberoylanilide hydroxamic acid

Epigenetic regulation of gene expression is involved in the development of many diseases. Histone acetylation is a posttranslational modification of the nucleosomal histone tails that is regulated by the balance of histone deacetylases and histone acetyltransferases. Alterations in the balance of histone acetylation have been shown to cause aberrant expression of genes that are a hallmark of many diseases, including systemic lupus erythematosus. In this study, we determined whether suberoylanilide hydroxamic acid (SAHA), a histone deacetylase inhibitor: 1) inhibits inflammatory mediator production in vitro and 2) modulates lupus progression in vivo. Mesangial cells isolated from 10-wk-old MRL/lpr mice were stimulated with LPS/IFN-gamma and incubated with SAHA. TNF-alpha, IL-6, NO, and inducible NO synthase expression were inhibited by SAHA. We then treated MRL/lpr mice with daily injections of SAHA from age 10 to 20 wk. The animals treated with SAHA had decreased spleen size and a concomitant decrease in CD4-CD8- (double-negative) T cells compared with controls. Serum autoantibody levels and glomerular IgG and C3 deposition in SAHA-treated mice were similar to controls. In contrast, proteinuria and pathologic renal disease were significantly inhibited in the mice receiving SAHA. These data indicate that SAHA blocks mesangial cell inflammatory mediator production in vitro and disease progression in vivo in MRL/lpr mice.

Human macrophages kill human mesangial cells by Fas-L-induced apoptosis when triggered by antibody via CD16

Glomerulonephritis may be triggered by antibody deposits that activate macrophages to promote tissue damage. Macrophage-induced apoptosis of human vascular smooth muscle cells and rodent mesangial cells is potentially relevant to glomerulonephritis. Therefore, studies of macrophage-induced apoptosis were extended to antibody-activated macrophages. That is, we studied antibody dependent cellular cytotoxicity (ADCC). To corroborate results, we studied biochemical versus microscopic measurements, soluble or immobilized immunoglobulin and vascular smooth muscle cells (VSMCs) or mesangial cells (MCs). U937 macrophages and human peripheral blood macrophages provoked antibody-dependent killing of MCs and VSMCs. Macrophage-induced death was apoptotic based on electron microscopy, annexin-V, activated caspase-3 and hypodiploid DNA. ADCC was inhibited by antagonistic antibodies to Fas-L and to CD16 (Fc-gamma-RIII) but not to CD64 (Fc-gamma-RI). In conclusion, antibody-dependent killing of human MCs by human macrophages was via Fas-L and CD16.

Mesangial expression of angiotensin II receptor in IgA nephropathy and its regulation by polymeric IgA1

BACKGROUND

Enhanced gene expression for the renin-angiotensin system (RAS) is detected in glomerular mesangial cells in IgA nephropathy (IgAN). Preliminary studies showed a reduced glomerular gene expression of angiotensin II subtype 1 receptor (AT1R), suggesting a regulatory response to high intrarenal angiotensin II (Ang II) concentration in IgAN.

METHODS

We examined the effect of polymeric IgA1 (pIgA1) from patients with IgAN on the expression of Ang II receptors in cultured human mesangial cells (HMC).

RESULTS

Polymeric IgA1 from patients with IgAN down-regulated the expression of AT1R in HMC in a dose-dependent manner. When similar experiments were conducted with addition of an angiotensin-converting enzyme inhibitor (captopril) or an AT1R antagonist (losartan), there was a significant increase in the expression of AT1R. Blockade of Ang II with captopril or losartan alone resulted in a stepwise increase of AT1R in cultured HMC. Down-regulation of Ang II subtype 2 receptor (AT2R) was not observed in HMC cultured with pIgA1 from patients with IgAN. The acute suppressive effect of pIgA1 from IgAN on the expression of AT1R was confirmed in HMC incubated with IgA isolated from 15 IgAN patients, 15 healthy subjects, and other glomerulonephritides control subjects. Reduced glomerular expression of AT1R (but not AT2R) was also demonstrated in renal biopsies from patients with IgAN.

CONCLUSION

Our findings demonstrate an altered AT1R expression in HMC in response to raised intrarenal Ang II in IgAN. Our in vitro studies also support that an imbalance of AT1R and AT2R activity in HMC following exposure to pIgA plays a significant pathogenetic role in the inflammatory injury in IgAN.

IgA nephropathy: an update

PURPOSE OF REVIEW

The elution of nephrectomy specimens from patients with IgA nephropathy yields IgA1 with galactose-deficient glycans in the hinge region. In this review, we summarize recent advances in our understanding of the role of the aberrant immunoglobulin in the pathogenesis of this form of glomerulonephritis. In the absence of a disease-specific therapy, we discuss current therapeutic approaches.

RECENT FINDINGS

Galactose-deficient IgA1 forms macromolecular complexes that bind to mesangial cells and stimulate them to proliferate, synthesize various cytokines and chemokines, and secrete extracellular matrix proteins. Whereas progress has been made in understanding the glycosylation pathways of IgA1 O-linked glycans and binding galactose-deficient IgA1-complexes to mesangial cells, there is still no IgA nephropathy-specific therapy. The current approach to suppress the effects of angiotensin II, by angiotensin-converting enzyme inhibitors, angiotensin II receptor type 1 blockers, or both, as a cornerstone of the therapy of IgA nephropathy has been strengthened by recent studies. Treatment with glucocorticoids, cyclophosphamide, or both, may be appropriate for a subset of IgA nephropathy patients.

SUMMARY

A better understanding of the mechanisms underlying the synthesis of galactose-deficient IgA1, the formation of circulating immune complexes, and interactions with mesangial cells will provide further insights into the pathogenetic mechanisms that culminate in the glomerular and interstitial damage of IgA nephropathy, and could identify novel therapeutic targets in the prevention and management of this renal disease.

Binding capacity and pathophysiological effects of IgA1 from patients with IgA nephropathy on human glomerular mesangial cells

IgA deposition in glomerular mesangium and the interaction with mesangial cells may well be the final common pathway to IgA nephropathy (IgAN). Altered hinge-region O-glycosylation of IgA1 from patients with IgAN may predispose to mesangial deposition and activation of the mesangial cell (MC) by IgA1, via a novel IgA1 receptor, and may be a key event in the pathogensis of IgAN. The aim of this study was to investigate the binding capacity and biological effects of IgA1, from both patients with IgAN and healthy controls, on human mesangial cells (HMC). Serum IgA1 was isolated with jacalin affinity chromatography, heated to aggregated form (aIgA1) and labelled with (125)I. Binding capacity of aIgA1 in vitro to cultured primary HMC was evaluated by a radioligand binding assay and the specificity of binding was determined by a competitive inhibition assay. Intracellular calcium release was studied by confocal analysis and phosphorylation of extracellular signal-regulated kinase (ERK) was determined by Western blot analysis. Change of cell cycles was demonstrated by flow cytometry and HMC proliferation was evaluated by direct cell count. Expression of TGF-beta mRNA and production of supernatant fibronectin were tested by RT-PCR and indirect competitive ELISA, respectively. aIgA1 from both the patients with IgAN and normal controls bound to HMC in a dose-dependent, saturable manner, and was saturated at approximately 500 pmoles per 0.5 ml of aIgA1. aIgA1 from patients with IgAN, however, bound to HMC at a higher speed and Scatchard analysis revealed a Kd of (8.89 +/- 2.1) x 10(-8)m versus (4.3 +/- 1.2) x 10(-7)m for aIgA1 from healthy controls (P = 0.026). The binding was specific because it was only inhibited by unlabelled Mono-IgA1 (mIgA1) and not by serum albumin or IgG. aIgA1 from patients with IgAN could induce release of intracellular calcium, phosphorylation of ERK, DNA synthesis, proliferation of HMC, expression of TGF-betamRNA and secretion of fibronectin in HMC in a similar time-dependent manner as aIgA1 from healthy controls, but the effects were much stronger and the durations were much longer (P < 0.05, respectively). We conclude that aIgA1 from patients with IgAN has a higher binding capacity to HMC and stronger biological effects than aIgA1 from healthy controls. This suggests that direct interaction between IgA1 and HMC and subsequential pathophysiological responses may play an important role in the pathogenesis for IgAN.

Aberrant glycosylation in IgA nephropathy (IgAN)

Immunoglobulin A nephropathy (IgAN) patients exhibit circulating IgA1 with reduced galactose (Gal) and/or sialic acid (Neu5Ac) and increased exposure of N-acetylgalactosamine (GalNAc). These IgA glycoforms fix complement and in mesangial cells regulate integrin expression, enhance nitric oxide synthase (NOS) activity, decrease endothelial growth factor synthesis, meanwhile depressing proliferation and increasing apoptosis. Drugs can be targeted to the effects enhanced by aberrantly glycosylated IgA1 on mesangial cells. Recent data suggest that aberrant IgA1 glycosylation may modulate clinical expression and progression of IgAN.

[Characterization of target antigens of the novel anti-mesangial cell antibodies in sera from patients with lupus nephritis]

OBJECTIVE

Novel anti-mesangial cell antibodies have been identified in sera of majority patients with lupus nephritis in our previous study. The aims of current study were to investigate the association of anti-mesangial cell antibodies and anti-DNA antibodies, and whether the target antigens were on mesangial cell membrane.

METHODS

Affinity parified anti-DNA antibodies and sera with depletion of anti-DNA antibodies from three patients with lupus nephritis were used in Western-blot analysis to identify antigens in culture human glomerular mesangial cell line. Cell membrane from in vitro cultured human mesagial cell line was separated by gradient centrifugation technique, and the target antigens were identified by Western-blot analysis using 1% Triton X-100 solublized membrane protein as antigens and four known anti-mesangial cell antibody positive sera from patients with lupus nephritis as probes.

RESULTS

Soluble proteins from in vitro cultured human mesangial cells could be blotted by both affinity purified anti-DNA antibodies (molecular weight at 63,000, 91,000 and 125,000) and sera with depletion of anti-DNA antibodies (molecular weight at 74,000 and 36,000). Proteins with molecular weight at 101,000, 91,000, 74,000 and 31,000 in mesangial cell membrane could be blotted by the four known anti-mesangial cell antibody positive sera.

CONCLUSION

Some anti-mesangial cell antibodies were not associated with anti-DNA antibodies and anti-mesiangial cell antibodies could direct interact with antigens located on mesangial cell membrane. Anti-mesangial cell antibodies may play an important role in the pathogenesis of lupus nephritis.

[Mesangial glomerulonephritis and intermediate uveitis]

Uveitis in children are less frequent than in adults. Their prognosis is variable because it may be found as an isolated and idiophatic condition or in association with definite clinical entities. The associated noninfectious diseases with predominantly renal involvement are tubulointerstitial nephritis and uveitis syndrome (TINU syndrome), mesangial glomerulonephritis isolated or in association with Behçet's disease. A case of 14-years-old girl with intermediate uveitis (pars planitis) and mesangial glomerulonephritis is presented. The ocular symptoms was eye redness and ocular pain and she has snow-banks in pars plana. She showed microscopic hematuria and intermitent proteinuria that increased during the ocular clinical exacerbation. Renal biopsy revealed both mild mesangial matrix increase and mesangial celullarity with normal tubulointerstitial structure and mesangial deposition of IgA and IgG immunoglobulins. This case is de first pediatric patient report in the literature with intermediate uveitis and mesangial glomerulonephritis with immune deposition. Mesangial glomerulonephritis were observed in patients whit Behçet disease, known etiological cause of uveitis in adults and children. These findings may suggest that uveitis and glomerulonephritis have common immunological pathogenesis including circulatory immune complexes. In uveitis patients, screening for associated extra-ocular and renal manifestations is mandatory and should have careful long-term follow-up with regular systemic evaluation.

Is there really an increase in non-minimal change nephrotic syndrome in children?

BACKGROUND

Reports on the worldwide increase in focal segmental glomerulosclerosis (FSGS) in childhood may have been hampered by referral bias. A true increase in FSGS possibly could alter the current practice of withholding renal biopsy in childhood nephrotic syndrome (NS) unless the patient fails to respond to a 28-day course of corticosteroid therapy.

METHODS

With these questions in mind, we analyzed a 17-year database covering a 275,000-child population with mandatory referral. The incidence of NS per 100,000 childhood population per year was calculated, charts of 159 patients with NS seen between 1985 and 2002 were reviewed, and a receiver operating characteristic (ROC) plot analysis was performed to analyze the diagnostic performance of remission time.

RESULTS

Results show that 115 of 159 patients had minimal change NS, diagnosed either on the basis of corticosteroid response (n = 89), verified by renal biopsy (n = 14), or with minimal change plus mesangial immunoglobulin M on histological examination (n = 12). The remaining 44 patients underwent a renal biopsy showing FSGS (n = 29; 18.2%), diffuse mesangial hypercellularity (n = 8; 5%), membranoproliferative glomerulonephritis (n = 1; 0.6%), membranous nephropathy (n = 3; 1.9%), or other diagnoses (n = 3). The incidence of FSGS increased significantly (P = 0.0253) from 0.37 to 0.94/100,000-child population/y in the two 8(1/2)-year intervals of our study. ROC plot analysis confirmed diagnostic sensitivity and specificity greater than 80% for remission time between 21 and 28 days of therapy.

CONCLUSION

We confirm the increasing incidence of FSGS in children with idiopathic NS in a well-defined catchment area and, at the same time, find no reason to change the initial therapy and current indications to perform renal biopsy in childhood NS.

Expression of CX3CL1/fractalkine by mesangial cells in vitro and in acute anti-Thy1 glomerulonephritis in rats

BACKGROUND

Mesangial cells (MCs) can promote glomerular macrophage accumulation in glomerulonephritis through production of a variety of chemokines. This study investigated the potential of MCs to synthesize CX3CL1/fractalkine, a CX3C chemokine, both in vitro and in acute anti-Thy1 glomerulonephritis in rats.

METHODS

Anti-Thy1 glomerulonephritis was induced in Wistar rats by a single injection of mouse anti-rat Thy1.1 antibody intravenously. Glomerular mRNAs for CX3CL1/fractalkine, CCL2/monocyte chemoattractant protein (MCP)-1, and their cognate receptors, CX3CR1 and CCR2, were determined by northern blot analysis or reverse-transcription polymerase chain reaction. CX3CL1/fractalkine mRNA and protein expression in vivo was localized by in situ hybridization and immunohistochemistry. Monocytes/macrophages and activated MCs were detected by immunohistochemistry. Regulation of CX3CL1/fractalkine expression in cultured MCs was determined by northern and western blot analysis.

RESULTS

After induction of anti-Thy1 disease, glomerular CX3CL1/fractalkine mRNA was significantly up-regulated, peaking at 2 h and sustaining into day 5 of the nephritis. A corresponding increase in urinary CX3CL1/fractalkine protein was evident after day 1 of the nephritis, but became more prominent during the MC proliferative phase (days 3-5). Meanwhile, induction of glomerular CCL2/MCP-1 mRNA and urinary CCL2/MCP-1 protein occurred within 24 h, and was barely detectable after day 3 of the nephritis. Urinary CCL2/MCP-1, but not CX3CL1/fractalkine, correlated with glomerular macrophage accumulation (r = 0.936, P<0.01) and glomerular CCR2 mRNA expression (r = 0.965, P<0.01). In contrast, only urinary CX3CL1/fractalkine coincided temporally to glomerular mRNA for CX3CR1 (r = 0.809, P < 0.01). Combined in situ hybridization and immunohistochemistry revealed that activated MCs were a major source for CX3CL1/fractalkine mRNA and protein during days 3-5 of the nephritis. Incubation of cultured MCs with tumour necrosis factor (TNF)-alpha, interleukin (IL)-1beta, platelet-derived growth factor (PDGF)-AB or basic fibroblast growth factor (bFGF) significantly up-regulated CX3CL1/fractalkine mRNA and protein expression. This cytokine- and growth factor-stimulated CX3CL1/fractalkine expression could be abolished by the nuclear factor-kappaB inhibitors, curcumin and MG132.

CONCLUSIONS

Our data demonstrate that activated MCs are a source for the augmented glomerular CX3CL1/fractalkine expression during the proliferative phase of acute anti-Thy1 glomerulonephritis. Up-regulation of MC CX3CL1/fractalkine by TNF-alpha, IL-1beta, PDGF-AB and bFGF is mediated, at least in part, via the nuclear factor-kappaB signalling pathway. The differential expression of CCL2/MCP-1 and CX3CL1/fractalkine may sequentially recruit distinct subsets of monocytes to the glomerulus during acute anti-Thy1 glomerulonephritis.

Differential effects of Sendai virus infection on mediator synthesis by mesangial cells from two mouse strains

BACKGROUND

Recently, we observed that the severity of glomerulonephritis in an experimental model of immunoglobulin A nephropathy (IgAN) induced by Sendai virus differs between C57BL/6 and BALB/c mouse strains. The determinants of differing renal insufficiency are not understood. In the present study, we examine the capacity for mesangial cells to support Sendai viral replication and assess the direct effects of Sendai virus on the production of selected cytokines, chemokines, and eicosanoids by mesangial cells, comparing C57BL/6 to BALB/c mouse strains.

METHODS

Sendai virus replication was measured by viral plaque assay using LLCMK2 cells. Production of cytokines [interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha)], chemokines (JE and KC), and eicosanoids [prostaglandin E2 (PGE2) and thromboxane B2 (TxB2)] in culture medium was evaluated by sandwich enzyme-linked immunosorbent assay (ELISA) or competitive enzyme immunoassay (EIA) after 48 hours' incubation with infectious or inactivated Sendai virus.

RESULTS

Sendai virus replicates equally well in mesangial cells from both strains, and infection evokes increased IL-6, JE, KC, and PGE2 production in relation to viral dose. BALB/c mesangial cells produce significantly more IL-6 and JE than those from C57BL/6, and the dose response for KC is steeper in BALB/c mesangial cells than those from C57BL/6. Synthesis of PGE2 in BALB/c mesangial cells is higher than that of C57BL/6 mesangial cells, both under basal conditions and in response to infectious Sendai virus, again in a dose-dependent manner. There is no TNF-alpha or thromboxane response to viral stimulation.

CONCLUSION

We conclude that different mesangial cell responses to this common mucosal viral pathogen might influence the severity of IgAN in our model system.

[Incidental mesangial IgA deposition in minimal change nephrotic syndrome(MCNS)]

The frequency of incidental mesangial IgA deposition and its clinicopathological features were investigated in patients with minimal change nephrotic syndrome(MCNS). Mesangial IgA deposition was present in 15/63 patients(23.8%), and co-deposition of IgA and C3 was present in 10/63 patients(15.9%). The serum IgA concentration was significantly higher in IgA(+) patients than in IgA(-) patients(341 +/- 79 mg/dl vs. 252 +/- 99 mg/dl, p = 0.034). The urinary red blood cell count tended to be higher in IgA(+) patients than in IgA(-) patients (12.8 +/- 24.9 vs. 5.0 +/- 7.9 counts/HPF, p = 0.58). Histologically, no significant differences were observed between IgA(+) and IgA(-) patients. After steroid treatment. 14 patients with mesangial IgA deposition showed complete remission and one patient had persistent proteinuria. The microhematuria also disappeared after steroid treatment in 13/15 patients (86.7%), although it reappeared in 6/13 patients(46%) during reduction of steroid administration. The present study indicated that the incidental mesangial IgA deposition was frequently observed in MCNS patients(23.8%). The phenomenon of mesangial IgA deposition was related to the higher concentration of serum IgA. However, no influence of mesangial IgA deposition in MCNS patients was found on the post-treatment amount of proteinuria, renal function and clinical outcome of MCNS.

Fibrillary noncongophilic renal and extrarenal deposits: a report on 10 cases

Cases in which glomerular deposits of Congo red negative amyloid-like fibrils were demonstrated by electron microscopic identification are included in this study. In the 1,266 kidney biopsies studied, there were 9 biopsies from 8 patients with fibrillary glomerulonephritis and 2 biopsies from 2 patients with systemic lupus In 1 case of fibrillary glomerulonephritis (FGN), autopsy was performed. Electron microscopic examination showed glomerular (100%) and extraglomerular (60%) fibrillary deposits in the biopsy samples of patients with FGN and also in patients with systemic lupus. In the autopsy case similar fibrillary deposits were demonstrated in the kidney, pancreas, spleen, lungs, and liver. The diameter of the fibrils, which were arranged similarly in all cases, varied from 8 to 27 nm individually, the length being about 1.5 microm. The authors speculate that extraglomerular kidney fibrillary deposits concurrent with the same type of deposits in other organs suggests systemic manifestation of FGN.

Bartter syndrome complicated by immune complex nephropathy. Case report and literature review

The unusual coincidence of Bartter syndrome and C1q nephropathy is described and the literature reviewed. An African-American girl presented at 4 years of age with acute hyponatremic dehydration and failure to thrive. Persistent hypokalemic alkalosis and secondary hyperaldosteronism were found. The case was atypical for Bartter syndrome in that proteinuria (0.19 g/day) was present. Renal biopsy showed juxtaglomerular hyperplasia and C1q nephropathy. Molecular analysis showed deletion of the renal chloride channel gene (CLCNKB) typical of autosomal recessive childhood Bartter syndrome. Chronic sodium and potassium chloride replacement therapy together with indomethacin normalized her metabolic status, and she experienced catch-up growth. Proteinuria persisted, however. This is the first documentation of C1q nephropathy, in mild form, complicating autosomal recessive Bartter syndrome. This case shows the importance of the renal biopsy and of molecular analysis in delineating the cause of atypical nephropathy associated with Bartter syndrome. These findings add to the evidence of a possible association between the congenital syndrome and acquired immune complex nephropathy.