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Yang H, Zhang W, Li Y, Li R. Neutrophil-to-lymphocyte ratio: An effective predictor of corticosteroid response in IgA nephropathy. Int Immunopharmacol 2019; 74:105678. [DOI: 10.1016/j.intimp.2019.105678] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 06/01/2019] [Accepted: 06/02/2019] [Indexed: 12/23/2022]
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Zhang Z, Yang Y, Jiang SM, Li WG. Efficacy and safety of immunosuppressive treatment in IgA nephropathy: a meta-analysis of randomized controlled trials. BMC Nephrol 2019; 20:333. [PMID: 31455248 PMCID: PMC6710882 DOI: 10.1186/s12882-019-1519-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023] Open
Abstract
Background Immunosuppressive agents have been widely used in the treatment of IgA nephropathy (IgAN), but the efficacy and safety remain controversial. The recent STOP-IgAN and TESTING studies have again focused attention on the application of immunosuppressive agents in IgAN. This study investigated the benefits and risks of immunosuppressive agents in IgAN. Methods MEDLINE, EMBASE, the Cochrane Library, and article reference lists were searched for randomized controlled trials (RCTs) comparing immunosuppressive agents with any other non-immunosuppressive agents for treating IgAN. A meta-analysis was performed on the outcomes of proteinuria, creatinine (Cr), estimated glomerular filtration rate (eGFR), and adverse events in patients with IgAN, and trial sequential analyses were also performed for outcomes. Results Twenty-nine RCTs (1957 patients) that met our inclusion criteria were identified. Steroids (weighted mean difference [WMD] –0.70, 95% confidence interval [CI] –1.2 to − 0.20), non-steroidal immunosuppressive agents (NSI) (WMD –0. 43, 95% CI − 0.55 to − 0.31), and combined steroidal and non-steroidal immunosuppressive agents (S&NSI) (WMD –1.46, 95% CI − 2.13 to − 0.79) therapy significantly reduced proteinuria levels compared with the the control group. Steroid treatment significantly reduced the risk of end-stage renal disease (ESRD) (relative risk [RR] 0.39, CI 0.19 to 0.79) compared with the control group. The immunosuppressive therapy group showed significant increases in gastrointestinal, hematological, dermatological, and genitourinary side effects, as well as impaired glucose tolerance or diabetes. Hyperkalemia was more common in the control group. Conclusion Immunosuppressive therapy can significantly reduce proteinuria and ESRD risk in patients with IgAN, but with a concomitant increase in adverse reactions. Therefore, care is required in the application of immunosuppressive agents in IgAN.
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Affiliation(s)
- Zheng Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Yue Yang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Shi-Min Jiang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China.,Graduate School of Peking Union Medical College, Beijing, China
| | - Wen-Ge Li
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China.
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Moriyama T. Clinical and histological features and therapeutic strategies for IgA nephropathy. Clin Exp Nephrol 2019; 23:1089-1099. [PMID: 30968243 DOI: 10.1007/s10157-019-01735-4] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/24/2019] [Indexed: 01/21/2023]
Abstract
Chronic glomerulonephritis is the second most common reason, after diabetic nephropathy, for initiation of dialysis in Japan and IgA nephropathy (IgAN) is the most prevalent form of chronic glomerulonephritis. In the half century since IgAN was initially reported, our understanding of the long-term prognosis, clinical and histological features, pathogenesis of onset and progression, risk factors for progression, and appropriate treatment under different clinical and histological conditions, has steadily increased. Strong experimental and clinical evidence, the Clinical Practice Guidelines for IgA Nephropathy in Japan, the Oxford Classification, and the Kidney Disease Improving Global Outcomes guidelines have all contributed to the appropriate treatment of IgAN. Several intensive therapies, such as tonsillectomy, steroid therapy, and their combinations, can result in clinical remission, and prevent the progression to end stage renal disease (ESRD). However, some IgAN patients still progress to ESRD even when treated with intensive therapies. In this review, we discuss the clinical and histological features of IgAN, focusing primarily on our previous reports, and our opinions on therapeutic strategies for IgAN.
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Affiliation(s)
- Takahito Moriyama
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
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Thompson A, Carroll K, A. Inker L, Floege J, Perkovic V, Boyer-Suavet S, W. Major R, I. Schimpf J, Barratt J, Cattran DC, S. Gillespie B, Kausz A, W. Mercer A, Reich HN, H. Rovin B, West M, Nachman PH. Proteinuria Reduction as a Surrogate End Point in Trials of IgA Nephropathy. Clin J Am Soc Nephrol 2019; 14:469-481. [PMID: 30635299 PMCID: PMC6419287 DOI: 10.2215/cjn.08600718] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IgA nephropathy (IgAN) is an important cause of ESKD for which there are no approved therapies. A challenge for evaluating treatments for IgAN is the usual long time course for progression to ESKD. The aim of this Kidney Health Initiative project was to identify surrogate end points that could serve as reliable predictors of a treatment's effect on long-term kidney outcomes in IgAN and be used as a basis for approval. Proteinuria was identified as the most widely recognized and well studied risk factor for progression to ESKD in IgAN. The workgroup performed a critical review of the data on proteinuria reduction as a surrogate end point for a treatment's effect on progression to ESKD in IgAN. Epidemiologic data indicate a strong and consistent relationship between the level and duration of proteinuria and loss of kidney function. Trial-level analyses of data from 13 controlled trials also show an association between treatment effects on percent reduction of proteinuria and treatment effects on a composite of time to doubling of serum creatinine, ESKD, or death. We conclude that data support the use of proteinuria reduction as a reasonably likely surrogate end point for a treatment's effect on progression to ESKD in IgAN. In the United States, reasonably likely surrogate end points can be used as a basis for accelerated approval of therapies intended to treat serious or life-threatening conditions, such as IgAN. The clinical benefit of products approved under this program would need to be verified in a postmarketing confirmatory trial.
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Affiliation(s)
- Aliza Thompson
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Jürgen Floege
- Division of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Sonia Boyer-Suavet
- Service de Néphrologie, Hôpital Pasteur, Centre Hospitalier Universitaire de Nice, Université Nice Sophia-Antipolis, Nice, France; Departments of
| | | | | | - Jonathan Barratt
- Infection, Inflammation and Immunity, University of Leicester, Leicester, UK
| | - Daniel C. Cattran
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Heather N. Reich
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Brad H. Rovin
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Melissa West
- American Society of Nephrology, Washington, DC; and
| | - Patrick H. Nachman
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota
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Qian G, Zhang X, Xu W, Zou H, Li Y. Efficacy and safety of glucocorticoids for patients with IgA nephropathy: a meta-analysis. Int Urol Nephrol 2019; 51:859-868. [PMID: 30843135 DOI: 10.1007/s11255-019-02094-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 01/30/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND The efficacy and safety of glucocorticoids for the treatment of patients with IgA nephropathy (IgAN) remains controversial. The aim of the study is to perform a metaanalysis of randomized controlled trials to evaluate the efficacy and safety of glucocorticoids for patients with IgAN. METHODS We searched PubMed, EMBASE and the Cochrane Library and article reference lists of Controlled Trials, and Clinical Trial Registries for randomized controlled trials comparing glucocorticoids with other non-immunosuppressive agents in patients with IgAN. RESULTS The present meta-analysis, including 10 RCTs and 791 patients from 12 published studies, showed that using glucocorticoids agents relatively preserves kidney function(RR 0.06, 95% CI 0.14-0.61) and plays an effective role on reducing the proteinuria(SMD, - 0.69; 95% CI 0.85 to - 0.53, p < 0.00001; heterogeneity I2 = 0%; p = 0.09) compared with a control group. Moreover, adverse events cannot be neglected, especially gastrointestinal tract (RR 3.10, 95% CI 1.37-6.98, p = 0.006; heterogeneity I2 = 0%, p = 0.86), and corticosteroid regimens in IgAN should be reviewed with regard to safety. CONCLUSIONS Glucocorticoids were wildly used to treat various diseases including IgAN. Meanwhile, adverse events cannot be neglected, such as gastrointestinal adverse events, infection and so on. Corticosteroid should be used with reserve, especially in those patients with hypertension and impaired renal function or older patients.
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Affiliation(s)
- Ge Qian
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China
| | - Xiaoyu Zhang
- Department of Non-communicable Disease Control and Prevention, Xi'an Municipal Center for Disease Control and Prevention, Xi'an, 710054, China
| | - Weicheng Xu
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China
| | - Hequn Zou
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China
| | - Yongqiang Li
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China.
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New strategies and perspectives on managing IgA nephropathy. Clin Exp Nephrol 2019; 23:577-588. [PMID: 30756248 PMCID: PMC6469670 DOI: 10.1007/s10157-019-01700-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/17/2019] [Indexed: 12/23/2022]
Abstract
IgA nephropathy is an inflammatory renal disease characterised by the deposition of IgA in the glomerular mesangium and is the most commonly reported primary glomerulonephritis worldwide. Thirty to forty percent of patients with the disease develop progressive renal function decline, requiring renal replacement therapy within two decades of diagnosis. Despite this, accurate individual risk stratification at diagnosis and predicting treatment response remains a challenge. Furthermore, there are currently no disease specific treatments currently licensed to treat the condition due to long standing challenges in the nature and prevalence of the disease. Despite this, there have been exciting recent advances in the field that may represent paradigm shifts in the way IgA nephropathy is managed in the near future. In this review, we explore the evidence base informing current approaches to management and explore new strategies and future directions in the diagnosis and management of IgA nephropathy.
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57
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Coppo R. Treatment of IgA nephropathy: Recent advances and prospects. Nephrol Ther 2018; 14 Suppl 1:S13-S21. [PMID: 29606258 DOI: 10.1016/j.nephro.2018.02.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/09/2018] [Indexed: 01/06/2023]
Abstract
IgA nephropathy, identified 50 years ago in France, is the most frequent glomerular disease worldwide. The course is variable, but in most of the cases there is a relentless decline in renal function, reaching end-stage renal failure in 10-60% of the cases after 10 years and in 40% after 20 years. These data justify the interest for finding a suitable therapeutic approach particularly in progressive cases. A supportive care, including renin-angiotensin system inhibitors is the priority in cases with slowly declining renal function, particularly when developing proteinuria. The recent supportive versus immunosuppressive therapy for the treatment of progressive IgA nephropathy (STOP-IgAN) randomized and controlled trial has further stressed the benefit of a strict supportive care including also life-style changes, protein and salt restriction. However, there is clear evidence from observational studies (including the European Validation Study of the Oxford Classification of IgA nephropathy [VALIGA]) and a new randomized and controlled trial (Therapeutic Evaluation of Steroids in IgA Nephropathy Global [TESTING]) of additional benefits of corticosteroid treatment in patients with proteinuric IgA nephropathy. However, the present treatment schedules carry severe side effects, mostly infectious complications, which indicate the need for less toxic interventions. The recent focus on the role of gut-kidney axis in IgA nephropathy has led to the search of corticosteroid formulations targeting the intestinal mucosal immune system (gut-associated lymphoid tissue). The NEFIGAN trial obtained interesting results in terms of reduction of proteinuria and stabilization of renal function using a budesonide formulation allowing a selective drug delivery at intestinal gut-associated lymphoid tissue sites. The adverse events, particularly infections, were found to be not clinically relevant. The possibility of a personalized approach to the treatment according to the renal biopsy lesions (Oxford MEST score) is supported by several uncontrolled studies and deserves great attention in the next future. New treatments options for IgA nephropathy include drugs targeting BAFF, a B-cell factor crucial for IgA synthesis or targeting the complement system, and also the possibility of acting directly on the deposited IgA by selective protease digestion.
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Affiliation(s)
- Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, 94, Piazza Polonia, 10126 Torino, TO, Italy.
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58
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Chen S, Yin Q, Ren S, Zhong X, Wang W, Li G, Wang L. A comparison of the effectiveness of cyclophosphamide, leflunomide, corticosteroids, or conservative management alone in patients with IgA nephropathy: a retrospective observational study. Sci Rep 2018; 8:13662. [PMID: 30209279 PMCID: PMC6135814 DOI: 10.1038/s41598-018-31727-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/06/2018] [Indexed: 11/08/2022] Open
Abstract
To compare the long-term efficacy of corticosteroids (P) alone or in combination with cyclophosphamide (CTX), leflunomide (LEF), or Angiotensin-convertase inhibitors or angiotensin II receptor blockers (ACEI/ARB) in treatment for IgA nephropathy (IgAN), 311 patients with IgAN were identified. Therapeutic effectiveness (including progression, partial remission, complete remission) and combined renal endpoint (defined as 30% reduction in eGFR or ESRD) were compared based on different therapies. After immunosuppressive and ACEI/ARB treatment, the levels of eGFR, proteinuria and albumin were significantly improved at the last follow-up, the extent of improvement of eGFR, proteinuria, and albumin was more notable in P + CTX group and P + LEF group. 41%, 52.2%, 55.3% and 55.2% in P + CTX, P + LEF, P and ACEI/ARB group achieved complete remission, respectively. Multivariate regression analysis indicated that only proteinuria (Relative risk (RR) 0.82(0.72-0.94), P = 0.004) and tubular atrophy/interstitial fibrosis (RR 0.26(0.13-0.57), P = 0.001) were predictors for complete remission. The optimal cutoffs of eGFR was 47.085 ml/min/1.73 m2 predicting renal function recovery in P + CTX therapy. In conclusion, tubular atrophy/interstitial fibrosis and massive proteinuria were poor predictors for complete remission in IgAN, it appears as though patients may have benefited from immunosuppressive treatment but that comparison to a well-matched contemporary control group or, ideally, a randomized controlled clinical trial, would be required to show this.
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Affiliation(s)
- Shasha Chen
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Qing Yin
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Song Ren
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Xiang Zhong
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Wei Wang
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Guisen Li
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China.
| | - Li Wang
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China
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Tsunoda R, Usui J, Hoshino J, Fujii T, Suzuki S, Takaichi K, Ubara Y, Yamagata K. Corticosteroids pulse therapy and oral corticosteroids therapy for IgA nephropathy patients with advanced chronic kidney disease: results of a multicenter, large-scale, long-term observational cohort study. BMC Nephrol 2018; 19:222. [PMID: 30189860 PMCID: PMC6127908 DOI: 10.1186/s12882-018-1019-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 08/28/2018] [Indexed: 12/30/2022] Open
Abstract
Background Corticosteroids are widely used to reduce the urine protein levels of patients with immunoglobulin A nephropathy (IgAN). However, their potential preventive effects on end-stage kidney disease (ESKD) are unclear. Methods We previously performed a large-scale, long-term multicenter cohort study of patients with biopsy-proven IgAN treated between 1981 and 2013 (n = 1923). Based on the results, we reported that corticosteroids pulse therapy was potentially effective for the treatment of patients with an eGFR ≥30 ml/min/1.73m2 and a urine protein amount of ≥1 g/gCr. In the present study, we extracted 766 patients with chronic kidney disease (CKD), stage G3–G4 (15 ≤ estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73m2) from the same cohort. We divided these patients into a steroid pulse (SP) group, oral steroid (OS) group, and no steroid (NS) group, and analyzed the risk of end-stage kidney disease (ESKD) stratified by eGFR and urine protein (UP) amounts. Results Over the median long-term follow-up of 70 ± 115 months, 37.1% of the patients with UP ≥1.0 g/day and 11.2% of the patients with UP < 1.0 g/day reached ESKD. Among the patients with UP ≥1 g/gCr, the SP group showed significantly better renal outcome (p < 0.001) than the OS and NS groups. In patients with UP < 1 g/gCr, there were no differences in renal survival among the treatment groups. These trends appeared even in the CKD stage G4 patients, and were also apparent in patients taking renin-angiotensin system inhibitors. The unprecedented long-term observation period in this study may have been necessary to reveal the favorable effect of corticosteroids on ESKD progression. Conclusions In our long-term multicenter study, Corticosteroids pulse therapy was associated with better renal outcomes in IgAN patients with higher UP values, even if their eGFR values were low.
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Affiliation(s)
- Ryoya Tsunoda
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Joichi Usui
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | | | - Takayuki Fujii
- Department of Nephrology, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Satoshi Suzuki
- Department of Nephrology, Seirei Sakura Citizen Hospital, Sakura, Japan
| | - Kenmei Takaichi
- Nephrology Center, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | | | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan.
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Soares MF, Roberts IS. Histologic Classification of IgA Nephropathy: Past, Present, and Future. Semin Nephrol 2018; 38:477-484. [DOI: 10.1016/j.semnephrol.2018.05.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Wu MY, Chen CS, Yiang GT, Cheng PW, Chen YL, Chiu HC, Liu KH, Lee WC, Li CJ. The Emerging Role of Pathogenesis of IgA Nephropathy. J Clin Med 2018; 7:jcm7080225. [PMID: 30127305 PMCID: PMC6112037 DOI: 10.3390/jcm7080225] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 08/12/2018] [Accepted: 08/16/2018] [Indexed: 12/20/2022] Open
Abstract
IgA nephropathy is an autoimmune disease induced by fthe ormation of galactose-deficient IgA1 and anti-glycans autoantibody. A multi-hit hypothesis was promoted to explain full expression of IgA nephropathy. The deposition of immune complex resulted in activation of the complement, increasing oxidative stress, promoting inflammatory cascade, and inducing cell apoptosis via mesangio-podocytic-tubular crosstalk. The interlinked signaling pathways of immune-complex-mediated inflammation can offer a novel target for therapeutic approaches. Treatments of IgA nephropathy are also summarized in our review article. In this article, we provide an overview of the recent basic and clinical studies in cell molecular regulation of IgAN for further treatment interventions.
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Affiliation(s)
- Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Chien-Sheng Chen
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Pei-Wen Cheng
- Yuh-Ing Junior College of Health Care & Management, Kaohsiung 807, Taiwan.
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung 813, Taiwan.
| | - Yu-Long Chen
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan.
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Hsiao-Chen Chiu
- Department of Obstetrics and Gynecology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231, Taiwan.
- Department of Obstetrics and Gynecology, School of Medicine, Tzu Chi University, Hualien 970, Taiwan.
| | - Kuan-Hung Liu
- Division of Nephrology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine National Cheng Kung University, Tainan 704, Taiwan.
| | - Wen-Chin Lee
- Division of Nephrology, Department of Internal Medicine, Chang Bing Show Chwan Memorial Hospital, Changhua 505, Taiwan.
| | - Chia-Jung Li
- Research Assistant Center, Show Chwan Memorial Hospital, Changhua 500, Taiwan.
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Abstract
Most glomerular diseases are immunologically mediated disorders of the kidney and are common causes of ESKD. In addition to supportive therapy, a wide range of immunosuppressive agents are used in the management of patients with these conditions. Immunosuppression requires a careful balance of risk and benefits, and many of these agents have a narrow therapeutic window and require close monitoring. This review describes the side effects of immunosuppressive agents used in recent randomized, controlled trials of glomerular disease, and highlights some of the key adverse events that determine the choice and prescription of these medications.
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Affiliation(s)
- J Ashley Jefferson
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
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63
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Selewski DT, Ambruzs JM, Appel GB, Bomback AS, Matar RB, Cai Y, Cattran DC, Chishti AS, D'Agati VD, D'Alessandri-Silva CJ, Gbadegesin RA, Hogan JJ, Iragorri S, Jennette JC, Julian BA, Khalid M, Lafayette RA, Liapis H, Lugani F, Mansfield SA, Mason S, Nachman PH, Nast CC, Nester CM, Noone DG, Novak J, O'Shaughnessy MM, Reich HN, Rheault MN, Rizk DV, Saha MK, Sanghani NS, Sperati CJ, Sreedharan R, Srivastava T, Swiatecka-Urban A, Twombley K, Vasylyeva TL, Weaver DJ, Yin H, Zee J, Falk RJ, Gharavi AG, Gillespie BW, Gipson DS, Greenbaum LA, Holzman LB, Kretzler M, Robinson BM, Smoyer WE, Flessner M, Guay-Woodford LM, Kiryluk K. Clinical Characteristics and Treatment Patterns of Children and Adults With IgA Nephropathy or IgA Vasculitis: Findings From the CureGN Study. Kidney Int Rep 2018; 3:1373-1384. [PMID: 30450464 PMCID: PMC6224619 DOI: 10.1016/j.ekir.2018.07.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 04/27/2018] [Accepted: 07/30/2018] [Indexed: 11/19/2022] Open
Abstract
Introduction The Cure Glomerulonephropathy Network (CureGN) is a 66-center longitudinal observational study of patients with biopsy-confirmed minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, or IgA nephropathy (IgAN), including IgA vasculitis (IgAV). This study describes the clinical characteristics and treatment patterns in the IgA cohort, including comparisons between IgAN versus IgAV and adult versus pediatric patients. Methods Patients with a diagnostic kidney biopsy within 5 years of screening were eligible to join CureGN. This is a descriptive analysis of clinical and treatment data collected at the time of enrollment. Results A total of 667 patients (506 IgAN, 161 IgAV) constitute the IgAN/IgAV cohort (382 adults, 285 children). At biopsy, those with IgAV were younger (13.0 years vs. 29.6 years, P < 0.001), more frequently white (89.7% vs. 78.9%, P = 0.003), had a higher estimated glomerular filtration rate (103.5 vs. 70.6 ml/min per 1.73 m2, P < 0.001), and lower serum albumin (3.4 vs. 3.8 g/dl, P < 0.001) than those with IgAN. Adult and pediatric individuals with IgAV were more likely than those with IgAN to have been treated with immunosuppressive therapy at or prior to enrollment (79.5% vs. 54.0%, P < 0.001). Conclusion This report highlights clinical differences between IgAV and IgAN and between children and adults with these diagnoses. We identified differences in treatment with immunosuppressive therapies by disease type. This description of baseline characteristics will serve as a foundation for future CureGN studies.
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Affiliation(s)
- David T. Selewski
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
- Correspondence: David T. Selewski, University of Michigan, 1540 East Hospital Drive, Room 12-250, Ann Arbor, Michigan 48109-4297, USA.
| | | | - Gerald B. Appel
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Andrew S. Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Raed Bou Matar
- Center for Pediatric Nephrology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yi Cai
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA
| | - Daniel C. Cattran
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Aftab S. Chishti
- Division of Nephrology, Hypertension and Renal Transplantation, University of Kentucky, Lexington, Kentucky, USA
| | - Vivette D. D'Agati
- Department of Pathology & Cell Biology, Columbia University Medical Center, New York, New York, USA
| | | | - Rasheed A. Gbadegesin
- Department of Pediatrics, Division of Nephrology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan J. Hogan
- Renal Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sandra Iragorri
- Division of Nephrology and Hypertension, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA
| | - J. Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Bruce A. Julian
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Myda Khalid
- Division of Nephrology, Department of Pediatrics, JW Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Richard A. Lafayette
- Division of Nephrology and Hypertension, Stanford University, Stanford, California, USA
| | | | | | | | - Sherene Mason
- Section of Pediatric Nephrology, Connecticut Children's Medical Center, Hartford, Connecticut, USA
| | - Patrick H. Nachman
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Cynthia C. Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Carla M. Nester
- Division of Pediatric Nephrology, Dialysis and Transplantation, Stead Family Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
- Molecular Otolaryngology and Renal Research Laboratory, University of Iowa, Iowa City, Iowa, USA
| | - Damien G. Noone
- Division of Nephrology, Department of Pediatrics, The Hospital for Sick Children, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jan Novak
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Heather N. Reich
- Division of Nephrology, Department of Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle N. Rheault
- Division of Nephrology, Department of Pediatrics, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Dana V. Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Manish K. Saha
- Division of Nephrology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Neil S. Sanghani
- Division of Nephrology and Hypertension, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C. John Sperati
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rajasree Sreedharan
- Division of Nephrology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Tarak Srivastava
- Children's Mercy Hospital and University of Missouri−Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Agnieszka Swiatecka-Urban
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Katherine Twombley
- Division of Pediatric Critical Care Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Tetyana L. Vasylyeva
- Department of Pediatrics, Division of Nephrology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA
| | - Donald J. Weaver
- Division of Nephrology and Hypertension, Levine Children's Hospital at Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Hong Yin
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jarcy Zee
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Ronald J. Falk
- Division of Nephrology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Ali G. Gharavi
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Brenda W. Gillespie
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Debbie S. Gipson
- Division of Nephrology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan, USA
| | - Larry A. Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Lawrence B. Holzman
- Department of Medicine, University of Pennsylvania Medical School, Philadelphia, Pennsylvania, USA
| | - Matthias Kretzler
- Department of Computational Medicine and Bioinformatics, University of Michigan School of Medicine, Ann Arbor, Michigan USA
- Division of Nephrology, Department of Internal Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | | | - William E. Smoyer
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Michael Flessner
- Division of Kidney, Urology, and Hematology, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Lisa M. Guay-Woodford
- Center for Translational Science, Children’s National Health System, Washington, DC, USA
| | - Krzysztof Kiryluk
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Krzysztof Kiryluk, Columbia University, Department of Medicine, Division of Nephrology, 1150 St Nicholas Avenue, Russ Berrie Pavilion #412, New York, New York 10032, USA.
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Lin Y, Jia J, Guo Y, He D, Zhang Y, Wang F, Yan T, Liu Y, Lin S. Corticosteroid for IgA Nephropathy: Are They Really Therapeutic? Am J Nephrol 2018; 47:385-394. [PMID: 29874651 DOI: 10.1159/000489580] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND IgA nephropathy (IgAN) is a common chronic glomerular disease that, in most patients, slowly progresses to end-stage kidney disease. The therapy with corticosteroid in IgAN is still a worldwide problem that is confusing the clinicians. METHODS MEDLINE, EMBASE, the Cochrane Library, and article reference lists were searched for randomized controlled trials (RCTs) that compared corticosteroids with placebo and any other non-immunosuppressive agents in treating IgAN. Twelve RCTs involving 1,057 patients were included. RESULTS Overall, we found that steroids had statistically significant effects in preventing the decline in renal function (relative risk 0.42, 95% CI 0.25-0.71, p < 0.001) and reducing proteinuria (SMD: -0.58 g/day, 95% CI -0.80 to -0.36 g/day) in patients with IgAN. The association between glucocorticoid and risk of kidney outcome was not modified by steroids' type (prednisone or methylprednisone), dose (≤30 or > 30 mg/day), duration (≤8 or > 8 months), or serum creatinine (< 1.10 or ≥1.10 mg/dL). But steroids increased the risk of side effects such as gastrointestinal and endocrinium symptoms. CONCLUSION This study provides the clear beneficial effects of the steroids therapy on the kidney function and proteinuria, although it should be used with caution.
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Affiliation(s)
- Yujia Lin
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Junya Jia
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Yipeng Guo
- Department of Epidemiology, Tianjin Public Health Bureau, Tianjin, China
| | - Dandan He
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Yaru Zhang
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Fuzhen Wang
- Department of Statistics, Fenyang Hospital of Shanxi Province, Fenyang, China
| | - Tiekun Yan
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Youxia Liu
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Shan Lin
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
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Feehally J. Immunosuppression in IgA Nephropathy: Guideline Medicine Versus Personalized Medicine. Semin Nephrol 2018; 37:464-477. [PMID: 28863793 DOI: 10.1016/j.semnephrol.2017.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The role of immunosuppression in IgAN remains controversial despite a growing evidence base of randomized controlled trials (RCTs). In IgAN with nephrotic syndrome the role for corticosteroids is limited to cases with minimal change on light microscopy. In crescentic IgAN, the use of immunosuppression is supported only by anecdotal data, and outcome may be poor especially when glomerular filtration rate is impaired severely at presentation or there are pathologic features of chronic injury. In slowly progressive IgAN, prediction of outcome now is based both on clinical and pathologic features. Most RCTs have studied patients with urine protein levels greater than 1 g/24 h and only a minority have enrolled patients with a glomerular filtration rate less than 60 mL/min. The Supportive versus immunosuppressive Therapy of Progressive IgA nephropathy (STOP) IgAN study emphasized the efficacy of supportive therapy (including blood pressure control and renin-angiotensin system blockade) in decreasing proteinuria to less than the usually accepted threshold for the use of corticosteroids. Earlier RCTs of corticosteroids usually did not deploy supportive therapy optimally. The recent Therapeutic Evaluation of STeroids in IgA Nephropathy Global (TESTING) study closed prematurely because of excess toxicity, but the high dose of corticosteroids seemed to provide benefit. Guidelines provide valuable information about the quality and limitations of available evidence that needs to be personalized in application to the individual patient's medical and nonmedical circumstances to ensure wise clinical decision making.
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Affiliation(s)
- John Feehally
- Department of Infection, Inflammation and Immunology, University of Leicester, Leicester, UK.
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Hu T, Liu Q, Xu Q, Liu H, Qiu W, Huang F, Zhang S, Lv Y. Tacrolimus decreases proteinuria in patients with refractory IgA nephropathy. Medicine (Baltimore) 2018; 97:e0610. [PMID: 29718866 PMCID: PMC6392720 DOI: 10.1097/md.0000000000010610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
In clinical practice, some IgA nephropathy (IgAN) patients show resistance to or are unable to achieve complete remission using steroids and/or immunosuppressants. The current study aimed to assess the efficacy and safety of tacrolimus in the treatment of cases of refractory IgAN.In this retrospective observational study, 34 primary IgAN patients with refractory proteinuria received tacrolimus for at least 12 months. Complete remission, partial remission, and other clinical data were measured at 1, 3, 6, and 12 months after the initiation of treatment.After 12 months, complete remission was achieved in 20 (58.8%) patients and partial remission in 5 (14.7%) patients, yielding a total response rate of 73.5%. The mean time for response to tacrolimus for those who achieved complete remission and partial remission was 7.0 ± 4.7 weeks. Serum creatinine (Scr), uric acid, estimated glomerular filtration rate, alanine aminotransferase, aspartate transaminase, white blood cell count, blood pressure, blood glucose, total cholesterol, and total triglyceride were stable over time. Three patients demonstrated a loss of eGFR >15 mL/min·1.73 m from baseline. Three cases of upper respiratory infection and 2 cases of urinary tract infection were observed during the study. Patients who achieved complete remission had better renal function and lower baseline proteinuria than partial remission and nonresponder patients. Crescent formation in biopsy specimens was seen more often in nonresponder patients.Tacrolimus was safe and effective at lowering proteinuria in refractory IgAN patients. Lower baseline proteinuria and better renal function were associated with a higher probability of complete remission, while crescent formation was associated with a worse prognosis.
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67
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Mucosal corticosteroid therapy of IgA nephropathy. Kidney Int 2018; 92:278-280. [PMID: 28709593 DOI: 10.1016/j.kint.2017.05.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/15/2017] [Indexed: 11/23/2022]
Abstract
The value of systemic immunosuppressive therapy for IgA nephropathy is uncertain. A recently completed randomized controlled phase II trial demonstrates that specially encapsulated budesonide, released preferentially in the terminal ileum, can reduce proteinuria and stabilize glomerular filtration rate in patients with IgA nephropathy.
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68
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Penfold RS, Prendecki M, McAdoo S, Tam FWK. Primary IgA nephropathy: current challenges and future prospects. Int J Nephrol Renovasc Dis 2018; 11:137-148. [PMID: 29695925 PMCID: PMC5905843 DOI: 10.2147/ijnrd.s129227] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IgA nephropathy (IgAN) is the most common form of primary glomerulonephritis worldwide, exhibiting a variable clinical and pathological course and significantly contributing to the global burden of chronic kidney disease and end-stage renal disease. Current standards of care focus on optimization of antihypertensive and antiproteinuric therapies (typically renin- angiotensin system blockade) to reduce disease progression. Much recent attention has focused on whether additional immunosuppression confers better outcomes than supportive management alone, and indeed, several trials have demonstrated renoprotective effects following the use of oral corticosteroids. However, results have been inconsistent, and perceived benefits must be balanced against risks and adverse effects associated with generalized immunosuppression, as highlighted by the high-profile STOP-IgAN and TESTING clinical trials. Recent translational research in vitro and animal models of IgAN have generated greater insight into potential therapeutic targets for this complex autoimmune disease. Deeper understanding of the roles of the mucosal immune barrier, complement activation and deposition, T-cell dependent and independent mechanisms of B cell activation, and of the deposition and downstream inflammatory signaling pathways of nephritogenic polymeric IgA1 complexes (e.g., signaling of immune receptors via spleen tyrosine kinase) has formed the rationale for the development of novel agents and clinical trials of more targeted therapies. However, translating findings into clinical practice is challenging, with many immunopathological features of IgAN specific to humans. Recent comprehensive reviews outline current understanding of mechanisms of IgAN as well as ongoing and future clinical trials; it is not our aim to replicate this here. Instead, we take a mechanistic approach to current treatment strategies, outlining advantages and limitations of each before exploring ongoing research with potential translation into future targeted therapies for this complex disease.
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Affiliation(s)
- Rose S Penfold
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK
| | - Maria Prendecki
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK
| | - Stephen McAdoo
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK
| | - Frederick WK Tam
- Renal and Vascular Inflammation Section, Department of Medicine, Imperial College London, London, UK
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69
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Laranjinha I, Matias P, Cassis J, Branco P, Ramos S, Barata JD, Weigert A. IGA nephropathy - Are intravenous steroid pulses more effective than oral steroids in relapse prevention? Nefrologia 2017; 38:355-360. [PMID: 29129388 DOI: 10.1016/j.nefro.2017.08.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/31/2017] [Accepted: 08/08/2017] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION It is recommended that IgA nephropathy (IgAN) is treated with steroids when the glomerular filtration rate (GFR) is >50ml/min and proteinuria >1g/day. Few studies have been performed comparing the two accepted steroid regimens (1g/day methylprednisolone pulses for 3 consecutive days at the beginning of months 1, 3 and 5, followed by 0.5mg/kg prednisolone on alternate days vs. 1mg/kg/day oral prednisolone). The aim of this study was to compare these two steroid regimens in IgAN treatment. METHODS We selected 39 patients with biopsy-proven IgAN treated with steroids. Mean age at diagnosis was 37.5 years, 23 males (59%), baseline proteinuria (Uprot) was 2.1 g/day and median serum creatinine (SCr) was 1.5mg/dl. The mean follow-up period was 56 months. Twenty-five patients (64%) were treated with methylprednisolone pulses and 14 (36%) with oral steroids. RESULTS Patients treated with steroid pulses presented lower relapse risk, defined as the reappearance of Uprot >1g/day and an Uprot increase of more than 50% (incidence rate ratio of 0.18, 95% CI 0.02-0.5). The Kaplan-Meier analysis showed longer relapse-free period (p=0.019). This result was confirmed in a multivariate analysis (p=0.026). However, we did not find other differences between the two steroid regimens. CONCLUSIONS In comparison to oral steroids, the intravenous pulse regimen was associated with a lower risk of relapse in IgAN, a known independent negative predictor of renal survival. No differences were found regarding the other renal outcomes.
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Affiliation(s)
- Ivo Laranjinha
- Hospital de Santa Cruz, Nephrology Department, Lisbon, Portugal; Nova Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal.
| | - Patrícia Matias
- Hospital de Santa Cruz, Nephrology Department, Lisbon, Portugal; Nova Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - João Cassis
- Centro Hospitalar de Lisboa Ocidental, Pathology Department, Lisbon, Portugal
| | - Patrícia Branco
- Hospital de Santa Cruz, Nephrology Department, Lisbon, Portugal; Nova Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Sância Ramos
- Centro Hospitalar de Lisboa Ocidental, Pathology Department, Lisbon, Portugal
| | | | - André Weigert
- Hospital de Santa Cruz, Nephrology Department, Lisbon, Portugal; University of Lisbon, Faculdade de Medicina, Lisbon, Portugal
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Rauen T, Fitzner C, Eitner F, Sommerer C, Zeier M, Otte B, Panzer U, Peters H, Benck U, Mertens PR, Kuhlmann U, Witzke O, Gross O, Vielhauer V, Mann JFE, Hilgers RD, Floege J. Effects of Two Immunosuppressive Treatment Protocols for IgA Nephropathy. J Am Soc Nephrol 2017; 29:317-325. [PMID: 29042456 DOI: 10.1681/asn.2017060713] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/14/2017] [Indexed: 11/03/2022] Open
Abstract
The role of immunosuppression in IgA nephropathy (IgAN) is controversial. In the Supportive Versus Immunosuppressive Therapy for the Treatment of Progressive IgA Nephropathy (STOP-IgAN) Trial, 162 patients with IgAN and proteinuria >0.75 g/d after 6 months of optimized supportive care were randomized into two groups: continued supportive care or additional immunosuppression (GFR≥60 ml/min per 1.73 m2: 6-month corticosteroid monotherapy; GFR=30-59 ml/min per 1.73 m2: cyclophosphamide for 3 months followed by azathioprine plus oral prednisolone). Coprimary end points were full clinical remission and GFR loss ≥15 ml/min per 1.73 m2 during the 3-year trial phase. In this secondary intention to treat analysis, we separately analyzed data from each immunosuppression subgroup and the corresponding patients on supportive care. Full clinical remission occurred in 11 (20%) patients receiving corticosteroid monotherapy and three (6%) patients on supportive care (odds ratio, 5.31; 95% confidence interval, 1.07 to 26.36; P=0.02), but the rate did not differ between patients receiving immunosuppressive combination and controls on supportive care (11% versus 4%, respectively; P=0.30). The end point of GFR loss ≥15 ml/min per 1.73 m2 did not differ between groups. Only corticosteroid monotherapy transiently reduced proteinuria at 12 months. Severe infections, impaired glucose tolerance, and/or weight gain in the first year were more frequent with either immunosuppressive regimen than with supportive care. In conclusion, only corticosteroid monotherapy induced disease remission in a minority of patients who had IgAN with relatively well preserved GFR and persistent proteinuria. Neither immunosuppressive regimen prevented GFR loss, and both associated with substantial adverse events.
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Affiliation(s)
- Thomas Rauen
- Division of Nephrology and Clinical Immunology and
| | - Christina Fitzner
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
| | - Frank Eitner
- Division of Nephrology and Clinical Immunology and.,Kidney Diseases Research, Bayer AG, Wuppertal, Germany
| | - Claudia Sommerer
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, University of Heidelberg, Heidelberg, Germany
| | - Britta Otte
- Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster, Germany
| | - Ulf Panzer
- Medical Clinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Harm Peters
- Department of Nephrology and Intensive Care and.,Dieter Scheffner Center for Medical Education, Charité Campus Mitte, Charité-Universitaetsmedizin Berlin, Berlin, Germany
| | - Urs Benck
- Department of Medicine V, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Peter R Mertens
- Department of Nephrology and Hypertension, Diabetes and Endocrinology, Otto von Guericke University, Magdeburg, Germany
| | - Uwe Kuhlmann
- Medical Clinic III, Central Hospital Bremen, Bremen, Germany
| | - Oliver Witzke
- Departments of Infectious Diseases and.,Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Oliver Gross
- Clinic for Nephrology and Rheumatology, University Medical Center Goettingen, Goettingen, Germany
| | - Volker Vielhauer
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig Maximilians Universität, Munich, Germany; and
| | - Johannes F E Mann
- Department of Nephrology, Hypertension and Rheumatology, Munich General Hospitals, Munich, Germany
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71
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Al-Lawati AI, Reich HN. Is there a role for immunosuppression in immunoglobulin A nephropathy? Nephrol Dial Transplant 2017; 32:i30-i36. [PMID: 28391341 DOI: 10.1093/ndt/gfw342] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 08/18/2016] [Indexed: 01/31/2023] Open
Abstract
The most common primary glomerular disease globally is IgA nephropathy (IgAN). It is often a slowly progressive disease, and ∼40% of patients will progress to kidney failure. Due to a lack of large clinical trial networks and a lack of surrogate markers of treatment efficacy, there are relatively few large multicenter clinical trials in IgAN. Given that both the pathogenesis and progression of IgAN are linked to defects in mucosal immune regulation and inflammation, use of immunosuppression to prevent kidney failure is well founded. However, recent clinical trials have supported improvement in disease parameters, but this has not always translated to parallel amelioration in longer-term outcome. In this review we summarize the most current clinical research examining the efficacy of immunosuppression in IgAN.
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Affiliation(s)
- Ali I Al-Lawati
- Division of Nephrology, Toronto Glomerulonephritis Registry, University Health Network, Toronto, Canada.,Sultan Qaboos University Hospital, Muscat, Oman
| | - Heather N Reich
- Division of Nephrology, Toronto Glomerulonephritis Registry, University Health Network, Toronto, Canada.,Gabor Zellerman Chair in Nephrology Research, University of Toronto, Toronto, Canada
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Lv J, Zhang H, Wong MG, Jardine MJ, Hladunewich M, Jha V, Monaghan H, Zhao M, Barbour S, Reich H, Cattran D, Glassock R, Levin A, Wheeler D, Woodward M, Billot L, Chan TM, Liu ZH, Johnson DW, Cass A, Feehally J, Floege J, Remuzzi G, Wu Y, Agarwal R, Wang HY, Perkovic V. Effect of Oral Methylprednisolone on Clinical Outcomes in Patients With IgA Nephropathy: The TESTING Randomized Clinical Trial. JAMA 2017; 318:432-442. [PMID: 28763548 PMCID: PMC5817603 DOI: 10.1001/jama.2017.9362] [Citation(s) in RCA: 323] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Guidelines recommend corticosteroids in patients with IgA nephropathy and persistent proteinuria, but the effects remain uncertain. OBJECTIVE To evaluate the efficacy and safety of corticosteroids in patients with IgA nephropathy at risk of progression. DESIGN, SETTING, AND PARTICIPANTS The Therapeutic Evaluation of Steroids in IgA Nephropathy Global (TESTING) study was a multicenter, double-blind, randomized clinical trial designed to recruit 750 participants with IgA nephropathy (proteinuria greater than 1 g/d and estimated glomerular filtration rate [eGFR] of 20 to 120 mL/min/1.73 m2 after at least 3 months of blood pressure control with renin-angiotensin system blockade] and to provide follow-up until 335 primary outcomes occurred. INTERVENTIONS Patients were randomized 1:1 to oral methylprednisolone (0.6-0.8 mg/kg/d; maximum, 48 mg/d) (n = 136) or matching placebo (n = 126) for 2 months, with subsequent weaning over 4 to 6 months. MAIN OUTCOMES AND MEASURES The primary composite outcome was end-stage kidney disease, death due to kidney failure, or a 40% decrease in eGFR. Predefined safety outcomes were serious infection, new diabetes, gastrointestinal hemorrhage, fracture/osteonecrosis, and cardiovascular events. The mean required follow-up was estimated to be 5 years. RESULTS After randomization of 262 participants (mean age, 38.6 [SD, 11.1] years; 96 [37%] women; eGFR, 59.4 mL/min/1.73 m2; urine protein excretion, 2.40 g/d) and 2.1 years' median follow-up, recruitment was discontinued because of excess serious adverse events. Serious events occurred in 20 participants (14.7%) in the methylprednisolone group vs 4 (3.2%) in the placebo group (P = .001; risk difference, 11.5% [95% CI, 4.8%-18.2%]), mostly due to excess serious infections (11 [8.1%] vs 0; risk difference, 8.1% [95% CI, 3.5%-13.9%]; P < .001), including 2 deaths. The primary renal outcome occurred in 8 participants (5.9%) in the methylprednisolone group vs 20 (15.9%) in the placebo group (hazard ratio, 0.37 [95% CI, 0.17-0.85]; risk difference, 10.0% [95% CI, 2.5%-17.9%]; P = .02). CONCLUSIONS AND RELEVANCE Among patients with IgA nephropathy and proteinuria of 1 g/d or greater, oral methylprednisolone was associated with an increased risk of serious adverse events, primarily infections. Although the results were consistent with potential renal benefit, definitive conclusions about treatment benefit cannot be made, owing to early termination of the trial. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01560052.
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Affiliation(s)
- Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Muh Geot Wong
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Meg J. Jardine
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Vivek Jha
- The George Institute for Global Health, New Delhi, India
- University of Oxford, Oxford, United Kingdom
| | - Helen Monaghan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Sean Barbour
- The University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - Richard Glassock
- David Geffen School of Medicine, University of California-Los Angeles
| | - Adeera Levin
- The University of British Columbia, Vancouver, British Columbia, Canada
| | - David Wheeler
- Royal Free and University College Medical School, London, United Kingdom
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, University of Oxford, Oxford, United Kingdom
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Zhi-Hong Liu
- Research Institute of Nephrology, Jinling Hospital, Nanjing, China
| | - David W. Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | - Alan Cass
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | | | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University, Aachen, Germany
| | - Giuseppe Remuzzi
- Mario Negri Institute for Pharmacological Research and Clinical Research Centre for Rare Diseases, Bergamo, Italy
| | - Yangfeng Wu
- Peking University Clinical Research Institute, Beijing, China
| | | | - Hai-Yan Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Stangou M, Papasotiriou M, Xydakis D, Oikonomaki T, Marinaki S, Zerbala S, Stylianou C, Kalliakmani P, Andrikos A, Papadaki A, Balafa O, Golfinopoulos S, Visvardis G, Moustakas G, Papachristou E, Kouloukourgiotou T, Kapsia E, Panagiotou A, Koulousios C, Kavlakoudis C, Georgopoulou M, Panagoutsos S, Vlahakos DV, Apostolou T, Stefanidis I, Siamopoulos K, Tzanakis I, Papadogiannakis A, Daphnis E, Iatrou C, Boletis JN, Papagianni A, Goumenos DS. IgA nephropathy in Greece: data from the registry of the Hellenic Society of Nephrology. Clin Kidney J 2017; 11:38-45. [PMID: 29423199 PMCID: PMC5798157 DOI: 10.1093/ckj/sfx076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/11/2017] [Indexed: 01/09/2023] Open
Abstract
Background Natural history, predisposing factors to an unfavourable outcome and the effect of various therapeutic regimens were evaluated in a cohort of 457 patients with immunoglobulin A nephropathy (IgAN) and follow-up of at least 12 months. Methods Patients with normal renal function and proteinuria <1 g/24 h as well as those with serum creatinine (SCr) >2.5 mg/dL and/or severe glomerulosclerosis received no treatment. Patients with normal or impaired renal function and proteinuria >1 g/24 h for >6 months received daily oral prednisolone or a 3-day course of intravenous (IV) methylprednisolone followed by oral prednisolone per os every other day or a combination of prednisolone and azathioprine. The clinical outcome was estimated using the primary endpoints of end-stage renal disease and/or doubling of baseline SCr. Results The overall 10-year renal survival was 90.8%, while end-stage renal disease and doubling of baseline SCr developed in 9.2% and 14.7% of patients, respectively. Risk factors related to the primary endpoints were elevated baseline SCr, arterial hypertension, persistent proteinuria >0.5 g/24 h and severity of tubulointerstial fibrosis. There was no difference in the clinical outcome of patients treated by the two regimens of corticosteroids; nevertheless, remission of proteinuria was more frequent in patients who received IV methylprednisolone (P = 0.000). The combination of prednisolone with azathioprine was not superior to IV methylprednisolone followed by oral prednisolone. Side effects related to immunossuppressive drugs were observed in 12.8% of patients. Conclusion The clinical outcome of patients with IgAN was related to the severity of clinical and histological involvement. The addition of azathioprine to a corticosteroid-based regimen for IgAN does not improve renal outcome.
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Affiliation(s)
- Maria Stangou
- Department of Nephrology, Hippokratio General Hospital, Aristotle University, Thessaloniki, Greece
| | - Marios Papasotiriou
- Department of Nephrology, University Hospital of Patras, Patras, Greece
- Correspondence and offprint requests to: Marios Papasotiriou; E-mail:
| | - Dimitrios Xydakis
- Department of Nephrology, Venizelio General Hospital of Heraklion, Heraklion Crete, Greece
| | | | - Smaragdi Marinaki
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | - Synodi Zerbala
- Department of Nephrology, General Hospital of Nikaia, Piraeus, Greece
| | | | | | - Aimilios Andrikos
- Department of Nephrology, Hatzikosta General Hospital of Ioannina, Ioannina, Greece
| | - Antonia Papadaki
- Department of Nephrology, General Hospital of Chania, Chania Crete, Greece
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Georgios Visvardis
- Department of Nephrology, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Georgios Moustakas
- Department of Nephrology, Gennimatas General Hospital of Athens, Athens, Greece
| | | | | | - Eleni Kapsia
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | | | | | - Christos Kavlakoudis
- Department of Nephrology, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Maria Georgopoulou
- Department of Nephrology, Gennimatas General Hospital of Athens, Athens, Greece
| | - Stylianos Panagoutsos
- Department of Nephrology, University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Demetrios V Vlahakos
- Department of Nephrology, Attikon University Hospital, National and Kapodistrian University, Athens, Greece
| | | | - Ioannis Stefanidis
- Department of Nephrology, University Hospital of Larissa, Larissa, Greece
| | - Kostas Siamopoulos
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Ioannis Tzanakis
- Department of Nephrology, General Hospital of Chania, Chania Crete, Greece
| | | | - Eugene Daphnis
- Department of Nephrology, University Hospital of Heraklion, Heraklion Crete, Greece
| | - Christos Iatrou
- Department of Nephrology, General Hospital of Nikaia, Piraeus, Greece
| | - John N Boletis
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokratio General Hospital, Aristotle University, Thessaloniki, Greece
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Nagaraju SP, Laxminarayana SLK, Mareddy AS, Prasad S, Kaza S, Shenoy S, Saraf K, Rangaswamy D, Attur RP, Parthasarathy R, Mateti UV, Guddattu V, Vankalakunti M. Role of corticosteroid therapy in IgA nephropathy; where do we stand? J Nephropathol 2017. [DOI: 10.15171/jnp.2017.61] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Fellström BC, Barratt J, Cook H, Coppo R, Feehally J, de Fijter JW, Floege J, Hetzel G, Jardine AG, Locatelli F, Maes BD, Mercer A, Ortiz F, Praga M, Sørensen SS, Tesar V, Del Vecchio L. Targeted-release budesonide versus placebo in patients with IgA nephropathy (NEFIGAN): a double-blind, randomised, placebo-controlled phase 2b trial. Lancet 2017; 389:2117-2127. [PMID: 28363480 DOI: 10.1016/s0140-6736(17)30550-0] [Citation(s) in RCA: 229] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 11/21/2016] [Accepted: 12/09/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND IgA nephropathy is thought to be associated with mucosal immune system dysfunction, which manifests as renal IgA deposition that leads to impairment and end-stage renal disease in 20-40% of patients within 10-20 years. In this trial (NEFIGAN) we aimed to assess safety and efficacy of a novel targeted-release formulation of budesonide (TRF-budesonide), designed to deliver the drug to the distal ileum in patients with IgA nephropathy. METHODS We did a randomised, double-blind, placebo-controlled phase 2b trial, comprised of 6-month run-in, 9-month treatment, and 3-month follow-up phases at 62 nephrology clinics across ten European countries. We recruited patients aged at least 18 years with biopsy-confirmed primary IgA nephropathy and persistent proteinuria despite optimised renin-angiotensin system (RAS) blockade. We randomly allocated patients with a computer algorithm, with a fixed block size of three, in a 1:1:1 ratio to 16 mg/day TRF-budesonide, 8 mg/day TRF-budesonide, or placebo, stratified by baseline urine protein creatinine ratio (UPCR). Patients self-administered masked capsules, once daily, 1 h before breakfast during the treatment phase. All patients continued optimised RAS blockade treatment throughout the trial. Our primary outcome was mean change from baseline in UPCR for the 9-month treatment phase, which was assessed in the full analysis set, defined as all randomised patients who took at least one dose of trial medication and had at least one post-dose efficacy measurement. Safety was assessed in all patients who received the intervention. This trial is registered with ClinicalTrials.gov, number NCT01738035. FINDINGS Between Dec 11, 2012, and June 25, 2015, 150 randomised patients were treated (safety set) and 149 patients were eligible for the full analysis set. Overall, at 9 months TRF-budesonide (16 mg/day plus 8 mg/day) was associated with a 24·4% (SEM 7·7%) decrease from baseline in mean UPCR (change in UPCR vs placebo 0·74; 95% CI 0·59-0·94; p=0·0066). At 9 months, mean UPCR had decreased by 27·3% in 48 patients who received 16 mg/day (0·71; 0·53-0·94; p=0·0092) and 21·5% in the 51 patients who received 8 mg/day (0·76; 0·58-1·01; p=0·0290); 50 patients who received placebo had an increase in mean UPCR of 2·7%. The effect was sustained throughout followup. Incidence of adverse events was similar in all groups (43 [88%] of 49 in the TRF-budesonide 16 mg/day group, 48 [94%] of 51 in the TRF-budesonide 8 mg/day, and 42 [84%] of 50 controls). Two of 13 serious adverse events were possibly associated with TRF-budesonide-deep vein thrombosis (16 mg/day) and unexplained deterioration in renal function in follow-up (patients were tapered from 16 mg/day to 8 mg/day over 2 weeks and follow-up was assessed 4 weeks later). INTERPRETATION TRF-budesonide 16 mg/day, added to optimised RAS blockade, reduced proteinuria in patients with IgA nephropathy. This effect is indicative of a reduced risk of future progression to end-stage renal disease. TRF-budesonide could become the first specific treatment for IgA nephropathy targeting intestinal mucosal immunity upstream of disease manifestation. FUNDING Pharmalink AB.
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Affiliation(s)
| | | | | | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy
| | | | | | | | - Gerd Hetzel
- HeinrichHeine-University, DaVita Renal Center, Düsseldorf, Germany
| | | | | | | | | | | | - Manuel Praga
- Complutense University, Investigation Institute Hospital 12 de Octubre, Madrid, Spain
| | - Søren S Sørensen
- Rigshospitalet-Copenhagen University Hospital, Copenhagen, Denmark
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Yoon CY, Chang TI, Kang EW, Lim BJ, Kie JH, Kee YK, Kim H, Park S, Yun HR, Jung SY, Jhee JH, Kwon YE, Oh HJ, Park JT, Yoo TH, Kang SW, Jeong HJ, Han SH. Clinical usefulness of the Oxford classification in determining immunosuppressive treatment in IgA nephropathy. Ann Med 2017; 49:217-229. [PMID: 27764976 DOI: 10.1080/07853890.2016.1252058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The Oxford classification has been widely used in IgA nephropathy. However, its clinical usefulness of determining immunosuppression is unknown. AIM Whether the Oxford classification could predict the development of proteinuria ≥1 g/g Cr and worsening kidney function, as well as the clinical efficacy of corticosteroid treatment according to each histologic variable of the Oxford-MEST. METHODS We included 377 patients with early-stage IgA nephropathy. The study endpoints were the development of a heavy proteinuria and a decline renal function. RESULTS The results showed that among the Oxford-MEST lesions, only M1 predicted the risk of the development of proteinuria ≥1.0 g/g Cr compared to other lesions in a time-varying Cox model adjusted for multiple confounding factors. In addition, the risk of reaching a 30% decline in eGFR was significantly higher in patients with M1 than in those with M0. Furthermore, patients with M1 had a greater decline of eGFR than patients with M0. However, steroid treatment in M1 lesion was not associated with improving clinical outcomes in the unmatched and propensity score matched cohort. CONCLUSIONS This finding may provide a rationale for using the Oxford classification as a guidance to initiate immunosuppression in the early stages of IgA nephropathy. KEY MESSAGES M1 has independently predictive role among the Oxford lesions in IgA nephropathy. Oxford classification should be defined during pathologic approach. Decision of starting immunosuppression according to the Oxford lesions.
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Affiliation(s)
- Chang-Yun Yoon
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
| | - Tae Ik Chang
- b Division of Nephrology, Department of Internal Medicine , National Health Insurance Service Medical Center, Ilsan Hospital , Goyang, Gyeonggi-do , Republic of Korea
| | - Ea Wha Kang
- b Division of Nephrology, Department of Internal Medicine , National Health Insurance Service Medical Center, Ilsan Hospital , Goyang, Gyeonggi-do , Republic of Korea
| | - Beom Jin Lim
- c Department of Pathology , Yonsei University College of Medicine , Seoul , Republic of Korea
| | - Jeong Hae Kie
- d Department of Pathology , National Health Insurance Corporation Ilsan Hospital , Goyang , Republic of Korea
| | - Youn Kyung Kee
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
| | - Hyoungnae Kim
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
| | - Seohyun Park
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
| | - Hae-Ryong Yun
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
| | - Su-Young Jung
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
| | - Jong Hyun Jhee
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
| | - Young Eun Kwon
- e Division of Nephrology, Department of Internal Medicine , Myongji Hospital, Seonam University College of Medicine , Goyang, Gyeonggi-do , Republic of Korea
| | - Hyung Jung Oh
- f Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital , Seoul , Republic of Korea
| | - Jung Tak Park
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
| | - Tae-Hyun Yoo
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
| | - Shin-Wook Kang
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
| | - Hyeon Joo Jeong
- c Department of Pathology , Yonsei University College of Medicine , Seoul , Republic of Korea
| | - Seung Hyeok Han
- a Department of Internal Medicine , College of Medicine, Institute of Kidney Disease Research, Yonsei University , Seoul , Republic of Korea
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Abstract
IgA nephropathy (IgAN) is a leading cause of CKD and renal failure. Recent international collaborative efforts have led to important discoveries that have improved our understanding of some of the key steps involved in the immunopathogenesis of IgAN. Furthermore, establishment of multicenter networks has contributed to rigorous design and execution of clinical trials that have provided important insights regarding immunotherapy in IgAN. In this article, we review emerging developments in clinical and translational IgAN research and describe how these novel findings will influence future strategies to improve the outcome of patients with IgAN.
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Affiliation(s)
- Jennifer C Rodrigues
- Department of Medicine, University of Toronto and Division of Nephrology, University Health Network, Toronto, Ontario, Canada
| | - Mark Haas
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California; and
| | - Heather N Reich
- Department of Medicine, University of Toronto and Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Gabor Zellerman Chair in Nephrology Research, University of Toronto, Toronto, Ontario, Canada
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Cai Q, Xie X, Wang J, Shi S, Liu L, Chen Y, Lv J, Zhang H. Severe Adverse Effects Associated With Corticosteroid Treatment in Patients With IgA Nephropathy. Kidney Int Rep 2017; 2:603-609. [PMID: 29142978 PMCID: PMC5678641 DOI: 10.1016/j.ekir.2017.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/18/2017] [Accepted: 02/03/2017] [Indexed: 12/05/2022] Open
Abstract
Introduction Few data are available on the risk of SAEs in corticosteroid users in IgAN populations. We describe the prevalence and risk factors of corticosteroid-related SAEs in a Chinese cohort. Methods A total of 1034 IgAN patients were followed up in our renal center from 2003 to 2014. Prevalence of corticosteroid use and corticosteroid-related SAEs were noted. Logistic regression was used to search for risk factors of SAEs in corticosteroid users. Results Of the 369 patients with steroids therapy, 46 patients (12.5%) with 58 events suffered SAEs, whereas only 18 patients (2.7%) without corticosteroids suffered SAEs (OR: 5.45; 95% CI: 3.07–9.68; P < 0.001). SAEs included diabetes mellitus (n = 19, 5.1%), severe or fatal infection (n = 18, 4.9%), osteonecrosis of the femoral head or bone fracture (n = 6, 1.6%), cardiocerebral vascular disease (n = 4, 1.1%), cataract (n = 3, 0.8%), and gastrointestinal hemorrhage (n = 1, 0.3%). Multivariable logistic regression analysis revealed that advanced age (OR: 1.05; 95% CI: 1.02–1.07; P < 0.001) and hypertension (OR: 1.04; 95% CI: 1.01–1.06; P = 0.009) were risk factors for corticosteroid-related SAEs. Impaired kidney function (estimated GFR: OR: O.98; 95% CI: 0.96–0.99; P = 0.036) was a risk factor for severe infection. Accumulated dosages of corticosteroids were not identified as a risk factor of SAEs (OR: 1.09; 95% CI: 0.91–1.30; P = 0.365). Discussion Corticosteroid use is associated with a high risk of SAEs in IgAN patients, especially those who are older, have hypertension, or impaired renal function. Current guidelines on corticosteroid regimens in IgAN should be reviewed with regard to safety.
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Affiliation(s)
- Qingqing Cai
- Renal Division, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Xinfang Xie
- Renal Division, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Jinwei Wang
- Renal Division, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Sufang Shi
- Renal Division, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Lijun Liu
- Renal Division, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Yuqing Chen
- Renal Division, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Jicheng Lv
- Renal Division, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
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Lionaki S, Panagiotellis K, Melexopoulou C, Boletis JN. The clinical course of IgA nephropathy after kidney transplantation and its management. Transplant Rev (Orlando) 2017; 31:106-114. [PMID: 28209246 DOI: 10.1016/j.trre.2017.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 12/07/2016] [Accepted: 01/26/2017] [Indexed: 01/06/2023]
Abstract
Immunoglobulin (Ig) A nephropathy is one of the most common primary glomerulonephritides worldwide causing end stage renal disease in up to 20-40% of affected patients, nearly two decades post diagnosis. Kidney transplantation is the treatment of choice for patients with renal failure, secondary to glomerular diseases. However, IgA nephropathy has a strong tendency to recur in the graft, and although initially thought to be a benign condition, several reports of graft loss, due to recurrent IgA nephropathy, there have been over the last three decades. Overall graft survival has been significantly improved in kidney transplantation, as a result of reduced incidence of acute rejection, as more potent and more specific immunosuppressive agents are now available in clinical practice. Thus, the rates of IgA nephropathy and other glomerulonephritides recurrence are expected to increase, since graft survival has been improved. However, the reported incidence of IgA nephropathy recurrence in the graft varies substantially across centers, as a consequence of different levels of interest, diverse biopsy policies and differing durations of follow up, of the published studies. Notably, recurrence rates of patients receiving graft biopsies by clinical indication only, ranges from 13% to 50% with graft loss being between 1.3% and 16%. The aim of this review is to underline important pathogenetic insights of IgA nephropathy, describe the clinical course of the disease after kidney transplantation, with emphasis on the incidence of recurrence and the associated risk factors, and finally provide all available options for its management in transplant recipients.
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Affiliation(s)
- Sophia Lionaki
- Department of Nephrology & Transplantation Unit, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece.
| | - Konstantinos Panagiotellis
- Department of Nephrology & Transplantation Unit, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - Christine Melexopoulou
- Department of Nephrology & Transplantation Unit, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
| | - John N Boletis
- Department of Nephrology & Transplantation Unit, Laiko Hospital, National and Kapodistrian University of Athens, Faculty of Medicine, Athens, Greece
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81
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Abstract
The optimal role of immunosuppressive therapy in the treatment of IgA nephropathy is controversial. Results of a recently completed randomized controlled trial provide strong support for comprehensive supportive care rather than immunosuppressive therapy in patients at high risk for progression.
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Affiliation(s)
- Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH University of Aachen, Aachen, Germany.
| | - Thomas Rauen
- Division of Nephrology and Clinical Immunology, RWTH University of Aachen, Aachen, Germany
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83
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Jullien P, Mariat C, Maillard N. STOP-IgAN signifie-t-elle STOP-corticoïdes au cours de la néphropathie à IgA ? Nephrol Ther 2016; 12:493-495. [DOI: 10.1016/j.nephro.2016.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 05/22/2016] [Indexed: 10/20/2022]
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84
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Lafayette RA, Canetta PA, Rovin BH, Appel GB, Novak J, Nath KA, Sethi S, Tumlin JA, Mehta K, Hogan M, Erickson S, Julian BA, Leung N, Enders FT, Brown R, Knoppova B, Hall S, Fervenza FC. A Randomized, Controlled Trial of Rituximab in IgA Nephropathy with Proteinuria and Renal Dysfunction. J Am Soc Nephrol 2016; 28:1306-1313. [PMID: 27821627 DOI: 10.1681/asn.2016060640] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/11/2016] [Indexed: 11/03/2022] Open
Abstract
IgA nephropathy frequently leads to progressive CKD. Although interest surrounds use of immunosuppressive agents added to standard therapy, several recent studies have questioned efficacy of these agents. Depleting antibody-producing B cells potentially offers a new therapy. In this open label, multicenter study conducted over 1-year follow-up, we randomized 34 adult patients with biopsy-proven IgA nephropathy and proteinuria >1 g/d, maintained on angiotensin-converting enzyme inhibitors or angiotensin receptor blockers with well controlled BP and eGFR<90 ml/min per 1.73 m2, to receive standard therapy or rituximab with standard therapy. Primary outcome measures included change in proteinuria and change in eGFR. Median baseline serum creatinine level (range) was 1.4 (0.8-2.4) mg/dl, and proteinuria was 2.1 (0.6-5.3) g/d. Treatment with rituximab depleted B cells and was well tolerated. eGFR did not change in either group. Rituximab did not alter the level of proteinuria compared with that at baseline or in the control group; three patients in each group had ≥50% reduction in level of proteinuria. Serum levels of galactose-deficient IgA1 or antibodies against galactose-deficient IgA1 did not change. In this trial, rituximab therapy did not significantly improve renal function or proteinuria assessed over 1 year. Although rituximab effectively depleted B cells, it failed to reduce serum levels of galactose-deficient IgA1 and antigalactose-deficient IgA1 antibodies. Lack of efficacy of rituximab, at least at this stage and severity of IgA nephropathy, may reflect a failure of rituximab to reduce levels of specific antibodies assigned salient pathogenetic roles in IgA nephropathy.
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Affiliation(s)
- Richard A Lafayette
- Division of Nephrology and Hypertension, Stanford University, Stanford, California
| | - Pietro A Canetta
- Division of Nephrology and Hypertension, Columbia University Medical Center, New York, New York
| | - Brad H Rovin
- Division of Nephrology, Ohio State University, Columbus, Ohio
| | - Gerald B Appel
- Division of Nephrology and Hypertension, Columbia University Medical Center, New York, New York
| | | | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, and
| | - James A Tumlin
- Division of Nephrology, University of Tennessee, Chattanooga, Tennessee; and
| | - Kshama Mehta
- Division of Nephrology and Hypertension, Stanford University, Stanford, California
| | | | | | - Bruce A Julian
- Departments of Microbiology and.,Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Felicity T Enders
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | | | - Barbora Knoppova
- Departments of Microbiology and.,Department of Immunology, Faculty of Medicine and Dentistry, Palacky University and University Hospital, Olomouc, Czech Republic
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85
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Abstract
IgA nephropathy (IgAN) is a common chronic glomerular disease that, in most patients, slowly progresses to ESRD. The immune and autoimmune responses that characterize IgAN indicate a potential benefit for corticosteroids. The 2012 Kidney Disease Improving Global Outcome (KDIGO) guidelines suggest giving corticosteroids to patients with rather preserved renal function (GFR>50 ml/min per 1.73 m2) and persistent proteinuria >1 g/d, despite 3-6 months of optimized supportive care with renin-angiotensin system blockers. However, the evidence supporting this guideline was considered of low quality. More recent results from large cohort studies and randomized, controlled trials have provided conflicting messages about the benefits of corticosteroid treatment over supportive care alone, mostly involving optimized renin-angiotensin system blockade, which might generate further uncertainty in the therapeutic choice. Overall, these results indicate that corticosteroids are a powerful tool for treating patients with IgAN; however, treatment success is not universal and mostly occurs in patients who are highly proteinuric with early CKD. In patients with advanced CKD, the side effects of corticosteroids increase, and the renal protection decreases. This brief review aimed at integrating the findings of these recently published reports to provide balanced advice for clinicians as well as suggestions for future trials.
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Affiliation(s)
- Rosanna Coppo
- Fondazione Ricerca Molinette, Nephrology, Dialysis and Transplantation, Regina Margherita Hospital, Turin, Italy
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Wan QJ, Hu HF, He YC, Luan SD, Chen HT, Li T, Xu Y, Xu HL, Liao Y. Tacrolimus combined with low-dose corticosteroids is an effective and safe therapeutic option for refractory IgA nephropathy. Exp Ther Med 2016; 12:1934-1938. [PMID: 27602099 DOI: 10.3892/etm.2016.3523] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 06/14/2016] [Indexed: 12/13/2022] Open
Abstract
Tacrolimus (TAC) has been shown to improve remission from proteinuria in patients with refractory IgA nephropathy (IgAN); however, the efficacy and safety of TAC in such patients have not been fully explored. Therefore, the present study was conducted to evaluate the tolerance to and efficacy of TAC combined with low-dose corticosteroids in patients with refractory IgAN. This was a single-center retrospective study. A total of 28 patients with refractory IgAN were randomly included and received TAC plus corticosteroid; 26 patients received TAC and prednisone, and 2 patients received TAC and methylprednisolone. In addition, all patients were treated with an angiotensin inhibitor. Total urinary protein excretion, serum albumin, blood glucose, complete remission (CR), partial remission (PR), cholesterol, low-density lipoprotein (LDL), serum creatinine (Scr) and estimated GFR (eGFR) were tested at baseline and at 3, 6 and 12 months after the initiation of treatment in all patients. The primary endpoints were CR and PR. Secondary endpoints included changes of Scr, eGFR, clinical data and adverse events. After 12 months, CR was achieved in 40.1% of patients and PR in 43.4%, yielding a total response rate of 83.5%, and the total urinary protein excretion, serum albumin, cholesterol and LDL results were improved significantly compared with those at baseline. Proteinuria and serum albumin results were significantly improved by month 3 of treatment. Two patients relapsed during months 3-6 of follow-up. At the 12-month follow-up, renal function was improved compared with the baseline level as evidenced by eGFR and Scr, respectively. The blood glucose level was stable. One case of pneumococcal pneumonia developed in a patient treated with TAC plus low-dose methylprednisolone and one case of upper gastrointestinal hemorrhage was found in a patient treated with TAC plus low-dose prednisone; both cases completely recovered after treatment. In conclusion, TAC combined with low-dose corticosteroids may be an effective and safe therapeutic option for the treatment of refractory IgAN. However, given the small number of patients in this study, further prospective randomized controlled trials are required with a larger sample of participants and longer follow-up period.
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Affiliation(s)
- Qi-Jun Wan
- Department of Nephrology, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China
| | - Hao-Fei Hu
- Department of Nephrology, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China
| | - Yong-Cheng He
- Department of Nephrology, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China
| | - Shao-Dong Luan
- Department of Nephrology, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China
| | - Hong-Tao Chen
- Department of Nephrology, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China
| | - Tong Li
- Department of Nephrology, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China
| | - Yi Xu
- Department of Nephrology, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China
| | - Hui-Li Xu
- Department of Nephrology, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China
| | - Ying Liao
- Department of Nephrology, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China
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87
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Pozzi C. Pro: STOP immunosuppression in IgA nephropathy? Nephrol Dial Transplant 2016; 31:1766-1770. [DOI: 10.1093/ndt/gfw285] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 04/21/2016] [Indexed: 01/07/2023] Open
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Feehally J, Barratt J. Should Immunosuppressive Therapy Be Used in Slowly Progressive IgA Nephropathy? Am J Kidney Dis 2016; 68:184-186. [DOI: 10.1053/j.ajkd.2016.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 11/11/2022]
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Sarcina C, Tinelli C, Ferrario F, Visciano B, Pani A, De Silvestri A, De Simone I, Del Vecchio L, Terraneo V, Furiani S, Santagostino G, Corghi E, Pozzi C. Corticosteroid Treatment Influences TA-Proteinuria and Renal Survival in IgA Nephropathy. PLoS One 2016; 11:e0158584. [PMID: 27416024 PMCID: PMC4945016 DOI: 10.1371/journal.pone.0158584] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 06/18/2016] [Indexed: 11/18/2022] Open
Abstract
The clinical course of IgA nephropathy (IgAN) and its outcome are extremely variable. Proteinuria at baseline has been considered one of the most important risk factors. More recently, mean proteinuria of follow-up (time-average proteinuria: TAp) was described as a stronger marker of renal survival, suggesting to consider it as a marker of disease activity and response to treatment. We evaluated predictors of renal survival in IgAN patients with different degrees of renal dysfunction and histological lesions, focusing on the role of the therapy in influencing TAp. We performed a retrospective analysis of three prospective, randomized, clinical trials enrolling 325 IgAN patients from 1989 to 2005. Patients were divided into 5 categories according to TAp. The primary endpoint of the 100% increase of serum creatinine occurred in 54 patients (16.6%) and renal survival was much better in groups having lower TAp. The median follow up was 66.6 months (range 12 to 144). The primary endpoint of the 100% increase of serum creatinine occurred in 54 patients (16,6%) and renal survival was much better in groups having lower TA proteinuria. At univariate analysis plasma creatinine and 24h proteinuria, systolic (SBP) and diastolic (DBP) blood pressure during follow-up and treatment with either steroid (CS) or steroid plus azathioprine (CS+A) were the main factors associated with lower TAp and renal survival. At multivariate analysis, female gender, treatment with S or S+A, lower baseline proteinuria and SBP during follow-up remained as the only variables independently influencing TAp. In conclusion, TA-proteinuria is confirmed as one of the best outcome indicators, also in patients with a severe renal insufficiency. A 6-month course of corticosteroids seems the most effective therapy to reduce TAp.
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Affiliation(s)
- Cristina Sarcina
- Department of Nephrology and Dialysis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Carmine Tinelli
- Biometry and Clinical Epidemiology Unit, Policlinico San Matteo, Pavia, Italy
| | - Francesca Ferrario
- Department of Nephrology and Dialysis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Bianca Visciano
- Department of Nephrology and Dialysis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Antonello Pani
- Department of Nephrology and Dialysis, G. Brotzu Hospital, Cagliari, Italy
| | | | - Ilaria De Simone
- Department of Nephrology and Dialysis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Lucia Del Vecchio
- Department of Nephrology, Dialysis and Renal Transplant A. Manzoni Hospital, Lecco, Italy
| | - Veronica Terraneo
- Department of Nephrology and Dialysis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Silvia Furiani
- Department of Nephrology and Dialysis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Gaia Santagostino
- Department of Nephrology and Dialysis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Enzo Corghi
- Department of Nephrology and Dialysis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
| | - Claudio Pozzi
- Department of Nephrology and Dialysis, E. Bassini Hospital, Cinisello Balsamo, Milan, Italy
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Abstract
IgA nephropathy is the most common form of primary glomerulonephritis worldwide and an important cause of chronic kidney disease and end-stage kidney failure. Its pathophysiology remains in part unsolved but it is recognized as an immune complex disease. Recent years have brought progress in the field through the discovery of several genetic susceptibility loci and the formulation of the multi-hit pathogenesis model. Presentation, clinical course and histology can be extremely variable, making any histological classification still difficult. Indeed, most therapeutic studies until now include patients based only on the severity of clinical criteria but the new classification of Oxford should change that. Only the management of patients with nephropathy with minimal change glomerular lesions and nephrotic syndrome, or extra-capillary glomerulonephritis and rapidly progressive renal failure, is consensual: Corticosteroids alone for the first and associated with immunosuppressive drugs for the latter. The recent Kidney Disease Improving Global Outcomes (KDIGO) consensus treatment guideline is still controversial, especially in light of the last clinical studies. Corticosteroid therapy can be discussed in patients with proteinuria greater than 1 g/day without renal failure. All IgA nephropathy patients should benefit from the global management of chronic glomerular disease, including a renin-angiotensin system blocker in the presence of hypertension or proteinuria.
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Affiliation(s)
- Evangéline Pillebout
- Service de néphrologie, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Jérôme Vérine
- Service d'anatomie pathologique, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
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Abstract
Most glomerulonephritides, even the more common types, are rare diseases. They are nevertheless important since they frequently affect young people, often cannot be cured, and can lead to chronic kidney disease, including end-stage renal failure, with associated morbidity and cost. For example, in young adults, IgA nephropathy is the most common cause of end-stage renal disease. In this Seminar, we summarise existing knowledge of clinical signs, pathogenesis, prognosis, and treatment of glomerulonephritides, with a particular focus on data published between 2008 and 2015, and the most common European glomerulonephritis types, namely IgA nephropathy, membranous glomerulonephritis, minimal change disease, focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, and the rare complement-associated glomerulonephritides such as dense deposit disease and C3 glomerulonephritis.
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Affiliation(s)
- Jürgen Floege
- Department of Nephrology and Clinical Immunology, University Hospital, Rheinisch Westfälische Technische Hochschule Aachen, Aachen, Germany.
| | - Kerstin Amann
- Department of Nephropathology, Department of Pathology, University of Erlangen-Nürnberg, Erlangen, Germany
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92
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Yeo SC, Liew A, Barratt J. Emerging therapies in immunoglobulin A nephropathy. Nephrology (Carlton) 2016; 20:788-800. [PMID: 26032537 DOI: 10.1111/nep.12527] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2015] [Indexed: 01/29/2023]
Abstract
Despite advances in our understanding of immunoglobulin A nephropathy (IgAN) over the past decade, there are currently no specific therapies capable of targeting key pathways involved in the pathogenesis of the disease. Recent studies have, however, provided new insights into important molecular pathways that are likely to be amenable to therapeutic manipulation in the future. Specifically, a deeper understanding of the role of mucosal immunity, B-cell activation and mesangial cell activation in IgAN has provided the impetus for a number of exciting phase II/III clinical trials in IgAN. In this review, we examine some of these on-going studies, first examining studies that clarify the role of traditional immunosuppression in IgAN, then focusing on novel therapies in early clinical studies, looking closely at the rationale for these agents in relation to our current understanding of the pathogenesis of IgAN. Finally, we examine emerging pathways and therapeutic agents that have the potential to be developed as novel therapies in the coming years. It is hoped that as we continue to develop a greater understanding of IgAN, emerging therapies will soon become a reality in the day-to-day treatment of patients with IgAN.
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Affiliation(s)
- See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
| | - Adrian Liew
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
| | - Jonathan Barratt
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK.,The John Walls Renal Unit, Leicester General Hospital, Leicester, UK
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93
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94
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Wen Y, Liu L, Zhou P, Li H, Wang Z, Zhang Y, Liang J. Tacrolimus restores podocyte injury and stabilizes the expression of Cabin1 in 5/6 nephrectomized rats. Ren Fail 2016; 38:564-70. [DOI: 10.3109/0886022x.2016.1148936] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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95
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Floege J. Highlights of the 2015 ERA-EDTA Congress--glomerular diseases. Nephrol Dial Transplant 2016; 31:177-80. [PMID: 26763671 DOI: 10.1093/ndt/gfv433] [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: 11/25/2015] [Accepted: 11/27/2015] [Indexed: 11/14/2022] Open
Abstract
The present paper summarizes highlights in the field of glomerular diseases presented at the 2015 European Renal Association congress in London. Topics covered include a European survey on renal biopsy practice and indications, the STOP-IgAN randomized controlled trial in patients with IgA-nephropathy, B-cell- targeting therapies in minimal change nephropathy and focal segmental glomerulosclerosis (FSGS), novel insights into the action of glucocorticosteroids in glomerular crescent and scar (FSGS) formation, the immunoproteasome in IgA-nephropathy, socio-economic factors and glomerular disease progression, glomerular CD80 (B7-1) expression in FSGS patients and aldosterone-antagonism in proteinuric renal diseases.
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Affiliation(s)
- Jürgen Floege
- Department of Nephrology and Clinical Immunology, University Hospital, Rheinisch Westfälische Technische Hochschule (RWTH), Aachen, Germany
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96
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Treatment of IgA nephropathy with renal insufficiency. J Nephrol 2016; 29:551-8. [DOI: 10.1007/s40620-015-0257-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
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97
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Barbour SJ, Espino-Hernandez G, Reich HN, Coppo R, Roberts IS, Feehally J, Herzenberg AM, Cattran DC, Bavbek N, Cook T, Troyanov S, Alpers C, Amore A, Barratt J, Berthoux F, Bonsib S, Bruijn J, D’Agati V, D’Amico G, Emancipator S, Emmal F, Ferrario F, Fervenza F, Florquin S, Fogo A, Geddes C, Groene H, Haas M, Hill P, Hogg R, Hsu S, Hunley T, Hladunewich M, Jennette C, Joh K, Julian B, Kawamura T, Lai F, Leung C, Li L, Li P, Liu Z, Massat A, Mackinnon B, Mezzano S, Schena F, Tomino Y, Walker P, Wang H, Weening J, Yoshikawa N, Zhang H, Coppo R, Troyanov S, Cattran D, Cook H, Feehally J, Roberts I, Tesar V, Maixnerova D, Lundberg S, Gesualdo L, Emma F, Fuiano L, Beltrame G, Rollino C, RC, Amore A, Camilla R, Peruzzi L, Praga M, Feriozzi S, Polci R, Segoloni G, Colla L, Pani A, Angioi A, Piras L, JF, Cancarini G, Ravera S, Durlik M, Moggia E, Ballarin J, Di Giulio S, Pugliese F, Serriello I, Caliskan Y, Sever M, Kilicaslan I, Locatelli F, Del Vecchio L, Wetzels J, Peters H, Berg U, Carvalho F, da Costa Ferreira A, Maggio M, Wiecek A, Ots-Rosenberg M, Magistroni R, Topaloglu R, Bilginer Y, D’Amico M, Stangou M, Giacchino F, Goumenos D, Kalliakmani P, Gerolymos M, Galesic K, Geddes C, Siamopoulos K, Balafa O, Galliani M, Stratta P, Quaglia M, Bergia R, Cravero R, Salvadori M, Cirami L, Fellstrom B, Kloster Smerud H, Ferrario F, Stellato T, Egido J, Martin C, Floege J, Eitner F, Lupo A, Bernich P, Menè P, Morosetti M, van Kooten C, Rabelink T, Reinders M, Boria Grinyo J, Cusinato S, Benozzi L, Savoldi S, Licata C, Mizerska-Wasiak M, Martina G, Messuerotti A, Dal Canton A, Esposito C, Migotto C, Triolo G, Mariano F, Pozzi C, Boero R, Bellur S, Mazzucco G, Giannakakis C, Honsova E, Sundelin B, Di Palma A, Ferrario F, Gutiérrez E, Asunis A, Barratt J, Tardanico R, Perkowska-Ptasinska A, Arce Terroba J, Fortunato M, Pantzaki A, Ozluk Y, Steenbergen E, Soderberg M, Riispere Z, Furci L, Orhan D, Kipgen D, Casartelli D, Galesic Ljubanovic D, Gakiopoulou H, Bertoni E, Cannata Ortiz P, Karkoszka H, Groene H, Stoppacciaro A, Bajema I, Bruijn J, Fulladosa Oliveras X, Maldyk J, Ioachim E. The MEST score provides earlier risk prediction in lgA nephropathy. Kidney Int 2016; 89:167-75. [DOI: 10.1038/ki.2015.322] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 08/17/2015] [Accepted: 09/03/2015] [Indexed: 01/12/2023]
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Rauen T, Eitner F, Fitzner C, Sommerer C, Zeier M, Otte B, Panzer U, Peters H, Benck U, Mertens PR, Kuhlmann U, Witzke O, Gross O, Vielhauer V, Mann JFE, Hilgers RD, Floege J. Intensive Supportive Care plus Immunosuppression in IgA Nephropathy. N Engl J Med 2015; 373:2225-36. [PMID: 26630142 DOI: 10.1056/nejmoa1415463] [Citation(s) in RCA: 437] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The outcomes of immunosuppressive therapy, when added to supportive care, in patients with IgA nephropathy are uncertain. METHODS We conducted a multicenter, open-label, randomized, controlled trial with a two-group, parallel, group-sequential design. During a 6-month run-in phase, supportive care (in particular, blockade of the renin-angiotensin system) was adjusted on the basis of proteinuria. Patients who had persistent proteinuria with urinary protein excretion of at least 0.75 g per day were randomly assigned to receive supportive care alone (supportive-care group) or supportive care plus immunosuppressive therapy (immunosuppression group) for 3 years. The primary end points in hierarchical order were full clinical remission at the end of the trial (protein-to-creatinine ratio <0.2 [with both protein and creatinine measured in grams] and a decrease in the estimated glomerular filtration rate [eGFR] of <5 ml per minute per 1.73 m(2) of body-surface area from baseline) and a decrease in the eGFR of at least 15 ml per minute per 1.73 m(2) at the end of the trial. The primary end points were analyzed with the use of logistic-regression models. RESULTS The run-in phase was completed by 309 of 337 patients. The proteinuria level decreased to less than 0.75 g of urinary protein excretion per day in 94 patients. Of the remaining 162 patients who consented to undergo randomization, 80 were assigned to the supportive-care group, and 82 to the immunosuppression group. After 3 years, 4 patients (5%) in the supportive-care group, as compared with 14 (17%) in the immunosuppression group, had a full clinical remission (P=0.01). A total of 22 patients (28%) in the supportive-care group and 21 (26%) in the immunosuppression group had a decrease in the eGFR of at least 15 ml per minute per 1.73 m(2) (P=0.75). There was no significant difference in the annual decline in eGFR between the two groups. More patients in the immunosuppression group than in the supportive-care group had severe infections, impaired glucose tolerance, and weight gain of more than 5 kg in the first year of treatment. One patient in the immunosuppression group died of sepsis. CONCLUSIONS The addition of immunosuppressive therapy to intensive supportive care in patients with high-risk IgA nephropathy did not significantly improve the outcome, and during the 3-year study phase, more adverse effects were observed among the patients who received immunosuppressive therapy, with no change in the rate of decrease in the eGFR. (Funded by the German Federal Ministry of Education and Research; STOP-IgAN ClinicalTrials.gov number, NCT00554502.).
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Affiliation(s)
- Thomas Rauen
- From the Division of Nephrology and Clinical Immunology (T.R., F.E., J.F.) and Department of Medical Statistics (C.F., R.-D.H.), RWTH Aachen University, Aachen, Bayer Pharma, Kidney Diseases Research, Wuppertal (F.E.), Department of Nephrology, University of Heidelberg, Heidelberg (C.S., M.Z.), Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster (B.O.), University Medical Center Hamburg-Eppendorf, Hamburg (U.P.), Department of Nephrology and Dieter Scheffner Center for Medical Education, Charité Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin (H.P.), Department of Medicine V, University Medical Center Mannheim, University of Heidelberg, Mannheim (U.B.), Department of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg (P.R.M.), Medical Clinic III, Central Hospital Bremen, Bremen (U.K.), Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen (O.W.), Clinic for Nephrology and Rheumatology, University Medical Center Goettingen, Goettingen (O.G.), and Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität (V.V.), and Department of Nephrology, Hypertension and Rheumatology, Munich General Hospital (J.F.E.M.), Munich - all in Germany
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Identifying the ideal metric of proteinuria as a predictor of renal outcome in idiopathic glomerulonephritis. Kidney Int 2015; 88:1392-1401. [DOI: 10.1038/ki.2015.241] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 06/05/2015] [Accepted: 06/18/2015] [Indexed: 12/28/2022]
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100
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