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de Cos M, Mosoyan G, Chauhan K, Troost JP, Wong JS, Lefferts S, Morgan P, Meliambro K, Egerman M, Ray J, Parker T, Levine D, Seshan S, Bardash Y, Horowitz B, Kent CA, Shaw MM, Perlman A, Moledina DG, Coca SG, Campbell KN. Urinary Plasminogen as a Marker of Disease Progression in Human Glomerular Disease. Am J Kidney Dis 2024; 84:205-214.e1. [PMID: 38452919 PMCID: PMC11260534 DOI: 10.1053/j.ajkd.2024.01.520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/27/2023] [Accepted: 01/12/2024] [Indexed: 03/09/2024]
Abstract
RATIONALE & OBJECTIVE Glomerular disorders have a highly variable clinical course, and biomarkers that reflect the molecular mechanisms underlying their progression are needed. Based on our previous work identifying plasminogen as a direct cause of podocyte injury, we designed this study to test the association between urine plasmin(ogen) (ie, plasmin and its precursor plasminogen) and end-stage kidney disease (ESKD). STUDY DESIGN Multicenter cohort study. SETTING & PARTICIPANTS 1,010 patients enrolled in the CureGN Cohort with biopsy-proven glomerular disease (focal segmental glomerulosclerosis, membranous nephropathy, and immunoglobulin A nephropathy). PREDICTORS The main predictor was urine plasmin(ogen) at baseline. Levels were measured by an electrochemiluminescent immunoassay developed de novo. Traditional clinical and analytical characteristics were used for adjustment. The ratio of urine plasmin(ogen)/expected plasmin(ogen) was evaluated as a predictor in a separate model. OUTCOME Progression to ESKD. ANALYTICAL APPROACH Cox regression was used to examine the association between urinary plasmin(ogen) and time to ESKD. Urinary markers were log2 transformed to approximate normal distribution and normalized to urinary creatinine (Log2uPlasminogen/cr, Log2 urinary protein/cr [UPCR]). Expected plasmin(ogen) was calculated by multiple linear regression. RESULTS Adjusted Log2uPlasminogen/cr was significantly associated with ESKD (HR per doubling Log2 uPlasminogen/cr 1.31 [95% CI, 1.22-1.40], P<0.001). Comparison of the predictive performance of the models including Log2 uPlasminogen/cr, Log2 UPCR, or both markers showed the plasmin(ogen) model superiority. The ratio of measured/expected urine plasmin(ogen) was independently associated with ESKD: HR, 0.41 (95% CI, 0.22-0.77) if ratio<0.8 and HR 2.42 (95% CI, 1.54-3.78) if ratio>1.1 (compared with ratio between 0.8 and 1.1). LIMITATIONS Single plasmin(ogen) determination does not allow for the study of changes over time. The use of a cohort of mostly white patients and the restriction to patients with 3 glomerular disorders limits the external validity of our analysis. CONCLUSIONS Urinary plasmin(ogen) and the ratio of measured/expected plasmin(ogen) are independently associated with ESKD in a cohort of patients with glomerular disease. Taken together with our previous experimental findings, urinary plasmin(ogen) could be a useful biomarker in prognostic decision making and a target for the development of novel therapies in patients with proteinuria and glomerular disease. PLAIN-LANGUAGE SUMMARY Glomerular diseases are an important cause of morbidity and mortality in patients of all ages. Knowing the individual risk of progression to dialysis or transplantation would help to plan the follow-up and treatment of these patients. Our work studies the usefulness of urinary plasminogen as a marker of progression in this context, since previous studies indicate that plasminogen may be involved in the mechanisms responsible for the progression of these disorders. Our work in a sample of 1,010 patients with glomerular disease demonstrates that urinary plasminogen (as well as the ratio of measured to expected plasminogen) is associated with the risk of progression to end-stage kidney disease. Urine plasminogen exhibited good performance and, if further validated, could enable risk stratification for timely interventions in patients with proteinuria and glomerular disease.
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Affiliation(s)
- Marina de Cos
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gohar Mosoyan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kinsuk Chauhan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan P Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan
| | - Jenny S Wong
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sean Lefferts
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Paul Morgan
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kristin Meliambro
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marc Egerman
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Justina Ray
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tom Parker
- Rogosin Institute, Weill Cornell Medicine, New York, New York
| | - Daniel Levine
- Rogosin Institute, Weill Cornell Medicine, New York, New York
| | - Surya Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Yoni Bardash
- St. Joseph's University Medical, Paterson, New Jersey
| | - Benjamin Horowitz
- Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey
| | - Candice A Kent
- Section of Nephrology and Clinical and Translational Research Accelerator, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Melissa M Shaw
- Section of Nephrology and Clinical and Translational Research Accelerator, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Alan Perlman
- Rogosin Institute, Weill Cornell Medicine, New York, New York; Division of Nephrology and Hypertension, Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Dennis G Moledina
- Section of Nephrology and Clinical and Translational Research Accelerator, Department of Internal Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Steven G Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Kirk N Campbell
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.
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Tang C, Chen P, Si FL, Lv JC, Shi SF, Zhou XJ, Liu LJ, Zhang H. Time-Varying Proteinuria and Progression of IgA Nephropathy: A Cohort Study. Am J Kidney Dis 2024; 84:170-178.e1. [PMID: 38364955 DOI: 10.1053/j.ajkd.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 02/18/2024]
Abstract
RATIONALE & OBJECTIVE Proteinuria is a surrogate end point for predicting long-term kidney outcomes in IgA nephropathy (IgAN) with levels<1g/day identified as a therapeutic target. However, this threshold has not been sufficiently studied. We quantified the associations of progression of IgAN with various levels of proteinuria. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 1,530 patients with IgAN and at least 12 months of follow-up at Peking University First Hospital. EXPOSURE Proteinuria levels updated over time (time-varying proteinuria, TVP). OUTCOME A composite kidney outcome of a 50% reduction in the estimated glomerular filtration rate or end-stage kidney disease. ANALYTICAL APPROACH Marginal structural models. RESULTS After a median follow-up period of 43.5 (IQR, 27.2-72.8) months, 254 patients (16.6%) developed the composite kidney outcome. A graded association was observed between TVP and composite kidney outcomes with higher risk among those with proteinuria of≥0.5g/day. Compared with TVP<0.3g/day, the HRs for proteinuria levels of 0.3 to<0.5g/day, 0.5 to<1.0g/day, 1.0 to<2.0g/day, and≥2.0g/day were 2.22 (95% CI, 0.88-5.58), 4.04 (95% CI, 1.93-8.46), 8.46 (95% CI, 3.80-18.83), and 38.00 (95% CI, 17.62-81.95), respectively. The trend was more pronounced in patients with baseline proteinuria of≥1.0g/day, among whom a higher risk was observed with TVP of 0.3 to<0.5g/day compared with TVP<0.3g/day (HR, 3.26 [95% CI, 1.07-9.92], P=0.04). However, in patients with baseline proteinuria levels of<1g/day, the risk of composite kidney outcome only began to increase when TVP was≥1.0g/day (HR, 3.25 [95% CI, 1.06-9.90]). LIMITATIONS Single-center observational study, selection bias, and unmeasured confounders. CONCLUSIONS This study showed that patients with IgAN and proteinuria levels of>0.5g/day, have an elevated risk of kidney failure especially among patients with proteinuria levels≥1.0g/day before initiating treatment. These data may serve to inform the selection of proteinuria targets in the treatment of IgAN. PLAIN-LANGUAGE SUMMARY The presence of proteinuria has often been considered a surrogate end point and a possible therapeutic target in clinical trials in IgA nephropathy (IgAN). Some guidelines recommend a reduction in proteinuria to<1g/day as a treatment goal based on the results of previous longitudinal studies. However, these findings may have been biased because they did not properly adjust for time-dependent confounders. Using marginal structural models to appropriately account for these confounding influences, we observed that patients with IgAN and proteinuria levels≥0.5g/day have an elevated risk of kidney failure, especially among patients who had proteinuria levels of≥1.0g/day before initiating treatment. These data may serve to inform the selection of proteinuria targets in the treatment of IgAN.
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Affiliation(s)
- Chen Tang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Pei Chen
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Feng-Lei Si
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Ji-Cheng Lv
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Su-Fang Shi
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Xu-Jie Zhou
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
| | - Li-Jun Liu
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China.
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, and Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, People's Republic of China
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Chen T, Chen T, Xu W, Liang S, Xu F, Liang D, Li X, Zeng C, Xie G, Liu Z. Development and External Validation of a Multidimensional Deep Learning Model to Dynamically Predict Kidney Outcomes in IgA Nephropathy. Clin J Am Soc Nephrol 2024; 19:898-907. [PMID: 38728096 PMCID: PMC11254022 DOI: 10.2215/cjn.0000000000000471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 05/07/2024] [Indexed: 05/12/2024]
Abstract
Key Points A dynamic model predicts IgA nephropathy prognosis based on deep learning. Longitudinal clinical data and deep learning improve predictive accuracy and interpretability in GN. Background Accurately predicting kidney outcomes in IgA nephropathy is crucial for clinical decision making. Insufficient use of longitudinal data in previous studies has limited the accuracy and interpretability of prediction models for failing to reflect the chronic nature of IgA nephropathy. The aim of this study was to establish a multivariable dynamic deep learning model using comprehensive longitudinal data for the prediction of kidney outcomes in IgA nephropathy. Methods In this retrospective cohort study of 2056 patients with IgA nephropathy from 18 kidney centers, a total of 28,317 data points were collected by the sliding window method. Among them, 15,462 windows in a single center were randomly assigned to training (80%) and validation (20%) sets and 8797 windows in 18 kidney centers were assigned to an independent test set. Interpretable multivariable long short-term memory, a deep learning model, was implemented to predict kidney outcomes (kidney failure or 50% decline in kidney function) based on time-invariant variables measured at biopsy and time-variant variables measured during follow-up. Risk performance was evaluated using the Kaplan–Meier analysis and C-statistic. Trajectory analysis was performed to assess the various trends of clinical variables during follow-up. Results The model achieved a higher C-statistic (0.93; 95% confidence interval, 0.92 to 0.95) on the test set than the machine learning prediction model that we developed in a previous study using only baseline information (C-statistic, 0.84; 95% confidence interval, 0.80 to 0.88). The Kaplan–Meier analysis showed that groups with lower predicted risks from the full model survived longer than groups with higher risks. Time-variant variables demonstrated higher importance scores than time-invariant variables. Within time-variant variables, more recent measurements showed higher importance scores. Further interpretation showed that certain trajectory groups of time-variant variables such as serum creatinine and urine protein were associated with elevated risks of adverse outcomes. Conclusions In IgA nephropathy, a deep learning model can be used to accurately and dynamically predict kidney prognosis based on longitudinal data, and time-variant variables show strong ability to predict kidney outcomes.
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Affiliation(s)
- Tingyu Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Tiange Chen
- School of Public Health, Peking University Health Science Center, Beijing, China
- Ping An Healthcare Technology, Beijing, China
| | - Wenjie Xu
- Ping An Healthcare Technology, Beijing, China
| | - Shaoshan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Feng Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Dandan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiang Li
- Ping An Healthcare Technology, Beijing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Guotong Xie
- Ping An Healthcare Technology, Beijing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Zhuang K, Wang W, Xu C, Guo X, Ren X, Liang Y, Duan Z, Song Y, Zhang Y, Cai G. Machine learning-based diagnosis and prognosis of IgAN: A systematic review and meta-analysis. Heliyon 2024; 10:e33090. [PMID: 38988582 PMCID: PMC11234108 DOI: 10.1016/j.heliyon.2024.e33090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 06/04/2024] [Accepted: 06/13/2024] [Indexed: 07/12/2024] Open
Abstract
Purpose Plenty of studies have explored the diagnosis and prognosis of IgA nephropathy (IgAN) based on machine learning (ML), but the accuracy lacks the support of evidence-based medical evidence. We aim at this problem to guide the precision treatment of IgAN. Methods Embase, Pubmed, Cochrane Library, and Web of Science were searched systematically until February 24th, 2024, for publications on ML-based diagnosis and prognosis of IgAN. Subgroup analysis or meta-regression was conducted according to modeling method, follow-up time, endpoint definition, and variable type. Further, the rank sum test was applied to compare the discrimination ability of prognosis. Results A total of 47 studies involving 51,935 patients were eligible. Among the 38 diagnostic models, the pooled C-index was 0.902 (95 % CI: 0.878-0.926) in 27 diagnostic models. Of the 162 prognostic models, the C-index for model discrimination of 144 prognostic models was 0.838 (95 % CI: 0.827-0.850) in training. The overall discrimination ability of prognosis was as follows: COX regression > new ML models (e.g. ANN, DT, RF, SVM, XGBoost) > traditional ML models (logistic regression) > Naïve Bayesian network (P < 0.05). External validation of IIgAN-RPT in 19 models showed a pooled C-index of 0.801 (95 % CI: 0.784-0.817). Conclusions New ML models have shown application values that are as good as traditional ML models, both in diagnosis and prognosis. In addition, future models are desired to use a more sensitive prognostic endpoint (albuminuria), improve predictive ability in moderate progression risk, and ultimately translate into clinically applicable intelligent tools.
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Affiliation(s)
- Kaiting Zhuang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Wenjuan Wang
- School of Medicine, Nankai University, Tianjin, 300071, China
| | - Cheng Xu
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Xinru Guo
- School of Medicine, Nankai University, Tianjin, 300071, China
| | - Xuejing Ren
- Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Henan Key Laboratory of Kidney Disease and Immunology, Academy of Medical Sciences, Zhengzhou University, Zhengzhou, Henan, 450003, China
| | - Yanjun Liang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Zhiyu Duan
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Yanqi Song
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Yifan Zhang
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
| | - Guangyan Cai
- Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases Research, Beijing 100853, China
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Lafayette R, Barbour S, Israni R, Wei X, Eren N, Floege J, Jha V, Kim SG, Maes B, Phoon RKS, Singh H, Tesař V, Lin CJF, Barratt J. A phase 2b, randomized, double-blind, placebo-controlled, clinical trial of atacicept for treatment of IgA nephropathy. Kidney Int 2024; 105:1306-1315. [PMID: 38552841 DOI: 10.1016/j.kint.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 02/26/2024] [Accepted: 03/04/2024] [Indexed: 04/17/2024]
Abstract
Atacicept is a first-in-class, dual anti-B-cell Activation Factor-A Proliferation-Inducing Ligand fusion protein in clinical evaluation for treatment of IgA nephropathy. To compare efficacy and safety of atacicept versus placebo in patients with IgAN, this randomized, double-blind, placebo-controlled phase 2b clinical trial ORIGIN enrolled 116 individuals with biopsy-proven IgA nephropathy. Participants were randomized to atacicept 150, 75, or 25 mg versus placebo once weekly for up to 36 weeks. Primary and key secondary endpoints were changes in urine protein creatinine ratio based on 24-hour urine collection at weeks 24 and 36, respectively, in the combined atacicept 150 mg and 75 mg group versus placebo. The primary endpoint was met at week 24 as the mean urine protein creatinine ratio was reduced from baseline by 31% in the combined atacicept group versus 8% with placebo, resulting in a significant 25% reduction with atacicept versus placebo. At week 36, the key secondary endpoint was met as the mean urine protein creatinine ratio reduced from baseline by 34% in the combined atacicept group versus a 2% increase with placebo, resulting in a significant 35% reduction with atacicept versus placebo. The reduction in proteinuria was accompanied by stabilization in endpoint eGFR with atacicept compared to a decline with placebo at week 36, resulting in significant between-group geometric mean difference of 11%, approximating an absolute difference of 5.7 mL/min/1.73m2. Endpoint galactose deficient IgA1 levels significantly decreased from baseline by 60% versus placebo. The safety profile of atacicept was like placebo. Thus, our results provide evidence to support a pivotal, phase 3 study of atacicept in IgA nephropathy.
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Affiliation(s)
- Richard Lafayette
- Division of Nephrology, Department of Medicine, Stanford University, Stanford, California, USA
| | - Sean Barbour
- Division of Nephrology, Department of Medicine, The University of British Columbia, Vancouver, Canada
| | - Rubeen Israni
- Clinical Development, Vera Therapeutics, Inc., Brisbane, California, USA
| | - Xuelian Wei
- Biostatistics, Vera Therapeutics, Inc., Brisbane, California, USA
| | - Necmi Eren
- Department of Nephrology, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, Rheinisch Westfälische Technische Hochschule, Aachen University Hospital, Aachen, Germany
| | - Vivekanand Jha
- The George Institute for Global Health India, New Delhi, India; Faculty of Medicine, School of Public Health, Imperial College, London, UK; Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Sung Gyun Kim
- Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Bart Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Richard K S Phoon
- Westmead Clinical School, The University of Sydney, Sydney, Australia
| | | | - Vladimír Tesař
- Department of Nephrology, First Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Celia J F Lin
- Medical, Vera Therapeutics, Inc., Brisbane, California, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, College of Medicine Biological Sciences and Psychology, University of Leicester, Leicester, UK.
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Trachtman H, Komers R, Inrig J. Sparsentan: the first and only non-immunosuppressive therapy for the reduction of proteinuria in IgA nephropathy. Expert Rev Clin Immunol 2024; 20:571-576. [PMID: 38362830 DOI: 10.1080/1744666x.2024.2319132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/12/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION IgA nephropathy is one of the most common forms of glomerular disease. Patients with persistent proteinuria are at increased risk of progression to kidney failure. There is a significant need for safe and effective therapies to lower proteinuria in these patients. Sparsentan is a non-immunosuppressive agent that acts as a dual angiotensin and endothelin receptor antagonist. It lowers proteinuria in experimental models of glomerular disease and in affected patients. AREAS COVERED This review covers the immunological and non-immunological actions of sparsentan in glomerular disease. It reviews the clinical trials that evaluated the impact of the drug in pediatric and adult patients with IgA nephropathy. It places the use of sparsentan in an overall treatment paradigm for the full spectrum of patients with IgA nephropathy including nonspecific renoprotective agents such as inhibitors of the renin-angiotensin-aldosterone axis and SGLT2 transporter and immunosuppressive drugs. The review represents a search of the current literature about the effect of the drug on normal physiology and the pathogenesis of IgA nephropathy. EXPERT OPINION The safety, tolerability, and therapeutic efficacy of sparsentan have been demonstrated in long-term studies of patients with primary glomerular diseases extending over 5 years. The evidence in support of a beneficial treatment effect of sparsentan is stronger in IgAN than in FSGS. It is anticipated that sparsentan will supplant the use of ACEI or ARB as the first-line therapy to reduce proteinuria prior to the implementation of immunosuppressive agents in patients with IgA nephropathy. It may be combined with other renoprotective drugs like SGLT2 inhibitors. Practice guidelines are needed to promote safe and effective use of this new drug by nephrologists caring for patients with IgAN in all clinical settings.
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Affiliation(s)
- Howard Trachtman
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Jula Inrig
- Travere Therapeutics, Inc, San Diego, CA, USA
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Selvaskandan H, Jhaveri KD, Rizk DV. Primary IgA Nephropathy: New Insights and Emerging Therapies. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:180-193. [PMID: 39004458 DOI: 10.1053/j.akdh.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 03/12/2024] [Accepted: 04/01/2024] [Indexed: 07/16/2024]
Abstract
Primary IgA nephropathy (IgAN) is a common glomerular disorder defined by predominant mesangial IgA deposition. Once thought to follow a progressive course in 10-20% of those diagnosed, emerging evidence now suggests most will progress to kidney failure over their lifetimes. Although the lack of safe and effective treatments to impede disease progression continues to present a challenge, the landscape of IgAN has dramatically evolved over the last 2 years. Driven by fundamental changes to accepted end points for IgAN clinical trials as well as fascinating new insights into the pathophysiology of IgAN, a swathe of novel and repurposed therapies are currently being evaluated. Already, two novel drugs, targeted-release formulation budesonide and sparsentan, have received conditional approvals for the treatment of IgAN, with sodium glucose co-transporter 2 inhibitors establishing themselves as further options. Soon to join this ensemble are likely to be treatments that modulate the complement system and B-cell activity; several are currently undergoing clinical trials in IgAN with promising interim results. In this review, we provide an overview of evolving epidemiological insights, disease mechanisms, emerging therapies, and contemporary challenges surrounding the management of IgAN.
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Affiliation(s)
- Haresh Selvaskandan
- Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Kenar D Jhaveri
- Northwell Health, New Hyde Park, NY; Glomerular Center at Northwell Health, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
| | - Dana V Rizk
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Barr B, Barbour S. New therapies for immunoglobulin A nephropathy: what's the standard of care in 2023? Curr Opin Nephrol Hypertens 2024; 33:311-317. [PMID: 38411173 DOI: 10.1097/mnh.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW As the most common primary glomerulonephritis, immunoglobulin A (IgA) nephropathy (IgAN) is an important cause of kidney failure and mortality. Until recently, therapeutic options were limited. Fortunately, there have been numerous recent clinical trials demonstrating efficacy of new therapies in slowing chronic kidney disease (CKD) progression at varying stages of disease. RECENT FINDINGS The TESTING trial has provided high-quality evidence for slowing estimated glomerular filtration rate (eGFR) decline with a reduced-dose glucocorticoid regimen, while demonstrating an improved safety profile. Targeted-release budesonide represents a well tolerated therapy for reducing eGFR decline. Mycophenolate mofetil may reduce CKD progression in some populations, while hydroxychloroquine is efficacious in reducing proteinuria. Sodium-glucose cotransporter (SGLT2) inhibitors and sparsentan are effective therapies for CKD due to IgAN, but should not be used in lieu of disease-modifying immunosuppressive therapy. Many new therapies are approaching readiness for clinical use. SUMMARY Numerous therapeutic options now exist and include disease-modifying and nephroprotective drugs. Identifying the right treatment for the right patient is now the clinical challenge and, with new drugs on the horizon, represents the primary unmet research need in this rapidly-developing field.
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Affiliation(s)
- Bryce Barr
- Section of Nephrology, Department of Medicine, Max Rady College of Medicine, University of Manitoba
| | - Sean Barbour
- Division of Nephrology, University of British Columbia
- BC Renal, Vancouver, British Columbia, Canada
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Koehler S, Hengel FE, Dumoulin B, Damashek L, Holzman LB, Susztak K, Huber TB. The 14th International Podocyte Conference 2023: from podocyte biology to glomerular medicine. Kidney Int 2024; 105:935-952. [PMID: 38447880 DOI: 10.1016/j.kint.2024.01.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/11/2023] [Accepted: 01/02/2024] [Indexed: 03/08/2024]
Abstract
The 14th International Podocyte Conference took place in Philadelphia, Pennsylvania, USA from May 23 to 26, 2023. It commenced with an early-career researchers' meeting on May 23, providing young scientists with a platform to present and discuss their research findings. Throughout the main conference, 29 speakers across 9 sessions shared their insights on podocyte biology, glomerular medicine, novel technologic advancements, and translational approaches. Additionally, the event featured 3 keynote lectures addressing engineered chimeric antigen receptor T cell- and mRNA-based therapies and the use of biobanks for enhanced disease comprehension. Furthermore, 4 brief oral abstract sessions allowed scientists to present their findings to a broad audience. The program also included a panel discussion addressing the challenges of conducting human research within the American Black community. Remarkably, after a 5-year hiatus from in-person conferences, the 14th International Podocyte Conference successfully convened scientists from around the globe, fostering the presentation and discussion of crucial research findings, as summarized in this review. Furthermore, to ensure continuous and sustainable education, research, translation, and trial medicine related to podocyte and glomerular diseases for the benefit of patients, the International Society of Glomerular Disease was officially launched during the conference.
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Affiliation(s)
- Sybille Koehler
- III. Department of Medicine and Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Felicitas E Hengel
- III. Department of Medicine and Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Bernhard Dumoulin
- III. Department of Medicine and Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany; Renal, Electrolyte, and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Laurel Damashek
- International Society of Glomerular Disease, Florence, Massachusetts, USA
| | - Lawrence B Holzman
- Renal, Electrolyte, and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Katalin Susztak
- Renal, Electrolyte, and Hypertension Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Institute of Diabetes, Obesity and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Tobias B Huber
- III. Department of Medicine and Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany; International Society of Glomerular Disease, Florence, Massachusetts, USA.
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Campbell KN, Gibson KL, Jhaveri KD. Nephritic Syndromes: A Lot to Progress. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:167-169. [PMID: 39004456 DOI: 10.1053/j.akdh.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/16/2024]
Affiliation(s)
- Kirk N Campbell
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keisha L Gibson
- Division of Pediatric Nephrology, UNC Kidney Center, Chapel Hill, NC
| | - Kenar D Jhaveri
- Northwell Health, Glomerular Center at Northwell Health, Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
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Del Vecchio L, Allinovi M, Comolli S, Peiti S, Rimoldi C, Locatelli F. Drugs in Development to Treat IgA Nephropathy. Drugs 2024; 84:503-525. [PMID: 38777962 DOI: 10.1007/s40265-024-02036-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2024] [Indexed: 05/25/2024]
Abstract
IgA nephropathy is a common glomerulonephritis consequent to the autoimmune response to aberrant glycosylated immunoglobulin (Ig) A antibodies. Although it has historically been considered a benign disease, it has since become clear that a substantial percentage of patients reach end-stage kidney failure over the years. Several therapeutic attempts have been proposed, with systemic steroids being the most prevalent, albeit burdened by possible serious adverse events. Thanks to the more in-depth knowledge of the pathogenesis of IgA nephropathy, new treatment targets have been identified and new drugs developed. In this narrative review, we summarise the molecules under clinical development for the treatment of IgA nephropathy. As a search strategy, we used PubMed, Google, ClinicalTrials.gov and abstracts from recent international congresses. TRF budesonide and sparsentan are the two molecules at a more advanced stage, just entering the market. Other promising agents are undergoing phase III clinical development. These include anti-APRIL and anti-BLyS/BAFF antibodies and some complement inhibitors. Other new possible strategies include spleen tyrosine kinase inhibitors, anti-CD40 ligands and anti-CD38 antibodies. In an era increasingly characterised by 'personalised medicine' and 'precision therapy' approaches and considering that the potential therapeutic armamentarium for IgA nephropathy will be very broad in the near future, the identification of biomarkers capable of helping the nephrologist to select the right drug for the right patient should be the focus of future studies.
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Affiliation(s)
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Stefania Comolli
- Department of Nephrology and Dialysis, ASST Sette Laghi, Varese, Italy
| | - Silvia Peiti
- Department of Nephrology and Dialysis, ASST Lariana, Como, Italy
| | | | - Francesco Locatelli
- Past Director of the Department of Nephrology and Dialysis, ASST Lecco, Lecco, Italy
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Li JJ, Li L, Li S, Tang XY, Sun HF, Liu JX. Sinomenine Hydrochloride Protects IgA Nephropathy Through Regulating Cell Growth and Apoptosis of T and B Lymphocytes. Drug Des Devel Ther 2024; 18:1247-1262. [PMID: 38645988 PMCID: PMC11032719 DOI: 10.2147/dddt.s449119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 04/08/2024] [Indexed: 04/23/2024] Open
Abstract
Purpose Sinomenine hydrochloride (SH) is used to treat chronic inflammatory diseases such as rheumatoid arthritis and may also be efficacious against Immunoglobulin A nephropathy (IgAN). However, no trial has investigated the molecular mechanism of SH on IgAN. Therefore, this study aims to investigate the effect and mechanism of SH on IgAN. Methods The pathological changes and IgA and C3 depositions in the kidney of an IgAN rat model were detected by periodic acid-Schiff (PAS) and direct immunofluorescence staining. After extracting T and B cells using immunomagnetic beads, we assessed their purity, cell cycle phase, and apoptosis stage through flow cytometry. Furthermore, we quantified cell cycle-related and apoptosis-associated proteins by Western blotting. Results SH reduced IgA and C3 depositions in stage 4 IgAN, thereby decreasing inflammatory cellular infiltration and mesangial injury in an IgAN model induced using heteroproteins. Furthermore, SH arrested the cell cycle of lymphocytes T and B from the spleen of IgAN rats. Regarding the mechanism, our results demonstrated that SH regulated the Cyclin D1 and Cyclin E1 protein levels for arresting the cell cycle and it also regulated Bax and Bcl-2 protein levels, thus increasing Cleaved caspase-3 protein levels in Jurkat T and Ramos B cells. Conclusion SH exerts a dual regulation on the cell cycle and apoptosis of T and B cells by controlling cell cycle-related and apoptosis-associated proteins; it also reduces inflammatory cellular infiltration and mesangial proliferation. These are the major mechanisms of SH in IgAN.
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Affiliation(s)
- Jun-Jian Li
- School of Pharmacy, Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, People’s Republic of China
- School of Pharmaceutical Sciences, School of Basic Medical Sciences, Hunan Provincial Key Laboratory of Dong Medicine, Hunan University of Medicine, Huaihua, People’s Republic of China
| | - Li Li
- School of Pharmaceutical Sciences, School of Basic Medical Sciences, Hunan Provincial Key Laboratory of Dong Medicine, Hunan University of Medicine, Huaihua, People’s Republic of China
| | - Shuang Li
- School of Pharmaceutical Sciences, School of Basic Medical Sciences, Hunan Provincial Key Laboratory of Dong Medicine, Hunan University of Medicine, Huaihua, People’s Republic of China
- Harbin Voolga Technology Co., Ltd., Harbin, People’s Republic of China
| | - Xin-Yi Tang
- School of Pharmaceutical Sciences, School of Basic Medical Sciences, Hunan Provincial Key Laboratory of Dong Medicine, Hunan University of Medicine, Huaihua, People’s Republic of China
| | - Hui-Feng Sun
- School of Pharmacy, Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, People’s Republic of China
| | - Jian-Xin Liu
- School of Pharmaceutical Sciences, School of Basic Medical Sciences, Hunan Provincial Key Laboratory of Dong Medicine, Hunan University of Medicine, Huaihua, People’s Republic of China
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Barratt J, Liew A, Yeo SC, Fernström A, Barbour SJ, Sperati CJ, Villanueva R, Wu MJ, Wang D, Borodovsky A, Badri P, Yureneva E, Bhan I, Cattran D. Phase 2 Trial of Cemdisiran in Adult Patients with IgA Nephropathy: A Randomized Controlled Trial. Clin J Am Soc Nephrol 2024; 19:452-462. [PMID: 38214599 PMCID: PMC11020434 DOI: 10.2215/cjn.0000000000000384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 12/15/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND IgA nephropathy is the most common primary GN. Clinical features of IgA nephropathy include proteinuria, which is the strongest known surrogate of progression to kidney failure. Complement pathway activation is a critical driver of inflammation and tissue injury in IgA nephropathy. Cemdisiran is an investigational RNA interference therapeutic that suppresses hepatic production of complement component 5 (C5), thereby potentially reducing proteinuria in IgA nephropathy. We evaluated the efficacy and safety of cemdisiran in adult patients with IgA nephropathy at high risk of kidney disease progression. METHODS In this phase 2, 36-week, double-blind study, adult patients with IgA nephropathy and urine protein ≥1 g/24 hours were randomized (2:1) to subcutaneous cemdisiran 600 mg or placebo every 4 weeks in combination with the standard of care. The primary end point was percentage change from baseline at week 32 in urine protein-to-creatinine ratio (UPCR) measured by 24-hour urine collection. Additional end points included change from baseline in UPCR measured by spot urine, serum C5 level, and safety assessments. RESULTS Thirty-one patients were randomized (cemdisiran, N =22; placebo, N =9). Cemdisiran-treated patients had a placebo-adjusted geometric mean change in 24-hour UPCR of -37.4% (cemdisiran-adjusted geometric mean ratio to baseline [SEM], 0.69 [0.10]) at week 32. Spot UPCR was consistent with 24-hour UPCR placebo-adjusted change of -45.8% (cemdisiran-adjusted geometric mean ratio to baseline [SEM], 0.73 [0.11]). Mean (SD) change in serum C5 level from baseline at week 32 was -98.7% (1.2) with cemdisiran and 25.2% (57.7) with placebo. Over 36 weeks, most adverse events were mild or moderate and transient; the most common adverse event after cemdisiran treatment was injection-site reaction (41%). CONCLUSIONS These findings indicate that treatment with cemdisiran resulted in a reduction of proteinuria at week 32 and was well tolerated.
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Affiliation(s)
- Jonathan Barratt
- Department of Cardiovascular Medicine, University of Leicester, Leicester, United Kingdom
| | - Adrian Liew
- Mount Elizabeth Novena Hospital, Singapore, Singapore
| | - See Cheng Yeo
- Renal Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - Anders Fernström
- Department of Nephrology, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Sean J. Barbour
- University of British Columbia, Division of Nephrology, Vancouver, British Columbia, Canada
| | - C. John Sperati
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ming-Ju Wu
- Department of Internal Medicine, Taichung Veterans General Hospital and Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Dazhe Wang
- Alnylam Pharmaceuticals, Cambridge, Massachusetts
| | | | | | | | - Ishir Bhan
- Alnylam Pharmaceuticals, Cambridge, Massachusetts
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Wang C, Cai X, Lin S, Lin Y. Hydroxychloroquine ameliorates immune functionality and intestinal flora disorders of IgA nephropathy by inhibition of C1GALT1/Cosmc pathway. Immunopharmacol Immunotoxicol 2024; 46:218-228. [PMID: 38151955 DOI: 10.1080/08923973.2023.2300306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/24/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Hydroxychloroquine (HCQ) has emerged as a potential and secure antiproteinuric agent in IgA nephropathy (IgAN). This study endeavored to explore the impact of HCQ on the immune functionality and intestinal flora disorders in IgAN rats, as well as to elucidate the underlying mechanisms through in vivo and in vitro experiments. METHODS IgAN model was established in Sprague-Dawley rats through the administration of BSA, LPS, and CCl4, and the IgAN rats received a continuous 8-week treatment with HCQ. Moreover, the human glomerular mesangial cells (HMCs) were incubated with IgA1 to establish an in vitro cellular model of IgAN. At the end of experimental period, samples were collected for further analysis. RESULTS HCQ ameliorated the elevated levels of 24hUTP, SCr, BUN, the number of urinary RBC, and the activation of inflammation-related proteins within the TLR4/NF-κB signaling pathway. In the IgAN rat group, there was a pronounced escalation in IgA deposition, mesangial matrix hyperplasia, and glomerular inflammatory cell infiltration, while the administration of HCQ effectively mitigated these pathological changes. In addition, the reduced production of CD4+CD25+Foxp3+ Treg in the IgAN group was effectively reversed by HCQ. Furthermore, HCQ has the capacity to restore the compromised state of the intestinal mucosal barrier induced by IgAN and mitigate the circumstances of intestinal permeability and disruption in the intestinal flora. CONCLUSION HCQ diminishes IgA aberrant glycosylation levels, ameliorates renal and intestinal histopathological damage, and attenuates intestinal flora disorders and immune dysfunction in IgAN rats by means of activating the C1GALT1/Cosmc pathway.
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Affiliation(s)
- Chaochao Wang
- Department of Nephrology, Zhejiang Chinese Medical University Affiliated Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
| | - Xiaoqiao Cai
- Department of Nephrology, Zhejiang Chinese Medical University Affiliated Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
| | - Shengfen Lin
- Department of Nephrology, Zhejiang Chinese Medical University Affiliated Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
| | - Yongqiang Lin
- Department of Nephrology, Zhejiang Chinese Medical University Affiliated Wenzhou Hospital of Integrated Traditional Chinese and Western Medicine, Wenzhou, China
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Lerma EV, Thakker KM, Bensink ME, Lieblich R, Bunke CM, Gong W, Rava AR, Wang K, Amari DT, Oliveri D, Murphy MV, Cork DM, Velez JCQ. Kidney Failure Events, Cardiovascular Disease Events, and All-Cause Mortality in Patients with IgA Nephropathy in a Real-World Database. KIDNEY360 2024; 5:427-436. [PMID: 38323871 PMCID: PMC11000736 DOI: 10.34067/kid.0000000000000379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 01/22/2024] [Indexed: 02/08/2024]
Abstract
Key Points In our US real-world cohort study of patients with IgA nephropathy, elevated proteinuria and progression to kidney failure (KF) were associated with a higher risk of cardiovascular disease/mortality events. Elevated pre-KF proteinuria was also associated with progression to KF/mortality events. Incremental costs associated with CKD stage, nephrotic syndrome, and cardiovascular disease events and of these events were high. Background IgA nephropathy (IgAN)–associated glomerular injury leads to proteinuria, hematuria, and progressive loss of GFR, with progression to kidney failure (KF). This retrospective study evaluated the prognostic effects of proteinuria and progression to KF on cardiovascular disease (CVD)/mortality events and KF/mortality events in the United States. Methods We conducted a noninterventional, retrospective cohort study in adult patients with IgAN using Optum's deidentified Market Clarity Data (January 1, 2007, to March 31, 2021). Adult (age ≥18 years) patients with at least two signs, disease, symptoms natural language processing term entries for IgAN, within 180 and ≥30 days apart within the identification period were included. Outcomes were assessed by time-dependent proteinuria (≥1 versus <1 g/d) and KF status (pre versus post). Descriptive statistics were used for categorical and continuous variables. Multivariable Cox proportional hazard models with time-dependent predictors were used to estimate differences across groups. Results Patients with pre-KF status and proteinuria ≥1 g/d were more likely to have a CVD/mortality event during follow-up (adjusted hazard ratio [HR; 95% confidence interval (CI)]: 1.80 [1.12 to 2.89]; P < 0.001) or a KF/mortality event (adjusted HR [95% CI]: 2.10 [1.73 to 2.56]; P < 0.001). Patients with post-KF status were more likely to have a CVD/mortality event during follow-up (adjusted HR [95% CI]: 3.28 [2.82 to 3.81]; P < 0.001). Conclusions Elevated proteinuria and progression to KF were associated with a higher risk of CVD/mortality events. Elevated pre-KF proteinuria was also associated with progression to KF/mortality events. On the basis of our real-world retrospective database analysis, we hypothesize that novel IgAN therapies that reduce proteinuria and slow the rate of progression to KF have the potential to reduce CVD risk, improve kidney outcomes, and prolong/increase overall survival.
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Affiliation(s)
- Edgar V. Lerma
- University of Illinois Chicago/Advocate Christ Medical Center, Oak Lawn, Illinois
| | | | | | | | | | - Wu Gong
- Travere Therapeutics, Inc., San Diego, California
| | | | - Kaijun Wang
- Travere Therapeutics, Inc., San Diego, California
| | | | | | | | | | - Juan Carlos Q. Velez
- Department of Nephrology, Ochsner Health, New Orleans, Louisiana
- Ochsner Clinical School, The University of Queensland, Brisbane, Queensland, Australia
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Jiang Y, Chen P, Zhao W, Liu L, Shi S, Lv J, Zhang H. Distinct characteristics and prognosis of IgA nephropathy patients with nephrotic syndrome: a propensity score-matched cohort study. Front Med (Lausanne) 2024; 11:1344219. [PMID: 38439903 PMCID: PMC10910015 DOI: 10.3389/fmed.2024.1344219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/07/2024] [Indexed: 03/06/2024] Open
Abstract
Introduction IgA nephropathy (IgAN) is the most prevalent primary glomerulonephritis globally. While nephrotic syndrome (NS) is uncommon in IgAN, its significance remains unclear. Methods We conducted a retrospective analysis of 170 IgAN patients, classifying them into NS (n = 85) and non-NS (n = 5) groups. Our study aims to compare their clinical characteristics, treatment responses, and prognoses. Patients were selected based on renal biopsy from 2003 to 2020. Propensity score matching ensured comparability. Clinical, pathological, and immunological data were analyzed. Composite endpoints were defined as end-stage kidney disease (ESKD) or a 30% decline in estimated glomerular filtration rate (eGFR). Results NS patients showed higher eGFR (74.3 ± 36.8 vs. 61.5 ± 33.6 mL/min.1.73 m2, p = 0.02), severe hematuria (35.0 (4.7,147.5) vs. 4.0 (1.8,45,0) cells/μl, p < 0.001), severe foot process effacement (p = 0.01), and lower C3 levels (1.0 ± 0.3 vs. 1.1 ± 0.2 g/L, p = 0.03). In contrast, the non-NS group had higher BMI (24.3 ± 4.0 vs. 26.8 ± 3.7 kg/m2, p < 0.001) and elevated serum uric acid levels (376 (316,417) vs. 400 (362, 501) mmol/L, p = 0.001), suggesting metabolic factors might contribute to their condition. Both groups exhibited similar MESTC scores. NS patients had higher complete remission rates (26.2% vs. 14.1%, p = 0.04). Cox regression revealed NS independently associated with a higher risk of composite endpoints (HR = 1.97, 95% CI 1.05-3.72, p = 0.04). Linear mixed models did not show significant eGFR trajectory differences. Discussion This study has established that IgAN patients with NS exhibit distinct characteristics, including active disease and increased complement activation. NS is independently associated with a poorer prognosis, emphasizing the need for targeted interventions in this subgroup.
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Affiliation(s)
- Yuanyuan Jiang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Pei Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Wenjing Zhao
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Lijun Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Sufang Shi
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
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Lim RS, Yeo SC, Barratt J, Rizk DV. An Update on Current Therapeutic Options in IgA Nephropathy. J Clin Med 2024; 13:947. [PMID: 38398259 PMCID: PMC10889409 DOI: 10.3390/jcm13040947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 01/30/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
Immunoglobulin A nephropathy (IgAN) remains the leading cause of primary glomerular disease worldwide. Outcomes are poor with high rates of progressive chronic kidney disease and kidney failure, which contributes to global healthcare costs. Although this disease entity has been described, there were no disease-specific treatments until recently, with the current standard of care focusing on optimal supportive measures including lifestyle modifications and optimization of the renin-angiotensin-aldosterone blockade. However, with significant advances in the understanding of the pathogenesis of IgAN in the past decade, and the acceptance of surrogate outcomes for accelerated drug approval, there have been many new investigational agents tested to target this disease. As these agents become available, we envision a multi-pronged treatment strategy that simultaneously targets the consequences of ongoing nephron loss, stopping any glomerular inflammation, inhibiting pro-fibrotic signals in the glomerulus and tubulo-interstitium, and inhibiting the production of pathogenic IgA molecules. This review is an update on a previous review published in 2021, and we aim to summarize the developments and updates in therapeutic strategies in IgAN and highlight the promising discoveries that are likely to add to our armamentarium.
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Affiliation(s)
- Regina Shaoying Lim
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; (R.S.L.); (S.C.Y.)
| | - See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; (R.S.L.); (S.C.Y.)
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK;
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester LE5 4PW, UK
| | - Dana V. Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, ZRB 614, 1720 2nd Avenue South, Birmingham, AL 35294, USA
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Gan Y, Cai Y, Li J, Wu J, Zhang R, Han Q, Li W, Yang Q. Development and validation of a diagnostic nomogram to evaluate tubular atrophy/interstitial fibrosis of IgA nephropathy. Int J Med Sci 2024; 21:674-680. [PMID: 38464822 PMCID: PMC10920839 DOI: 10.7150/ijms.91804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/10/2024] [Indexed: 03/12/2024] Open
Abstract
Background: IgA nephropathy (IgAN) is a cause of chronic kidney disease (CKD). Tubular atrophy/interstitial fibrosis is associated with IgAN prognosis. However, simple tools for predicting pathological lesions of IgAN remain limited. Our objective was to develop a tool for evaluating tubular atrophy/interstitial fibrosis in patients with IgAN. Methods: In this cross-sectional study, 410 biopsy-verified IgAN patients were included. The factors associated with the incident interstitial fibrosis or tubular atrophy in IgAN were confirmed by using logistic regression analysis. A nomogram was developed using logistic regression coefficients to evaluate tubular atrophy or interstitial fibrosis. Receiver operating characteristic curves (ROC) and calibration curves were used to determine the discriminative ability and predictive accuracy of the nomogram. Results: In this study, the IgAN patients with tubular atrophy or interstitial fibrosis were older and had a higher percentage of males, hypertension and urinary protein excretion (UPE), with high levels of serum cystatin C, serum creatinine, high-sensitivity C-reactive protein and serum C4. The eGFRcr-cys equation calculated using serum creatinine, cystatin C and UPE were considered independent influencing factors of tubular atrophy or interstitial fibrosis in patients with IgAN. Furthermore, the nomogram demonstrated good discrimination (AUC: 0.87, 95% CI 0.81 to 0.93) and calibration in the validation cohort. Conclusion: The eGFRcr-cys and UPE are associated with tubular atrophy or interstitial fibrosis in patients with IgAN. Diagnostic nomogram can predict tubular atrophy or interstitial fibrosis in IgAN.
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Affiliation(s)
| | | | | | | | | | | | | | - Qiongqiong Yang
- Department of Nephrology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Tunnicliffe DJ, Reid S, Craig JC, Samuels JA, Molony DA, Strippoli GF. Non-immunosuppressive treatment for IgA nephropathy. Cochrane Database Syst Rev 2024; 2:CD003962. [PMID: 38299639 PMCID: PMC10832348 DOI: 10.1002/14651858.cd003962.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most common primary glomerular disease, with approximately 20% to 40% of patients progressing to kidney failure within 25 years. Non-immunosuppressive treatment has become a mainstay in the management of IgAN by improving blood pressure (BP) management, decreasing proteinuria, and avoiding the risks of long-term immunosuppressive management. Due to the slowly progressive nature of the disease, clinical trials are often underpowered, and conflicting information about management with non-immunosuppressive treatment is common. This is an update of a Cochrane review, first published in 2011. OBJECTIVES To assess the benefits and harms of non-immunosuppressive treatment for treating IgAN in adults and children. We aimed to examine all non-immunosuppressive therapies (e.g. anticoagulants, antihypertensives, dietary restriction and supplementation, tonsillectomy, and herbal medicines) in the management of IgAN. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to December 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of non-immunosuppressive agents in adults and children with biopsy-proven IgAN were included. DATA COLLECTION AND ANALYSIS Two authors independently reviewed search results, extracted data and assessed study quality. Results were expressed as mean differences (MD) for continuous outcomes and risk ratios (RR) for dichotomous outcomes with 95% confidence intervals (CI) using random-effects meta-analysis. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS This review includes 80 studies (4856 participants), of which 24 new studies (2018 participants) were included in this review update. The risk of bias within the included studies was mostly high or unclear for many of the assessed methodological domains, with poor reporting of important key clinical trial methods in most studies. Antihypertensive therapies were the most examined non-immunosuppressive therapy (37 studies, 1799 participants). Compared to placebo or no treatment, renin-angiotensin system (RAS) inhibition probably decreases proteinuria (3 studies, 199 participants: MD - 0.71 g/24 h, 95% CI -1.04 to -0.39; moderate certainty evidence) but may result in little or no difference to kidney failure or doubling of serum creatinine (SCr), or complete remission of proteinuria (low certainty evidence). Death, remission of haematuria, relapse of proteinuria or > 50% increase in SCr were not reported. Compared to symptomatic treatment, RAS inhibition (3 studies, 168 participants) probably decreases proteinuria (MD -1.16 g/24 h, 95% CI -1.52 to -0.81) and SCr (MD -9.37 µmol/L, 95% CI -71.95 to -6.80) and probably increases creatinine clearance (2 studies, 127 participants: MD 23.26 mL/min, 95% CI 10.40 to 36.12) (all moderate certainty evidence); however, the risk of kidney failure is uncertain (1 study, 34 participants: RR 0.20, 95% CI 0.01 to 3.88; very low certainty evidence). Death, remission of proteinuria or haematuria, or relapse of proteinuria were not reported. The risk of adverse events may be no different with RAS inhibition compared to either placebo or symptomatic treatment (low certainty evidence). In low certainty evidence, tonsillectomy in people with IgAN in addition to standard care may increase remission of proteinuria compared to standard care alone (2 studies, 143 participants: RR 1.90, 95% CI 1.45 to 2.47) and remission of microscopic haematuria (2 studies, 143 participants: RR 1.93, 95% CI 1.47 to 2.53) and may decrease relapse of proteinuria (1 study, 73 participants: RR 0.70, 95% CI 0.57 to 0.85) and relapse of haematuria (1 study, 72 participants: RR 0.70, 95% CI 0.51 to 0.98). Death, kidney failure and a > 50% increase in SCr were not reported. These trials have only been conducted in Japanese people with IgAN, and the findings' generalisability is unclear. Anticoagulant therapy, fish oil, and traditional Chinese medicines exhibited small benefits to kidney function in patients with IgAN when compared to placebo or no treatment. However, compared to standard care, the kidney function benefits are no longer evident. Antimalarial therapy compared to placebo in one study reported an increase in a > 50% reduction of proteinuria (53 participants: RR 3.13 g/24 h, 95% CI 1.17 to 8.36; low certainty evidence). Although, there was uncertainty regarding adverse events from this study due to very few events. AUTHORS' CONCLUSIONS Available RCTs focused on a diverse range of interventions. They were few, small, and of insufficient duration to determine potential long-term benefits on important kidney and cardiovascular outcomes and harms of treatment. Antihypertensive agents appear to be the most beneficial non-immunosuppressive intervention for IgAN. The antihypertensives examined were predominantly angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. The benefits of RAS inhibition appear to outweigh the harms in patients with IgAN. The certainty of the evidence of RCTs demonstrating a benefit of tonsillectomy to patients with Japanese patients with IgAN was low. In addition, these findings are inconsistent across observational studies in people with IgAN of other ethnicities; hence, tonsillectomy is not widely recommended, given the potential harm of therapy. The RCT evidence is insufficiently robust to demonstrate efficacy for the other non-immunosuppressive treatments evaluated here.
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Affiliation(s)
| | - Sharon Reid
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jonathan C Craig
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Joshua A Samuels
- Division of Pediatric Nephrology and Hypertension, UT-Houston Health Science Center, Houston, TX, USA
| | - Donald A Molony
- Internal Medicine, UT-Houston Health Science Center, Houston, TX, USA
| | - Giovanni Fm Strippoli
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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20
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Joshi A, Mariani LH. Reaping the rewards of mechanistic discovery in glomerular disease. Nat Rev Nephrol 2024; 20:77-78. [PMID: 38123699 DOI: 10.1038/s41581-023-00804-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Arpita Joshi
- Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Laura H Mariani
- Division of Nephrology, University of Michigan, Ann Arbor, MI, USA.
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21
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Yano Y, Nagasu H, Kanegae H, Nangaku M, Hirakawa Y, Sugawara Y, Nakagawa N, Wada J, Sugiyama H, Nakano T, Wada T, Shimizu M, Suzuki H, Komatsu H, Nakashima N, Kitaoka K, Narita I, Okada H, Suzuki Y, Kashihara N. Kidney outcomes associated with haematuria and proteinuria trajectories among patients with IgA nephropathy in real-world clinical practice: The Japan Chronic Kidney Disease Database. Nephrology (Carlton) 2024; 29:65-75. [PMID: 37871587 DOI: 10.1111/nep.14250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 09/01/2023] [Accepted: 10/04/2023] [Indexed: 10/25/2023]
Abstract
AIM Among patients with Immunoglobulin A (IgA) nephropathy, we aimed to identify trajectory patterns stratified by the magnitude of haematuria and proteinuria using repeated urine dipstick tests, and assess whether the trajectories were associated with kidney events. METHODS Using a nationwide multicentre chronic kidney disease (CKD) registry, we analysed data from 889 patients with IgA nephropathy (mean age 49.3 years). The primary outcome was a sustained reduction in eGFR of 50% or more from the index date and thereafter. During follow-up (median 49.0 months), we identified four trajectories (low-stable, moderate-decreasing, moderate-stable, and high-stable) in both urine dipstick haematuria and proteinuria measurements, respectively. RESULTS In haematuria trajectory analyses, compared to the low-stable group, the adjusted hazard ratios (HRs) (95% confidence interval [CI]) for kidney events were 2.59 (95% CI, 1.48-4.51) for the high-stable, 2.31 (95% CI, 1.19-4.50) for the moderate-stable, and 1.43 (95% CI, (0.72-2.82) for the moderate-decreasing groups, respectively. When each proteinuria trajectory group was subcategorized according to haematuria trajectories, the proteinuria group with high-stable and with modest-stable haematuria trajectories had approximately 2-times higher risk for eGFR reduction ≥50% compared to that with low-stable haematuria trajectory. CONCLUSION Assessments of both haematuria and proteinuria trajectories using urine dipstick could identify high-risk IgA nephropathy patients.
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Affiliation(s)
- Yuichiro Yano
- Noncommunicable Disease (NCD) Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan
- Department of Family Medicine and Community Health, Duke University, Durham, North Carolina, USA
| | - Hajime Nagasu
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Hiroshi Kanegae
- Office of Research and Analysis, Genki Plaza Medical Center for Health Care, Tokyo, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yosuke Hirakawa
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yuka Sugawara
- Division of Nephrology and Endocrinology, University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Naoki Nakagawa
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
| | - Jun Wada
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
| | - Miho Shimizu
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
| | - Hitoshi Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Hiroyuki Komatsu
- Center for Medical Education and Career Development, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Naoki Nakashima
- Medical Information Center, Kyushu University Hospital, Fukuoka, Japan
| | - Kaori Kitaoka
- Noncommunicable Disease (NCD) Epidemiology Research Center, Shiga University of Medical Science, Otsu, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Hirokazu Okada
- Department of Nephrology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
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22
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Caster DJ, Lafayette RA. The Treatment of Primary IgA Nephropathy: Change, Change, Change. Am J Kidney Dis 2024; 83:229-240. [PMID: 37742867 DOI: 10.1053/j.ajkd.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 07/20/2023] [Accepted: 08/07/2023] [Indexed: 09/26/2023]
Abstract
IgA nephropathy (IgAN) is the most common glomerular disease in the world. However, the approach to treatment remains controversial. There has been an explosion of clinical trials over the past decade both to further examine corticosteroid use and usher in additional treatment considerations, including 2 newly approved therapies for IgAN. Sodium glucose cotransporter 2 inhibitors are proving to be effective therapy across proteinuric chronic kidney diseases, and IgAN is not likely to be an exception. Further supportive agents are looking highly promising and so are novel agents that specifically focus on the pathophysiology of this disease, including endothelin blockade, complement inhibition, and B-cell targeted strategies. We suggest a present-day approach to treatment of individuals with IgAN, expose the limitations in our knowledge, and discuss new treatments that may arise, hoping they come with evidence about optimal utilization. Change appears to be inevitable for our approach to the treatment of IgA nephropathy. This is truly an exciting and optimistic time.
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Affiliation(s)
- Dawn J Caster
- Division of Nephrology and Hypertension, University of Louisville, Louisville, Kentucky
| | - Richard A Lafayette
- Division of Nephrology, Stanford University Medical Center, Stanford, California.
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23
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Zhang H, Rizk DV, Perkovic V, Maes B, Kashihara N, Rovin B, Trimarchi H, Sprangers B, Meier M, Kollins D, Papachristofi O, Milojevic J, Junge G, Nidamarthy PK, Charney A, Barratt J. Results of a randomized double-blind placebo-controlled Phase 2 study propose iptacopan as an alternative complement pathway inhibitor for IgA nephropathy. Kidney Int 2024; 105:189-199. [PMID: 37914086 DOI: 10.1016/j.kint.2023.09.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 08/30/2023] [Accepted: 09/27/2023] [Indexed: 11/03/2023]
Abstract
Targeting the alternative complement pathway is an attractive therapeutic strategy given its role in the pathogenesis of immunoglobulin A nephropathy (IgAN). Iptacopan (LNP023) is an oral, proximal alternative complement inhibitor that specifically binds to Factor B. Our randomized, double-blind, parallel-group adaptive Phase 2 study (NCT03373461) enrolled patients with biopsy-confirmed IgAN (within previous three years) with estimated glomerular filtration rates of 30 mL/min/1.73 m2 and over and urine protein 0.75 g/24 hours and over on stable doses of renin angiotensin system inhibitors. Patients were randomized to four iptacopan doses (10, 50, 100, or 200 mg bid) or placebo for either a three-month (Part 1; 46 patients) or a six-month (Part 2; 66 patients) treatment period. The primary analysis evaluated the dose-response relationship of iptacopan versus placebo on 24-hour urine protein-to-creatinine ratio (UPCR) at three months. Other efficacy, safety and biomarker parameters were assessed. Baseline characteristics were generally well-balanced across treatment arms. There was a statistically significant dose-response effect, with 23% reduction in UPCR achieved with iptacopan 200 mg bid (80% confidence interval 8-34%) at three months. UPCR decreased further through six months in iptacopan 100 and 200 mg arms (from a mean of 1.3 g/g at baseline to 0.8 g/g at six months in the 200 mg arm). A sustained reduction in complement biomarker levels including plasma Bb, serum Wieslab, and urinary C5b-9 was observed. Iptacopan was well-tolerated, with no reports of deaths, treatment-related serious adverse events or bacterial infections, and led to strong inhibition of alternative complement pathway activity and persistent proteinuria reduction in patients with IgAN. Thus, our findings support further evaluation of iptacopan in the ongoing Phase 3 trial (APPLAUSE-IgAN; NCT04578834).
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Affiliation(s)
- Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, People's Republic of China.
| | - Dana V Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Vlado Perkovic
- University of New South Wales, Sydney, New South Wales, Australia
| | - Bart Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Brad Rovin
- Division of Nephrology, the Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hernán Trimarchi
- Nephrology Service and Kidney Transplantation Unit, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Ben Sprangers
- Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium; Department of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | | | | | | | - Julie Milojevic
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | - Guido Junge
- Novartis Institutes for BioMedical Research, Basel, Switzerland
| | | | - Alan Charney
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; The John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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24
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Koike K, Kawamura T, Hirano K, Nishikawa M, Shimizu A, Joh K, Katafuchi R, Hashiguchi A, Yano Y, Matsuzaki K, Matsushima M, Tsuboi N, Maruyama S, Narita I, Yokoo T, Suzuki Y. Clinicopathological prognostic stratification for proteinuria and kidney survival in IgA nephropathy: a Japanese prospective cohort study. Clin Kidney J 2024; 17:sfad294. [PMID: 38213485 PMCID: PMC10783253 DOI: 10.1093/ckj/sfad294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Indexed: 01/13/2024] Open
Abstract
Background We require a clinicopathological risk stratification method for immunoglobulin A nephropathy (IgAN) to predict kidney outcomes. We examined a renal failure risk group (RF-RG) classification system created following a prior multicentre, retrospective study to determine if RF-RG could predict kidney outcomes. Methods We collected data from Japanese patients with IgAN registered between 1 April 2005 and 31 August 2015. The primary outcome was a composite 50% increase in serum creatinine from baseline or dialysis induction. The secondary outcomes were times to proteinuria remission (ProR) and haematuria remission (HemR). Results The enrolled 991 patients from 44 facilities were followed for a median of 5.5 years (interquartile range 2.5-7.5), during which 87 composite events (8.8%) occurred. RF-RG was significantly associated with the primary outcome {hazard ratio [HR] II 2.78 [95% confidence interval (CI) 1.12-6.93], III 7.15 (2.90-17.6), IV 33.4 (14.1-79.0), I as a reference, P < .001}.The discrimination performance was good [C-statistic 0.81 (95% CI 0.76-0.86)] and the time-dependent C-statistics exceeded 0.8 over 10 years. Among the 764 patients with proteinuria and 879 patients with haematuria at baseline, 515 and 645 patients showed ProR and HemR, respectively. ProR was significantly less frequent in patients with advanced disease [subdistribution HR: II 0.79 (95% CI 0.67-0.94), III 0.53 (0.41-0.66), IV 0.15 (0.09-0.23), I as a reference, P < .001]. We also observed an association between HemR and RF-RG. Conclusions RF-RG demonstrated good predictive ability for kidney outcomes.
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Affiliation(s)
- Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Tetsuya Kawamura
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Keita Hirano
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
- Division of Nephrology, Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Masako Nishikawa
- Clinical Research Support Center, Jikei University School of Medicine, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Kensuke Joh
- Department of Pathology, Jikei University School of Medicine, Tokyo, Japan
| | - Ritsuko Katafuchi
- National Hospital Organization Fukuoka-Higashi Medical Center, Fukuoka, Japan
| | - Akinori Hashiguchi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Yuichiro Yano
- Department of Advanced Epidemiology, Noncommunicable Disease Epidemiology Research Center, Shiga University of Medical Science, Shiga, Japan
- Department of Family Medicine and Community Health, Duke University, Durham, NC, USA
| | | | - Masato Matsushima
- Division of Clinical Epidemiology, Research Center for Medical Sciences, Jikei University School of Medicine, Tokyo, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Ichiei Narita
- Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, Jikei University School of Medicine, Tokyo, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
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25
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Derebail VK, Nachman PH. Sparsentan and the Expanding Landscape of IgA Nephropathy Treatment. Clin J Am Soc Nephrol 2024; 19:122-125. [PMID: 37499685 PMCID: PMC10843334 DOI: 10.2215/cjn.0000000000000268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Vimal K. Derebail
- UNC Kidney Center, Division of Nephrology and Hypertension, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Patrick H. Nachman
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
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26
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Rheault MN, Alpers CE, Barratt J, Bieler S, Canetta P, Chae DW, Coppock G, Diva U, Gesualdo L, Heerspink HJL, Inrig JK, Kirsztajn GM, Kohan D, Komers R, Kooienga LA, Lieberman K, Mercer A, Noronha IL, Perkovic V, Radhakrishnan J, Rote W, Rovin B, Tesar V, Trimarchi H, Tumlin J, Wong MG, Trachtman H. Sparsentan versus Irbesartan in Focal Segmental Glomerulosclerosis. N Engl J Med 2023; 389:2436-2445. [PMID: 37921461 DOI: 10.1056/nejmoa2308550] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
BACKGROUND An unmet need exists for focal segmental glomerulosclerosis (FSGS) treatment. In an 8-week, phase 2 trial, sparsentan, a dual endothelin-angiotensin receptor antagonist, reduced proteinuria in patients with FSGS. The efficacy and safety of longer-term treatment with sparsentan for FSGS are unknown. METHODS In this phase 3 trial, we enrolled patients with FSGS (without known secondary causes) who were 8 to 75 years of age; patients were randomly assigned to receive sparsentan or irbesartan (active control) for 108 weeks. The surrogate efficacy end point assessed at the prespecified interim analysis at 36 weeks was the FSGS partial remission of proteinuria end point (defined as a urinary protein-to-creatinine ratio of ≤1.5 [with protein and creatinine both measured in grams] and a >40% reduction in the ratio from baseline). The primary efficacy end point was the estimated glomerular filtration rate (eGFR) slope at the time of the final analysis. The change in eGFR from baseline to 4 weeks after the end of treatment (week 112) was a secondary end point. Safety was also evaluated. RESULTS A total of 371 patients underwent randomization: 184 were assigned to receive sparsentan and 187 to receive irbesartan. At 36 weeks, the percentage of patients with partial remission of proteinuria was 42.0% in the sparsentan group and 26.0% in the irbesartan group (P = 0.009), a response that was sustained through 108 weeks. At the time of the final analysis at week 108, there were no significant between-group differences in the eGFR slope; the between-group difference in total slope (day 1 to week 108) was 0.3 ml per minute per 1.73 m2 of body-surface area per year (95% confidence interval [CI], -1.7 to 2.4), and the between-group difference in the slope from week 6 to week 108 (i.e., chronic slope) was 0.9 ml per minute per 1.73 m2 per year (95% CI, -1.3 to 3.0). The mean change in eGFR from baseline to week 112 was -10.4 ml per minute per 1.73 m2 with sparsentan and -12.1 ml per minute per 1.73 m2 with irbesartan (difference, 1.8 ml per minute per 1.73 m2; 95% CI, -1.4 to 4.9). Sparsentan and irbesartan had similar safety profiles, and the frequency of adverse events was similar in the two groups. CONCLUSIONS Among patients with FSGS, there were no significant between-group differences in eGFR slope at 108 weeks, despite a greater reduction in proteinuria with sparsentan than with irbesartan. (Funded by Travere Therapeutics; DUPLEX ClinicalTrials.gov number, NCT03493685.).
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Affiliation(s)
- Michelle N Rheault
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Charles E Alpers
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Jonathan Barratt
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Stewart Bieler
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Pietro Canetta
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Dong-Wan Chae
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Gaia Coppock
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Ulysses Diva
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Loreto Gesualdo
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Hiddo J L Heerspink
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Jula K Inrig
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Gianna M Kirsztajn
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Donald Kohan
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Radko Komers
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Laura A Kooienga
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Kenneth Lieberman
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Alex Mercer
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Irene L Noronha
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Vlado Perkovic
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Jai Radhakrishnan
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - William Rote
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Brad Rovin
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Vladimir Tesar
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Hernán Trimarchi
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - James Tumlin
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Muh Geot Wong
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
| | - Howard Trachtman
- From the Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis (M.N.R.); the Department of Laboratory Medicine and Pathology, University of Washington, Seattle (C.E.A.); the Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, United Kingdom (J.B.); Travere Therapeutics, San Diego, CA (S.B., U.D., J.K.I., R.K., W.R.); the Division of Nephrology, Columbia University Irving Medical Center, New York (P.C., J.R.); the Division of Nephrology, Department of Internal Medicine, Seoul Red Cross Hospital, Seoul, South Korea (D.-W.C.); Penn Renal Electrolyte and Hypertension Perelman, University of Pennsylvania, Philadelphia (G.C.); the Nephrology, Dialysis, and Transplantation Unit, University of Bari Aldo Moro, Bari, Italy (L.G.); the Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, the Netherlands (H.J.L.H.); the George Institute for Global Health (H.J.L.H., V.P.) and the Faculty of Medicine and Health (V.P.), University of New South Wales, Sydney, and the Department of Renal Medicine, Concord Repatriation General Hospital, and Concord Clinical School, University of Sydney, Concord, NSW (M.G.W.) - all in Australia; the Department of Medicine (Nephrology), Federal University of São Paulo (G.M.K.), and the Division of Nephrology, University of São Paulo (I.L.N.) - both in São Paulo; the Department of Internal Medicine, Division of Nephrology, School of Medicine, University of Utah, Salt Lake City (D.K.); Colorado Kidney Care, Denver (L.A.K.); Hackensack University Medical Center, Hackensack, NJ (K.L.); JAMCO Pharma Consulting, Stockholm (A.M.); the Division of Nephrology, Ohio State University Wexner Medical Center, Columbus (B.R.); Všeobecná fakultní nemocnice v Praze, Prague, Czech Republic (V.T.); the Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires (H. Trimarchi); the Renal Division, Emory University, Atlanta, and the NephroNet Clinical Trials Consortium, Lawrenceville - both in Georgia (J.T.); and the Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor (H. Trachtman)
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Campbell KN, Griffin S, Trachtman H, Geletka R, Wong MG. Practical Considerations for the Use of Sparsentan in the Treatment of Patients with IgAN in Clinical Practice. Int J Nephrol Renovasc Dis 2023; 16:281-291. [PMID: 38149041 PMCID: PMC10750480 DOI: 10.2147/ijnrd.s430377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 12/12/2023] [Indexed: 12/28/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. It is characterized by the mesangial deposition of IgA-containing immune complexes, triggering damage to the glomerular filtration barrier that is amplified by the tandem action of endothelin-1 and angiotensin II at their receptors. Proteinuria and progressive glomerular damage cause loss of kidney function in up to 50% of patients within 10-20 years. The risk of progression is strongly associated with persistent proteinuria (>0.75-1 g/day). Current standard of care involves interventions to decrease proteinuria and control blood pressure. Immunosuppressive agents, used in selected patients at high risk for progression, can be associated with significant side effects. Sparsentan, a novel non-immunosuppressive single-molecule Dual Endothelin Angiotensin Receptor Antagonist (DEARA), received FDA accelerated approval based on interim results from the PROTECT trial, which demonstrated that sparsentan-treated patients achieved a significantly greater reduction in proteinuria from baseline versus the active control irbesartan and that sparsentan was generally safe and well tolerated. Sparsentan is the first non-immunosuppressive treatment to be FDA-approved for the reduction of proteinuria in adults with IgAN at high risk of disease progression. We provide practical guidance for the clinical use of sparsentan in adults with IgAN.
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Affiliation(s)
- Kirk N Campbell
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Siân Griffin
- Department of Nephrology, University Hospital of Wales, Cardiff, UK
| | - Howard Trachtman
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Rob Geletka
- Travere Therapeutics, Inc., San Diego, CA, USA
| | - Muh Geot Wong
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia
- Concord Clinical School, University of Sydney, Concord, NSW, Australia
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Tang C, Chen P, Si FL, Yao YX, Lv JC, Shi SF, Zhou XJ, Liu LJ, Zhang H. Intensive blood pressure control and the progression of IgA nephropathy: a cohort study using marginal structural models. Nephrol Dial Transplant 2023; 39:55-63. [PMID: 37391382 DOI: 10.1093/ndt/gfad139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND In chronic kidney disease, current guidelines recommend systolic blood pressure (SBP) below 120 mmHg. However, the renoprotective effect of intensive blood-pressure (BP) lowering on immunoglobulin A nephropathy (IgAN) remains undetermined. We aimed to determine the effect of intensive BP control on the progression of IgAN. METHODS At Peking University First Hospital, 1530 patients with IgAN were enrolled. An examination of the relationship between baseline and time-updated BP and composite kidney outcomes, defined as development of end-stage kidney disease (ESKD) or a 30% decline in estimated glomerular filtration rate (eGFR), was conducted. Baseline and time-updated BPs were modeled using multivariate causal hazards models and marginal structural models (MSMs). RESULTS In a median follow-up of 43.5 (interquartile range 27.2, 72.7) months, 367 (24.0%) patients experienced the composite kidney outcomes. No significant associations were found between baseline BP and the composite outcomes. Using MSMs with time-updated SBP for analysis, a U-shaped association was found. In reference to SBP 110-119 mmHg, hazard ratios (95% confidence intervals) for the SBP categories <110, 120-129, 130-139 and ≥140 mmHg were 1.48 (1.02-2.17), 1.13 (0.80-1.60), 2.21 (1.54-3.16) and 2.91 (1.94-4.35), respectively. The trend was more prominent in patients with proteinuria ≥1 g/day and eGFR ≥60 mL/min/1.73 m2. After analyzing time-updated diastolic BP, no similar trend was observed. CONCLUSIONS In patients with IgAN, intensive BP control during the treatment period may retard the kidney disease progression, but the potential risk of hypotension still needs to be considered.
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Affiliation(s)
- Chen Tang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Pei Chen
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Feng-Lei Si
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Yu-Xuan Yao
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ji-Cheng Lv
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Su-Fang Shi
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xu-Jie Zhou
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Li-Jun Liu
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
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29
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Reich HN, Barbour SJ. PROTECTing the kidneys in IgA nephropathy. Lancet 2023; 402:2046-2047. [PMID: 37931627 DOI: 10.1016/s0140-6736(23)02418-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Heather N Reich
- Department of Medicine, Divison of Nephrology, University of Toronto, University Health Network, Toronto, ON M5G 2C4, Canada.
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia, Vancouver, BC, Canada
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30
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Rajasekaran A, Larkina M, Julian BA, Canetta PA, Roehm BA, Khalid M, Mariani LH, Rizk DV. Optimal Conservative Therapy Use among Adult Cure Glomerulonephropathy Participants with IgA Nephropathy. KIDNEY360 2023; 4:1763-1769. [PMID: 37962551 PMCID: PMC10758511 DOI: 10.34067/kid.0000000000000306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023]
Abstract
Optimal supportive therapy with BP and proteinuria control is pivotal in treating patients with IgA nephropathy. Suboptimal treatment of hypertension and proteinuria persisted in many patients with IgA nephropathy in the Cure Glomerulonephropathy Network study. Many patients had above-target proteinuria despite optimal BP control and may benefit from novel therapies or clinical trials.
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Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Maria Larkina
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Bruce A. Julian
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Pietro A. Canetta
- Division of Nephrology, Columbia University Irving Medical Center, New York, New York
| | - Bethany A. Roehm
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Myda Khalid
- Division of Pediatric Nephrology, Indiana University, Indianapolis, Indiana
| | - Laura H. Mariani
- Division of Nephrology, University of Michigan, Ann Arbor, Michigan
| | - Dana V. Rizk
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, Alabama
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31
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Gadola L, Cabrera MJ, Garau M, Coitiño R, Aunchayna MH, Noboa O, Alvarez MA, Balardini S, Desiderio G, Dibello N, Ferreiro A, Giró S, Luzardo L, Maino A, Orihuela L, Ottati MG, Urrestarazú A. Long-term follow-up of an IgA nephropathy cohort: outcomes and risk factors. Ren Fail 2023; 45:2152694. [PMID: 36688795 PMCID: PMC9873278 DOI: 10.1080/0886022x.2022.2152694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
AIM IgA nephropathy (IgAN), the most common glomerulopathy worldwide and in Uruguay, raised treatment controversies. The study aimed to analyze long-term IgAN outcomes and treatment. METHODS A retrospective analysis of a Uruguayan IgAN cohort, enrolled between 1985 and 2009 and followed up until 2020, was performed. The Ethics Committee approved the study. The inclusion criteria were (a) biopsy-proven IgAN; (b) age ≥12 years; and (c) available clinical, histologic, and treatment data. The patients were divided into two groups, with immunosuppressive (IS) or without (NoIS) treatment. Outcomes (end-stage kidney disease/kidney replacement therapy [ESKD/KRT] or all-cause death) were obtained from mandatory national registries. RESULTS The study population included 241 patients (64.7% men), median age 32 (19.5) years, baseline blood pressure <130/80 mmHg in 37%, and microhematuria in 67.5% of patients. Baseline proteinuria, glomerulosclerosis, and a higher crescent percentage were significantly more frequent in the IS group. Proteinuria improved in both groups. Renal survival at 20 years was 74.6% without difference between groups. In the overall population and in the NoIS group, bivariate Cox regression analysis showed that baseline proteinuria, endocapillary hypercellularity, tubule interstitial damage, and crescents were associated with a higher risk of ESKD/KRT or death, but in the IS group, proteinuria and endocapillary hypercellularity were not. In the multivariate Cox analysis, proteinuria in the NoIS group, crescents in the IS group and tubule interstitial damage in both groups were independent risk factors. CONCLUSION The IS group had more severe risk factors than the NoIS group but attained a similar outcome.
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Affiliation(s)
- Liliana Gadola
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay,Centro de Nefrología. Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay,CONTACT Liliana Gadola Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), 18 de Julio 2103/802, CP 11200, Montevideo, Uruguay
| | - María Jimena Cabrera
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay
| | - Mariela Garau
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay,Centro de Nefrología. Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Ruben Coitiño
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay
| | - María Haydée Aunchayna
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay,Centro de Nefrología. Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Oscar Noboa
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay,Centro de Nefrología. Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | | | - Sylvia Balardini
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay
| | - Graciela Desiderio
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay
| | - Nelson Dibello
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay
| | - Alejandro Ferreiro
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay,Centro de Nefrología. Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Soledad Giró
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay
| | - Leonella Luzardo
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay,Centro de Nefrología. Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Alfredo Maino
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay
| | - Lucía Orihuela
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay
| | - María Gabriela Ottati
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay,Centro de Nefrología. Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Andrés Urrestarazú
- Programa de Prevención y Tratamiento de las Glomerulopatías (PPTG), Montevideo, Uruguay
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Cattran DC, Floege J, Coppo R. Evaluating Progression Risk in Patients With Immunoglobulin A Nephropathy. Kidney Int Rep 2023; 8:2515-2528. [PMID: 38106572 PMCID: PMC10719597 DOI: 10.1016/j.ekir.2023.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 12/19/2023] Open
Abstract
The highly variable rate of decline in kidney function in patients with immunoglobulin A nephropathy (IgAN) provides a major clinical challenge. Predicting which patients will progress to kidney failure, and how quickly, is difficult. Multiple novel therapies are likely to be approved in the short-term, but clinicians lack the tools to identify patients most likely to benefit from specific treatments at the right time. Noninvasive and validated markers for selecting at-risk patients and longitudinal monitoring are urgently needed. This review summarizes what is known about demographic, clinical, and histopathologic prognostic markers in the clinician's toolkit, including the International IgAN Prediction Tool. We also briefly review what is known on these topics in children and adolescents with IgAN. Although helpful, currently used markers leave clinicians heavily reliant on histologic features from the diagnostic kidney biopsy and standard clinical data to guide treatment choice, and very few noninvasive markers reflect treatment efficacy over time. Novel prognostic and predictive markers are under clinical investigation, with considerable progress being made in markers of complement activation. Other areas of research are the interplay between gut microbiota and galactose-deficient IgA1 expression; microRNAs; imaging; artificial intelligence; and markers of fibrosis. Given the rate of therapeutic advancement, the remaining gaps in biomarker research need to be addressed. We finish by describing our route to clinical utility of predictive and prognostic markers in IgAN. This route will provide us with the chance to improve IgAN prognosis by using robust, clinically practical markers to inform patient care.
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Affiliation(s)
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University, Aachen, Germany
| | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
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33
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Obrișcă B, Vornicu A, Mocanu V, Dimofte G, Andronesi A, Bobeică R, Jurubiță R, Sorohan B, Caceaune N, Ismail G. An open-label study evaluating the safety and efficacy of budesonide in patients with IgA nephropathy at high risk of progression. Sci Rep 2023; 13:20119. [PMID: 37978255 PMCID: PMC10656480 DOI: 10.1038/s41598-023-47393-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023] Open
Abstract
We sought to evaluate the efficacy and safety of budesonide (Budenofalk) in the treatment of patients with IgA Nephropathy. We conducted a prospective, interventional, open-label, single-arm, non-randomized study that enrolled 32 patients with IgAN at high risk of progression (BUDIGAN study, ISRCTN47722295, date of registration 14/02/2020). Patients were treated with Budesonide at a dose of 9 mg/day for 12 months, subsequently tapered to 3 mg/day for another 12 months. The primary endpoints were change of eGFR and proteinuria at 12, 24 and 36 months. The study cohort had a mean eGFR and 24-h proteinuria of 59 ± 24 ml/min/1.73m2 and 1.89 ± 1.5 g/day, respectively. Treatment with budesonide determined a reduction in proteinuria at 12-, 24- and 36-months by -32.9% (95% CI - 53.6 to - 12.2), - 49.7% (95% CI - 70.1 to - 29.4) and - 68.1% (95% CI - 80.6 to - 55.7). Budesonide determined an eGFR preservation corresponding to a 12-, 24- and 36-months change of + 7.68% (95% CI - 4.7 to 20.1), + 7.42% (95% CI - 7.23 to 22.1) and + 4.74% (95%CI - 13.5 to 23), respectively. The overall eGFR change/year was + 0.83 ml/min/y (95% CI - 0.54 to 4.46). Budesonide was well-tolerated, and treatment emergent adverse events were mostly mild in severity and reversible. Budesonide was effective in the treatment of patients with IgAN at high-risk of progression in terms of reducing proteinuria and preserving renal function over 36 months of therapy.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania.
| | - Alexandra Vornicu
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Valentin Mocanu
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - George Dimofte
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Andreea Andronesi
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Raluca Bobeică
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Roxana Jurubiță
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Bogdan Sorohan
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
| | - Nicu Caceaune
- Department of Internal Medicine, Fundeni Clinical Institute, Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- Department of Nephrology, Fundeni Clinical Institute, Bucharest, Romania
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Terinte-Balcan G, Stefan G. A closer look: ultrastructural evaluation of high-risk progression IgA nephropathy. Ultrastruct Pathol 2023; 47:461-469. [PMID: 37700534 DOI: 10.1080/01913123.2023.2256836] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/05/2023] [Indexed: 09/14/2023]
Abstract
This retrospective, cross-sectional study sought to examine the ultrastructural characteristics of glomerular lesions using Transmission Electron Microscopy (TEM) in IgA nephropathy (IgAN) and their relationship with the high risk of progression phenotype defined by KDIGO guideline as proteinuria ≥1 g/24 hours despite 3 months of optimized supportive care. We analyzed 81 IgAN patients (median age 41 years, 67% male, eGFR 43.8 mL/min, proteinuria 1.04 g/day); 42 (52%) of them had high risk of progression. There were no differences in terms of age, sex, comorbidities, eGFR, and hematuria between the two groups. High-risk patients more often had segmental glomerulosclerosis (29% vs 8%, p 0.01) in optical microscopy, while in TEM had more frequent podocyte hypertrophy (62% vs 26%, p 0.001) and podocyte foot process detachment from the glomerular basement membrane (19% vs 8%, p 0.05), more often thicker (19% vs 5%, p 0.05) and duplicated (26% vs 10%, p 0.05) glomerular basement membrane, and the presence of subendothelial and subepithelial deposits (31% vs 13%, p 0.05). However, in multivariate binary logistic regression analysis, only podocyte hypertrophy (OR 3.14; 95%CI 1.12, 8.79) was an independent risk factor for high-risk progression in IgAN. These findings highlight the importance of podocytopathy in IgAN progression.
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Affiliation(s)
- George Terinte-Balcan
- Department of Nephrology, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Ultrastructural Pathology Laboratory, "Victor Babes" National Institute of Pathology, Bucharest, Romania
| | - Gabriel Stefan
- Department of Nephrology, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
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35
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Kohan DE, Barratt J, Heerspink HJ, Campbell KN, Camargo M, Ogbaa I, Haile-Meskale R, Rizk DV, King A. Targeting the Endothelin A Receptor in IgA Nephropathy. Kidney Int Rep 2023; 8:2198-2210. [PMID: 38025243 PMCID: PMC10658204 DOI: 10.1016/j.ekir.2023.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/09/2023] [Accepted: 07/24/2023] [Indexed: 12/01/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide and carries a substantial risk of kidney failure. New agency-approved therapies, either specifically for IgAN or for chronic kidney disease (CKD) in general, hold out hope for mitigating renal deterioration in patients with IgAN. The latest addition to this therapeutic armamentarium targets the endothelin-A receptor (ETAR). Activation of ETAR on multiple renal cell types elicits a host of pathophysiological effects, including vasoconstriction, cell proliferation, inflammation, apoptosis, and fibrosis. Blockade of ETAR is renoprotective in experimental models of IgAN and reduces proteinuria in patients with IgAN. This review discusses the evidence supporting the use of ETAR blockade in IgAN as well as addressing the potential role for this class of agents among the current and emerging therapies for treating this disorder.
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Affiliation(s)
- Donald E. Kohan
- Division of Nephrology, University of Utah Health, Salt Lake City, Utah, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Kirk N. Campbell
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Ike Ogbaa
- Chinook Therapeutics, Seattle, Washington, USA
| | | | - Dana V. Rizk
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew King
- Chinook Therapeutics, Seattle, Washington, USA
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36
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Rajasekaran A, Green TJ, Renfrow MB, Julian BA, Novak J, Rizk DV. Current Understanding of Complement Proteins as Therapeutic Targets for the Treatment of Immunoglobulin A Nephropathy. Drugs 2023; 83:1475-1499. [PMID: 37747686 PMCID: PMC10807511 DOI: 10.1007/s40265-023-01940-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide and a frequent cause of kidney failure. Currently, the diagnosis necessitates a kidney biopsy, with routine immunofluorescence microscopy revealing IgA as the dominant or co-dominant immunoglobulin in the glomerular immuno-deposits, often with IgG and sometimes IgM or both. Complement protein C3 is observed in most cases. IgAN leads to kidney failure in 20-40% of patients within 20 years of diagnosis and reduces average life expectancy by about 10 years. There is increasing clinical, biochemical, and genetic evidence that the complement system plays a paramount role in the pathogenesis of IgAN. The presence of C3 in the kidney immuno-deposits differentiates the diagnosis of IgAN from subclinical glomerular mesangial IgA deposition. Markers of complement activation via the lectin and alternative pathways in kidney-biopsy specimens are associated with disease activity and are predictive of poor outcome. Levels of select complement proteins in the circulation have also been assessed in patients with IgAN and found to be of prognostic value. Ongoing genetic studies have identified at least 30 loci associated with IgAN. Genes within some of these loci encode complement-system regulating proteins that can interact with immune complexes. The growing appreciation for the central role of complement components in IgAN pathogenesis highlighted these pathways as potential treatment targets and sparked great interest in pharmacological agents targeting the complement cascade for the treatment of IgAN, as evidenced by the plethora of ongoing clinical trials.
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Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Todd J Green
- Department of Microbiology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew B Renfrow
- Department of Biochemistry and Molecular Genetics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bruce A Julian
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jan Novak
- Department of Microbiology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dana V Rizk
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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Gleeson PJ, O'Shaughnessy MM, Barratt J. IgA nephropathy in adults-treatment standard. Nephrol Dial Transplant 2023; 38:2464-2473. [PMID: 37418237 DOI: 10.1093/ndt/gfad146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Indexed: 07/08/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary form of glomerular disease worldwide and carries a high lifetime risk of kidney failure. The underlying pathogenesis of IgAN has been characterized to a sub-molecular level; immune complexes containing specific O-glycoforms of IgA1 are central. Kidney biopsy remains the gold-standard diagnostic test for IgAN and histological features (i.e. MEST-C score) have also been shown to independently predict outcome. Proteinuria and blood pressure are the main modifiable risk factors for disease progression. No IgAN-specific biomarker has yet been validated for diagnosis, prognosis or tracking response to therapy. There has been a recent resurgence of investigation into IgAN treatments. Optimized supportive care with lifestyle interventions and non-immunomodulatory drugs remains the backbone of IgAN management. The menu of available reno-protective medications is rapidly expanding beyond blockade of the renin-angiotensin-aldosterone system to include sodium-glucose cotransporter 2 and endothelin type A receptor antagonism. Systemic immunosuppression can further improve kidney outcomes, although recent randomized controlled trials have raised concerns regarding infectious and metabolic toxicity from systemic corticosteroids. Studies evaluating more refined approaches to immunomodulation in IgAN are ongoing: drugs targeting the mucosal immune compartment, B-cell promoting cytokines and the complement cascade are particularly promising. We review the current standards of treatment and discuss novel developments in pathophysiology, diagnosis, outcome prediction and management of IgAN.
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Affiliation(s)
- Patrick J Gleeson
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
- Department of Medicine, School of Microbiology, APC Microbiome Ireland, University College Cork, Cork, Ireland
| | | | - Jonathan Barratt
- The Mayer IgA Nephropathy Laboratories, University of Leicester, Leicester, UK
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Trachtman H, Diva U, Murphy E, Wang K, Inrig J, Komers R. Implications of Complete Proteinuria Remission at any Time in Focal Segmental Glomerulosclerosis: Sparsentan DUET Trial. Kidney Int Rep 2023; 8:2017-2028. [PMID: 37850006 PMCID: PMC10577371 DOI: 10.1016/j.ekir.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/12/2023] [Accepted: 07/24/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction Focal segmental glomerulosclerosis (FSGS) is a rare glomerular disease with high unmet clinical need. Interest in proteinuria as a surrogate end point for regulatory approval of novel treatments has increased. We assessed the relationship between achieving complete remission (CR) of proteinuria at least once during follow-up and long-term kidney outcomes. Methods This post hoc analysis included all patients enrolled in the DUET trial of sparsentan in FSGS and the open-label extension (OLE). Evaluations occurred every 12 weeks, including blood pressure (BP), edema, proteinuria, and kidney function. CR was defined as a urine protein/creatinine ratio ≤0.3g/g in a first morning urine sample. Results A total of 108 patients who received ≥1 sparsentan dose were included in this study. During a median follow-up of 47.0 months, 46 patients (43%) experienced ≥1 CR, 61% occurring within 12 months of starting sparsentan. There was an increased likelihood of CR with a higher sparsentan dose or baseline subnephrotic-range proteinuria. Achieving ≥1 CR was associated with significantly slower rate of estimated glomerular filtration rate (eGFR) decline versus non-CR patients (P < 0.05). Use of immunosuppressive agents was more frequent in patients who achieved a CR. However, the antiproteinuric effect of sparsentan was additive to that achieved with concomitant immunosuppressive treatment. No unanticipated adverse events occurred. Conclusion We conclude that sparsentan can be safely administered for extended periods and exerts a sustained antiproteinuric effect. Achievement of CR at any time during follow-up, even if it is not sustained, may be an indicator of a favorable response to treatment and a predictor of improved kidney function outcomes.
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Affiliation(s)
- Howard Trachtman
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Ulysses Diva
- Biometrics, Travere Therapeutics, Inc., San Diego, California, USA
| | - Edward Murphy
- Biometrics, Travere Therapeutics, Inc., San Diego, California, USA
| | - Kaijun Wang
- Biometrics, Travere Therapeutics, Inc., San Diego, California, USA
| | - Jula Inrig
- Nephrology, Travere Therapeutics, Inc., San Diego, California, USA
| | - Radko Komers
- Nephrology, Travere Therapeutics, Inc., San Diego, California, USA
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Caster DJ, Abner CW, Walker PD, Wang K, Heo J, Rava AR, Bunke M. Clinicopathological Characteristics of Adult IgA Nephropathy in the United States. Kidney Int Rep 2023; 8:1792-1800. [PMID: 37705898 PMCID: PMC10496075 DOI: 10.1016/j.ekir.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 09/15/2023] Open
Abstract
Introduction IgA nephropathy (IgAN) is a progressive autoimmune kidney disease and a leading cause of glomerular disease that can result in kidney failure (KF). The median age at diagnosis is 35 to 37 years and approximately 50% of patients will progress to KF within 20 years. We aimed to enhance the understanding of renal histology and chronic kidney disease (CKD) stage at the time of IgAN diagnosis using a large real-world biopsy cohort. Methods This retrospective cohort study evaluated biopsy data and clinical characteristics from adult patients within the US who were diagnosed with IgAN between January 1, 2016 to May 31, 2020. Descriptive statistics were summarized and relationship(s) between each Oxford Classification (MEST-C) component score with 24-hour proteinuria or CKD stage were examined using regression analysis. Results A total of 4375 patients (mean age 47.7 years, 62.7% male) met eligibility criteria. Mild to moderate mesangial hypercellularity (47.3%), segmental sclerosis (65.0%), tubular atrophy ≥25% (57.4%), and crescents (18.5%) were identified; and 74.6% of patients were at CKD stage ≥3. Proteinuria ≥1 g/d was associated with higher MEST-C scores, and the odds of mesangial hypercellularity, segmental sclerosis, tubular atrophy, and crescents increased with CKD stage. Conclusion Most patients with IgAN in our US cohort were diagnosed at CKD stage ≥3 and had high MEST-C scores and proteinuria that are suggestive of significant disease burden at the time of kidney biopsy. Strategies are required to raise awareness and promote earlier detection of asymptomatic urinary abnormalities before extensive irreversible kidney damage has occurred.
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Affiliation(s)
| | | | | | - Kaijun Wang
- Travere Therapeutics, Inc., San Diego, California, USA
| | | | | | - Martin Bunke
- Travere Therapeutics, Inc., San Diego, California, USA
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Yau K, Wang C, Al Batran R, Macphee A, Beaucage M, Farragher JF. Knowledge Translation in Glomerulonephritis: Successes in Translational Research From the Bench to Bedside. Can J Kidney Health Dis 2023; 10:20543581231191839. [PMID: 37637870 PMCID: PMC10457520 DOI: 10.1177/20543581231191839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/28/2023] [Indexed: 08/29/2023] Open
Abstract
Purpose of review Glomerulonephritis refers to a rare group of diseases characterized by glomerular inflammation, which collectively are a common cause of kidney failure. Until recently, there was a lack of high-quality clinical trials to inform the care of patients with glomerulonephritides. We identified examples of successful translational research spanning from basic science to clinical applications, and highlight gaps in implementation science. Sources of information The focus of our review was derived from discussions between health care professionals, researchers, and patient partners. We also performed literature searches pertaining to the treatment of glomerulonephritis in PubMed and Google Scholar. Methods Examples of successful knowledge translation were generated through review of new evidence in the past 5 years and by iterative discussions by the authors. We then conducted a narrative review of several themes related to knowledge translation in glomerulonephritis. This was complemented by an interview with a patient partner to provide an example of a patient's perspective living with glomerulonephritis. Key findings We summarized selected recent advances in glomerulonephritis and its knowledge translation in the following domains: (1) identification of auto-antibodies in membranous nephropathy and minimal change disease; (2) clinical trials of novel targeted therapies for IgA nephropathy and lupus nephritis, which have led to approval of new treatments; (3) developments in research networks and clinical trials in glomerulonephritis; (4) recognition of the importance in developing standardized patient reported outcome measures in clinical trials; and (5) barriers in knowledge translation including access to medication. Limitations A systematic search of the literature and formal assessment of quality of evidence were beyond the scope of this review.
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Affiliation(s)
- Kevin Yau
- Division of Nephrology, University of Toronto, Toronto, ON, Canada
| | - Carol Wang
- Division of Nephrology, Western University, London, ON, Canada
| | - Rami Al Batran
- Faculte de Pharmacie, Universite de Montreal, Montreal, QC, Canada
| | - Anne Macphee
- Kidney Research Scientist Core Education and National Training Patient Community Advisory Network, Montreal, QC, Canada
| | - Mary Beaucage
- Kidney Research Scientist Core Education and National Training Patient Community Advisory Network, Montreal, QC, Canada
- Patient Governance Council, Indigenous Peoples’ Engagement and Research Council, Can-SOLVE CKD, Vancouver, BC, Canada
- The Canadian Donation and Transplantation Research Program, Edmonton, AB, Canada
- Provincial Patient and Family Advisory Council, Ontario Renal Network, Toronto, Ontario, Canada
| | - Janine F. Farragher
- Department of Occupational Science & Occupational Therapy, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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Tan Q, Xue H, Ni X, Fan L, Du W. Comparative effectiveness and safety for the treatments despite optimized renin-angiotensin system blockade among IgA nephropathy patients at high-risk of disease progression: A network meta-analysis of randomized controlled trials. Eur J Intern Med 2023; 114:66-73. [PMID: 37179138 DOI: 10.1016/j.ejim.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/08/2023] [Accepted: 04/13/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Approximately 20-40% of IgA nephropathy patients would develop end-stage renal disease, for whom safety concerns remained a major setback when using conventional pharmaceutical treatments. Evidence is lacking for optimal selection of effective and safe pharmaceuticals to slow the disease progression. To compare the effectiveness and safety profile of different treatments despite optimized RAS blockade for IgA nephropathy patients at high-risk of disease progression. STUDY DESIGN PubMed, ScienceDirect and Web of science databases published from 1990 to March 18th, 2023 without language restriction. Immunosuppressant and cortico-steroid treatments were considered as two independent regimens. RESULTS Fifteen trials with 1,983 participants were evaluated for the occurrence of five outcomes. For ESRD, dapagliflozin was superior to placebo (RR: 0.30; 95% CI 0.11, 0.80), immunosuppressant (RR:0.14; 95% CI 0.02,0.81) and RAS (RR:0.10; 95% CI 0.01,0.69). Glucocorticoid was superior to placebo (RR: 0.71; 95%CI 0.52,0.99). For clinical remission, immunosuppressant was superior to placebo (RR: 2.71; 95%CI 1.16, 6.31) and RAS monotherapy (RR: 2.87; 95%CI 1.60, 5.17). For 50% reduction in 24 h proteinuria or UPCR, immunosuppressant was superior to placebo (RR: 2.71; 95%CI 1.16, 6.31) and RAS monotherapy (RR: 2.40; 95%CI 1.04, 5.55). For SAE, dapagliflozin was superior to glucocorticoid (RR: 0.22; 95%CI 0.09, 0.54), whereas glucocorticoid was inferior to placebo (RR: 2.91; 95%CI 1.39, 6.07). Cluster ranking showed dapagliflozin appeared to have the lowest SAE risk and the best comparative therapeutic efficacy in preventing ESRD. CONCLUSIONS The current findings highlighted dapagliflozin was a promising pharmaceutical treatment alternative to achieve optimal outcomes for IgA nephropathy patients at high risk of disease progression. REGISTRATION PROSPERO CRD42022374418.
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Affiliation(s)
- Qiong Tan
- School of Public Health, Southeast University, China.
| | - Hui Xue
- School of Public Health, Southeast University, China
| | - Xiaoyan Ni
- School of Public Health, Southeast University, China
| | - Lijun Fan
- School of Public Health, Southeast University, China
| | - Wei Du
- School of Public Health, Southeast University, China.
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Friedli I, Baid-Agrawal S, Unwin R, Morell A, Johansson L, Hockings PD. Magnetic Resonance Imaging in Clinical Trials of Diabetic Kidney Disease. J Clin Med 2023; 12:4625. [PMID: 37510740 PMCID: PMC10380287 DOI: 10.3390/jcm12144625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Chronic kidney disease (CKD) associated with diabetes mellitus (DM) (known as diabetic kidney disease, DKD) is a serious and growing healthcare problem worldwide. In DM patients, DKD is generally diagnosed based on the presence of albuminuria and a reduced glomerular filtration rate. Diagnosis rarely includes an invasive kidney biopsy, although DKD has some characteristic histological features, and kidney fibrosis and nephron loss cause disease progression that eventually ends in kidney failure. Alternative sensitive and reliable non-invasive biomarkers are needed for DKD (and CKD in general) to improve timely diagnosis and aid disease monitoring without the need for a kidney biopsy. Such biomarkers may also serve as endpoints in clinical trials of new treatments. Non-invasive magnetic resonance imaging (MRI), particularly multiparametric MRI, may achieve these goals. In this article, we review emerging data on MRI techniques and their scientific, clinical, and economic value in DKD/CKD for diagnosis, assessment of disease pathogenesis and progression, and as potential biomarkers for clinical trial use that may also increase our understanding of the efficacy and mode(s) of action of potential DKD therapeutic interventions. We also consider how multi-site MRI studies are conducted and the challenges that should be addressed to increase wider application of MRI in DKD.
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Affiliation(s)
- Iris Friedli
- Antaros Medical, BioVenture Hub, 43183 Mölndal, Sweden
| | - Seema Baid-Agrawal
- Transplant Center, Sahlgrenska University Hospital, University of Gothenburg, 41345 Gothenburg, Sweden
| | - Robert Unwin
- AstraZeneca R&D BioPharmaceuticals, Translational Science and Experimental Medicine, Early Cardiovascular, Renal & Metabolic Diseases (CVRM), Granta Park, Cambridge CB21 6GH, UK
| | - Arvid Morell
- Antaros Medical, BioVenture Hub, 43183 Mölndal, Sweden
| | | | - Paul D Hockings
- Antaros Medical, BioVenture Hub, 43183 Mölndal, Sweden
- MedTech West, Chalmers University of Technology, 41345 Gothenburg, Sweden
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Adam G, Adam AM, Robu S, Harabor V, Harabor A, Nechita A, Marin DB, Morariu ID, Cioanca O, Vasilache IA, Hancianu M. The Effects of Perilla frutescens Extracts on IgA Nephropathy: A Systematic Review and Meta-Analysis. Pharmaceuticals (Basel) 2023; 16:988. [PMID: 37513901 PMCID: PMC10385934 DOI: 10.3390/ph16070988] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Chronic renal disorders (CRD) are associated with significant comorbidities and necessitate complex therapeutic management. As time passed, Perilla frutescens (PF) became a promising therapeutic option for CRD. The aim of this systematic review and meta-analysis was to outline the therapeutic effects of PF extracts on various models of immunoglobulin a (IgA) nephropathy; (2) Methods: Medline, Embase, and Cochrane databases were used to find relevant studies. All prospective interventional studies that evaluated the effect of PF extract versus placebo on rat models of chronic renal disorders were assessed according to the international guidelines; (3) Results: Our search yielded 23 unique records, out of which only five were included in the analysis. Our results showed that administration of PF extracts led to a statistically significant reduction in proteinuria and PCNA levels in rats that received high doses of the extract as well as in the PCNA level and DNA synthesis in rats that received low doses of the extract. The evaluated outcomes benefited from a low degree of heterogeneity; (4) Conclusions: Some of the evaluated outcomes were significantly reduced by both high and low doses of extracts from Perilla frutescens. Further studies are needed to determine the exact effect over IgA nephropathy in human subjects.
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Affiliation(s)
- Gigi Adam
- Faculty of Pharmacy, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Department of Pharmaceutical Sciences, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800216 Galati, Romania
| | - Ana-Maria Adam
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800216 Galati, Romania
| | - Silvia Robu
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800216 Galati, Romania
| | - Valeriu Harabor
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800216 Galati, Romania
| | - Anamaria Harabor
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800216 Galati, Romania
| | - Aurel Nechita
- Clinical and Surgical Department, Faculty of Medicine and Pharmacy, 'Dunarea de Jos' University, 800216 Galati, Romania
| | - Denisa Batir Marin
- Faculty of Pharmacy, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ionela-Daniela Morariu
- Faculty of Pharmacy, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Oana Cioanca
- Faculty of Pharmacy, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Ingrid-Andrada Vasilache
- Department of Obstetrics and Gynecology, 'Grigore T. Popa' University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Monica Hancianu
- Faculty of Pharmacy, "Grigore T. Popa" University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
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Gentile M, Sanchez-Russo L, Riella LV, Verlato A, Manrique J, Granata S, Fiaccadori E, Pesce F, Zaza G, Cravedi P. Immune abnormalities in IgA nephropathy. Clin Kidney J 2023; 16:1059-1070. [PMID: 37398689 PMCID: PMC10310525 DOI: 10.1093/ckj/sfad025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Indexed: 09/10/2023] Open
Abstract
Immunoglobulin A (IgA) nephropathy (IgAN) is the most common primary glomerulonephritis worldwide and it is characterized by mesangial IgA deposition. Asymptomatic hematuria with various degrees of proteinuria is the most common clinical presentation and up to 20%-40% of patients develop end-stage kidney disease within 20 years after disease onset. The pathogenesis of IgAN involves four sequential processes known as the "four-hit hypothesis" which starts with the production of a galactose-deficient IgA1 (gd-IgA1), followed by the formation of anti-gd-IgA1 IgG or IgA1 autoantibodies and immune complexes that ultimately deposit in the glomerular mesangium, leading to inflammation and injury. Although several key questions about the production of gd-IgA1 and the formation of anti-gd-IgA1 antibodies remain unanswered, a growing body of evidence is shedding light on the innate and adaptive immune mechanisms involved in this complex pathogenic process. Herein, we will focus on these mechanisms that, along with genetic and environmental factors, are thought to play a key role in disease pathogenesis.
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Affiliation(s)
- Micaela Gentile
- Translational Transplant Research Center and Department of Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
- UO Nefrologia, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Luis Sanchez-Russo
- Translational Transplant Research Center and Department of Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Leonardo V Riella
- Division of Nephrology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alberto Verlato
- Translational Transplant Research Center and Department of Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
| | - Joaquin Manrique
- Nephrology Service, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Simona Granata
- Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy
| | - Francesco Pesce
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari “A. Moro”, Bari, Italy
| | - Gianluigi Zaza
- Nephrology, Dialysis and Transplantation Unit, University of Foggia, Foggia, Italy
| | - Paolo Cravedi
- Translational Transplant Research Center and Department of Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
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Yu X, Li J, Tao C, Jiao J, Wan J, Zhong C, Yang Q, Shi Y, Zhang G, Yang H, Li Q, Wang M. Validation of the children international IgA nephropathy prediction tool based on data in Southwest China. Front Pediatr 2023; 11:1183562. [PMID: 37425278 PMCID: PMC10327563 DOI: 10.3389/fped.2023.1183562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023] Open
Abstract
Background Immunoglobulin A nephropathy (IgAN) is one of the most common kidney diseases leading to renal injury. Of pediatric cases, 25%-30% progress into end-stage kidney disease (ESKD) in 20-25 years. Therefore, predicting and intervening in IgAN at an early stage is crucial. The purpose of this study was to validate the availability of an international predictive tool for childhood IgAN in a cohort of children with IgAN treated at a regional medical centre. Methods An external validation cohort of children with IgAN from medical centers in Southwest China was formed to validate the predictive performance of the two full models with and without race differences by comparing four measures: area under the curve (AUC), the regression coefficient of linear prediction (PI), survival analysis curves for different risk groups, and R2D. Results A total of 210 Chinese children, including 129 males, with an overall mean age of 9.43 ± 2.71 years, were incorporated from this regional medical center. In total, 11.43% (24/210) of patients achieved an outcome with a GFR decrease of more than 30% or reached ESKD. The AUC of the full model with race was 0.685 (95% CI: 0.570-0.800) and the AUC of the full model without race was 0.640 (95% CI: 0.517-0.764). The PI of the full model with race and without race was 0.816 (SE = 0.006, P < 0.001) and 0.751 (SE = 0.005, P < 0.001), respectively. The results of the survival curve analysis suggested the two models could not well distinguish between the low-risk and high-risk groups (P = 0.359 and P = 0.452), respectively, no matter the race difference. The evaluation of model fit for the full model with race was 66.5% and without race was 56.2%. Conclusions The international IgAN prediction tool has risk factors chosen based on adult data, and the validation cohort did not fully align with the derivation cohort in terms of demographic characteristics, clinical baseline levels, and pathological presentation, so the tool may not be highly applicable to children. We need to build IgAN prediction models that are more applicable to Chinese children based on their particular data.
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Affiliation(s)
- Xixi Yu
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Jiacheng Li
- Department of Hematology and Oncology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chengrong Tao
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Jia Jiao
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Junli Wan
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Cheng Zhong
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Qin Yang
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Yongqi Shi
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Gaofu Zhang
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Haiping Yang
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Qiu Li
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Mo Wang
- Department of Nephrology, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders,Children’s Hospital of Chongqing Medical University, Chongqing, China
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Ma S, Zhao M, Chang M, Shi X, Shi Y, Zhang Y. Effects and mechanisms of Chinese herbal medicine on IgA nephropathy. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2023; 117:154913. [PMID: 37307737 DOI: 10.1016/j.phymed.2023.154913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/16/2023] [Accepted: 06/02/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Immunoglobulin A nephropathy (IgAN), is the main cause of end-stage renal disease, that causes serious physical and psychological burden to patients worldwide. Some traditional treatment measures, such as blocking the renin-angiotensin-aldosterone system, controlling blood pressure, and following a low-protein diet, may not achieve satisfactory results. Therefore, more effective and safe therapies for IgAN are urgently needed. PURPOSE The aim of this review is to summarize the clinical efficacy of Chinese herbal medicines (CHMs) and their active ingredients in the treatment and management of IgAN based on the results of clinical trials, systematic reviews, and meta-analyses, to fully understand the advantages and perspectives of CHMs in the treatment of IgAN. STUDY DESIGN AND METHODS For this review, the following electronic databases were consulted: PubMed, ResearchGate, Science Direct, Web of Science, Chinese National Knowledge Infrastructure and Wanfang Data, "IgA nephropathy," "traditional Chinese medicine," "Chinese herbal medicine," "herb," "mechanism," "Meta-analysis," "systematic review," "RCT" and their combinations were the keywords to search the relevant literature. Data were collected from 1990 to 2022. RESULTS This review found that the active ingredients of CHMs commonly act on multiple signaling pathways in the clinical treatment of IgAN, mainly with antioxidant, anti-inflammatory and anti-fibrosis effects, and regulation of autophagy. CONCLUSION Compared with the single-target therapy of modern medicine, CHMs can regulate the corresponding pathways from the aspects of anti-inflammation, anti-oxidation, anti-fibrosis and autophagy to play a multi-target treatment of IgAN through syndrome differentiation and treatment, which has good clinical efficacy and can be used as the first choice or alternative therapy for IgAN treatment. This review provides evidence and research direction for a comprehensive clinical understanding of the protective effect of Chinese herbal medicine on IgAN.
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Affiliation(s)
- Sijia Ma
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Mingming Zhao
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Meiying Chang
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Xiujie Shi
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Yue Shi
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China
| | - Yu Zhang
- Department of Nephrology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China.
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Pitcher D, Braddon F, Hendry B, Mercer A, Osmaston K, Saleem MA, Steenkamp R, Wong K, Turner AN, Wang K, Gale DP, Barratt J. Long-Term Outcomes in IgA Nephropathy. Clin J Am Soc Nephrol 2023; 18:727-738. [PMID: 37055195 PMCID: PMC10278810 DOI: 10.2215/cjn.0000000000000135] [Citation(s) in RCA: 53] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/06/2023] [Accepted: 03/27/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND IgA nephropathy can progress to kidney failure, and risk assessment soon after diagnosis has advantages both for clinical management and the development of new therapeutics. We present relationships among proteinuria, eGFR slope, and lifetime risks for kidney failure. METHODS The IgA nephropathy cohort (2299 adults and 140 children) of the UK National Registry of Rare Kidney Diseases (RaDaR) was analyzed. Patients enrolled had a biopsy-proven diagnosis of IgA nephropathy plus proteinuria >0.5 g/d or eGFR <60 ml/min per 1.73 m 2 . Incident and prevalent populations and a population representative of a typical phase 3 clinical trial cohort were studied. Analyses of kidney survival were conducted using Kaplan-Meier and Cox regression. eGFR slope was estimated using linear mixed models with random intercept and slope. RESULTS The median (Q1, Q3) follow-up was 5.9 (3.0, 10.5) years; 50% of patients reached kidney failure or died in the study period. The median (95% confidence interval [CI]) kidney survival was 11.4 (10.5 to 12.5) years; the mean age at kidney failure/death was 48 years, and most patients progressed to kidney failure within 10-15 years. On the basis of eGFR and age at diagnosis, almost all patients were at risk of progression to kidney failure within their expected lifetime unless a rate of eGFR loss ≤1 ml/min per 1.73 m 2 per year was maintained. Time-averaged proteinuria was significantly associated with worse kidney survival and more rapid eGFR loss in incident, prevalent, and clinical trial populations. Thirty percent of patients with time-averaged proteinuria of 0.44 to <0.88 g/g and approximately 20% of patients with time-averaged proteinuria <0.44 g/g developed kidney failure within 10 years. In the clinical trial population, each 10% decrease in time-averaged proteinuria from baseline was associated with a hazard ratio (95% CI) for kidney failure/death of 0.89 (0.87 to 0.92). CONCLUSIONS Outcomes in this large IgA nephropathy cohort are generally poor with few patients expected to avoid kidney failure in their lifetime. Significantly, patients traditionally regarded as being low risk, with proteinuria <0.88 g/g (<100 mg/mmol), had high rates of kidney failure within 10 years.
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Affiliation(s)
- David Pitcher
- UK Renal Registry, The UK Kidney Association, Bristol, United Kingdom
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Fiona Braddon
- UK Renal Registry, The UK Kidney Association, Bristol, United Kingdom
| | - Bruce Hendry
- Travere Therapeutics, Inc., San Diego, California
| | | | - Kate Osmaston
- UK Renal Registry, The UK Kidney Association, Bristol, United Kingdom
| | - Moin A. Saleem
- University of Bristol & Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Retha Steenkamp
- UK Renal Registry, The UK Kidney Association, Bristol, United Kingdom
| | - Katie Wong
- UK Renal Registry, The UK Kidney Association, Bristol, United Kingdom
- Department of Renal Medicine, University College London, London, United Kingdom
| | | | - Kaijun Wang
- Travere Therapeutics, Inc., San Diego, California
| | - Daniel P. Gale
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Jonathan Barratt
- University of Leicester & Leicester General Hospital, Leicester, United Kingdom
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Ghaddar M, Barratt J, Barbour SJ. An update on corticosteroid treatment for IgA nephropathy. Curr Opin Nephrol Hypertens 2023; 32:263-270. [PMID: 36866805 DOI: 10.1097/mnh.0000000000000881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW The use of corticosteroids to treat IgA nephropathy (IgAN) has been limited by many controversies related to uncertain benefit and safety concerns. Recent trials have tried to address these limitations. RECENT FINDINGS After being paused because of an excess of adverse events in the full-dose steroid arm, the TESTING trial compared a reduced dose of methylprednisolone to placebo in patients with IgAN after optimization of supportive therapy. Steroid treatment was associated with a significant reduction in the risk of a 40% decline in estimated glomerular filtration rate (eGFR), kidney failure and kidney death as well as a sustained decrease in proteinuria compared with placebo. Serious adverse events were more frequent with the full dose regimen but less common in the reduced dose regimen. A phase III trial evaluating a new formulation of targeted-release budesonide showed a significant reduction in short-term proteinuria and has resulted in accelerated FDA approval for use in the United States. In a subgroup analysis of DAPA-CKD trial, sodium-glucose transport protein 2 inhibitors reduced the risk of kidney function decline in patients who have completed or are not eligible for immunosuppression. SUMMARY Both reduced-dose corticosteroids and targeted-release budesonide are new therapeutic options that can be used in patients with high-risk disease. More novel-targeted therapies with a better safety profile are currently under investigations.
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Affiliation(s)
- Malak Ghaddar
- Division of Nephrology, University of British Columbia
- BC Renal, Vancouver, British Columbia, Canada
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia
- BC Renal, Vancouver, British Columbia, Canada
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Rizk DV, Rovin BH, Zhang H, Kashihara N, Maes B, Trimarchi H, Perkovic V, Meier M, Kollins D, Papachristofi O, Charney A, Barratt J. Targeting the Alternative Complement Pathway With Iptacopan to Treat IgA Nephropathy: Design and Rationale of the APPLAUSE-IgAN Study. Kidney Int Rep 2023; 8:968-979. [PMID: 37180505 PMCID: PMC10166738 DOI: 10.1016/j.ekir.2023.01.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 01/06/2023] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Introduction Targeting the alternative complement pathway (AP) is an attractive therapeutic strategy because of its role in immunoglobulin A nephropathy (IgAN) pathophysiology. Iptacopan (LNP023), a proximal complement inhibitor that specifically binds to factor B and inhibits the AP, reduced proteinuria and attenuated AP activation in a Phase 2 study of patients with IgAN, thereby supporting the rationale for its evaluation in a Phase 3 study. Methods APPLAUSE-IgAN (NCT04578834) is a multicenter, randomized, double-blind, placebo-controlled, parallel-group, Phase 3 study enrolling approximately 450 adult patients (aged ≥18 years) with biopsy-confirmed primary IgAN at high risk of progression to kidney failure despite optimal supportive treatment. Eligible patients receiving stable and maximally tolerated doses of angiotensin-converting enzyme inhibitors (ACEis) or angiotensin receptor blockers (ARBs) will be randomized 1:1 to either iptacopan 200 mg or placebo twice daily for a 24-month treatment period. A prespecified interim analysis (IA) will be performed when approximately 250 patients from the main study population complete the 9-month visit. The primary objective is to demonstrate superiority of iptacopan over placebo in reducing 24-hour urine protein-to-creatinine ratio (UPCR) at the IA and demonstrate the superiority of iptacopan over placebo in slowing the rate of estimated glomerular filtration rate (eGFR) decline (total eGFR slope) estimated over 24 months at study completion. The effect of iptacopan on patient-reported outcomes, safety, and tolerability will be evaluated as secondary outcomes. Conclusions APPLAUSE-IgAN will evaluate the benefits and safety of iptacopan, a novel targeted therapy for IgAN, in reducing complement-mediated kidney damage and thus slowing or preventing disease progression.
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Affiliation(s)
- Dana V. Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brad H. Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Peking University Institute of Nephrology, Beijing, People’s Republic of China
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, Kurashiki, Japan
| | - Bart Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Hernán Trimarchi
- Nephrology Service and Kidney Transplantation Unit, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Vlado Perkovic
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | - Alan Charney
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester and The John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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Heerspink HJL, Radhakrishnan J, Alpers CE, Barratt J, Bieler S, Diva U, Inrig J, Komers R, Mercer A, Noronha IL, Rheault MN, Rote W, Rovin B, Trachtman H, Trimarchi H, Wong MG, Perkovic V. Sparsentan in patients with IgA nephropathy: a prespecified interim analysis from a randomised, double-blind, active-controlled clinical trial. Lancet 2023; 401:1584-1594. [PMID: 37015244 DOI: 10.1016/s0140-6736(23)00569-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Sparsentan is a novel, non-immunosuppressive, single-molecule, dual endothelin and angiotensin receptor antagonist being examined in an ongoing phase 3 trial in adults with IgA nephropathy. We report the prespecified interim analysis of the primary proteinuria efficacy endpoint, and safety. METHODS PROTECT is an international, randomised, double-blind, active-controlled study, being conducted in 134 clinical practice sites in 18 countries. The study examines sparsentan versus irbesartan in adults (aged ≥18 years) with biopsy-proven IgA nephropathy and proteinuria of 1·0 g/day or higher despite maximised renin-angiotensin system inhibitor treatment for at least 12 weeks. Participants were randomly assigned in a 1:1 ratio to receive sparsentan 400 mg once daily or irbesartan 300 mg once daily, stratified by estimated glomerular filtration rate at screening (30 to <60 mL/min per 1·73 m2 and ≥60 mL/min per 1·73 m2) and urine protein excretion at screening (≤1·75 g/day and >1·75 g/day). The primary efficacy endpoint was change from baseline to week 36 in urine protein-creatinine ratio based on a 24-h urine sample, assessed using mixed model repeated measures. Treatment-emergent adverse events (TEAEs) were safety endpoints. All endpoints were examined in all participants who received at least one dose of randomised treatment. The study is ongoing and is registered with ClinicalTrials.gov, NCT03762850. FINDINGS Between Dec 20, 2018, and May 26, 2021, 404 participants were randomly assigned to sparsentan (n=202) or irbesartan (n=202) and received treatment. At week 36, the geometric least squares mean percent change from baseline in urine protein-creatinine ratio was statistically significantly greater in the sparsentan group (-49·8%) than the irbesartan group (-15·1%), resulting in a between-group relative reduction of 41% (least squares mean ratio=0·59; 95% CI 0·51-0·69; p<0·0001). TEAEs with sparsentan were similar to irbesartan. There were no cases of severe oedema, heart failure, hepatotoxicity, or oedema-related discontinuations. Bodyweight changes from baseline were not different between the sparsentan and irbesartan groups. INTERPRETATION Once-daily treatment with sparsentan produced meaningful reduction in proteinuria compared with irbesartan in adults with IgA nephropathy. Safety of sparsentan was similar to irbesartan. Future analyses after completion of the 2-year double-blind period will show whether these beneficial effects translate into a long-term nephroprotective potential of sparsentan. FUNDING Travere Therapeutics.
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Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.
| | | | - Charles E Alpers
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester General Hospital, Leicester, UK
| | - Stewart Bieler
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands
| | | | - Jula Inrig
- Travere Therapeutics, San Diego, CA, USA
| | | | | | - Irene L Noronha
- Laboratory of Cellular, Genetic, and Molecular Nephrology, Division of Nephrology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Michelle N Rheault
- Division of Pediatric Nephrology, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Brad Rovin
- Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Howard Trachtman
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Hernán Trimarchi
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | - Muh Geot Wong
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia; Concord Clinical School, University of Sydney, Concord, NSW, Australia
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; Faculty of Medicine & Health, University of New South Wales Sydney, Sydney, NSW, Australia
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