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Mertowska P, Mertowski S, Smarz-Widelska I, Grywalska E. Biological Role, Mechanism of Action and the Importance of Interleukins in Kidney Diseases. Int J Mol Sci 2022; 23:ijms23020647. [PMID: 35054831 PMCID: PMC8775480 DOI: 10.3390/ijms23020647] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/04/2022] [Accepted: 01/05/2022] [Indexed: 12/12/2022] Open
Abstract
Each year, the number of patients who are diagnosed with kidney disease too late is increasing, which leads to permanent renal failure. This growing problem affects people of every age, sex and origin, and its full etiopathogenesis is not fully understood, although the involvement of genetic susceptibility, infections, immune disorders or high blood pressure is suggested. Difficulties in making a correct and quick diagnosis are caused by the lack of research on early molecular markers, as well as educational and preventive activities among the public, which leads to the late detection of kidney diseases. An important role in the homeostasis and disease progression, including kidney diseases, is attributed to interleukins, which perform several biological functions and interact with other cells and tissues of the body. The aim of this article was to systematize the knowledge about the biological functions performed by interleukins in humans and their involvement in kidney diseases development. In our work, we took into account the role of interleukins in acute and chronic kidney disease and kidney transplantation.
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Affiliation(s)
- Paulina Mertowska
- Department of Experimental Immunology, Medical University of Lublin, 4A Chodzki Street, 20-093 Lublin, Poland; (P.M.); (E.G.)
| | - Sebastian Mertowski
- Department of Experimental Immunology, Medical University of Lublin, 4A Chodzki Street, 20-093 Lublin, Poland; (P.M.); (E.G.)
- Correspondence:
| | - Iwona Smarz-Widelska
- Department of Nephrology, Cardinal Stefan Wyszynski Provincial Hospital in Lublin, Al. Kraśnicka Street, 20-718 Lublin, Poland;
| | - Ewelina Grywalska
- Department of Experimental Immunology, Medical University of Lublin, 4A Chodzki Street, 20-093 Lublin, Poland; (P.M.); (E.G.)
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Cirillo L, Lugli G, Raglianti V, Ravaglia F, Buti E, Landini S, Becherucci F. OUP accepted manuscript. Clin Kidney J 2022; 15:2006-2019. [PMID: 36325008 PMCID: PMC9613436 DOI: 10.1093/ckj/sfac123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Indexed: 11/29/2022] Open
Abstract
Podocytopathies are glomerular disorders in which podocyte injury drives proteinuria and progressive kidney disease. They encompass a broad spectrum of aetiologies, resulting in pathological pictures of minimal-changes, focal segmental glomerulosclerosis, diffuse mesangial sclerosis or collapsing glomerulopathy. Despite improvement in classifying podocytopathies as a distinct group of disorders, the histological definition fails to capture the relevant biological heterogeneity underlying each case, manifesting as extensive variability in disease progression and response to therapies. Increasing evidence suggests that podocytopathies can result from a single causative factor or a combination of multiple genetic and/or environmental risk factors with different relative contributions, identifying complex physiopathological mechanisms. Consequently, the diagnosis can still be challenging. In recent years, significant advances in genetic, microscopy and biological techniques revolutionized our understanding of the molecular mechanisms underlying podocytopathies, pushing nephrologists to integrate innovative information with more conventional data obtained from kidney biopsy in the diagnostic workflow. In this review, we will summarize current approaches in the diagnosis of podocytopathies, focusing on strategies aimed at elucidating the aetiology underlying the histological picture. We will provide several examples of an integrative view of traditional concepts and new data in patients with suspected podocytopathies, along with a perspective on how a reclassification could help to improve not only diagnostic pathways and therapeutic strategies, but also the management of disease recurrence after kidney transplantation. In the future, the advantages of precision medicine will probably allow diagnostic trajectories to be increasingly focused, maximizing therapeutic results and long-term prognosis.
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Affiliation(s)
- Luigi Cirillo
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
- Department of Biomedical, Experimental and Clinical Sciences ‘Mario Serio’, University of Florence, Florence, Italy
| | - Gianmarco Lugli
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
- Department of Biomedical, Experimental and Clinical Sciences ‘Mario Serio’, University of Florence, Florence, Italy
| | | | | | - Elisa Buti
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Samuela Landini
- Medical Genetics Unit, Meyer Children's Hospital, Florence, Italy
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103
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Pathak N, Gunasekaran I, Ambriose M, Nanda SK. Nell1 as Target Antigen for Mercury Related Membranous Nephropathy: A Case Report. Indian J Nephrol 2022; 32:502-505. [PMID: 36568593 PMCID: PMC9775599 DOI: 10.4103/ijn.ijn_415_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/25/2021] [Accepted: 11/23/2021] [Indexed: 12/27/2022] Open
Abstract
Membranous nephropathy constitutes 30% of adult nephrotic syndrome. Of all cases of membranous nephropathy, primary membranous nephropathy is commonest. Mercury is known to be a cause of secondary membranous nephropathy. There is no human data on the pathophysiology of mercury-related membranous nephropathy, but animal studies suggested an autoimmune mechanism behind it. There is no data to the best of our knowledge about target antigen for mercury-related membranous nephropathy. We are reporting a case of NELL-1 positive mercury-related membranous nephropathy that started resolving after stopping siddha medication and taking antiproteinuric. There was also concomitant euthyroid lymphocytic thyroiditis with anti-TPO positive, which started after exposure to siddha medication, which suggests systemic autoimmune phenomenon due to mercury exposure.
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Affiliation(s)
- Nabadwip Pathak
- Department of Nephrology, Pondicherry Institute of Medical Science, Pondicherry, India,Address for correspondence: Dr. Nabadwip Pathak, No. 34, Church Street, Shivaji Nagar, Puducherry, India. E-mail:
| | - Indra Gunasekaran
- Department of Pathology, Pondicherry Institute of Medical Science, Pondicherry, India
| | - Moses Ambriose
- Department of Pathology, Pondicherry Institute of Medical Science, Pondicherry, India
| | - Sunil Kumar Nanda
- Department of Biochemistry, Pondicherry Institute of Medical Science, Pondicherry, India
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104
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Lv D, Jiang S, Zhang M, Zhu X, Yang F, Wang H, Li S, Liu F, Zeng C, Qin W, Li L, Liu Z. Treatment of Membranous Nephropathy by Disulfiram through Inhibition of Podocyte Pyroptosis. KIDNEY DISEASES 2022; 8:308-318. [PMID: 36157258 PMCID: PMC9386405 DOI: 10.1159/000524164] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/17/2022] [Indexed: 11/19/2022]
Abstract
Introduction Membranous nephropathy (MN) is a common chronic kidney disease in adults and a major challenge of clinical practice for its treatment. Despite major advances, since the discovery of the phospholipase A2 receptor as the major autoantigen of podocytes in MN, the mechanisms leading to glomerular damage remain elusive. Pyroptosis, a newly discovered type of programed necrotic cell death mainly mediated by gasdermin, was found to be responsible for podocyte injury in MN in our recent work. Objectives The aim of this study was to explore the therapeutic effect of an FDA-approved drug, disulfiram (DSF), in the treatment of MN by inhibiting pyroptosis. Methods and Results DSF significantly alleviated C3a/C5a-induced podocyte injury in vitro and renal lesions in passive Heymann nephritis (PHN) rats, as reflected by the decreased percentage of propidium iodide staining podocytes, decreased lactate dehydrogenase release from cultured podocytes and improvement in 24-h urine protein, serum albumin, serum creatinine, abnormal alterations of podocyte injury markers Desmin and WT-1 and podocyte foot process fusion in PHN rats. The protective effect of DSF on podocyte injury in vitro and in vivo can be ascribed to its inhibition of the activation and membrane translocation of the pyroptosis executor gasdermin D (GSDMD) in podocytes. DSF also inhibited the increase and activation of the pyroptosis signaling pathway NLRP3-ASC-Caspase-1/IL-18/GSDMD in C3a/C5a-treated podocytes and renal tissue of PHN rats. Conclusion DSF is a potential drug for MN treatment, and its clinical application needs to be further investigated.
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Affiliation(s)
- Daoyuan Lv
- Department of Nephrology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
| | - Song Jiang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
| | - Mingchao Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
| | - Xiaodong Zhu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
| | - Fan Yang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
| | - Hui Wang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
| | - Shen Li
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
| | - Feng Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
| | - Weisong Qin
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
| | - Limin Li
- School of Life Science and Technology, China Pharmaceutical University, Nanjing, China
- *Limin Li,
| | - Zhihong Liu
- Department of Nephrology, Jinling Hospital, The First School of Clinical Medicine, Southern Medical University, Nanjing, China
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing, China
- **Zhihong Liu,
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105
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Rojas-Rivera J, Fervenza FC, Ortiz A. Recent Clinical Trials Insights into the Treatment of Primary Membranous Nephropathy. Drugs 2021; 82:109-132. [PMID: 34932208 PMCID: PMC8844164 DOI: 10.1007/s40265-021-01656-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2021] [Indexed: 11/03/2022]
Abstract
Immunosuppressive therapy is mandatory for primary membranous nephropathy with persistent nephrotic proteinuria or anti-phospholipase A2 receptor antibodies, reduced kidney function, or another risk factor for progression. Rituximab has demonstrated efficacy for proteinuria remission compared with renin-angiotensin system blockade or cyclosporine in two well-powered randomized controlled trials. More recently, STARMEN showed that alternating glucocorticoid-cyclophosphamide is superior to sequential tacrolimus-rituximab for proteinuria remission, although it was associated with a higher risk of non-serious adverse events. However, sequential tacrolimus-rituximab involved delayed lower dose rituximab and was the worst-performing rituximab regimen among those tested in randomized clinical trials. The RI-CYCLO pilot study did not demonstrate superiority of glucocorticoid-cyclophosphamide over rituximab and found no difference in adverse events. Overall, STARMEN and RI-CYCLO confirmed the efficacy of glucocorticoid-cyclophosphamide in patients with high-risk membranous nephropathy and the role of rituximab as a valid alternative. However, none of the trials tested an optimized rituximab protocol involving a second rituximab cycle before declaring treatment failure. Calcineurin inhibitors should be considered third-line drugs and sequential use of calcineurin inhibitor rituximab did not add over rituximab-only regimens. We critically review recent randomized controlled trials, propose a research agenda, and call for multinational pragmatic trials that enroll patients at referral centers to address unmet research needs.
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Affiliation(s)
- Jorge Rojas-Rivera
- Division of Nephrology and Hypertension, Hospital Universitario Fundación Jiménez Díaz, IIS-Fundación Jiménez Díaz, and Autonomous University of Madrid, Avenida de los Reyes Católicos 2 (3rd Floor - Nephrology and Hypertension), 28040, Madrid, Spain.
| | | | - Alberto Ortiz
- Division of Nephrology and Hypertension, Hospital Universitario Fundación Jiménez Díaz, IIS-Fundación Jiménez Díaz, and Autonomous University of Madrid, Avenida de los Reyes Católicos 2 (3rd Floor - Nephrology and Hypertension), 28040, Madrid, Spain
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106
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B Cells in Primary Membranous Nephropathy: Escape from Immune Tolerance and Implications for Patient Management. Int J Mol Sci 2021; 22:ijms222413560. [PMID: 34948358 PMCID: PMC8708506 DOI: 10.3390/ijms222413560] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/13/2021] [Accepted: 12/14/2021] [Indexed: 12/03/2022] Open
Abstract
Membranous nephropathy (MN) is an important cause of nephrotic syndrome and chronic kidney disease (CKD) in adults. The pathogenic significance of B cells in MN is increasingly recognized, especially following the discovery of various autoantibodies that target specific podocytic antigens and the promising treatment responses seen with B cell depleting therapies. The presence of autoreactive B cells and autoantibodies that bind to antigens on podocyte surfaces are characteristic features of MN, and are the result of breaches in central and peripheral tolerance of B lymphocytes. These perturbations in B cell tolerance include altered B lymphocyte subsets, dysregulation of genes that govern immunoglobulin production, aberrant somatic hypermutation and co-stimulatory signalling, abnormal expression of B cell-related cytokines, and increased B cell infiltrates and organized tertiary lymphoid structures within the kidneys. An understanding of the role of B cell tolerance and homeostasis may have important implications for patient management in MN, as conventional immunosuppressive treatments and novel B cell-targeted therapies show distinct effects on proliferation, differentiation and reconstitution in different B cell subsets. Circulating B lymphocytes and related cytokines may serve as potential biomarkers for treatment selection, monitoring of therapeutic response and prediction of disease relapse. These recent advances in the understanding of B cell tolerance in MN have provided greater insight into its immunopathogenesis and potential novel strategies for disease monitoring and treatment.
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107
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Glassock RJ. Precision medicine for the treatment of glomerulonephritis: A bold goal but not yet a transformative achievement. Clin Kidney J 2021; 15:657-662. [PMID: 35371458 PMCID: PMC8967540 DOI: 10.1093/ckj/sfab270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
The revolution in our ability to recognize the alterations in fundamental biology brought about by disease has fostered a renewed interest in precision or personalized medicine (“the right treatment, or diagnostic test, for the right patient at the right time”). This nascent field has been led by oncology, immune-hematology and infectious disease, but nephrology is catching up, and quickly. Specific forms of glomerulonephritis thought to represent specific “diseases” have been “downgraded” to “patterns of injury”. New entities have emerged through application of sophisticated molecular technologies; often embraced by the term “multi-omics”. Kidney biopsies are now interpreted by next generation imaging and machine learning. Many opportunities are manifest that will translate these remarkable developments into novel safe and effective treatment regimens for specific pathogenic pathways evoking glomerulonephritis and its progression to kidney failure. A few successes emboldens a positive look to the future. A sustained and highly collaborative engagement with this new paradigm will be required for this field, full of hope and high expectations, to realize its goal of transforming glomerular therapeutics from “one size fits all (or many)” to a true individualized management principle.
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Affiliation(s)
- Richard J Glassock
- Emeritus Professor, Department of Medicine, Geffen School of Medicine. Los Angeles, CA, USA
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108
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Angeletti A, Bruschi M, Moroni G, Sinico RA, Franceschini F, Fredi M, Vaglio A, Cavagna L, Petretto A, Pratesi F, Migliorini P, Locatelli F, Pazzola G, Pesce G, Bagnasco M, Manfredi A, Ramirez GA, Esposito P, Murdaca G, Negrini S, Cipriani L, Trezzi B, Emmi G, Cavazzana I, Binda V, d’Alessandro M, Fenaroli P, Pisani I, Garibotto G, Montecucco C, Santoro D, Scolari F, Volpi S, Mosca M, Tincani A, Candiano G, Prunotto M, Verrina E, Ravelli A, Ghiggeri GM. Second Wave Antibodies in Autoimmune Renal Diseases: The Case of Lupus Nephritis. J Am Soc Nephrol 2021; 32:3020-3023. [PMID: 34599042 PMCID: PMC8638388 DOI: 10.1681/asn.2021050659] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Clinical Trial registry name and registration number: Zeus study, NCT02403115.
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Affiliation(s)
- Andrea Angeletti
- Department of Integrated Pediatric and Hemato-Oncology Sciences, Laboratory of Molecular Nephrology, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
- Division of Nephrology, Dialysis and Transplantation, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Maurizio Bruschi
- Department of Integrated Pediatric and Hemato-Oncology Sciences, Laboratory of Molecular Nephrology, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | - Franco Franceschini
- Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, Azienda Socio Sanitaria Territoriale Spedali Civili and Università of Brescia, Brescia, Italy
| | - Micaela Fredi
- Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, Azienda Socio Sanitaria Territoriale Spedali Civili and Università of Brescia, Brescia, Italy
| | - Augusto Vaglio
- Department of Biomedical, Experimental and Clinical Sciences “Mario Serio,” University of Firenze, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Lorenzo Cavagna
- Division of Rheumatology, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo, Pavia, Italy
| | - Andrea Petretto
- Integrated Department of Services and Laboratories, Core Facilities Proteomics Laboratory, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Federico Pratesi
- Clinical Immunology Unit, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Paola Migliorini
- Clinical Immunology Unit, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | | | - Giulia Pazzola
- Department of Medical Specialties, Nephrology and Dialysis, Arciospedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Giampaola Pesce
- Medical and Radiometabolic Therapy Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Marcello Bagnasco
- Medical and Radiometabolic Therapy Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Angelo Manfredi
- Unit of Internal Medicine and Immunology, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Giuseppe A. Ramirez
- Unit of Internal Medicine and Immunology, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Pasquale Esposito
- Unit of Nephrology, Dialysis and Transplantation, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Murdaca
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Simone Negrini
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Leda Cipriani
- Division of Nephrology, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Barbara Trezzi
- Department of Medicine and Surgery, University of Milan, Bicocca, Italy
| | - Giacomo Emmi
- Lupus Clinic Department of Biomedicine, University of Florence, University Hospital Careggi, Florence, Italy
| | - Ilaria Cavazzana
- Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, Azienda Socio Sanitaria Territoriale Spedali Civili and Università of Brescia, Brescia, Italy
| | - Valentina Binda
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Matteo d’Alessandro
- Division of Nephrology, Dialysis and Transplantation, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Paride Fenaroli
- Nephrology Unit, University Hospital, University of Parma, Parma, Italy
| | - Isabella Pisani
- Nephrology Unit, University Hospital, University of Parma, Parma, Italy
| | - Giacomo Garibotto
- Division of Nephrology, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Carlomaurizio Montecucco
- Division of Rheumatology, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo, Pavia, Italy
| | - Domenico Santoro
- Nephrology and Dialysis Unit, University of Messina and G Martino Hospital, Messina, Italy
| | - Francesco Scolari
- Division of Nephrology and Dialysis, University of Brescia and Ospedale di Montichiari, Brescia, Italy
| | - Stefano Volpi
- Division of Paediatric Rheumatology Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Marta Mosca
- Rheumatologu Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, Azienda Socio Sanitaria Territoriale Spedali Civili and Università of Brescia, Brescia, Italy
| | - Giovanni Candiano
- Department of Integrated Pediatric and Hemato-Oncology Sciences, Laboratory of Molecular Nephrology, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Marco Prunotto
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Enrico Verrina
- Division of Nephrology, Dialysis and Transplantation, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Angelo Ravelli
- Division of Paediatric Rheumatology Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Gian Marco Ghiggeri
- Department of Integrated Pediatric and Hemato-Oncology Sciences, Laboratory of Molecular Nephrology, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
- Division of Nephrology, Dialysis and Transplantation, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
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Bobart SA, Han H, Tehranian S, De Vriese AS, Roman JCL, Sethi S, Zand L, Andrades Gomez C, Giesen CD, Soler MJ, Bomback AS, Fervenza FC. Noninvasive Diagnosis of PLA2R-Associated Membranous Nephropathy: A Validation Study. Clin J Am Soc Nephrol 2021; 16:1833-1839. [PMID: 34782349 PMCID: PMC8729491 DOI: 10.2215/cjn.05480421] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Kidney biopsy is the current gold standard to diagnose membranous nephropathy. Approximately 70%-80% of patients with primary membranous nephropathy have circulating anti-phospholipase A2 receptor antibodies. We previously demonstrated that in proteinuric patients with preserved eGFR and absence of associated conditions (e.g., autoimmunity, malignancy, infection, drugs, and paraproteinemia), a positive anti-phospholipase A2 receptor antibody test by ELISA and immunofluorescence assay confirms the diagnosis of membranous nephropathy noninvasively. These data have not been externally validated. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The clinical and pathologic characteristics of patients with a positive anti-phospholipase A2 receptor antibody test at the Mayo Clinic, the University Hospital Vall D'Hebron (Barcelona), and the Columbia University Medical Center (New York) were retrospectively reviewed. Biopsy findings and presence or absence of a potential associated condition were assessed. RESULTS From a total of 276 patients with positive anti-phospholipase A2 receptor serology, previously reported patients (n=33), kidney transplant recipients (n=9), pediatric patients (n=2), and patients without kidney biopsy (n=69) were excluded. Among the 163 remaining patients, associated conditions were identified in 47 patients, and 15 patients had diabetes mellitus. All 101 patients of the final cohort had a primary diagnosis of membranous nephropathy on kidney biopsy. In the 79 patients with eGFR≥60 ml/min per 1.73 m2, none of the biopsy findings altered diagnosis or management. Among the 22 patients with decreased eGFR, additional findings included superimposed acute interstitial nephritis (n=1). CONCLUSIONS In patients with preserved eGFR and absence of associated conditions or diabetes, a positive anti-phospholipase A2 receptor test by either ELISA >20 RU/ml or a positive immunofluorescence assay confirms the diagnosis of membranous nephropathy, precluding the requirement for a kidney biopsy.
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Affiliation(s)
- Shane A. Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- Department of Nephrology and Hypertension, Cleveland Clinic Florida, Weston, Florida
| | - Heedeok Han
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Shahrzad Tehranian
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - An S. De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | | | - Callen D. Giesen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Maria Jose Soler
- Nephrology Department, University Hospital Vall D’Hebron, Barcelona, Spain
| | - Andrew S. Bomback
- Division of Nephrology, Columbia University Medical Center, New York, New York
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110
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Caza TN, Al-Rabadi LF, Beck LH. How Times Have Changed! A Cornucopia of Antigens for Membranous Nephropathy. Front Immunol 2021; 12:800242. [PMID: 34899763 PMCID: PMC8662735 DOI: 10.3389/fimmu.2021.800242] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
The identification of the major target antigen phospholipase A2 receptor (PLA2R) in the majority of primary (idiopathic) cases of membranous nephropathy (MN) has been followed by the rapid identification of numerous minor antigens that appear to define phenotypically distinct forms of disease. This article serves to review all the known antigens that have been shown to localize to subepithelial deposits in MN, as well as the distinctive characteristics associated with each subtype of MN. We will also shed light on the novel proteomic approaches that have allowed identification of the most recent antigens. The paradigm of an antigen normally expressed on the podocyte cell surface leading to in-situ immune complex formation, complement activation, and subsequent podocyte injury will be discussed and challenged in light of the current repertoire of multiple MN antigens. Since disease phenotypes associated with each individual target antigens can often blur the distinction between primary and secondary disease, we encourage the use of antigen-based classification of membranous nephropathy.
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Affiliation(s)
| | - Laith F. Al-Rabadi
- Department of Internal Medicine (Nephrology & Hypertension), University of Utah, Salt Lake City, UT, United States
| | - Laurence H. Beck
- Department of Medicine (Nephrology), Boston University School of Medicine and Boston Medical Center, Boston, MA, United States
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111
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Jurubiță R, Obrișcă B, Achim C, Micu G, Sorohan B, Bobeică R, Vornicu A, Găman M, Căpușă C, Ștefan G, Viașu L, Mircescu G, Ismail G. Anti-phospholipase A2 receptor antibody screening in nephrotic syndrome may identify a distinct subset of patients with primary membranous nephropathy. Int Urol Nephrol 2021; 54:1713-1723. [PMID: 34799809 DOI: 10.1007/s11255-021-03061-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE We sought to investigate the utility of anti-PLA2R antibody as a non-invasive screening method for the diagnosis of primary MN in patients with nephrotic syndrome (NS). METHODS All consecutive patients with NS admitted in our department, between 01.01.2015 and 31.12.2019 were screened for anti-PLA2R antibodies by an ELISA assay (EUROIMMUN, Lübeck, DE). A positive anti-PLA2R serology was defined as an ELISA value over 2 RU/ml. Subsequently, all patients underwent kidney biopsy to confirm the histological diagnosis. RESULTS Of the 203 patients with NS, we identified 67 patients with "high" titer of anti-PLA2R antibodies (> 20 RU/ml) and 47 patients with "intermediate" titer (2-20 RU/ml). In the entire cohort, the area under the curve (AUC) was 0.83 (95% CI 0.78-0.89; p < 0.001). With a cutoff of 20 RU/ml, the anti-PLA2R antibodies had a 64% sensitivity (95% CI 53-73%) and 94% specificity (95% CI 88-97%) to discriminate MN from other causes of NS. In addition, the PPV and NPV were 91% (95% CI 82-95%) and 75% (95% CI 69-79%). When analyzing the posttest effect, we identified a LR+ of 11.56 (95% CI 5.2-25.2) and LR- of 0.38 (95% CI 0.29-0.5). The overall accuracy of the test was 80.3% (95% CI 74-85%) and the diagnostic odds ratio was 30.42. When performing subgroup analysis, we identified that in younger patients, in those with preserved renal function or with negative workup for secondary causes, the diagnostic performance of anti-PLA2R antibodies was improved, the sensitivity increasing to 68-71%, the PPV to 93-95% and the LR+ to 12.23-15.4. CONCLUSION Serum anti-PLA2R antibody screening in patients with NS is a useful method for the diagnosis of primary MN. In younger patients (less than 60 years old) who have a preserved renal function and a negative workup for secondary causes of NS, a positive anti-PLA2R test highly predicts a diagnosis of primary MN.
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Affiliation(s)
- Roxana Jurubiță
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania. .,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Camelia Achim
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Georgia Micu
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Bogdan Sorohan
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Raluca Bobeică
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Alexandra Vornicu
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Maria Găman
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania
| | - Cristina Căpușă
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gabriel Ștefan
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Liliana Viașu
- Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gabriel Mircescu
- Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.,Department of Nephrology, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, Fundeni street 258, 022328, Bucharest, Romania.,Department of Nephrology, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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112
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Giannini G, Arend LJ. The Prevalence of Mesangial Electron-Dense Deposits in PLA2R-Positive Membranous Nephropathy. Nephron Clin Pract 2021; 146:167-171. [PMID: 34802007 DOI: 10.1159/000519912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/25/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Membranous nephropathy (MN) is a common cause of nephrotic syndrome in adults and can be primary or secondary. The antigenic target of antibodies in 70% of primary cases is phospholipase A2 receptor (PLA2R). The presence or absence of mesangial electron-dense deposits has been used to distinguish between primary and secondary MN. Mesangial deposits suggest MN due to lupus, infection, or other causes, though they are reported to occur in approximately 10% of primary MN. Staining for PLA2R is now frequently used for confirming a diagnosis of primary MN. If mesangial deposits predict a secondary cause, they should be more frequent in PLA2R-negative biopsies. METHODS A review of institutional kidney biopsies between March 2017 and June 2020 identified all cases of MN. Cases with a diagnosis of lupus or near "full-house" staining by immunofluorescence microscopy (IF) were excluded. Light microscopy, IF, and electron microscopy (EM) were performed. PLA2R staining was performed by IF. EM for all cases was reviewed and electron-dense deposit location, distribution, and size were determined. RESULTS Ninety-three cases of MN were identified, of which 86 had both PLA2R staining and EM performed. Of these, 51 cases (59%) were positive for PLA2R and 35 (41%) were negative. Mesangial electron-dense deposits were present in 22 (25.6%) of the 86 cases, including 27.5% (14/51) of PLA2R-positive cases and 22.8% (8/35) of PLA2R-negative cases. No difference was seen in size or distribution of deposits, or other features considered suggestive of secondary MN. CONCLUSION PLA2R-negative cases were not more likely to have mesangial deposits than PLA2R-positive cases. Mesangial deposits should not be used as an indicator of secondary MN.
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Affiliation(s)
- Gabriel Giannini
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lois J Arend
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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113
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Morel A, Buob D, Goujon JM, Belhadj K, Verpont MC, Audard V, Moktefi A. Thrombospondin type-1 domain-containing 7A-related membranous nephropathy associated with glomerular AL amyloidosis. Pathology 2021; 54:654-657. [PMID: 34774302 DOI: 10.1016/j.pathol.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Antoine Morel
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire, Innovative Therapy for Immune Disorders, Créteil, France; Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - David Buob
- Sorbonne Université, AP-HP, Service d'Anatomie et Cytologie Pathologiques, Hôpital Tenon, Paris, France
| | - Jean-Michel Goujon
- Département de Pathologie, Unité de Pathologie Ultrastructurale, CHU Poitiers, Poitiers, France; Centre de Référence Maladies Rares Amylose AL et Autres Maladies Par Dépôts D'immunoglobulines Monoclonales, Poitiers, France
| | - Karim Belhadj
- AP-HP, Hôpitaux Universitaires Henri Mondor, Unité Hémopathies Lymphoïdes, Créteil, France; AP-HP, Hôpitaux Universitaires Henri Mondor, Réseau Amylose Mondor, Groupe de Recherche Clinique sur les Amyloses, Amyloid Research Institute, Créteil, France
| | | | - Vincent Audard
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire, Innovative Therapy for Immune Disorders, Créteil, France; Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France; AP-HP, Hôpitaux Universitaires Henri Mondor, Réseau Amylose Mondor, Groupe de Recherche Clinique sur les Amyloses, Amyloid Research Institute, Créteil, France
| | - Anissa Moktefi
- Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France; AP-HP, Hôpitaux Universitaires Henri Mondor, Réseau Amylose Mondor, Groupe de Recherche Clinique sur les Amyloses, Amyloid Research Institute, Créteil, France; AP-HP, Hôpitaux Universitaires Henri Mondor, Département de Pathologie, Créteil, France.
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Caravaca-Fontán F, Fernandez-Juarez GM, Floege J, Goumenos D, Kronbichler A, Turkmen K, van Kooten C, Frangou E, Stevens KI, Segelmark M, Tesar V, Anders HJ, Bruchfeld A. The management of membranous nephropathy - an update. Nephrol Dial Transplant 2021; 37:1033-1042. [PMID: 34748001 DOI: 10.1093/ndt/gfab316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Indexed: 11/13/2022] Open
Abstract
In the last decades several important advances have taken place in the understanding of the pathogenesis underlying membranous nephropathy, which have sparked renewed interest in its management. Four landmark trials in membranous nephropathy, and a fifth clinical trial-which was a pilot study-, have been published in the last years. The results from some of these trials have had a significant impact in the recommendations included in the 2021 Kidney Disease: Improving Global Outcomes (KDIGO) Guideline for the Management of Glomerular Diseases, which represent a significant step forward compared to the previous guideline in several aspects such as diagnosis, disease monitoring and treatment strategies. However, considering the rapidly evolving advances in the knowledge of membranous nephropathy and the recent publication of the STARMEN and RI-CYCLO trials, several recommendations contained in the guideline warrant updates. This manuscript provides a perspective of the Immunonephrology Working Group of the European Renal Association (ERA) regarding the management of membranous nephropathy in native kidneys of adult patients.
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Affiliation(s)
| | | | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University Hospital, Aachen, Germany
| | - Dimitrios Goumenos
- Department of Nephrology and Renal Transplantation, Patras University Hospital, Patras, Greece
| | | | - Kultigin Turkmen
- Division of Nephrology, Department of Internal Medicine, Necmettin Erbakan University, Konya, Turkey
| | - Cees van Kooten
- Division of Nephrology and Transplant Medicine, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Eleni Frangou
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus. Medical School, University of Cyprus, Nicosia, Cyprus
| | - Kate I Stevens
- Department of Nephrology and Transplantation, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Mårten Segelmark
- Division of Nephrology, Department of Clinical Sciences Lund, Lund University and Skane University Hospital, Lund, Sweden.,Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Vladimir Tesar
- Department of Nephrology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Hans-Joachim Anders
- Department of Internal Medicine IV, Hospital of the Ludwig Maximilians University, Munich, Germany
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Renal Medicine, Karolinska University Hospital and CLINTEC Karolinska Institutet, Stockholm, Sweden
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115
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Uffing A, Hullekes F, Riella LV, Hogan JJ. Recurrent Glomerular Disease after Kidney Transplantation: Diagnostic and Management Dilemmas. Clin J Am Soc Nephrol 2021; 16:1730-1742. [PMID: 34686531 PMCID: PMC8729409 DOI: 10.2215/cjn.00280121] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Recurrent glomerular disease after kidney transplant remains an important cause of allograft failure. Many of the different entities post-transplant still suffer from incomplete knowledge on pathophysiology, and therefore lack targeted and effective therapies. In this review, we focus on specific clinical dilemmas encountered by physicians in managing recurrent glomerular disease by highlighting new insights into the understanding and treatment of post-transplant focal segmental glomerulosclerosis, membranous nephropathy, atypical hemolytic uremic syndrome, C3 glomerulopathy, amyloid light-chain (AL) amyloidosis, and IgA nephropathy.
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Affiliation(s)
- Audrey Uffing
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Hullekes
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V. Riella
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan J. Hogan
- Division of Renal Electrolyte and Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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116
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Liu W, Huang G, Rui H, Geng J, Hu H, Huang Y, Huo G, Liu B, Xu A. Course monitoring of membranous nephropathy: Both autoantibodies and podocytes require multidimensional attention. Autoimmun Rev 2021; 21:102976. [PMID: 34757091 DOI: 10.1016/j.autrev.2021.102976] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/18/2021] [Accepted: 10/24/2021] [Indexed: 01/15/2023]
Abstract
A variety of podocyte antigens have been identified in human membranous nephropathy (MN), which is divided into various antigen-dominated subtypes, confirming the concept that MN is the common pattern of glomerular injury in multiple autoimmune responses. The detection of autoantibodies has been widely used, which promoted the clinical practice of MN toward personalized precision medicine. However, given the potential risks of immunosuppressive therapy, more autoantibodies and biomarkers need to be identified to predict the prognosis and therapeutic response of MN more accurately. In this review, we attempted to summarize the autoantigens/autoantibodies and autoimmune mechanisms that can predict disease states based on the current understanding of MN pathogenesis, especially the podocyte injury manifestations. In conclusion, both the autoimmune response and podocyte injury require multidimensional attention in the disease course of MN.
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Affiliation(s)
- Wenbin Liu
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Guangrui Huang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Hongliang Rui
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Jie Geng
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Haikun Hu
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Yujiao Huang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Guiyang Huo
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Baoli Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.
| | - Anlong Xu
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China.
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117
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Angeletti A, Migliorini P, Bruschi M, Pratesi F, Candiano G, Prunotto M, Verrina E, Ghiggeri GM. Anti-alpha enolase multi-antibody specificity in human diseases. Clinical significance and molecular mechanisms. Autoimmun Rev 2021; 20:102977. [PMID: 34718161 DOI: 10.1016/j.autrev.2021.102977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/06/2021] [Indexed: 11/30/2022]
Abstract
Alpha-enolase (Eno) is an ubiquitary glycolytic enzyme playing multiple functions that go well beyond its principal metabolic role of energy supplier during glycolysis. Eno is localized in the cytoplasm, but also expressed on the cell membrane, where it binds plasminogen allowing its activation. Its shorter form, in the nucleus, acts as transcription factor. In inflammatory conditions, Eno undergoes post-translational modifications, such as citrullination, oxidation and phosphorylation. Eno is also an autoantigen in different disorders. In fact, autoantibodies to Eno have been detected in rheumatoid arthritis, lupus nephritis, primary glomerulonephritis, cancer, infections and other disorders, and in many cases they represent specific markers to be utilized in clinical practice. Anti-Eno antibodies in the different clinical conditions are not equal: they differ in isotype and often recognize different epitopes on the enzyme. IgG1 and IgG3 are prevalent in Rheumatoid Arthritis, IgG2 in Lupus nephritis and IgG4 in primary autoimmune glomerulopathy. This review analyzes the characteristics of anti-Eno autoantibodies in autoimmune disorders and cancer, describing their fine specificity and isotype restriction. The post-translational modifications that are target of autoantibodies are also discussed, as they represent the basis for elucidating the molecular mechanisms responsible for epitope generation. Despite an impressive amount of experimental work on anti-Eno antibodies, it is still necessary to validate the use of anti-Eno antibodies as biomarkers of selected diseases and extend the knowledge on the mechanisms of anti-Eno autoantibody production. Strategies that downmodulate the immune response to Eno may represent in the future novel approaches in the treatment of autoimmune disorders.
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Affiliation(s)
- Andrea Angeletti
- Division of Nephrology, Dialysis, and Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy; Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Italy
| | - Paola Migliorini
- Clinical Immunology Unit, Department of Internal Medicine, University of Pisa, Italy.
| | - Maurizio Bruschi
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Italy
| | - Federico Pratesi
- Clinical Immunology Unit, Department of Internal Medicine, University of Pisa, Italy
| | - Giovanni Candiano
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Italy
| | - Marco Prunotto
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Enrico Verrina
- Division of Nephrology, Dialysis, and Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, and Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy; Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Italy.
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118
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Sethi S. Membranous nephropathy: a single disease or a pattern of injury resulting from different diseases. Clin Kidney J 2021; 14:2166-2169. [PMID: 34603694 PMCID: PMC8483682 DOI: 10.1093/ckj/sfab069] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Indexed: 12/13/2022] Open
Abstract
Membranous nephropathy (MN) is defined as disease entity characterized by thickening of the glomerular basement membranes due to subepithelial (SE) deposition of immune complexes. It is typically classified into primary MN (70%) when there is no disease association, and secondary MN (30%) when there is an underlying disease association such as lupus, malignancy, infections or drugs. Phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing 7A (THSD7A) are target antigens in 70% and 1–5% of primary MN, respectively. The antigens in the remaining MN were not known. Recently, multiple novel proteins/target antigens have been identified in MN. These include exostosin 1/2, neural epidermal growth-like 1 protein, semaphorin 3B, protocadherin 7 and neural cell adhesion molecule 1. Some of these antigens are present in the setting of primary MN, some in secondary MN and some in both, thus blurring the lines between primary and secondary MN. Preliminary studies show that each of the new antigen-associated MN has distinct clinical, kidney biopsy findings and outcome data. We propose that each new protein/antigen-associated MN is a specific disease that results in the common MN pattern of injury characterized by thickened glomerular basement membrane (GBM) with or without spikes or pinholes on light microscopy, granular immunoglobulin G with or without complement 3 on immunofluorescence microscopy and SE electron-dense deposits on electron microscopy. In other words, MN is truly only a pattern of injury resulting from specific diseases that cause deposition of SE immune deposits along the GBM. It is of paramount importance to ascertain the specific disease entity causing the MN pattern not only for precise diagnosis and management, but also for future studies on these newly described diseases.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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119
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Abstract
Membranous nephropathy (MN) is a glomerular disease that can occur at all ages. In adults, it is the most frequent cause of nephrotic syndrome. In ~80% of patients, there is no underlying cause of MN (primary MN) and the remaining cases are associated with medications or other diseases such as systemic lupus erythematosus, hepatitis virus infection or malignancies. MN is an autoimmune disease characterized by a thickening of the glomerular capillary walls due to immune complex deposition. Identification of the phospholipase A2 receptor (PLA2R) as the major antigen in adults in 2009 induced a paradigm shift in disease diagnosis and monitoring and several other antigens have since been characterized. Disease outcome is difficult to predict and around one-third of patients will undergo spontaneous remission. In those at high risk of progression, immunosuppressive therapy with cyclophosphamide plus corticosteroids has substantially reduced the need for kidney replacement therapy. Owing to carcinogenic risk, other treatments (calcineurin inhibitors and CD20-targeted B cell depletion therapy (rituximab)) have been developed. However, disease relapses are frequent when calcineurin inhibitors are stopped and the remission rate with rituximab is lower than with cyclophosphamide, particularly in patients with high PLA2R antibody titres. Other new drugs are already available and antigen-specific immunotherapies are being developed.
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120
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Autoimmune-mediated renal disease and hypertension. Clin Sci (Lond) 2021; 135:2165-2196. [PMID: 34533582 DOI: 10.1042/cs20200955] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 08/20/2021] [Accepted: 09/06/2021] [Indexed: 12/18/2022]
Abstract
Hypertension is a major risk factor for cardiovascular disease, chronic kidney disease (CKD), and mortality. Troublingly, hypertension is highly prevalent in patients with autoimmune renal disease and hastens renal functional decline. Although progress has been made over the past two decades in understanding the inflammatory contributions to essential hypertension more broadly, the mechanisms active in autoimmune-mediated renal diseases remain grossly understudied. This Review provides an overview of the pathogenesis of each of the major autoimmune diseases affecting the kidney that are associated with hypertension, and describes the current state of knowledge regarding hypertension in these diseases and their management. Specifically, discussion focuses on Systemic Lupus Erythematosus (SLE) and Lupus Nephritis (LN), Immunoglobulin A (IgA) Nephropathy, Idiopathic Membranous Nephropathy (IMN), Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated glomerulonephritis, and Thrombotic Thrombocytopenic Purpura (TTP). A summary of disease-specific animal models found to exhibit hypertension is also included to highlight opportunities for much needed further investigation of underlying mechanisms and novel therapeutic approaches.
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121
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Caza TN, Hassen SI, Kenan DJ, Storey A, Arthur JM, Herzog C, Edmondson RD, Bourne TD, Beck LH, Larsen CP. Transforming Growth Factor Beta Receptor 3 (TGFBR3)-Associated Membranous Nephropathy. KIDNEY360 2021; 2:1275-1286. [PMID: 35369660 PMCID: PMC8676385 DOI: 10.34067/kid.0001492021] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/10/2021] [Indexed: 02/04/2023]
Abstract
Background Membranous lupus nephritis (MLN) comprises 10%-15% of lupus nephritis and increases morbidity and mortality of patients with SLE through complications of nephrotic syndrome and chronic kidney failure. Identification of the target antigens in MLN may enable noninvasive monitoring of disease activity, inform treatment decisions, and aid in prognostication, as is now possible for idiopathic MN caused by antibodies against the phospholipase A2 receptor. Here, we show evidence for type III TGF-β receptor (TGFBR3) as a novel biomarker expressed in a subset of patients with MLN. Methods Mass spectrometry was used for protein discovery through enrichment of glomerular proteins by laser capture microdissection and through elution of immune complexes within MLN biopsy specimens. Colocalization with IgG within glomerular immune deposits from patients and disease controls was evaluated by confocal microscopy. Immunostaining of consecutive case series was used to determine the overall frequency in MN and MLN. Results TGFBR3 was found to be enriched in glomeruli and coimmunoprecipitated with IgG within a subset of MLN biopsy specimens by mass spectrometry. Staining of consecutive MN cases without clinical evidence of SLE did not show TGFBR3 expression (zero of 104), but showed a 6% prevalence in MLN (11 of 199 cases). TGFBR3 colocalized with IgG along the glomerular basement membranes in TGFBR3-associated MN, but not in controls. Conclusions Positive staining for TGFBR3 within glomerular immune deposits represents a distinct form of MN, substantially enriched in MLN. A diagnosis of TGFBR3-associated MN can alert the clinician to search for an underlying autoimmune disease.
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Affiliation(s)
| | | | | | - Aaron Storey
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - John M Arthur
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Christian Herzog
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Rick D Edmondson
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
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122
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Immunopathological analysis of the expression of glomerular exostosin 1 and exostosin 2 in Japanese patients with lupus nephritis. Virchows Arch 2021; 479:997-1005. [PMID: 34302213 DOI: 10.1007/s00428-021-03164-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/22/2021] [Accepted: 07/17/2021] [Indexed: 10/20/2022]
Abstract
Exostosin 1 and exostosin 2 (EXT1/EXT2) on glomerular basement membrane (GBM) were recently reported as novel putative antigens in secondary membranous nephropathy with autoimmune disease. However, the clinical significance of glomerular EXT1/EXT2 remains elusive in patients with lupus nephritis (LN). The immunofluorescence staining pattern of glomerular EXT1/EXT2 is also undetermined in membranous LN (MLN) or proliferative LN (PLN). We cross-sectionally analyzed patients with MLN (pure class V, n = 11) and PLN (class III, IV, and mixed class III/IV + V, n = 22) who underwent renal biopsies between 2010 and 2020 at Showa University Hospital. Glomerular EXT1/EXT2 expressions were evaluated by immunofluorescence. T-helper (Th) cell-related serum inflammatory cytokines were measured using enzyme-linked immunosorbent assay. The positivity for both EXT1/EXT2 was higher in patients with MLN than PLN (90.9% vs 63.6%, P = 0.212). MLN showed global and bright granular EXT1/EXT2 expressions along GBM, while PLN showed segmental and moderate expressions on GBM. Additionally, glomerular EXT1/EXT2 positivity was not associated with the degree of proteinuria or renal function in MLN and PLN patients, but the levels of serum anti-dsDNA antibody and circulating immune complexes were lower in patients with EXT1/EXT2-positive MLN than EXT1/EXT2-negative PLN. Moreover, serum complement levels and IL-4/IFN-γ ratios were elevated in EXT1/EXT2-positive MLN than EXT1/EXT2-negative PLN. Collectively, immunofluorescence staining for glomerular EXT1/EXT2 had characteristic patterns between MLN and PLN. Glomerular EXT1/EXT2 expressions tended to be high in Th2-dominant MLN patients without severe hypocomplementemia and elevated autoantibodies. Thus, EXT1/EXT2 might be involved in the unique developmental mechanism of MLN.
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Seshan SV, Salvatore SP. Recurrent Glomerular Diseases in Renal Transplantation with Focus on Role of Electron Microscopy. GLOMERULAR DISEASES 2021; 1:205-236. [PMID: 36751386 PMCID: PMC9677743 DOI: 10.1159/000517259] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/12/2021] [Indexed: 11/19/2022]
Abstract
Background The common causes of renal transplant complications include active or chronic rejection process, infections, and toxicity but also recurrent or de novo diseases, which play an important role in affecting long-term graft function or graft loss. Summary Recurrent disease in renal transplantation is defined as recurrence of the original kidney disease leading to end-stage kidney disease. They comprise a heterogeneous group of predominantly glomerular and some tubulointerstitial and vascular lesions, which include primary kidney diseases (e.g., focal segmental glomerulosclerosis, membranous glomerulonephritis, and IgA nephropathy) or those secondary to systemic autoimmune, metabolic, and infectious processes that can range from subclinical to clinically overt acute, subacute, or chronic clinical presentations. In addition to the knowledge of prior renal disease and routine/periodic serum and urine testing for kidney function, a complete transplant renal biopsy examination is essential in the identification and differentiation of these diseases. The time of onset and severity of these diseases depend on the underlying etiopathogenetic mechanisms and the varied rates of recurrence in the early or late posttransplant period, often being modified by the current immunosuppressive protocols and other donor and recipient predisposing characteristics. Key Messages Transplant kidney biopsy findings provide diagnostic accuracy and prognostic information regarding the potential for reversibility along with detection of unsuspected or clinically symptomatic recurrent diseases, with any concomitant rejection process or toxicity, for appropriate therapeutic decision-making. Routine electron microscopy in transplant kidney biopsies is a valuable tool in recognizing fully developed or early/subtle features of evolving recurrent diseases, often during the subclinical phases, in for cause or surveillance allograft biopsies.
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Truong L, Seshan SV. Lupus Nephritis: The Significant Contribution of Electron Microscopy. GLOMERULAR DISEASES 2021; 1:180-204. [PMID: 36751382 PMCID: PMC9677729 DOI: 10.1159/000516790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/22/2021] [Indexed: 11/19/2022]
Abstract
Background Systemic lupus erythematosus (SLE) represents a principal prototype of a multisystemic autoimmune disease with the participation of both cell- and antibody-mediated mechanisms causing significant renal impairment. A renal biopsy diagnosis is the gold standard for clinical renal disease in SLE, which includes a broad range of indications. Summary Renal disease in SLE can involve glomerular, tubulointerstitial, and/or vascular compartments, none of which are mutually exclusive. In most instances, the basic pathogenetic mechanism involves tissue deposition of immune complexes and/or cell-mediated mechanisms, identified by light microscopy, immunohistochemical methods, and electron microscopy (EM), evoking intraglomerular proliferative, inflammatory, and other tissue responses. These produce a spectrum of histologic lesions, depending on the participation of a wide range of clinical triggers, namely, genetic, serological, and immunological factors, correlating with their underlying pathogenetic potential. In addition to light and immunofluorescence microscopy, EM in this setting facilitates an accurate diagnosis, assesses disease activity, delineates subclasses, differentiates from primary forms of non-lupus renal lesions, identifies organized deposits, and rarely, identifies other forms of nonimmune complex lesions such as podocytopathies, amyloidosis, and thrombotic microangiopathy. Key Messages EM findings that are distinctive for most of the renal lesions in SLE include immune complex and nonimmune complex diseases as well as overlapping entities. Routine ultrastructural examination not only provides significant diagnostic and prognostic information from both initial and repeat renal biopsies from lupus patients but also contributes toward the understanding of the underlying pathophysiology of the disease process.
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Affiliation(s)
- Luan Truong
- Department of Pathology and Genomic Medicine, The Houston Methodist Hospital, Houston, Texas, USA,Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Surya V. Seshan
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA,*Surya V. Seshan,
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Seshan SV, Salvatore SP. De novo Glomerular Disease and the Significance of Electron Microscopy in Renal Transplantation. GLOMERULAR DISEASES 2021; 1:160-172. [PMID: 36751493 PMCID: PMC9677720 DOI: 10.1159/000517124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 05/07/2021] [Indexed: 11/19/2022]
Abstract
Background De novo glomerular diseases comprising those both common and unique to transplant may develop in the renal allograft leading to posttransplant proteinuria, hematuria, or allograft failure. Electron microscopy (EM) is a useful adjunct to the standard light and immunofluorescence microscopy for accurately diagnosing these diseases and subsequently aiding the clinician in initiating appropriate treatments. Summary De novo diseases are those new-onset diseases in renal transplantation that are unrelated to the original kidney disease in the recipient. They include virtually any primary or secondary glomerular, tubulointerstitial, or vascular diseases, ranging from subclinical to clinically overt, having acute, subacute, or chronic clinical presentations. This review focuses on common or significant, mainly glomerular, entities, with particular attention to the EM findings. The time of onset, stage, and severity of these diseases may often be modified by the current immunosuppressive protocols and other donor and recipient predisposing characteristics. Key Messages A renal allograft biopsy not only improves our understanding of the pathophysiology but also provides diagnostic accuracy prognostic information, and potential for reversibility. In some cases, the biopsy leads to detection of unsuspected or clinically asymptomatic de novo diseases in the setting of other concomitant rejection processes, infection, or toxicity, which can dictate appropriate therapy. Routine EM in transplant kidney biopsies is a valuable modality in recognizing fully developed or early/subtle features of evolving de novo diseases, often during the subclinical phases, in "for cause" or surveillance/protocol allograft biopsies.
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Jurubiță R, Obrișcă B, Sorohan B, Achim C, Micu GE, Mircescu G, Ismail G. Clinical Phenotypes and Predictors of Remission in Primary Membranous Nephropathy. J Clin Med 2021; 10:jcm10122624. [PMID: 34203607 PMCID: PMC8232294 DOI: 10.3390/jcm10122624] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/11/2021] [Accepted: 06/11/2021] [Indexed: 02/02/2023] Open
Abstract
(1) Background: We sought to investigate the clinical outcome and to identify the independent predictors of clinical remission in a prospectively followed cohort of patients with primary membranous nephropathy (pMN). (2) Methods: We conducted a prospective, observational, non-interventional study that included 65 consecutive patients diagnosed with pMN between January 2015 and December 2019 at our department and followed for at least 24 months. The primary outcomes evaluated during the follow-up period were the occurrence of immunological and clinical remission (either complete or partial remission). Univariate and multivariate Cox proportional hazard regression analyses were performed to identify independent predictors of clinical remission. (3) Results: In the study cohort, 13 patients had a PLA2R-negative pMN, while, of those with PLA2R-associated pMN, 27 patients had a low anti-PLA2R antibody titer (<200 RU/mL), and 25 patients had a high anti-PLA2R antibody titer at baseline (≥200 RU/mL). The clinical outcome was better in patients with PLA2R-negative pMN compared to patients with PLA2R-positive pMN. These patients had a higher percentage of complete remissions (46.2%, compared to 33.3% in those with low anti-PLA2R antibody titer or 24% in those with high anti-PLA2R antibody titer), a faster decline of 24 h proteinuria and lower time to complete remission. In multivariate Cox regression analysis, patients with PLA2R-negative pMN had a 3.1-fold and a 2.87-fold higher chance for achieving a complete or partial remission compared to patients with high anti-PLA2R antibody titer or to all PLA2R-positive patients, respectively. Additionally, patients with a baseline 24 h proteinuria of less than 8 g/day and with an immunological remission at 24 months had a 2.4-fold (HR, 2.4; 95%CI, 1.19-4.8) and a 2.2-fold (HR, 2.26; 95%CI, 1.05-4.87), respectively, higher chance of achieving a clinical response. By contrary, renal function at diagnosis, type of therapeutic intervention or anti-PLA2R antibody titer did not predict the occurrence of clinical remission. (4) Conclusions: We identified a different clinical phenotype between PLA2R-positive and PLA2R-negative pMN. Additionally, we have shown that baseline proteinuria seems to be a more important predictor of clinical outcome than anti-PLA2R-ab titer.
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Affiliation(s)
- Roxana Jurubiță
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
| | - Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Correspondence: ; Tel.: +40-721-256-797
| | - Bogdan Sorohan
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Camelia Achim
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Georgia Elena Micu
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
| | - Gabriel Mircescu
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Nephrology, “Dr. Carol Davila” Teaching Hospital of Nephrology, 010731 Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
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Hirose G, Uchida T, Kojima A, Sugisaki K, Yamada M, Nagase Y, Takaki T, Nagahama K, Oda T. Membranous Nephropathy With Monoclonal IgM Lambda Deposits in a Patient With IgM Monoclonal Gammopathy: A Case Report. Front Med (Lausanne) 2021; 8:608741. [PMID: 34113625 PMCID: PMC8185035 DOI: 10.3389/fmed.2021.608741] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 04/27/2021] [Indexed: 11/18/2022] Open
Abstract
We report a case of membranous nephropathy with monoclonal immunoglobulin (Ig)M lambda deposits in a patient with IgM monoclonal gammopathy, in whom histological changes were observed on repeat renal biopsy. A 72-year-old Japanese woman was referred to our hospital because of massive proteinuria. A prominent increase in monoclonal IgM lambda level was identified, and she was diagnosed as having IgM monoclonal gammopathy of undetermined significance. Renal biopsy showed glomerular subepithelial electron-dense deposits that were found to be granular deposits of IgM lambda but not kappa or IgG by immunofluorescence staining, resulting in a diagnosis of membranous nephropathy with monoclonal IgM deposits. The second biopsy, which was performed 2 years later because of exacerbation of her nephrotic syndrome, demonstrated less immunofluorescence staining of IgM, and dominant IgG2 deposition without light chain restriction. Interestingly, immunostaining for thrombospondin-type-1-domain-containing-7A was positive in both renal biopsy tissues, although the second biopsy showed clearly stronger immunoreactivity. The effect of steroid therapy was limited; however, rituximab treatment improved both the hematological and renal abnormalities. Solitary deposition of IgM in membranous nephropathy is a quite rare condition. To our knowledge, this is the first case of monoclonal gammopathy of renal significance presenting as membranous nephropathy with monoclonal IgM deposits, in which chronological immunohistochemical changes were observed and rituximab therapy was effective.
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Affiliation(s)
- Go Hirose
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Takahiro Uchida
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Aki Kojima
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Kentaro Sugisaki
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Muneharu Yamada
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
| | - Yoshihiro Nagase
- Division of Electron Microscopy, Showa University School of Medicine, Tokyo, Japan
| | - Takashi Takaki
- Division of Electron Microscopy, Showa University School of Medicine, Tokyo, Japan
| | - Kiyotaka Nagahama
- Department of Pathology, Kyorin University School of Medicine, Tokyo, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan
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Brglez V, Seitz-Polski B. Growing Understanding of the Antigenic Basis for Membranous Nephropathy. Clin J Am Soc Nephrol 2021; 16:677-678. [PMID: 33849934 PMCID: PMC8259470 DOI: 10.2215/cjn.03530321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Vesna Brglez
- UR2CA, Côte d’Azur University, Nice, France,Rare Diseases Reference Center “Nephrotic Syndrome,” Côte d’Azur University, Nice, France
| | - Barbara Seitz-Polski
- UR2CA, Côte d’Azur University, Nice, France,Rare Diseases Reference Center “Nephrotic Syndrome,” Côte d’Azur University, Nice, France,Department of Nephrology, Dialysis and Transplantation, Nice University Hospital, Nice, France,Department of Immunology, Nice University Hospital, Nice, France
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129
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Kudose S, Sekulic M, Mehring CJ, Santoriello D, Batal I, Stokes MB, D’Agati VD, Markowitz GS. NELL1-Associated Membranous Glomerulopathy After Hematopoietic Stem Cell Transplantation. Kidney Int Rep 2021; 6:1992-1995. [PMID: 34307995 PMCID: PMC8258497 DOI: 10.1016/j.ekir.2021.04.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Satoru Kudose
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
- Correspondence: Satoru Kudose, Department of Pathology, Columbia University Irving Medical Center, Room VC14-238, 630 West 168th St., New York, New York 10032.
| | - Miroslav Sekulic
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | | | - Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - M. Barry Stokes
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Vivette D. D’Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Glen S. Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
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130
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Sethi S, Madden B, Debiec H, Morelle J, Charlesworth MC, Gross L, Negron V, Buob D, Chaudhry S, Jadoul M, Fervenza FC, Ronco P. Protocadherin 7-Associated Membranous Nephropathy. J Am Soc Nephrol 2021; 32:1249-1261. [PMID: 33833079 PMCID: PMC8259689 DOI: 10.1681/asn.2020081165] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/21/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Membranous nephropathy (MN) results from deposition of antigen-antibody complexes along the glomerular basement membrane (GBM). PLA2R, THSD7A, NELL1, and SEMA3B account for 80%-90% of target antigens in MN. METHODS We performed laser microdissection and mass spectrometry (MS/MS) in kidney biopsies from 135 individuals with PLA2R-negative MN, and used immunohistochemistry/immunofluorescence and confocal microscopy to confirm the MS/MS finding, detect additional cases, and localize the novel protein. We also performed MS/MS and immunohistochemistry on 116 controls and used immunofluorescence microscopy to screen biopsy samples from two validation cohorts. Western blot and elution studies were performed to detect antibodies in serum and biopsy tissue. RESULTS MS/MS studies detected a unique protein, protocadherin 7 (PCDH7), in glomeruli of ten (5.7%) PLA2R-negative MN cases, which also were negative for PLA2R, THSD7A, EXT1/EXT2, NELL1, and SEMA3B. Spectral counts ranged from six to 24 (average 13.2 [SD 6.6]). MS/MS did not detect PCDH7 in controls (which included 28 PLA2R-positive cases). In all ten PCDH7-positive cases, immunohistochemistry showed bright granular staining along the GBM, which was absent in the remaining cases of PLA2R-negative MN and control cases. Four of 69 (5.8%) cases in the validation cohorts (all of which were negative for PLA2R, THSD7A, EXT1, NELL1, and SEMA3B) were PCDH7-positive MN. Kidney biopsy showed minimal complement deposition in 12 of the 14 PCDH7-associated cases. Confocal microscopy showed colocalization of PCDH7 and IgG along the GBM. Western blot analysis using sera from six patients showed antibodies to nonreduced PCDH7. Elution of IgG from frozen tissue of PCDH7-associated MN showed reactivity against PCDH7. CONCLUSIONS MN associated with the protocadherin PCDH7 appears to be a distinct, previously unidentified type of MN.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Benjamin Madden
- Medical Genome Facility, Proteomics Core, Mayo Clinic, Rochester, Minnesota
| | - Hanna Debiec
- Unité Mixte de Recherche S 1155, Sorbonne Université, Université Pierre et Marie Curie Paris 06 and Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium,Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | | | - LouAnn Gross
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Vivian Negron
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - David Buob
- Unité Mixte de Recherche S 1155, Sorbonne Université, Université Pierre et Marie Curie Paris 06 and Institut National de la Santé et de la Recherche Médicale, Paris, France,Department of Pathology, Tenon Hospital, Paris, France
| | | | - Michel Jadoul
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium,Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | | | - Pierre Ronco
- Unité Mixte de Recherche S 1155, Sorbonne Université, Université Pierre et Marie Curie Paris 06 and Institut National de la Santé et de la Recherche Médicale, Paris, France,Division of Nephrology, Centre Hospitalier du Mans, Le Mans, France
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131
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Lerner GB, Virmani S, Henderson JM, Francis JM, Beck LH. A conceptual framework linking immunology, pathology, and clinical features in primary membranous nephropathy. Kidney Int 2021; 100:289-300. [PMID: 33857571 DOI: 10.1016/j.kint.2021.03.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/07/2021] [Accepted: 03/25/2021] [Indexed: 12/22/2022]
Abstract
Primary membranous nephropathy is a leading cause of adult nephrotic syndrome. The field took a major step forward with the identification of phospholipase A2 receptor (PLA2R) as a target antigen in the majority of cases and with the ability to measure circulating autoantibodies to PLA2R. Since then, the existence of additional target antigens such as thrombospondin type-1 domain-containing 7A, exostosin 1 and 2, neural EGFL like 1, and semaphorin 3B has been demonstrated. The ability to detect and monitor levels of circulating autoantibodies has opened a new window onto the humoral aspect of primary membranous nephropathy. Clinicians now rely on clinical parameters such as proteinuria, as well as levels of circulating autoantibodies against PLA2R and the results of immunofluorescence staining for PLA2R within kidney biopsy tissue, to guide the management of this disease. The relationship between immunologic and clinical disease course is consistent, but not necessarily intuitive. In addition, kidney biopsy provides only a single snapshot of disease that needs to be interpreted in light of changing clinical and serological findings. A clear understanding of these dynamic parameters is essential for staging, treatment, and management of this disease. This review aims to shed light on current knowledge regarding the development and time course of changes in the serum levels of autoantibodies against PLA2R, proteinuria, and histological findings that underlie the pathophysiology of primary membranous nephropathy.
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Affiliation(s)
- Gabriel B Lerner
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samarth Virmani
- Department of Internal Medicine, University of Central Florida College of Medicine, Gainesville, Florida, USA
| | - Joel M Henderson
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Jean M Francis
- Department of Medicine, Section of Nephrology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Laurence H Beck
- Department of Medicine, Section of Nephrology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.
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Klomjit N, Zand L. Rituximab Is Preferable to Cyclophosphamide for Treatment of Membranous Nephropathy: COMMENTARY. KIDNEY360 2021; 2:1702-1705. [PMID: 35378023 PMCID: PMC8785832 DOI: 10.34067/kid.0002492021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Nattawat Klomjit
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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133
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Obrișcă B, Sorohan B, Tuță L, Ismail G. Advances in Lupus Nephritis Pathogenesis: From Bench to Bedside. Int J Mol Sci 2021; 22:ijms22073766. [PMID: 33916456 PMCID: PMC8038540 DOI: 10.3390/ijms22073766] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 11/29/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is the prototype of autoimmune disorders caused by a loss of tolerance to endogenous nuclear antigens triggering an aberrant autoimmune response targeting various tissues. Lupus nephritis (LN), a major cause of morbidity and mortality in patients with SLE, affects up to 60% of patients. The recent insights into the genetic and molecular basis of SLE and LN paved the way for newer therapies to be developed for these patients. Apart from the traditional B-cell-centered view of this disease pathogenesis, acknowledging that multiple extrarenal and intrarenal pathways contribute to kidney-specific autoimmunity and injury may help refine the individual therapeutic and prognostic characterization of such patients. Accordingly, the formerly induction-maintenance treatment strategy was recently challenged with the exciting results obtained from the trials that evaluated add-on therapy with voclosporin, belimumab, or Obinutuzumab. The scope of this review is to provide an insight into the current knowledge of LN pathogenesis and future therapeutic strategies.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, Fundeni Street 258, 022328 Bucharest, Romania; (B.O.); (B.S.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Bogdan Sorohan
- Department of Nephrology, Fundeni Clinical Institute, Fundeni Street 258, 022328 Bucharest, Romania; (B.O.); (B.S.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Liliana Tuță
- Department of Nephrology, “Ovidius” University, 900527 Constanta, Romania;
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, Fundeni Street 258, 022328 Bucharest, Romania; (B.O.); (B.S.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Correspondence:
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134
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Mechanisms of Primary Membranous Nephropathy. Biomolecules 2021; 11:biom11040513. [PMID: 33808418 PMCID: PMC8065962 DOI: 10.3390/biom11040513] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022] Open
Abstract
Membranous nephropathy (MN) is an autoimmune disease of the kidney glomerulus and one of the leading causes of nephrotic syndrome. The disease exhibits heterogenous outcomes with approximately 30% of cases progressing to end-stage renal disease. The clinical management of MN has steadily advanced owing to the identification of autoantibodies to the phospholipase A2 receptor (PLA2R) in 2009 and thrombospondin domain-containing 7A (THSD7A) in 2014 on the podocyte surface. Approximately 50–80% and 3–5% of primary MN (PMN) cases are associated with either anti-PLA2R or anti-THSD7A antibodies, respectively. The presence of these autoantibodies is used for MN diagnosis; antibody levels correlate with disease severity and possess significant biomarker values in monitoring disease progression and treatment response. Importantly, both autoantibodies are causative to MN. Additionally, evidence is emerging that NELL-1 is associated with 5–10% of PMN cases that are PLA2R- and THSD7A-negative, which moves us one step closer to mapping out the full spectrum of PMN antigens. Recent developments suggest exostosin 1 (EXT1), EXT2, NELL-1, and contactin 1 (CNTN1) are associated with MN. Genetic factors and other mechanisms are in place to regulate these factors and may contribute to MN pathogenesis. This review will discuss recent developments over the past 5 years.
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Tesar V, Hruskova Z. Autoantibodies in the Diagnosis, Monitoring, and Treatment of Membranous Nephropathy. Front Immunol 2021; 12:593288. [PMID: 33828546 PMCID: PMC8019786 DOI: 10.3389/fimmu.2021.593288] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 02/22/2021] [Indexed: 01/25/2023] Open
Abstract
The discovery of anti-podocyte antibodies in primary membranous nephropathy (MN) has revolutionized our approach toward the diagnosis and treatment of this disease. Evaluation of serum levels of anti-podocyte antibodies paved the way for non-invasive diagnosis and helped distinguish between primary and secondary MN although the relationship between anti-podocyte antibodies and cancer remains to be elucidated. Serum levels of anti-PLA2R antibodies directed against the major podocyte autoantigen are related to MN activity and the decrease in serum levels of anti-PLA2R antibodies in response to treatment (immunologic remission) also serves as an early indicator of the later putative proteinuric remission, enabling personalization of the treatment. The serum levels of anti-podocyte antibodies also enable the prediction of renal outcomes in terms of both remission and the risk of progression to end-stage renal disease. The positivity of anti-PLA2R antibodies before renal transplantation is associated with the risk of recurrence of MN. It remains to be established if all these relations observed in patients with anti-PLA2R antibodies are also valid for expanding spectrum of antibodies directed against recently discovered minor antigens (e.g., THSD7A, NELL-1, semaphorin 3B).
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Affiliation(s)
- Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine, General University Hospital, Charles University, Prague, Czechia
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Moszczuk B, Kiryluk K, Pączek L, Mucha K. Membranous Nephropathy: From Research Bench to Personalized Care. J Clin Med 2021; 10:jcm10061205. [PMID: 33799372 PMCID: PMC7998937 DOI: 10.3390/jcm10061205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/15/2021] [Accepted: 03/08/2021] [Indexed: 12/13/2022] Open
Abstract
Membranous nephropathy is a glomerulopathy that causes nephrotic syndrome and, in at least a third of cases, lasting end-stage kidney disease (ESKD). It is also a rare case of revolutionary changes in our understanding of the disease, that translates from scientific findings to real diagnosis and treatment recommendations in less than ten years. In this review we present: (1) a short history and traditional approach to patients with membranous nephropathy, (2) current recommendations and treatment options that have emerged in recent years, (3) findings of new studies, with a particular focus on serological/immunological methods, genomic and proteomic studies, still requiring validation. With further development in this field, membranous nephropathy may become one of the first nephrological conditions that apply a truly personalized approach with the omission of invasive measures such as kidney biopsy.
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Affiliation(s)
- Barbara Moszczuk
- Department of Immunology, Transplantology and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland; (B.M.); (L.P.)
- Department of Clinical Immunology, Medical University of Warsaw, 02-006 Warsaw, Poland
| | - Krzysztof Kiryluk
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA;
| | - Leszek Pączek
- Department of Immunology, Transplantology and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland; (B.M.); (L.P.)
- Institute of Biochemistry and Biophysics, Polish Academy of Sciences, 02-106 Warsaw, Poland
| | - Krzysztof Mucha
- Department of Immunology, Transplantology and Internal Diseases, Medical University of Warsaw, 02-006 Warsaw, Poland; (B.M.); (L.P.)
- Institute of Biochemistry and Biophysics, Polish Academy of Sciences, 02-106 Warsaw, Poland
- Correspondence: or ; Tel.: +48-(22)-502-1641
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Bobart SA, Tehranian S, Sethi S, Alexander MP, Nasr SH, Moura Marta C, Vrana JA, Said S, Giesen CD, Lieske JC, Fervenza FC, De Vriese AS. A Target Antigen-Based Approach to the Classification of Membranous Nephropathy. Mayo Clin Proc 2021; 96:577-591. [PMID: 33673911 DOI: 10.1016/j.mayocp.2020.11.028] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 11/25/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To describe the clinical and pathological phenotype of membranous nephropathy (MN) associated with M-type-phospholipase-A2-receptor (PLA2R), thrombospondin-type-1-domain-containing-7A (THSD7A), semaphorin 3B (SEMA3B), neural-epidermal-growth-factor-like-1-protein (NELL-1), protocadherin 7 (PCDH7), exostosin 1/exostosin 2 (EXT1/EXT2) and neural cell adhesion molecule 1 (NCAM-1) as target antigens. METHODS A retrospective cohort of 270 adult patients with biopsy-proven MN diagnosed between January 2015 and April 2020 was classified as PLA2R-, THSD7A-, SEMA3B-, NELL-1-, PCDH7-, EXT1/EXT2-, NCAM-1-associated or septuple-negative MN using serologic tests, immunostaining, and/or mass spectrometry. Clinical, biochemical, pathologic, and follow-up data were systematically abstracted from the medical records, including disease activity of conditions traditionally associated with MN and occurring within 5 years of MN diagnosis. RESULTS Patients with PLA2R-associated MN were predominantly middle-aged white men without associated disease. The presence of associated disease did not affect the clinical and pathologic characteristics of PLA2R-associated MN, suggesting that they were coincidental rather than causally linked. THSD7A-, NELL-1-, PCDH7-, and NCAM-1-associated MN were rare and SEMA3B-associated MN was not discovered in our cohort. EXT1/EXT2-associated MN was primarily diagnosed in younger women with active systemic autoimmunity. A significant proportion of septuple-negative patients had associated malignancy or systemic autoimmunity. CONCLUSION The widely used distinction between primary and secondary MN has limitations. We propose a refined terminology that combines the target antigen and associated disease to better classify MN and guide clinical decision making.
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Affiliation(s)
- Shane A Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Cleveland Clinic Florida, Weston
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Julie A Vrana
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Samar Said
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Callen D Giesen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Ghent University, Ghent, Belgium.
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