101
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Huang B, Zhang Y, Wang L, Xu W, Zhang J, Zhang Q, Sheng H, Hu Z. Phospholipase A2 Receptor Antibody IgG4 Subclass Improves Sensitivity and Specificity in the Diagnosis of Idiopathic Membranous Nephropathy. Kidney Blood Press Res 2019; 44:848-857. [PMID: 31242492 DOI: 10.1159/000500456] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Accepted: 04/04/2019] [Indexed: 11/19/2022] Open
Abstract
AIMS The aim of this study was to develop a new method for detecting anti-phospholipase A2 receptor-IgG4 to improve the sensitivity and specificity in the diagnosis of idiopathic membranous nephropathy (IMN). METHODS A highly sensitive quantitative assay was developed for the detection of serum anti-phospholipase A2 receptor-IgG4 with europium chelation by time-resolved fluoroimmunoassay (TRFIA), and a mouse anti-human IgG4 tracer was prepared using europium chelation for detection. The specificity and sensitivity of anti-phospholipase A2 receptor-IgG4 in the diagnosis of IMN were further assessed in patients with different kidney diseases. RESULTS The detection limit of anti-PLA2R-IgG4 was 0.69 ng/mL. The measurement range of anti-PLA2R-IgG4 TRFIA was 0.69-2,500 ng/mL. Mean serum anti-PLA2R-IgG4 was 21.27 ± 15.15 ng/mL in 45 healthy volunteers, 31.08 ± 18.17 ng/mL in 29 IgA nephropathy patients, 49.10 ± 34.32 ng/mL in 8 lupus nephropathy patients, and 10,324.11 ± 17,030.40 ng/mL in 30 IMN patients. The anti-PLA2R-IgG4 cutoff concentration was >161.2 ng/mL with the sensitivity of 90.0% and specificity of 100% in the diagnosis of IMN. However, the cutoff for other kidney diseases was lower than 161.2 ng/mL. CONCLUSION The serum anti-phospholipase A2 receptor IgG4 detected with the method developed in this study has higher sensitivity and higher specificity than total IgG in the diagnosis of IMN.
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Affiliation(s)
- Biao Huang
- School of Life Sciences, Zhejiang Sci-Tech University, Hangzhou, China.,Jiangsu Institute of Nuclear Medicine, Wuxi, China
| | - Yi Zhang
- Jiangsu Institute of Nuclear Medicine, Wuxi, China
| | - Liang Wang
- Wuxi Children's Hospital, Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, China
| | - Wenwei Xu
- Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jue Zhang
- Jiangsu Institute of Nuclear Medicine, Wuxi, China
| | - Qiuhua Zhang
- Wuxi Children's Hospital, Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, China
| | - Huiming Sheng
- Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,
| | - Zhigang Hu
- Wuxi Children's Hospital, Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, China
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102
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Circulating antibodies against M-type phospholipase A2 receptor and thrombospondin type-1 domain-containing 7A in Chinese patients with membranous nephropathy. Int Urol Nephrol 2019; 51:1371-1377. [DOI: 10.1007/s11255-019-02146-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 04/10/2019] [Indexed: 11/25/2022]
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103
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Circulating anti-phospholipase A2 receptor antibodies as a diagnostic and prognostic marker in Greek patients with idiopathic membranous nephropathy – a retrospective cohort study. ROMANIAN JOURNAL OF INTERNAL MEDICINE 2019; 57:141-150. [DOI: 10.2478/rjim-2018-0044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction
. Circulating autoantibodies against phospholipase A2 receptor (anti-PLA2R) are recognized as key elements in the pathogenesis of idiopathic membranous nephropathy. In current clinical practice, they are increasingly gaining attention as novel tools for diagnosis and disease monitoring. We investigated the diagnostic and prognostic utility of anti-PLA2R antibody measurements in Greek patients with biopsy-proven membranous nephropathy.
Methods
. Anti-PLA2R levels were measured in serum samples from 33 patients at diagnosis using ELISA and were associated with treatment outcome. Moreover, serial anti-PLA2R measurements were performed in 15 patients under different clinical conditions and level alterations were correlated with disease activity.
Results
. Positive anti-PLA2R antibodies at diagnosis were found in 16 of 33 patients (48.5%). Anti-PLA2R levels were independently associated with the achievement of complete remission of nephrotic syndrome after immunosuppressive treatment compared to partial remission (p = 0.02, R2 = 0.265, 95%CI -0.019 to -0.0003). Higher detectable antibody levels at diagnosis were correlated with higher proteinuria levels (r = 0.813, p = 0.0001, 95%CI 0.532 to 0.933) and lower eGFR at the end of follow-up (r = -0.634, p = 0.0083, 95%CI -0.86 to -0.202). Serial antibody measurements during follow-up showed that anti-PLA2R titers were significantly reduced at the end of treatment after complete remission was achieved, remained low under sustained clinical remission, and increased during relapse.
Conclusions
. Our findings confirm the usefulness of anti-PLA2R measurements in the diagnosis of idiopathic membranous nephropathy. Low levels of anti-PLA2R antibodies at diagnosis are predictive of complete remission of nephrotic syndrome following immunosuppressive treatment. Serial anti-PLA2R measurements correlate well with clinical status throughout the follow-up period and could be used routinely for monitoring of disease activity and treatment planning.
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104
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Passerini P, Malvica S, Tripodi F, Cerutti R, Messa P. Membranous Nephropathy (MN) Recurrence After Renal Transplantation. Front Immunol 2019; 10:1326. [PMID: 31244861 PMCID: PMC6581671 DOI: 10.3389/fimmu.2019.01326] [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: 03/12/2019] [Accepted: 05/24/2019] [Indexed: 11/22/2022] Open
Abstract
Primary membranous nephropathy (MN) is a frequent cause of NS in adults. In native kidneys the disease may progress to ESRD in the long term, in some 40–50% of untreated patients. The identification of the pathogenic role of anti-podocyte autoantibodies and the development of new therapeutic options has achieved an amelioration in the prognosis of this disease. MN may also develop in renal allograft as a recurrent or a de novo disease. Since the de novo MN may have some different pathogenetic and morphologic features compared to recurrent MN, in the present paper we will deal only with the recurrent disease. The true incidence of the recurrent form is difficult to assess. This is mainly due to the variable graft biopsy policies in kidney transplantation, among the different transplant centers. Anti-phospholipase A2 receptor (PLA2R) autoantibodies are detected in 70–80% of patients. The knowledge of anti-PLA2R status before transplant is useful in predicting the risk of recurrence. In addition, the serial survey of the anti-PLA2R titers is important to assess the rate of disease progression and the response to treatment. Currently, there are no established guidelines for prevention and treatment of recurrent MN. Symptomatic therapy may help to reduce the signs and symptoms related to the nephrotic syndrome. Anecdotal cases of response to cyclical therapy with steroids and cyclophosphamide have been published. Promising results have been reported with rituximab in both prophylaxis and treatment of recurrence. However, these results are based on observational data, and prospective controlled trials are still missing.
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Affiliation(s)
- Patrizia Passerini
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silvia Malvica
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Federica Tripodi
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Roberta Cerutti
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Piergiorgio Messa
- Dialysis, and Renal Transplant Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community, Università degli Studi di Milano, Milan, Italy
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105
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Prognostic value of phospholipase A2 receptor in primary membranous nephropathy: a systematic review and meta-analysis. Int Urol Nephrol 2019; 51:1581-1596. [PMID: 31140029 DOI: 10.1007/s11255-019-02147-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 04/10/2019] [Indexed: 02/05/2023]
Abstract
PURPOSE We aimed to evaluate the prognostic value of serum anti-PLA2R and glomerular PLA2R deposit (gPLA2R) in predicting remission of proteinuria in Primary Membranous Nephropathy (PMN) patients. METHODS PUBMED, EMBASE, WEB OF SCIENCE, COCHRANE LIBRARY and CNKI were searched from 2008 January to December 2018. Heterogeneity was assessed by Cochran Q test and I2. Source of heterogeneity was explored by subgroup analysis and sensitivity analysis. RESULTS Totally 2345 patients from 29 cohort studies were eligible for inclusion. The results suggested that PMN patients with negative anti-PLA2R at the time of biopsy had a 1.31 times (95% CI 1.12-1.46, p < 0.05) higher possibility in achieving remission than those with positive anti-PLA2R. The clearance of anti-PLA2R at the end of immunosuppressive therapy showed an even greater chance of achieving remission (RR = 2.86, 95% CI 1.75-4.69, p < 0.05). The relative ratios for complete remission and spontaneous remission with negative anti-PLA2R were 1.65 (95% CI 1.46-1.87, p < 0.05) and 1.93, respectively (95% CI 1.53-2.45, p < 0.05), and heterogeneity percentages were I2 = 18% and 46%, respectively. The possibility for remission was significantly greater among PMN patients with negative gPLA2R (RR = 1.30, 95% CI 1.13-1.50, p < 0.05). Subgroup analyses revealed that retrospective design of study might be the potential source of heterogeneity. CONCLUSIONS Negative anti-PLA2R or gPLA2R might predict higher possibility of remission, and the presence of anti-PLA2R or gPLA2R might serve as a useful biomarker for clinical outcome and predicting response to immunosuppressive therapy in PMN.
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106
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Chi JN, Lai TS, Wu CF, Fu TY, Chou YH, Chiu YL, Lin WC, Chiang WC, Chen YM, Wu MS. The relationship of anti-phospholipase A2 receptor antibody and C5a complement with disease activity and short-term outcome in idiopathic membranous nephropathy. J Formos Med Assoc 2019; 118:898-906. [DOI: 10.1016/j.jfma.2018.12.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 11/20/2018] [Accepted: 12/27/2018] [Indexed: 12/17/2022] Open
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107
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A comparison of cyclophosphamide versus tacrolimus in terms of treatment effect for idiopathic membranous nephropathy: A meta-analysis. Nefrologia 2019; 39:269-276. [DOI: 10.1016/j.nefro.2018.10.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 10/04/2018] [Accepted: 10/07/2018] [Indexed: 02/02/2023] Open
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108
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Lu H, Cui Z, Zhou XJ, Jin QZ, Yu XJ, Wang SX, Wang Y, Zhou FD, Zhao MH. Plasma exchange and rituximab treatments in primary membranous nephropathy combined with crescentic glomerulonephritis: A case report. Medicine (Baltimore) 2019; 98:e15303. [PMID: 31045764 PMCID: PMC6504248 DOI: 10.1097/md.0000000000015303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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
RATIONALE Crescent formation is rare in primary membranous nephropathy (MN). Anti-phospholipase A2 receptor (PLA2R) antibodies are detectable in these patients. The mechanism and treatments are unknown. PATIENT CONCERNS A 72-year-old female patient who presented with nephrotic syndrome, hematuria, and rapidly progressive kidney dysfunction. DIAGNOSES Kidney biopsy was performed and the diagnosis was MN in combination with crescentic glomerulonephritis. Circulating anti-PLA2R IgG3 and IgG4 were detected of high level. INTERVENTIONS The patient received plasma exchange and rituximab besides corticosteroids. OUTCOMES The patient achieved complete remission of proteinuria and recovery of kidney function after the clearance of anti-PLA2R antibodies. LESSON This case suggests a pathogenic role of anti-PLA2R antibodies in the mechanism of crescent formation in MN, which may need intensive therapy to eliminate the antibodies quickly.
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MESH Headings
- Aged
- Female
- Glomerulonephritis, Membranoproliferative/blood
- Glomerulonephritis, Membranoproliferative/drug therapy
- Glomerulonephritis, Membranoproliferative/immunology
- Glomerulonephritis, Membranoproliferative/pathology
- Glomerulonephritis, Membranous/blood
- Glomerulonephritis, Membranous/drug therapy
- Glomerulonephritis, Membranous/immunology
- Glomerulonephritis, Membranous/pathology
- Hematuria/diagnosis
- Hematuria/etiology
- Humans
- Immunoglobulin G/blood
- Immunologic Factors/therapeutic use
- Kidney/pathology
- Kidney/physiopathology
- Nephrotic Syndrome/pathology
- Plasma Exchange/methods
- Proteinuria/pathology
- Receptors, Phospholipase A2/antagonists & inhibitors
- Receptors, Phospholipase A2/immunology
- Remission Induction
- Rituximab/administration & dosage
- Rituximab/therapeutic use
- Treatment Outcome
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Affiliation(s)
- Hui Lu
- Renal Division, Department of Medicine, Peking University First Hospital
- Institute of Nephrology, Peking University
- Key Laboratory of Renal Disease, Ministry of Health of China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China
| | - Zhao Cui
- Renal Division, Department of Medicine, Peking University First Hospital
- Institute of Nephrology, Peking University
- Key Laboratory of Renal Disease, Ministry of Health of China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China
| | - Xu-jie Zhou
- Renal Division, Department of Medicine, Peking University First Hospital
- Institute of Nephrology, Peking University
- Key Laboratory of Renal Disease, Ministry of Health of China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China
| | - Qi-zhuang Jin
- Renal Division, Department of Medicine, Peking University First Hospital
- Institute of Nephrology, Peking University
- Key Laboratory of Renal Disease, Ministry of Health of China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China
| | - Xiao-juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital
- Institute of Nephrology, Peking University
- Key Laboratory of Renal Disease, Ministry of Health of China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China
| | - Su-xia Wang
- Electron Microscopy Laboratory, Peking University First Hospital
| | - Yu Wang
- Renal Division, Department of Medicine, Peking University First Hospital
- Institute of Nephrology, Peking University
- Key Laboratory of Renal Disease, Ministry of Health of China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China
| | - Fu-de Zhou
- Renal Division, Department of Medicine, Peking University First Hospital
- Institute of Nephrology, Peking University
- Key Laboratory of Renal Disease, Ministry of Health of China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China
| | - Ming-hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital
- Institute of Nephrology, Peking University
- Key Laboratory of Renal Disease, Ministry of Health of China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
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109
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Hamilton P, Wilson F, Chinnadurai R, Sinha S, Singh M, Ponnusamy A, Hall P, Dhaygude A, Kanigicherla D, Brenchley P. The investigative burden of membranous nephropathy in the UK. Clin Kidney J 2019; 13:27-34. [PMID: 32082550 PMCID: PMC7025364 DOI: 10.1093/ckj/sfz036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 03/08/2019] [Indexed: 01/10/2023] Open
Abstract
Background Membranous nephropathy (MN) represents two distinct disease entities. Primary MN is now recognized as an autoimmune condition associated with the anti-PLA2R antibody and secondary MN occurs in tandem with malignancy, infection, drug therapy and other autoimmune conditions. Prior to the development of accessible enzyme-linked immunosorbent assays, the diagnosis of MN was one of exclusion. We studied whether the introduction of serum anti-PLA2R antibody testing leads to a reduction in the frequency of investigations in MN patients. Methods Patients from three UK centres with a diagnosis of MN between 2009 and 2014 were identified. We compared patients who had a positive anti-PLA2R test within 6 months of biopsy with those who had no test or a negative test. Records were reviewed for investigations that took place 6 months prior to and 6 months following the biopsy date to see if these were normal or identified a secondary cause of MN. Results In total, 184 patients were included: 80 had no test, 66 had a negative anti-PLA2R test and 38 had a positive test within 6 months of diagnosis. In 2012, 46.5% of patients had an anti-PLA2R test, increasing to 93.3% in 2014. From 2012 to 2014 the number of screening tests dropped from 10.03 to 4.29 and the costs from £497.92 to £132.94. Conclusions Since its introduction, a progressively higher proportion of patients diagnosed with MN had an anti-PLA2R test. This has led to a reduction in the number of screening tests and in the cost of investigations carried out. The anti-PLA2R test has the potential to reduce this burden as its use becomes more widespread.
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Affiliation(s)
- Patrick Hamilton
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK.,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Fiona Wilson
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Rajkumar Chinnadurai
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Vascular Research Group, Salford Royal Hospital, Salford, UK
| | - Smeeta Sinha
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Vascular Research Group, Salford Royal Hospital, Salford, UK
| | - Malinder Singh
- Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston, UK
| | - Arvind Ponnusamy
- Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston, UK
| | - Peter Hall
- Cancer Research UK Edinburgh Centre, MRC Institute of Genetics and Molecular Medicine, Western General Hospital, Edinburgh, UK
| | - Ajay Dhaygude
- Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston, UK
| | - Durga Kanigicherla
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK.,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Paul Brenchley
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK.,Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
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110
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Combined Plasmatic and Tissue Approach to Membranous Nephropathy-Proposal of a Diagnostic Algorithm Including Immunogold Labelling: Changing the Paradigm of a Serum-based Approach. Appl Immunohistochem Mol Morphol 2019; 28:376-383. [PMID: 30925495 DOI: 10.1097/pai.0000000000000753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Membranous nephropathy represents the most frequent cause of nephrotic syndrome in the adult, leading to end-stage renal disease in one third of all the patients. In the last years, the discovery of circulating autoantibodies against phospholipase A2 receptor 1 (PLA2R) and thrombospondin type-1 containing 7A domain (THSD7A), shed light on the pathogenesis of idiopathic forms, being responsible for 70% and 3% of all the cases, respectively. These identifications allowed the development of serological and histologic tests to detect autoantibodies and relative targets for diagnostic and prognostic purposes. Rising evidences suggest that serum titer correlates with disease activity and response to therapy. For these reasons, for patients with nephrotic syndrome, a serum-based approach has been proposed, reserving renal biopsy only in cases with doubtful/negative serology. However, the recent introduction of useful criteria for the interpretation of PLA2R/THSD7A immunohistochemistry could lead to high values of sensitivity and specificity for the in situ detection of target antigens. The present multicentric study on a series of membranous nephropathy cases with available serum/histologic correlation will show the importance of the crosstalk among the different techniques, recovering the possible role of electron microscopy in challenging situations.
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111
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Cheng G, Liu J, Gilbert A, Cao Y, An C, Lv Z, Wang C, Nie R, Zhang J, Liu Y, Xia M, Li S, Cai H, Li Y, Li Y, Qin X. Serum phospholipase A2 receptor antibodies and immunoglobulin G subtypes in adult idiopathic membranous nephropathy: Clinical value assessment. Clin Chim Acta 2019; 490:135-141. [DOI: 10.1016/j.cca.2018.12.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 12/12/2018] [Accepted: 12/27/2018] [Indexed: 01/13/2023]
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112
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Comparison of measurements of anti-PLA2R antibodies in Japanese patients with membranous nephropathy using in-house and commercial ELISA. Clin Exp Nephrol 2019; 23:465-473. [DOI: 10.1007/s10157-019-01712-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 02/18/2018] [Indexed: 10/27/2022]
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113
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Keri KC, Blumenthal S, Kulkarni V, Beck L, Chongkrairatanakul T. Primary membranous nephropathy: comprehensive review and historical perspective. Postgrad Med J 2019; 95:23-31. [DOI: 10.1136/postgradmedj-2018-135729] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 12/01/2018] [Indexed: 11/04/2022]
Abstract
Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in non-diabetic Caucasian adults over 40 years of age. It has an estimated incidence of 8–10 cases per 1 million. Fifty per cent of patients diagnosed with primary MN continue to have nephrotic syndrome and 30% of patients may progress to end-stage renal disease over 10 years. Although it was recognised as a distinct clinic-pathological entity in 1940s by immunofluorescence and electron microscopy, the pathogenesis and treatment have become more apparent only in the last decade. Discovery of M-type phospholipase A2 receptor (PLA2R) antibodies and thrombospondin type 1 domain-containing 7A antibodies has given new perspectives in understanding the pathogenesis of the disease process. Anti-PLA2R antibody is the first serologic marker that has promising evidence to be used as a tool to prognosticate the course of the disease. More importantly, therapeutic agents such as rituximab and adrenocorticotropic hormone analogues are the newer therapeutic options that should be considered in the therapy of primary MN.
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114
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Han WW, Tang LJ, Kong XL, Yang H, Xu DM. Clinical significance of autoantibodies in the assessment and treatment of idiopathic membranous nephropathy. Exp Ther Med 2018; 17:1825-1830. [PMID: 30783455 DOI: 10.3892/etm.2018.7108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 09/22/2017] [Indexed: 11/05/2022] Open
Abstract
The present study aimed to explore the correlation between the dynamic serum levels of phospholipase A2 receptor (PLA2R), aldose reductase (AR) and superoxide dismutase 2(SOD2) antibodies with disease activity and treatment response in patients with idiopathic membranous nephropathy (IMN). The present study included 56 patients with IMN who were diagnosed through a renal biopsy and presenting with nephrotic syndrome. The patients were divided into two treatment groups: One treated with cyclophosphamide (CTX) and one with tacrolimus (FK506). Serum was collected prior to treatment, and at 1, 3, 6, 9 and 12 months after the start of the 12-month-long therapy. Samples were tested by ELISA to measure anti-PLA2R, anti-AR and anti-SOD2 antibody titers. In addition, urinary protein excretion, serum albumin (Alb) and other blood biochemical indexes were measured. Theanti-PLA2R antibody positivity rate was 71.43% in the patients prior to treatment. After 12 months of treatment, proteinuria and PLA2R antibody levels were decreased, whereas serum Alb was increased. There was no significant difference of remission rates between the CTX and FK506 groups. In conclusion, the results of the present study indicate that the anti-PLA2R antibody level is correlated with the severity of IMN, whereas anti-AR and anti-SOD2 antibody levels are not. In addition, there was no significant difference between the CTX and FK506 groups in regards to the remission rates of patients with IMN.
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Affiliation(s)
- Wen-Wen Han
- Department of Clinical Medicine, Shandong University, Jinan, Shandong 250012, P.R. China.,Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, Shandong 250014, P.R. China
| | - Li-Jun Tang
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, Shandong 250014, P.R. China
| | - Xiang-Lei Kong
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, Shandong 250014, P.R. China
| | - Huan Yang
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, Shandong 250014, P.R. China
| | - Dong-Mei Xu
- Department of Nephrology, Qianfoshan Hospital, Shandong University, Jinan, Shandong 250014, P.R. China
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115
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Szymanski JM, Waldman M, Conry-Cantilena C, West KA. Treatment-resistant PLA2R-negative membranous nephropathy responsive to low-density lipoprotein apheresis. J Clin Apher 2018; 34:495-498. [PMID: 30537217 DOI: 10.1002/jca.21677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 08/31/2018] [Accepted: 11/05/2018] [Indexed: 01/31/2023]
Abstract
Idiopathic membranous nephropathy is the most common cause of nephrotic syndrome in nondiabetic adults. The antibody most often implicated is the M-type phospholipase A2 receptor (PLA2R) antibody, found in >70% of primary membranous nephropathy cases. First-line therapy is immunosuppressive in nature, but for patients who are treatment-resistant there is a significant risk of end-stage renal disease and mortality. Hypercholesterolemia is not only a side effect of nephrotic syndrome, but also its presence may worsen renal function. A recent single-arm observational study in Japan found that low-density lipoprotein apheresis (LDL-A) was able to ameliorate nephrotic syndrome in half of patients who were resistant to medication. We present a case of treatment resistant PLA2R negative membranous nephropathy who had significant improvement following two courses of LDL-A. To our knowledge, this is the first such reported case in the United States.
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Affiliation(s)
- James M Szymanski
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Meryl Waldman
- National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), National Institutes of Health, Bethesda, MD, USA
| | - Cathy Conry-Cantilena
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - Kamille Aisha West
- Department of Transfusion Medicine, National Institutes of Health Clinical Center, Bethesda, MD, USA
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116
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Stahl RA, Reinhard L, Hoxha E. Characterization of autoantibodies in primary membranous nephropathy and their clinical significance. Expert Rev Clin Immunol 2018; 15:165-175. [PMID: 30433832 DOI: 10.1080/1744666x.2019.1548934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Membranous nephropathy (MN) is the most common cause of a nephrotic syndrome in Caucasian adults. The identification of target antigens in MN in the last decade has had a major impact on the clinical approach to these patients. Areas covered: Since the discoveries in animal models in the 1980s that circulating autoantibodies induce disease upon in situ binding to glomerular podocytes, many attempts have been undertaken to define the human antigens responsible for disease induction. Only in 2009 was Phospholipase A2 Receptor 1 described as the major antigen responsible for MN onset in about 70% of patients. Subsequently, in 2014, Thrombospondin Type-1 Domain-Containing 7A was identified as a second antigen, accounting for 2-3% of patients with MN. The knowledge of the role of these antibodies in MN has improved the diagnosis and management of patients and helped to better define the need for immunosuppressive treatment. Expert commentary: These discoveries over the last 10 years in the discipline of nephrology have clearly shown the improvements a better understanding of disease pathogenesis can bring for patient care.
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Affiliation(s)
- Rolf Ak Stahl
- a III. Department of Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Linda Reinhard
- a III. Department of Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Elion Hoxha
- a III. Department of Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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Wetzels JFM. Antibodies Against M-Type Phospholipase Receptor and Prediction of Outcome in Membranous Nephropathy: We are Not There Yet. Am J Nephrol 2018; 48:434-437. [PMID: 30472711 DOI: 10.1159/000494661] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 12/24/2022]
Affiliation(s)
- Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands,
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118
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Song EJ, Jeong KH, Yang YA, Lim JH, Jung HY, Choi JY, Cho JH, Kim CD, Kim YL, Park SH. Anti-phospholipase A2 receptor antibody as a prognostic marker in patients with primary membranous nephropathy. Kidney Res Clin Pract 2018; 37:248-256. [PMID: 30254849 PMCID: PMC6147192 DOI: 10.23876/j.krcp.2018.37.3.248] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 05/21/2018] [Accepted: 05/25/2018] [Indexed: 11/04/2022] Open
Abstract
Background Phospholipase A2 receptor (PLA2R) has been identified as a major autoantigen in primary membranous nephropathy (MN). We evaluated the association between anti-PLA2R antibodies and clinical outcome in Korean patients with primary MN. Methods A total of 66 patients with biopsy-proven MN were included. Serum level of anti-PLA2R antibodies was measured by enzyme-linked immunosorbent assay. Biochemical parameters were estimated initially and at follow-up. Results Anti-PLA2R antibodies were detected in 52.1% and 27.8% of patients with primary and secondary MN, respectively. Forty-eight patients with primary MN were grouped based on presence or absence of anti-PLA2R antibodies. Proteinuria was more severe in anti-PLA2R-positive patients than in anti-PLA2R-negative patients (urine protein/creatinine ratio 7.922 ± 3.985 g/g vs. 4.318 ± 3.304 g/g, P = 0.001), and anti-PLA2R antibody level was positively correlated with proteinuria. The incidence of chronic kidney disease stage ≥ 3 was higher in anti-PLA2R-positive patients compared with anti-PLA2R-negative patients (P = 0.004). The probabilities of spontaneous remission were higher in anti-PLA2R-negative patients compared with anti-PLA2R-positive patients (P < 0.001). Multivariate analysis demonstrated that anti-PLA2R antibodies are an independent risk factor for developing chronic kidney disease stage ≥ 3 and for not reaching spontaneous remission. Conclusion Detection of anti-PLA2R antibodies at diagnosis in patients with primary MN can predict prognosis and guide treatment decisions.
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Affiliation(s)
- Eun Joo Song
- Department of Internal Medicine, Daehyun Chumdan Geriatric Hospital, Daegu, Korea
| | - Kye Hwa Jeong
- Division of Nephrology and Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Young Ae Yang
- Division of Nephrology and Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jeong-Hoon Lim
- Division of Nephrology and Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Hee-Yeon Jung
- Division of Nephrology and Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ji-Young Choi
- Division of Nephrology and Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jang-Hee Cho
- Division of Nephrology and Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Chan-Duck Kim
- Division of Nephrology and Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Yong-Lim Kim
- Division of Nephrology and Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sun-Hee Park
- Division of Nephrology and Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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119
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Definition of a new cut-off for the anti-phospholipase A2 receptor (PLA2R) autoantibody immunoassay in patients affected by idiopathic membranous nephropathy. J Nephrol 2018; 31:899-905. [PMID: 30187382 DOI: 10.1007/s40620-018-0533-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 08/22/2018] [Indexed: 10/28/2022]
Abstract
Autoantibodies against phospholipase A2 receptor (PLA2R) are a sensitive and specific marker for idiopathic membranous nephropathy (IMN). The aim of our study was to redefine the cut-off value for the measurement of anti-PLA2R autoantibody levels by an automated enzyme immunoassay, in a large single-center cohort of Italian IMN patients at the time of diagnosis. Sixty-seven consecutive incident patients, with biopsy-proven IMN, were recruited. All patients were naïve to preceding immunosuppressive therapeutic regimens. The patient population had a mean age of 57 years and included 48 males and 19 females. Also, 200 patients with other renal diseases and 36 healthy subjects were studied as controls. The anti-PLA2R autoantibody levels were measured using the commercial enzyme-linked immunosorbent assay kit at the time of renal biopsy. At a cut-off value of 2.7 RU/ml (significantly lower than the manufacturer's recommended value of 14 RU/ml), calculated by receiver operating characteristic curves, the sensitivity and specificity of anti-PLA2R autoantibodies in the diagnosis of IMN was 88.1 and 96% respectively. The adapted cut-off value of 2.7 UI/ml increased sensitivity without affecting the specificity and it should be the recommended value for this method. Additionally our study confirmed the correlation, at baseline, between anti-PLA2R autoantibody levels and other biomarkers of disease activity.
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120
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Sprangers B, Decoo D, Dive D, Lysandropoulos A, Vanopdenbosch L, Bovy C. Management of adverse renal events related to alemtuzumab treatment in multiple sclerosis: a Belgian consensus. Acta Neurol Belg 2018; 118:143-151. [PMID: 29189966 PMCID: PMC5971040 DOI: 10.1007/s13760-017-0864-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 11/14/2017] [Indexed: 12/04/2022]
Abstract
Alemtuzumab is a humanized monoclonal antibody indicated for the treatment of adult patients with relapsing–remitting multiple sclerosis with active disease. Multiple sclerosis (MS) patients treated with alemtuzumab are at increased risk for autoimmune adverse events (thyroid disorders, immune thrombocytopenia, and renal disease). The use of alemtuzumab has been associated with the development of renal immune-mediated adverse events in 0.3% of patients in clinical trials in MS, which generally occurred within 39 months of the last administration. Both anti-GBM disease and membranous nephropathy have been associated with the use of alemtuzumab. Early detection is necessary to allow for early diagnosis and prevent adverse renal and patient outcomes. Through the implementation of the risk minimization measures, patients can be diagnosed, and treated if needed, early allowing for generally favorable outcomes. This important goal can be reached through health care professional and patient education, careful analysis of the monthly lab tests, and close collaboration between the patient, neurologist, and the nephrologist. This article presents the consensus of Belgian MS specialists and nephrologists on the practicalities of diagnosis, management, and treatment of alemtuzumab-associated renal adverse events based on good clinical practice.
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Affiliation(s)
- Ben Sprangers
- Department of Nephrology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Laboratory for Experimental Transplantation, Department of Microbiology and Immunology, University of Leuven, Leuven, Belgium.
| | - D Decoo
- Neurology Department, AZ Alma, Gentse Steenweg 132, 8340, Sijsele, Belgium
| | - D Dive
- Service de Neurologie, CHU Liège, Esneux, Belgium
| | - A Lysandropoulos
- Neuroimmunology, MS Unit, Neurology Department, CUB, Hôpital Erasme, Route de Lennik 808, 1070, Brussels, Belgium
| | - L Vanopdenbosch
- Department of Neurology, AZ Sint Jan Brugge Oostende, Ruddershove 10, 8000, Brugge, Belgium
| | - C Bovy
- Service de Néphrologie, CHU Sart-Tilman, B35, 4000, Liège, Belgium
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Wu W, Shang J, Tao C, Wang S, Hu X, Zhang S, Zhao Z. The prognostic value of phospholipase A2 receptor autoantibodies on spontaneous remission for patients with idiopathic membranous nephropathy: A meta-analysis. Medicine (Baltimore) 2018; 97:e11018. [PMID: 29879066 PMCID: PMC5999502 DOI: 10.1097/md.0000000000011018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 05/18/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The presence of antibodies against phospholipase A2 receptor (PLA2R-Abs) in serum at diagnosis is reported to be related to the rate of spontaneous remission in patients with idiopathic membranous nephropathy (IMN); however, there is still lack of enough samples to illustrate this problem. Here, we conducted a comprehensive meta-analysis to investigate the prognostic value of PLA2R-Abs on spontaneous remission for IMN patients in the absence of immunosuppressive therapy. METHODS A systematic search of the PubMed, EMBASE, and Cochrane Central databases was performed for relevant original articles published until October 2017. All studies focus on spontaneous remission rates in IMN patients associated with PLA2R-Abs, the endpoint of interest is spontaneous remission rate. Risk ratio (RR) and corresponding 95% confidence intervals (CI) were carried out using a fixed or random effects model. The data were analyzed by Review Manager 5.3 software. RESULTS A total of 5 articles involving 190 patients were included in this meta-analysis. There were significant differences between the 2 groups in spontaneous remission rate. The seropositive of PLA2R-Abs measured at the time of diagnosis was negatively correlated with the likelihood of spontaneous remission (RR = 0.69; 95% CI, 0.56-0.87; P = .001). CONCLUSION In PLA2R-Abs seronegative patients, the spontaneous remission rate is higher than that of PLA2R-Abs seropositive patients during symptomatic treatment. Therefore, in order to avoid malignant events caused by immunosuppressive therapy, maybe it is more beneficial to adopt conservative treatment for PLA2R-Abs seronegative patients at initial treatment.
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Preparation of an epitope-based recombinant diagnostic antigen specific to anti-phospholipase A 2 receptor 1 antibodies. BMC Biotechnol 2018; 18:31. [PMID: 29843797 PMCID: PMC5975665 DOI: 10.1186/s12896-018-0448-8] [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: 12/17/2017] [Accepted: 05/18/2018] [Indexed: 01/14/2023] Open
Abstract
Background According to recent studies, the phospholipase A2 receptor 1 (PLA2R1) may be used as a biomarker to diagnose idiopathic membranous nephropathy (iMN). Moreover, the immune-dominant regions of PLA2R1 have been identified. The aim of the present study was to construct a diagnostic antigen based on the immune-dominant region of PLA2R1 and develop a specific serological detection method for PLA2R1 antibodies. Results The tandem multi-epitope diagnostic antigen (designated ‘R101’), which includes aa 39–130 (CysR), aa 238–356 (CTLD1), and aa 1136–1234 (CTLD7) of PLA2R1; thioredoxin at the N-terminus; and a His tag at the C-terminus, was prepared at a concentration of 2.36 mg/mL and purity of 97.32% using Escherichia coli expression and affinity and anion exchange chromatography purification. The integrity and antigenicity of the R101 protein was demonstrated by western blot analysis using anti-Trx, anti-His, and anti-PLA2R1 monoclonal antibodies as the primary antibodies. By analysing 120 positive serum samples identified by biopsy-proven iMN (gold standard) and 240 negative samples identified by an established ELISA based on R101 protein, we concluded that the cut-off value, kappa value, sensitivity, specificity, and agreement rate were 0.305, 0.881, 91.67, 96.25, and 94.72% respectively. The receiver operating characteristic (ROC) curve illustrated that the diagnostic accuracy and practicability of the ELISA was excellent. The area under the curve was 0.986. Conclusions Using prokaryotic expression and chromatography purification, immune-dominant regions of PLA2R1 with excellent antigenicity can be prepared and applied to serological detection of PLA2R1 antibodies.
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Affiliation(s)
- Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
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124
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Li W, Zhao Y, Fu P. Diagnostic Test Accuracy of Serum Anti-PLA2R Autoantibodies and Glomerular PLA2R Antigen for Diagnosing Idiopathic Membranous Nephropathy: An Updated Meta-Analysis. Front Med (Lausanne) 2018; 5:101. [PMID: 29755981 PMCID: PMC5932148 DOI: 10.3389/fmed.2018.00101] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/28/2018] [Indexed: 02/05/2023] Open
Abstract
Background M-type phospholipase A2 receptor (PLA2R) is known as a major antigen on podocytes, which is involved with the pathogenesis of idiopathic membranous nephropathy (iMN). Many studies have shown that serum anti-PLA2R autoantibodies (sPLA2R) are prevalent in patients with iMN but are rarely detected in secondary membranous nephropathy (SMN) or other glomerulonephritis. The anti-PLA2R is considered as a promising serum biomarker in iMN but reports about its diagnostic value are variable and inconsistent. Objective To evaluate the diagnostic test accuracy (DTA) of anti-PLA2R and glomerular PLA2R antigen (gPLA2R) for diagnosing iMN. Method MEDLINE, EMBASE, WEB OF SCIENCE, and COCHRANE LIBRARY were searched from 2009 January to February 2018. Heterogeneity was evaluated by Q test and I2. Source of heterogeneity was explored by subgroup analysis and meta-regression. Meta-analysis was executed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. Results Totally, 35 studies were retrieved under the pre-set study eligibility criteria. Twenty-eight studies were included to evaluate the DTA of anti-PLA2R for differentiating iMN from non-iMN. They indicated a pooled sensitivity of 65% (63–67%), specificity of 97% (97–98%), positive likelihood ratio of 15.65 (9.95–24.62), and negative likelihood ratio of 0.37 (0.32–0.42) with a diagnostic OR (sDOR) of 50.41 (31.56 to 80.52) and AUC of 0.9393. No threshold effect was detected. The heterogeneity analysis for sDOR showed that I2 = 50.3% and Cochran-Q = 54.29, df = 27 (p = 0.0014). Heterogeneity was significant. Meta-regression revealed that sample size might be the potential source of heterogeneity. Subgroup analysis demonstrated that method type and ratio of patients with nephrotic-range proteinuria at baseline might be the source of heterogeneity. Sixteen studies reported the diagnostic value of glomerular PLA2R antigen for differentiating iMN from non-iMN. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, sDOR, and AUC were 79% (76–81%), 90% (88–92%), 8.17 (5.60–11.93), 0.25 (0.19–0.33), 39.37 (22.18–60.13), and 0.9278. Heterogeneity analysis showed that Cochran-Q = 35.36; df = 15 (p = 0.002), and I2 for sDOR was 57.6%. Conclusion sPLA2R and gPLA2R demonstrated a good diagnostic accuracy in differentiating iMN and non-iMN.
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Affiliation(s)
- Weiying Li
- Division of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yuliang Zhao
- Division of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ping Fu
- Division of Nephrology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Liang Q, Li H, Xie X, Qu F, Li X, Chen J. The efficacy and safety of tacrolimus monotherapy in adult-onset nephrotic syndrome caused by idiopathic membranous nephropathy. Ren Fail 2018; 39:512-518. [PMID: 28562168 PMCID: PMC6014322 DOI: 10.1080/0886022x.2017.1325371] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction: The purpose of the study is to evaluate the efficiency and safety of tacrolimus (TAC) monotherapy in the treatment of nephrotic idiopathic membranous nephropathy (IMN) compared with the protocol of cyclophosphamide (CTX) combined with corticosteroids. Methods: In total, 58 patients with nephrotic syndrome and biopsy-proven IMN were included in this study. 30 patients received TAC monotherapy with an initial dose of 0.05–0.1 mg/kg/day. 28 patients received transvenous CTX at a dose of 0.5–0.75 g/m2 once in every month initially for 6 months and once in every 2 or 3 months for the later period, and the regimen was combined with corticosteroids (prednisone 1 mg/kg/d). All patients were observed for the treatment effects, recurrence and side effects. Results: Twelve months after the initial treatment, a total of 24 (80%) patients in the TAC group and 23 (82.1%) patients in the CTX group achieved remission (either partial or complete remission). The survival curve of the probability of remission and complete remission were similar between the two groups (p > .05). Proteinuria (based on 24 h urinary protein excretion) was significantly decreased, and serum albumin was significantly increased after immunosuppressive treatment in both the groups. Estimated glomerular filtration rate (eGFR) was comparable between before and after treatment. The main adverse effects in TAC treatment were glucose intolerance, diabetes and abnormal aminotransferase. Conclusions: TAC monotherapy is an alternative therapeutic regimen for patients with nephrotic IMN. Its short-term efficiency and patient tolerance are both acceptable.
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Affiliation(s)
- Qian Liang
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Heng Li
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Xishao Xie
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Fangzhi Qu
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Xiayu Li
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
| | - Jianghua Chen
- a Kidney Disease Center, The First Affiliated Hospital, College of Medicine , Zhejiang University , Hangzhou , China
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Hamilton P, Kanigicherla D, Venning M, Brenchley P, Meads D. Rituximab versus the modified Ponticelli regimen in the treatment of primary membranous nephropathy: a Health Economic Model. Nephrol Dial Transplant 2018; 33:2145-2155. [DOI: 10.1093/ndt/gfy049] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 01/28/2018] [Indexed: 01/15/2023] Open
Affiliation(s)
- Patrick Hamilton
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Durga Kanigicherla
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Michael Venning
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - Paul Brenchley
- Manchester Institute of Nephrology and Transplantation, Manchester Royal Infirmary, Manchester, UK
| | - David Meads
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, Charles Thackrah Building, University of Leeds, Leeds, UK
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Seifert L, Hoxha E, Eichhoff AM, Zahner G, Dehde S, Reinhard L, Koch-Nolte F, Stahl RAK, Tomas NM. The Most N-Terminal Region of THSD7A Is the Predominant Target for Autoimmunity in THSD7A-Associated Membranous Nephropathy. J Am Soc Nephrol 2018; 29:1536-1548. [PMID: 29555830 DOI: 10.1681/asn.2017070805] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 02/09/2018] [Indexed: 01/22/2023] Open
Abstract
Background Thrombospondin type 1 domain-containing 7A (THSD7A) has been identified as a pathogenic autoantigen in membranous nephropathy (MN). However, the THSD7A epitopes targeted by patient autoantibodies are unknown.Methods We performed an in silico analysis of the THSD7A multidomain structure, expressed the folded domains in HEK293 cells, and tested for domain reactivity with 31 serum samples from patients with THSD7A-associated MN using Western and native blotting. Immunogenicity of the antigen domains was further investigated by cDNA immunization of rabbits and mice.Results We characterized the extracellular topology of THSD7A as a tandem string of 21 thrombospondin type 1 domains. Overall, 28 serum samples (90%) recognized multiple epitope domains along the molecule. Detailed epitope mapping revealed that the complex consisting of the first and second N-terminal domains (amino acids 48-192) was recognized by 27 of 31 patient serum samples (87%). Serum recognizing one or two epitope domains showed lower anti-THSD7A antibody levels than serum recognizing three or more epitope domains. During follow-up, a loss of epitope recognition was observed in seven of 16 patients, and it was accompanied by decreasing antibody levels and remission of proteinuria. In four of 16 patients, epitope recognition patterns changed during follow-up. Notably, immunization experiments in rabbits and mice revealed that induced antibodies, like patient autoantibodies, preferentially bound to the most N-terminal domains of THSD7A.Conclusions Our data show that the immune response in THSD7A-associated MN is polyreactive and that autoantibodies predominantly target the most N-terminal part of THSD7A.
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Affiliation(s)
| | | | - Anna M Eichhoff
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | - Friedrich Koch-Nolte
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Moroni G, Depetri F, Del Vecchio L, Gallelli B, Raffiotta F, Giglio E, Brunini F, D'Amico M, Longhi S, Radice A, Messa P, Sinico RA. Low-dose rituximab is poorly effective in patients with primary membranous nephropathy. Nephrol Dial Transplant 2018; 32:1691-1696. [PMID: 27387472 DOI: 10.1093/ndt/gfw251] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 05/28/2016] [Indexed: 11/14/2022] Open
Abstract
Background The optimal dosing and the efficacy of rituximab for primary membranous nephropathy (PMN) has not been established. This multicentric prospective study evaluates the efficacy and safety of low-dose rituximab (RTX) therapy in patients with PMN in clinical practice. Methods Thirty-four consecutive patients with PMN and nephrotic syndrome were included and received RTX (375 mg/m2) once (18 patients) or twice (16 patients). RTX was the first-line therapy for 19 (56%) and the second line for 15 (44%) patients. All patients were followed for 12 months after RTX and 24 for at least 18 months (mean 23.9 ± 18.6 months). Results At 12 months, 5 patients (14.7%) achieved complete response, 10 (29.4%) partial and 19 (55.8%) no response. Response occurred ∼6 months after RTX. At 24 months, the clinical situation was unchanged: two non-responders achieved partial response and two responders relapsed. Responders had significantly higher baseline GFR and lower anti-PLA2R antibodies compared with non-responders. Outcome was similar between one or two doses of RTX (non-responders 55.5 versus 56%, respectively) and between patients who had received previous therapy versus those receiving RTX as first-line therapy (non-responders 40 versus 68%, respectively). In the 15 patients already treated, the response to RTX was comparable to that of previous therapies. Conclusion Low-dose RTX obtains remission in <50% of PMN patients. Probably, higher doses and longer treatments are needed to induce and maintain a response. The balance between the costs and benefits should guide the selection of the patient and the optimal dosage.
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Affiliation(s)
- Gabriella Moroni
- Nephrological Unit, Fondazione Ca' Granda IRCCS Ospedale Maggiore Policlinico Milano, Italy
| | - Federica Depetri
- Nephrological Unit, Fondazione Ca' Granda IRCCS Ospedale Maggiore Policlinico Milano, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, A. Manzoni Hospital, Lecco, Italy
| | | | - Francesca Raffiotta
- Nephrological Unit, Fondazione Ca' Granda IRCCS Ospedale Maggiore Policlinico Milano, Italy
| | - Elisa Giglio
- Nephrological Unit, Fondazione Ca' Granda IRCCS Ospedale Maggiore Policlinico Milano, Italy
| | - Francesca Brunini
- Clinical Immunology Unit & Renal Unit, S. Carlo Borromeo Hospital, Milano, Italy
| | | | - Selena Longhi
- Department of Nephrology and Dialysis, A. Manzoni Hospital, Lecco, Italy
| | - Antonella Radice
- Microbiology and Virology Department, S. Carlo Borromeo Hospital, Milano, Italy
| | - Piergiorgio Messa
- Nephrological Unit, Fondazione Ca' Granda IRCCS Ospedale Maggiore Policlinico Milano, Italy
| | - Renato Alberto Sinico
- Department of Medicine and Surgery, Università degli Studi di Milano, Monza (MB), Italy
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Rodas LM, Matas-García A, Barros X, Blasco M, Viñas O, Llobell A, Martin N, Quintana LF. Antiphospholipase 2 receptor antibody levels to predict complete spontaneous remission in primary membranous nephropathy. Clin Kidney J 2018; 12:36-41. [PMID: 30747150 PMCID: PMC6366127 DOI: 10.1093/ckj/sfy005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 12/27/2017] [Indexed: 11/13/2022] Open
Abstract
Background M-type phospholipase A2 receptor (APLA2R) is considered the major antigen involved in the pathogenesis of adult primary membranous nephropathy (MN), which is the leading cause of non-diabetic nephrotic syndrome. Antibodies to this antigen have been proved to be an excellent biomarker of disease activity in primary MN. In fact, preliminary data suggest that the higher the antibody level the more proteinuria, and that a decrease in antibody level precedes the remission of proteinuria, but more solid evidence is needed. Methods The present work aims to characterize the predictive value of the level of antibodies against PLA2R as a biomarker of disease course and treatment response in a well-defined cohort of 62 patients from University Hospitals Clinic of Barcelona and Josep Trueta in Girona. The primary outcome was the appearance of a spontaneous complete remission (CR), defined as induction of a CR without the use of immunosuppressive agents. Results In common with other reports, this work confirms that spontaneous CR is more frequent in patients with low titre of APLA2R at diagnosis, but strikingly, in this cohort we found that spontaneous CR was achieved in patients with APLA2R levels <40 UI/mL. Furthermore, spontaneous CR were less frequently observed in patients with proteinuria >8 g/day. Conclusions In conclusion, these findings point out the important role of APLA2R as a tool to predict the disease course and establish personalized therapeutic options at the moment of diagnosis of primary MN. Specifically, patients with low titre of APLA2R (<40 UI/mL) and proteinuria <4/day could obtain benefit of a longer period of follow-up with conservative treatment after diagnosis.
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Affiliation(s)
- Lida M Rodas
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Departamento de Medicina, Universidad de Barcelona, Institut d' Invesigacions biomèdiques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ana Matas-García
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Departamento de Medicina, Universidad de Barcelona, Institut d' Invesigacions biomèdiques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Xoana Barros
- Servicio de Nefrología, Hospital Josep Trueta, Girona, Spain
| | - Miquel Blasco
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Departamento de Medicina, Universidad de Barcelona, Institut d' Invesigacions biomèdiques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Odette Viñas
- Servicio de Inmunología, Centro de Diagnóstico Biomédico (CDB), Hospital Clínic, Barcelona, Spain
| | - Arturo Llobell
- Servicio de Inmunología, Centro de Diagnóstico Biomédico (CDB), Hospital Clínic, Barcelona, Spain
| | - Nadia Martin
- Servicio de Nefrología, Hospital Josep Trueta, Girona, Spain
| | - Luis F Quintana
- Servicio de Nefrología y Trasplante Renal, Hospital Clínic, Departamento de Medicina, Universidad de Barcelona, Institut d' Invesigacions biomèdiques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain
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Dettmar AK, Wiech T, Kemper MJ, Soave A, Rink M, Oh J, Stahl RAK, Hoxha E. Immunohistochemical and serological characterization of membranous nephropathy in children and adolescents. Pediatr Nephrol 2018; 33:463-472. [PMID: 29034405 DOI: 10.1007/s00467-017-3817-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 09/12/2017] [Accepted: 09/13/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Membranous nephropathy (MN) is a common cause of nephrotic syndrome in adults, but is less frequent in children. Antibodies against four antigens leading to MN have been described in children: phospholipase A2 receptor 1 (PLA2R1), thrombospondin type-1 domain-containing 7A (THSD7A), neutral endopeptidase (NEP), and cationic bovine serum albumin (BSA). METHODS Twelve children with MN were included in this study. Sera of all patients were analyzed for antibodies against PLA2R1, THSD7A, NEP, and BSA. All sera were also analyzed using Western blot with human glomerular extracts (HGE) under non reducing conditions. In 5 cases renal biopsies were analyzed for PLA2R1, THSD7A, NEP, BSA, and all IgG subclasses. RESULTS Six patients were PLA2R1-antibody-positive, whereas THSD7A, NEP, and BSA antibodies were not found in any of our 12 patients. All sera were analyzed by Western blot using human glomerular extracts; however, no further potential antigens were found. Five kidney biopsies from 2 PLA2R1-antibody-positive and 3 PLA2R1-antibody-negative patients were available for additional analyses, confirming the diagnosis of PLA2R1-associated MN in 2 cases, whereas none of the biopsies revealed enhanced staining for THSD7A, NEP or BSA. IgG2 and IgG4 stainings were positive in both patients with PLA2R1-associated MN and negative in the other biopsies. During follow-up (median 24 months), 4 children with PLA2R1-associated MN went into remission, preceded by decline of PLA2R1 antibodies. Five of the 6 PLA2R1-antibody-negative children went into remission. CONCLUSIONS In children with MN, PLA2R1-associated MN appears to be common, whereas MN associated with THSD7A, NEP or BSA was not encountered. PLA2R1 antibody levels are closely associated with disease activity, whereas PLA2R1-antibody-negative patients often have a good prognosis. However, the pathophysiology of MN in a considerable number of children remains unclear.
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Affiliation(s)
- Anne K Dettmar
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Wiech
- Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Markus J Kemper
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Asklepios Klinik Nord-Heidberg, Hamburg, Germany
| | - Armin Soave
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Rink
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jun Oh
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf A K Stahl
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Elion Hoxha
- III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Abstract
IgG4 autoimmune diseases are characterized by the presence of antigen-specific autoantibodies of the IgG4 subclass and contain well-characterized diseases such as muscle-specific kinase myasthenia gravis, pemphigus, and thrombotic thrombocytopenic purpura. In recent years, several new diseases were identified, and by now 14 antigens targeted by IgG4 autoantibodies have been described. The IgG4 subclass is considered immunologically inert and functionally monovalent due to structural differences compared to other IgG subclasses. IgG4 usually arises after chronic exposure to antigen and competes with other antibody species, thus "blocking" their pathogenic effector mechanisms. Accordingly, in the context of IgG4 autoimmunity, the pathogenicity of IgG4 is associated with blocking of enzymatic activity or protein-protein interactions of the target antigen. Pathogenicity of IgG4 autoantibodies has not yet been systematically analyzed in IgG4 autoimmune diseases. Here, we establish a modified classification system based on Witebsky's postulates to determine IgG4 pathogenicity in IgG4 autoimmune diseases, review characteristics and pathogenic mechanisms of IgG4 in these disorders, and also investigate the contribution of other antibody entities to pathophysiology by additional mechanisms. As a result, three classes of IgG4 autoimmune diseases emerge: class I where IgG4 pathogenicity is validated by the use of subclass-specific autoantibodies in animal models and/or in vitro models of pathogenicity; class II where IgG4 pathogenicity is highly suspected but lack validation by the use of subclass specific antibodies in in vitro models of pathogenicity or animal models; and class III with insufficient data or a pathogenic mechanism associated with multivalent antigen binding. Five out of the 14 IgG4 antigens were validated as class I, five as class II, and four as class III. Antibodies of other IgG subclasses or immunoglobulin classes were present in several diseases and could contribute additional pathogenic mechanisms.
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Affiliation(s)
- Inga Koneczny
- Institute of Neurology, Medical University of Vienna, Vienna, Austria
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Lin L, Wang WM, Pan XX, Xu J, Gao CN, Zhang W, Ren H, Xie JY, Shen PY, Xu YW, Ni LY, Chen N. Biomarkers to detect membranous nephropathy in Chinese patients. Oncotarget 2018; 7:67868-67879. [PMID: 27634909 PMCID: PMC5356526 DOI: 10.18632/oncotarget.12014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 09/05/2016] [Indexed: 11/29/2022] Open
Abstract
Anti-M-type phospholipase A2 receptor (anti-PLA2R) is a widely accepted biomarker for clinical idiopathic membranous neurophathy (IMN). However, its ability to differentiate between IMN and secondary MN (SMN) is controversial. The objective of this study was to assess clinical MN biomarkers in blood, tissue and urine samples from Chinese patients. In total, 195 MN patients and 70 patients with other glomerular diseases were prospectively enrolled in the study. Participants were followed up for average of 17 months (range 3-39 months). Anti-PLA2R and anti-THSD7A (thrombospondin type-1 domain-containing 7A) were detected only in MN patient sera and not in controls. Serum anti-THSD7A and THSD7A-positive biopsies were detected in 1/18 and 2/18 PLA2R-negative MN cases, respectively. PLA2R and THSD7A were detected in 72.27% and 40% of SMN cases, respectively. While serum positivity for both anti-PLA2R and anti-THSD7A at the time of renal biopsy was specific to MN patients, neither antigen could discriminate between primary and secondary MN. We also found that high urinary levels of retinol binding protein (RBP) predicted poor proteinuria outcomes in study participants. Patients with low or medium urinary RBP levels achieved remission more frequently than those with high RBP.
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Affiliation(s)
- Li Lin
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Wei Ming Wang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao Xia Pan
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jing Xu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Chen Ni Gao
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Wen Zhang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Hong Ren
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Jing Yuan Xie
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Pin Yan Shen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yao Wen Xu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Li Yan Ni
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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Membranous Nephropathy and Anti-Podocytes Antibodies: Implications for the Diagnostic Workup and Disease Management. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6281054. [PMID: 29511687 PMCID: PMC5817285 DOI: 10.1155/2018/6281054] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/31/2017] [Accepted: 10/15/2017] [Indexed: 12/11/2022]
Abstract
The discovery of circulating antibodies specific for native podocyte antigens has transformed the diagnostic workup and greatly improved management of idiopathic membranous nephropathy (iMN). In addition, their identification has clearly characterized iMN as a largely autoimmune disorder. Anti-PLA2R1 antibodies are detected in approximately 70% to 80% and anti-THSD7A antibodies in only 2% of adult patients with iMN. The presence of anti-THSD7A antibodies is associated with increased risk of malignancy. The assessment of PLA2R1 and THSD7A antigen expression in glomerular immune deposits has a better sensitivity than measurement of the corresponding autoantibodies. Therefore, in the presence of circulating anti-podocytes autoantibodies and/or enhanced expression of PLA2R1 and THSD7A antigens MN should be considered as primary MN (pMN). Anti-PLA2R1 or anti-THSD7A autoantibodies have been proposed as biomarkers of autoimmune disease activity and their blood levels should be regularly monitored in pMN to evaluate disease activity and predict outcomes. We propose a revised clinical workup flow for patients with MN that recommends assessment of kidney biopsy for PLA2R1 and THSD7A antigen expression, screening for circulating anti-podocytes antibodies, and assessment for secondary causes, especially cancer, in patients with THSD7A antibodies. Persistence of anti-podocyte antibodies for 6 months or their increase in association with nephrotic proteinuria should lead to the introduction of immunosuppressive therapies. Recent data have reported the efficacy and safety of new specific therapies targeting B cells (anti-CD20 antibodies, inhibitors of proteasome) in pMN which should lead to an update of currently outdated treatment guidelines.
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Dobronravov VA, Mayer DA, Berezhnaya OV, Lapin SV, Mazing AV, Sipovsky VG, Smirnov AV. [Membranous nephropathy in a Russian population]. TERAPEVT ARKH 2017; 89:21-29. [PMID: 28745685 DOI: 10.17116/terarkh201789621-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To analyze the clinical and morphological manifestations of membranous nephropathy (MN) and to evaluate the efficiency of its therapy. MATERIAL AND METHODS MN cases in 2009 to 2016 were retrospectively detected with a subsequent analysis of patients with primary MN (PMN). The titer of IgG-autoantibodies to phospholipase A2 receptor (anti-PLA2R Ab) was determined by an indirect immunofluorescence assay. Treatment outcomes, such as the time course of changes in proteinuria, nephrotic syndrome (NS), and the development of complete and partial remissions (CR and PR), were assessed. RESULTS MN was detected in 201 cases; the secondary etiology of the disease was established in 24.9%. The prevalence of MN among morphologically confirmed glomerulopathies was 14%; that of PMN was 10.4%. The median period to diagnosis PMN was 8 (5; 19) months. 150 patients with PMN (66.7% were men; age was 50±15 years) were distributed according to the following morphological stages: Stages I (23.9%), II (48.5%), III (26.1%), and IV (1.5%). Elevated anti-PLA2R Ab levels were found in 51.6% of cases; NS in the presence of proteinuria was detected in 85.6% of patients. An estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2 was seen in 25% of cases. Treatment outcomes were evaluated in 80 cases; the median follow-up period was 19 (8; 40) months. 68% of cases had CR (32%) or PR (36%) with a median follow-up of 26 (13; 44) months. Spontaneous CRs or PRs were observed in 7.5% of the patients. Multivariate analysis showed that the probability of CR or PR increased 3.2-fold in the use of cyclophosphamide and/or cyclosporine and decreased as eGFR dropped. CONCLUSION In Russia, PMN is a common type of glomerulopathy, the specific features of which should include the low rates of spontaneous remissions and detection of anti-PLA2R Abs. For renal protection, the majority of patients with PMN require timely diagnosis and treatment; individualization of the choice of treatment and its enhanced efficiency call for further investigations.
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Affiliation(s)
- V A Dobronravov
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - D A Mayer
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - O V Berezhnaya
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - S V Lapin
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - A V Mazing
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - V G Sipovsky
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - A V Smirnov
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
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Xipell M, Rodas LM, Villarreal J, Molina A, Reinoso-Moreno J, Blasco M, Poch E, Diekmann F, Campistol JM, Quintana LF. The utility of phospholipase A2 receptor autoantibody in membranous nephropathy after kidney transplantation. Clin Kidney J 2017; 11:422-428. [PMID: 29988247 PMCID: PMC6007417 DOI: 10.1093/ckj/sfx128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 09/28/2017] [Indexed: 01/31/2023] Open
Abstract
Membranous nephropathy (MN) is estimated to cause end-stage renal disease in ∼ 5% of patients, in whom renal transplantation is the therapy of choice. Among patients receiving a transplant for MN, the disease will recur in the graft in 30–50%; among these, graft loss will occur in 50% within 10 years. Several studies have suggested that phospholipase A2 receptor autoantibody (aPLA2R) levels before transplantation might be useful in predicting recurrence, and their titration after transplantation is clinically relevant to assess the risk of recurrence and progression, to guide treatment indications and to monitor treatment response. In this review we describe the evolving role of aPLA2R as a biomarker in primary MN and its current usefulness in predicting recurrence of this autoimmune podocytopathy after renal transplantation.
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Affiliation(s)
- Marc Xipell
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Lida M Rodas
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Jesús Villarreal
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Alicia Molina
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Johanna Reinoso-Moreno
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Esteban Poch
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Fritz Diekmann
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Jose M Campistol
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
| | - Luis F Quintana
- Nephrology and Renal Transplantation Department, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universidad de Barcelona, Barcelona, Spain
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Liu Y, Li X, Ma C, Wang P, Liu J, Su H, Zhuo H, Kong X, Xu D, Xu D. Serum anti-PLA2R antibody as a diagnostic biomarker of idiopathic membranous nephropathy: The optimal cut-off value for Chinese patients. Clin Chim Acta 2017; 476:9-14. [PMID: 29126817 DOI: 10.1016/j.cca.2017.11.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 11/04/2017] [Accepted: 11/06/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The M-type phospholipase A2 receptor (PLA2R) is a specific target autoantigen identified in idiopathic membranous nephropathy (IMN). The autoantibody against PLA2R (anti-PLA2R) may be used to diagnose IMN. However, the appropriate diagnosis cut-off value for Chinese patients with IMN has not been established. METHODS In total, 119 patients who underwent renal biopsy (57 patients with IMN and 62 patients with non-IMN glomerulonephritis) and 22 healthy individuals were recruited for our observation study from Qianfoshan Hospital between September 2011 and March 2016. The serum concentration of anti-PLA2R was measured using a quantitative enzyme-linked immunosorbent assay (ELISA). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and receiver operating characteristic (ROC) curve of anti-PLA2R in diagnosing IMN were analysed based on the ELISA detection. RESULTS The sensitivity, specificity, PPV, and NPV of anti-PLA2R in the diagnosis of IMN in the Chinese patients were 82.5, 75, 69.1, and 86.3% for the 2RU/ml cut-off value; 78.9, 91.7, 86.5, and 86.5% for the 2.6RU/ml cut-off value; 59.6, 95.2, 89.5, and 77.7% for the 14RU/ml cut-off value; 50.9, 96.4, 90.6, and 74.3% for the 20RU/ml cut-off value; and 47.4, 97.6, 93.1, and 73.2% for the 40RU/ml cut-off value, respectively. The area under the ROC curve was 0.879. CONCLUSIONS The cut-off value of 2.6RU/ml is recommended for the use of anti-PLA2R for the diagnosis of IMN in Chinese patients based on the ELISA.
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Affiliation(s)
- Yipeng Liu
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, China.
| | - Xuan Li
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, China
| | - Chaoqun Ma
- Department of Emergency, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250014, China
| | - Ping Wang
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, China
| | - Ju Liu
- Medical Research Center, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, China
| | - Hong Su
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, China
| | - Hao Zhuo
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, China
| | - Xianglei Kong
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, China
| | - Dayu Xu
- Department of Nephrology, Zibo Central Hospital, Zibo 255000, China
| | - Dongmei Xu
- Department of Nephrology, Shandong Provincial Qianfoshan Hospital, Shandong University, Jinan 250014, China.
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Hamilton P, Kanigicherla D, Hanumapura P, Walz L, Kramer D, Fischer M, Brenchley P, Mitra S. Peptide GAM immunoadsorption therapy in primary membranous nephropathy (PRISM): Phase II trial investigating the safety and feasibility of peptide GAM immunoadsorption in anti-PLA2
R positive primary membranous nephropathy. J Clin Apher 2017; 33:283-290. [DOI: 10.1002/jca.21599] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/06/2017] [Accepted: 10/06/2017] [Indexed: 12/11/2022]
Affiliation(s)
- Patrick Hamilton
- Manchester Institute of Nephrology & Transplantation; Manchester Royal Infirmary; Oxford Road, Manchester M13 9WL United Kingdom
| | - Durga Kanigicherla
- Manchester Institute of Nephrology & Transplantation; Manchester Royal Infirmary; Oxford Road, Manchester M13 9WL United Kingdom
| | - Prasanna Hanumapura
- Manchester Institute of Nephrology & Transplantation; Manchester Royal Infirmary; Oxford Road, Manchester M13 9WL United Kingdom
| | - Lars Walz
- Fresenius Medical Care Deutschland GmbH; Else-Kröner-Straße 1, Bad Homburg 61352 Germany
| | - Dieter Kramer
- Fresenius Medical Care Deutschland GmbH; Else-Kröner-Straße 1, Bad Homburg 61352 Germany
| | - Moritz Fischer
- Fresenius Medical Care Deutschland GmbH; Else-Kröner-Straße 1, Bad Homburg 61352 Germany
| | - Paul Brenchley
- Manchester Institute of Nephrology & Transplantation; Manchester Royal Infirmary; Oxford Road, Manchester M13 9WL United Kingdom
| | - Sandip Mitra
- Manchester Institute of Nephrology & Transplantation; Manchester Royal Infirmary; Oxford Road, Manchester M13 9WL United Kingdom
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Angioi A, Lepori N, López AC, Sethi S, Fervenza FC, Pani A. Treatment of primary membranous nephropathy: where are we now? J Nephrol 2017; 31:489-502. [PMID: 28875476 DOI: 10.1007/s40620-017-0427-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/26/2017] [Indexed: 02/02/2023]
Abstract
In the last 10 years, basic science and clinical research have made important contributions to the understanding and management of primary membranous nephropathy (MN). The identification of antibodies directed against the M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing 7A protein have added a new perspective on diagnosis, monitoring the immunological activity, predicting prognosis and guiding therapy in patients with primary MN. Mounting evidence suggests that quantification and follow-up of antiPLA2R Abs levels can help in assessing prognosis and evaluate the response to treatment. The kidney disease improving global outcomes guidelines published in 2012 have not been updated. New data on the use of rituximab suggest it should be considered as a potential initial therapy in the treatment of patients with primary MN.
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Affiliation(s)
- Andrea Angioi
- Division of Nephrology and Dialysis, Azienda Ospedaliera G. Brotzu, Piazzale Ricchi n 1, 09100, Cagliari, Italy
| | - Nicola Lepori
- Division of Nephrology and Dialysis, Azienda Ospedaliera G. Brotzu, Piazzale Ricchi n 1, 09100, Cagliari, Italy
| | - Ana Coloma López
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, USA
| | - Sanjeev Sethi
- Department of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Antonello Pani
- Division of Nephrology and Dialysis, Azienda Ospedaliera G. Brotzu, Piazzale Ricchi n 1, 09100, Cagliari, Italy.
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Xu NX, Xie QH, Sun ZX, Wang J, Li Y, Wang L, Liu SJ, Xue J, Hao CM. Renal Phospholipase A2 Receptor and the Clinical Features of Idiopathic Membranous Nephropathy. Chin Med J (Engl) 2017; 130:892-898. [PMID: 28397717 PMCID: PMC5407034 DOI: 10.4103/0366-6999.204096] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: According to the renal phospholipase A2 receptor (PLA2R) immunohistochemistry, idiopathic membranous nephropathy (iMN) could be categorized into PLA2R-associated and non-PLA2R-associated iMN. This study aimed to examine whether the non-PLA2R-associated iMN had any difference in clinical features compared with PLA2R-associated iMN. Methods: A total of 231 adult patients diagnosed as iMN were recruited to this retrospective study. Renal PLA2R expression was examined by immunofluorescence. Among these patients, 186 (80.5%) with complete baseline clinical data were used for further study. Urinary protein excretion, serum albumin, and creatinine were analyzed. For those patients with follow-up longer than 1 year, the relationship between PLA2R and response to immunosuppressants were analyzed. The t-test was used for parametric analysis and the Mann-Whitney U-test was used for nonparametric analysis. Categorical variables were described as frequencies or percentages, and the data were analyzed with Pearson's Chi-square test or Fisher's exact test. Results: Of the 231 iMN patients, 189 showed renal detectable PLA2R expression (81.8%). The baseline serum creatinine, serum albumin, and urine protein excretion were not significantly different between PLA2R-associated (n = 145) and non-PLA2R-associated iMN patients (n = 41). However, about 1/3 of the non-PLA2R-associated iMN had abnormal serological tests, significantly more common than PLA2R-associated iMN (31.7% vs. 8.3%, P = 0.000). The non-PLA2R-associated iMN had lower C4 levels compared with PLA2R-associated iMN (P = 0.004). The non-PLA2R-associated iMN patients also showed a better response to immunosuppressants (complete remission [CR] 42.9%; partial remission [PR] 14.3%) compared with PLA2R-associated iMN (CR 3.2%; PR 48.4%, P = 0.004) at the 3rd month. Conclusions: There were no significant differences in serum creatinine, albumin, and urine protein excretion between PLA2R-associated and non-PLA2R-associated iMN, while the non-PLA2R-associated iMN patients showed more abnormal serological tests. The non-PLA2R-associated iMN seemed to respond more quickly to the immunosuppressive therapy compared with PLA2R-associated iMN.
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Affiliation(s)
- Ning-Xin Xu
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Qiong-Hong Xie
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Zhu-Xing Sun
- Department of Nephrology, Wuxi People's Hospital, Wuxi, Jiangsu 214023, China
| | - Jia Wang
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yan Li
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Liang Wang
- Department of Nephrology, Wuxi People's Hospital, Wuxi, Jiangsu 214023, China
| | - Shao-Jun Liu
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jun Xue
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Chuan-Ming Hao
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
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141
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Kronbichler A, Oh J, Meijers B, Mayer G, Shin JI. Recent Progress in Deciphering the Etiopathogenesis of Primary Membranous Nephropathy. BIOMED RESEARCH INTERNATIONAL 2017; 2017:1936372. [PMID: 28904948 PMCID: PMC5585565 DOI: 10.1155/2017/1936372] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Accepted: 07/18/2017] [Indexed: 12/24/2022]
Abstract
Primary membranous nephropathy (MN) is the leading cause of nephrotic syndrome in adults. Discovery of several antibodies has contributed to an increased understanding of MN. Antibodies against the M-type phospholipase A2 receptor (PLA2R) are present in 50-100% with primary MN and are associated with a lower frequency of spontaneous remission. High levels are linked with a higher probability of treatment resistance, higher proteinuria, and impaired renal function, as well as a more rapid decline of kidney function during follow-up. Immunologic remission precedes reduction of proteinuria by months. Pretransplant evaluation of PLA2R antibodies is warranted to predict recurrence of disease following renal transplantation. Several risk alleles related to the PLA2R1 gene and within the HLA loci have been identified, whereas epitope spreading of PLA2R may predict treatment response. More recently, thrombospondin type 1 domain-containing 7A (THSD7A) antibodies have been discovered in primary MN. Several other rare antigens have been described, including antibodies against neutral endopeptidase as a cause of antenatal MN and circulating cationic bovine serum albumin as an antigen with implications in childhood MN. This review focuses on the progress with a special focus on diagnostic accuracy, predictive value, and treatment implications of the established and proposed antigens.
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Affiliation(s)
- Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Jun Oh
- Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Björn Meijers
- Department of Nephrology, UZ Leuven, Leuven, Belgium
- Department of Immunology and Microbiology, KU Leuven, Leuven, Belgium
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstraße 35, 6020 Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Severance Children's Hospital, Seoul, Republic of Korea
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142
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Tomas NM, Meyer-Schwesinger C, von Spiegel H, Kotb AM, Zahner G, Hoxha E, Helmchen U, Endlich N, Koch-Nolte F, Stahl RAK. A Heterologous Model of Thrombospondin Type 1 Domain-Containing 7A-Associated Membranous Nephropathy. J Am Soc Nephrol 2017; 28:3262-3277. [PMID: 28814510 DOI: 10.1681/asn.2017010030] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 05/25/2017] [Indexed: 11/03/2022] Open
Abstract
Thrombospondin type 1 domain-containing 7A (THSD7A) is a target for autoimmunity in patients with membranous nephropathy (MN). Circulating autoantibodies from patients with THSD7A-associated MN have been demonstrated to cause MN in mice. However, THSD7A-associated MN is a rare disease, preventing the use of patient antibodies for larger experimental procedures. Therefore, we generated antibodies against the human and mouse orthologs of THSD7A in rabbits by coimmunization with the respective cDNAs. Injection of these anti-THSD7A antibodies into mice induced a severe nephrotic syndrome with proteinuria, weight gain, and hyperlipidemia. Immunofluorescence analyses revealed granular antigen-antibody complexes in a subepithelial location along the glomerular filtration barrier 14 days after antibody injection, and immunohistochemistry for rabbit IgG and THSD7A as well as ultrastructural analyses showed the typical characteristics of human MN. Mice injected with purified IgG from rabbit serum that was taken before immunization failed to develop any of these changes. Notably, MN developed in the absence of detectable complement activation, and disease was strain dependent. In vitro, anti-THSD7A antibodies caused cytoskeletal rearrangement and activation of focal adhesion signaling. Knockdown of the THSD7A ortholog, thsd7aa, in zebrafish larvae resulted in altered podocyte differentiation and impaired glomerular filtration barrier function, with development of pericardial edema, suggesting an important role of THSD7A in glomerular filtration barrier integrity. In summary, our study introduces a heterologous mouse model that allows further investigation of the molecular events that underlie MN.
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Affiliation(s)
| | | | | | - Ahmed M Kotb
- Institute of Anatomy and Cell Biology, University Medicine Greifswald, Greifswald, Germany; and.,Department of Anatomy and Histology, Faculty of Veterinary Medicine, Assiut University, Assiut, Egypt
| | | | | | | | - Nicole Endlich
- Institute of Anatomy and Cell Biology, University Medicine Greifswald, Greifswald, Germany; and
| | - Friedrich Koch-Nolte
- Institute of Immunology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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143
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Abstract
In patients with membranous nephropathy, alkylating agents (cyclophosphamide or chlorambucil) alone or in combination with steroids achieve remission of nephrotic syndrome more effectively than conservative treatment or steroids alone, but can cause myelotoxicity, infections, and cancer. Calcineurin inhibitors can improve proteinuria, but are nephrotoxic. Most patients relapse after treatment withdrawal and can become treatment dependent, which increases the risk of nephrotoxicity. The discovery of nephritogenic autoantibodies against podocyte M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain- containing protein 7A (THSD7A) antigens provides a clear pathophysiological rationale for interventions that specifically target B-cell lineages to prevent antibody production and subepithelial deposition. The anti-CD20 monoclonal antibody rituximab is safe and achieves remission of proteinuria in approximately two-thirds of patients with membranous nephropathy. In those with PLA2R-related disease, remission can be predicted by anti-PLA2R antibody depletion and relapse by antibody re-emergence into the circulation. Thus, integrated evaluation of serology and proteinuria could guide identification of affected patients and treatment with individually tailored protocols. Nonspecific and toxic immunosuppressive regimens will fall out of use. B-cell modulation by rituximab and second-generation anti-CD20 antibodies (or plasma cell-targeted therapy in anti-CD20 resistant forms of disease) will lead to a novel therapeutic paradigm for patients with membranous nephropathy.
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144
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Pang L, Zhang AM, Li HX, Du JL, Jiao LL, Duan N, Liu Y, Yu D. Serum anti-PLA2R antibody and glomerular PLA2R deposition in Chinese patients with membranous nephropathy: A cross-sectional study. Medicine (Baltimore) 2017; 96:e7218. [PMID: 28614271 PMCID: PMC5478356 DOI: 10.1097/md.0000000000007218] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [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
M-type phospholipase A2 receptor (PLA2R) is the major target antigen in primary membranous nephropathy (PMN). Previous studies have evaluated the diagnostic value of serum anti-PLA2R antibody. However, the correlation of serum anti-PLA2R antibody and glomerular PLA2R deposition, and their association with clinical characteristics need to be further evaluated.A total of 136 patients were involved as inception group because serum anti-PLA2R antibody and glomerular PLA2R antigen were simultaneously measured. We examined serum anti-PLA2R antibody by ELISA and glomerular PLA2R deposition by immunofluorescence assay.Positive serum anti-PLA2R antibody and glomerular PLA2R deposition were seen in 58.8% (80/136) and 95.6% (130/136) patients, respectively (P < .001). Proteinuria, serum total protein, serum albumin, serum creatinine, and estimated glomerular filtration rate (eGFR) had significant differences between patients with serum anti-PLA2R antibody and those without. Serum anti-PLA2R antibody levels were correlated with serum albumin, serum creatinine, eGFR, and proteinuria. Glomerular PLA2R deposition intensities were weakly correlated with proteinuria. Unexpectedly, there was a positive correlation rather than a negative correlation between glomerular PLA2R deposition intensity and eGFR.In conclusion, serum anti-PLA2R antibody is more closely correlated with disease activity and renal function than glomerular PLA2R deposition.
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Affiliation(s)
- Lu Pang
- Department of Clinical Laboratory, Peking University First Hospital, Beijing
| | - Ai-Min Zhang
- Department of Clinical Laboratory, Tianjin Nankai Hospital, Tianjin, The People's Republic of China
| | - Hai-Xia Li
- Department of Clinical Laboratory, Peking University First Hospital, Beijing
| | - Jia-Lin Du
- Department of Clinical Laboratory, Peking University First Hospital, Beijing
| | - Li-Li Jiao
- Department of Clinical Laboratory, Peking University First Hospital, Beijing
| | - Nan Duan
- Department of Clinical Laboratory, Peking University First Hospital, Beijing
| | - Yi Liu
- Department of Clinical Laboratory, Peking University First Hospital, Beijing
| | - Dan Yu
- Department of Clinical Laboratory, Peking University First Hospital, Beijing
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145
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Hoxha E, von Haxthausen F, Wiech T, Stahl RAK. Membranous nephropathy-one morphologic pattern with different diseases. Pflugers Arch 2017; 469:989-996. [PMID: 28555350 DOI: 10.1007/s00424-017-2000-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 05/14/2017] [Accepted: 05/16/2017] [Indexed: 01/05/2023]
Abstract
Since the discovery of the phospholipase A2 receptor 1 (PLA2R1) and thrombospondin type-1 domain-containing 7A (THSD7A) as endogenous antigens involved in the development of membranous nephropathy (MN) in over 80% of adult patients, substantial progress in the diagnosis, prognosis, and therapy of MN has been made. In most cases of patients with MN, it is now possible to specifically define the responsible pathogenic mechanisms of disease and make a diagnosis even without a renal biopsy. Moreover, the presence of antibodies in the blood and the detection of the antigens in renal biopsies allow the definite diagnosis without the morphologic uncertainties, which now still apply for only about 20% of all renal biopsies showing MN. The discovery that the expression of THSD7A in malignant tumors might serve as the site of primary antigen recognition for the immune system to start MN might lead to a better understanding of not only tumor-associated MN, which accounts for up to 10% of all patients with MN, but also of the pathomechanisms relevant for MN development in general.
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Affiliation(s)
- Elion Hoxha
- III. Medizinische Klinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.,SFB 1192, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | | | - Thorsten Wiech
- SFB 1192, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.,Sektion Nephropathologie, Institut für Pathologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Rolf A K Stahl
- SFB 1192, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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146
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Burbelo PD, Beck LH, Waldman M. Detection and monitoring PLA 2R autoantibodies by LIPS in membranous nephropathy. J Immunol Methods 2017; 444:17-23. [PMID: 28167276 PMCID: PMC5376496 DOI: 10.1016/j.jim.2017.02.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 01/02/2017] [Accepted: 02/02/2017] [Indexed: 02/08/2023]
Abstract
Autoantibodies against the M-type phospholipase A2 receptor (PLA2R) are specific markers for primary membranous nephropathy (MN). Quantification of PLA2R autoantibodies is an important, noninvasive tool that facilitates the diagnosis and monitoring of primary MN. In this report we describe a highly quantitative luciferase immunoprecipitation systems (LIPS) assay for detecting PLA2R autoantibodies. For these studies, a cDNA fragment encoding the first 858 amino acids of PLA2R protein was cloned to generate N-terminal antigen fusion constructs with Gaussia luciferase (Gluc) and Nano luciferase (NanoLuc) reporters. Following transfection, crude cell extracts containing the recombinant PLA2R-luciferase fusion proteins were tested by LIPS on healthy controls, subjects with other kidney disease and subjects with MN. LIPS testing with both reporters detected robust PLA2R autoantibody levels in a subset of patients with primary MN and demonstrated 100% sensitivity compared to ELISA and/or Western blotting. The PLA2R-NanoLuc LIPS assay demonstrated 100% specificity matching the ELISA, but the specificity of the PLA2R-Gluc LIPS assays was slightly lower (97%). Further analysis revealed that autoantibody levels determined by PLA2R-NanoLuc LIPS correlated well with urinary protein excretion (R=0.79) and disease activity and was very sensitive for detecting clinical relapse. These results highlight the potential utility of the LIPS PLA2R-NanoLuc assay for diagnosis and management of MN.
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Affiliation(s)
- Peter D Burbelo
- Dental Clinical Research Core, NIDCR, NIH, Bethesda, MD, United States.
| | - Laurence H Beck
- Department of Medicine, Section of Nephrology, Boston University School of Medicine, Boston, Mass, United States
| | - Meryl Waldman
- Kidney Disease Branch, NIDDK, NIH, Bethesda, MD, United States
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147
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A novel Time-resolved Fluoroimmunoassay for the quantitative detection of Antibodies against the Phospholipase A2 Receptor. Sci Rep 2017; 7:46096. [PMID: 28397878 PMCID: PMC5387400 DOI: 10.1038/srep46096] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 03/08/2017] [Indexed: 11/08/2022] Open
Abstract
A highly sensitive time-resolved fluoroimmunoassay (TRFIA) was developed to quantify serum antibodies against the phospholipase A2 receptor (anti-PLA2R-IgG) for differential diagnosis of membranous nephropathy. Recombinant PLA2R (rPLA2R) was coated onto 96-well plates as a capture. A goat-anti-human IgG tracer was prepared with europium-chelate for detection. After bound/free separation by washing, the fluorescence counts of bound tracer were measured for quantifying serum anti-PLA2R-IgG concentration. A purified anti-PLA2R-IgG calibrator was first prepared for ensuring that consistent quantitative results could be obtained. The assay detection limit was 0.03 mg/L with linear measurement range of 0.03-340 mg/L. The intra- and inter-assay coefficients of variation (CVs) were 3.8% and 6.2%, respectively. The average serum anti-PLA2R-IgG concentration in 45 healthy volunteers, 31 IgA nephropathy, 9 lupus nephropathy, and 52 idiopathic membranous nephropathy patients was 0.53 ± 0.18 mg/L, 0.70 ± 0.41 mg/L, 1.08 ± 0.65 mg/L, and 9.00 ± 11.82 mg/L, respectively. The cut-off point for an abnormal anti-PLA2R-IgG concentration was defined as >0.89 mg/L. The positive rates in serum from patients with IgA nephropathy, lupus nephropathy, and idiopathic membranous nephropathy were 29.0%, 44.4%, and 88.5%, respectively. The availability of this quantitation method will facilitate the use of serum anti-PLA2R-IgG for diagnosing idiopathic membranous nephropathy.
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148
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Pourcine F, Dahan K, Mihout F, Cachanado M, Brocheriou I, Debiec H, Ronco P. Prognostic value of PLA2R autoimmunity detected by measurement of anti-PLA2R antibodies combined with detection of PLA2R antigen in membranous nephropathy: A single-centre study over 14 years. PLoS One 2017; 12:e0173201. [PMID: 28257452 PMCID: PMC5336294 DOI: 10.1371/journal.pone.0173201] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 02/16/2017] [Indexed: 01/24/2023] Open
Abstract
Introduction Clinical course of membranous nephropathy (MN) is difficult to predict. Measurement of circulating anti-PLA2R autoantibodies (PLA2R-Ab) and detection in immune deposits of PLA2R antigen (PLA2R-Ag) are major advances in disease understanding. We evaluated the clinical significance of these biomarkers. Methods In this 14-year retrospective study, we collected data from 108 MN patients and assessed the relationship between clinical course, PLA2R-Ab and PLA2R-Ag. We also assessed THSD7A status. Results Eighty-five patients suffered from primary MN (PMN) and 23 patients from a secondary form. The median follow-up was 30.4 months [interquartile range, 17.7;56.7]. Among the 77 patients with PMN and available serum and/or biopsy, 69 (89.6%) had PLA2R-related disease as shown by anti-PLA2R-Ab and/or PLA2R-Ag, while 8 patients (8/77, 10.4%) were negative for both. There was no significant difference between these two groups in age at diagnosis and outcome assessed by proteinuria, serum albumin level and eGFR. Two of the 8 negative patients were positive for THSD7A. In patients with PLA2R related PMN, younger age, lower proteinuria, higher eGFR, and lower PLA2R-Ab level at baseline and after 6 months were associated with remission of proteinuria. Initial PLA2R-Ab titer ≤ 97.6 RU/mL and complete depletion of PLA2R-Ab within 6-months were significantly associated with spontaneous remission at the end of follow-up. In rituximab treated patients, lower PLA2R-Ab titer at initiation of treatment, and absence of PLA2R-Ab and higher serum albumin level at 3 months were significantly associated with remission. Noticeably, 81.8% of the patients who achieved remission completely cleared PLA2R-Ab. Depletion of PLA2R-Ab and increase of serum albumin level preceded the decrease of proteinuria. Conclusion Assessment of PLA2R autoimmunity is essential for patient management. Combination of PLA2R-Ab and PLA2R-Ag increases diagnosis sensitivity. PLA2R-Ab titer is a biomarker of disease severity at initial assessment, and the kinetics of the antibody are significantly correlated to disease evolution.
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Affiliation(s)
- Franck Pourcine
- Assistance Publique-Hôpitaux de Paris, Hôpital Henri Mondor, Department of Nephrology and Transplantation, Créteil, France
| | - Karine Dahan
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Department of Nephrology and Dialysis, Paris, France
| | - Fabrice Mihout
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Department of Nephrology and Dialysis, Paris, France
| | - Marine Cachanado
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint Antoine, Department of Clinical Pharmacology and Unité de Recherche Clinique, Paris, France
| | - Isabelle Brocheriou
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Department of Pathology, Paris, France
| | - Hanna Debiec
- Sorbonne Universités, Université Pierre et Marie Curie Univ Paris, Paris, France
- Institut National de la Santé Et la Recheche Médicale, Unit, Paris, France
| | - Pierre Ronco
- Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Department of Nephrology and Dialysis, Paris, France
- Sorbonne Universités, Université Pierre et Marie Curie Univ Paris, Paris, France
- Institut National de la Santé Et la Recheche Médicale, Unit, Paris, France
- * E-mail:
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149
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Jullien P, Seitz Polski B, Maillard N, Thibaudin D, Laurent B, Ollier E, Alamartine E, Lambeau G, Mariat C. Anti-phospholipase A2 receptor antibody levels at diagnosis predicts spontaneous remission of idiopathic membranous nephropathy. Clin Kidney J 2017; 10:209-214. [PMID: 28396737 PMCID: PMC5381233 DOI: 10.1093/ckj/sfw121] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 09/19/2016] [Indexed: 11/27/2022] Open
Abstract
Background: The diagnostic role of circulating anti-phospholipase A2 receptor antibodies (anti-PLA2R Abs) is now well recognized in idiopathic membranous nephropathy (iMN). These Abs could also be interesting as predictors of clinical outcome. In this study, we explored the prognostic value of anti-PLA2R Abs measured in a cohort of iMN patients, with a special focus on their ability to detect patients achieving spontaneous remission. Methods: All adult patients with biopsy-proven iMN diagnosed between 1978 and 2007 were retrospectively screened in our centre. Using a validated enzyme-linked immunosorbent assay, levels of anti-PLA2R Abs were measured from serum samples obtained at the time of renal biopsy and stored at −80°C until processing. Clinical data on disease activity, treatments and outcomes were collected by reviewing patients’ medical records. The association between anti-PLA2R Ab titres and clinical activity/outcome was assessed by Cox proportional hazard and Kaplan–Meier methods. Results: In this retrospective study, 68 patients were included in the final analysis (median follow-up of 81 months). No significant association was found between anti-PLA2R Ab titres at diagnosis with baseline proteinuria, baseline estimated glomerular filtration rate or chronic kidney disease progression. Spontaneous remission was observed in 22% of patients. Ab titres were significantly and gradually correlated in a dose–response manner with the likelihood of spontaneous remission. Conclusions: While Ab titres measured at diagnosis were not found to predict the activity of iMN, evaluation of anti-PLA2R Ab titres might prove useful in the early identification of patients likely to achieve spontaneous remission.
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Affiliation(s)
- Perrine Jullien
- Service de Néphrologie, Dialyse, Transplantation Rénale, Hôpital Nord, CHU de Saint-Etienne, GIMAP, EA 3065, Université Jean Monnet, Saint-Etienne, Comue Université de Lyon, Lyon, France
| | - Barbara Seitz Polski
- Institut de Pharmacologie Moléculaire et Cellulaire, UMR7275, CNRS, Université de Nice Sophia Antipolis, Valbonne, France
| | - Nicolas Maillard
- Service de Néphrologie, Dialyse, Transplantation Rénale, Hôpital Nord, CHU de Saint-Etienne, GIMAP, EA 3065, Université Jean Monnet, Saint-Etienne, Comue Université de Lyon, Lyon, France
| | - Damien Thibaudin
- Service de Néphrologie, Dialyse, Transplantation Rénale, Hôpital Nord, CHU de Saint-Etienne, GIMAP, EA 3065, Université Jean Monnet, Saint-Etienne, Comue Université de Lyon, Lyon, France
| | - Blandine Laurent
- Service de Néphrologie, Dialyse, Transplantation Rénale, Hôpital Nord, CHU de Saint-Etienne, GIMAP, EA 3065, Université Jean Monnet, Saint-Etienne, Comue Université de Lyon, Lyon, France
| | - Edouard Ollier
- Laboratoire de Pharmacologie et Toxicologie, Hôpital Nord, CHU de Saint-Etienne, Saint-Etienne, France
| | - Eric Alamartine
- Service de Néphrologie, Dialyse, Transplantation Rénale, Hôpital Nord, CHU de Saint-Etienne, GIMAP, EA 3065, Université Jean Monnet, Saint-Etienne, Comue Université de Lyon, Lyon, France
| | - Gérard Lambeau
- Institut de Pharmacologie Moléculaire et Cellulaire, UMR7275, CNRS, Université de Nice Sophia Antipolis, Valbonne, France
| | - Christophe Mariat
- Service de Néphrologie, Dialyse, Transplantation Rénale, Hôpital Nord, CHU de Saint-Etienne, GIMAP, EA 3065, Université Jean Monnet, Saint-Etienne, Comue Université de Lyon, Lyon, France
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150
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De Vriese AS, Glassock RJ, Nath KA, Sethi S, Fervenza FC. A Proposal for a Serology-Based Approach to Membranous Nephropathy. J Am Soc Nephrol 2017; 28:421-430. [PMID: 27777266 PMCID: PMC5280030 DOI: 10.1681/asn.2016070776] [Citation(s) in RCA: 218] [Impact Index Per Article: 31.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Primary membranous nephropathy (MN) is an autoimmune disease mainly caused by autoantibodies against the recently discovered podocyte antigens: the M-type phospholipase A2 receptor 1 (PLA2R) and thrombospondin type 1 domain-containing 7A (THSD7A). Assays for quantitative assessment of anti-PLA2R antibodies are commercially available, but a semiquantitative test to detect anti-THSD7A antibodies has been only recently developed. The presence or absence of anti-PLA2R and anti-THSD7A antibodies adds important information to clinical and immunopathologic data in discriminating between primary and secondary MN. Levels of anti-PLA2R antibodies and possibly, anti-THSD7A antibodies tightly correlate with disease activity. Low baseline and decreasing anti-PLA2R antibody levels strongly predict spontaneous remission, thus favoring conservative therapy. Conversely, high baseline or increasing anti-PLA2R antibody levels associate with nephrotic syndrome and progressive loss of kidney function, thereby encouraging prompt initiation of immunosuppressive therapy. Serum anti-PLA2R antibody profiles reliably predict response to therapy, and levels at completion of therapy may forecast long-term outcome. Re-emergence of or increase in antibody titers precedes a clinical relapse. Persistence or reappearance of anti-PLA2R antibodies after kidney transplant predicts development of recurrent disease. We propose that an individualized serology-based approach to MN, used to complement and refine the traditional proteinuria-driven approach, will improve the outcome in this disease.
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Affiliation(s)
- An S De Vriese
- Division of Nephrology, AZ Sint-Jan Brugge-Oostende, Brugge, Belgium;
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine, University of California, Los Angeles, California; and
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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