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Abstract
PURPOSE OF REVIEW Lupus nephritis is a common severe manifestation of systemic lupus erythematosus. Despite recent advances in therapeutics and understanding of its pathogenesis, there are still substantial unmet needs. This review discusses recent discoveries in these areas, especially the role of tubulointerstitial inflammation (TII) in lupus nephritis. RECENT FINDINGS Non-white ethnicity is still a major risk and poor prognostic factor in lupus nephritis. TII and fibrosis have been found to be associated with worse renal outcome but the current lupus nephritis treatment guidelines and trials are based on the degree of glomerular inflammation. In combination with mycophenolate mofetil, a B-cell-targeted therapy (belimumab) and a calcineurin inhibitor (voclosporin) have shown efficacy in recent lupus nephritis trials. However, response rates have been modest. While lupus glomerulonephritis results from immune complex deposition derived from systemic autoantibodies, TII arises from complex processes associated with in situ adaptive cell networks. These include local antibody production, and cognate or antigen-induced interactions between T follicular helper cells, and likely other T-cell populations, with antigen presenting cells including B cells, myeloid dendritic cells and plasmacytoid dendritic cells. SUMMARY Better understanding of the pathogenesis of TII will identify novel therapeutic targets predicted to improve outcomes in our patients with lupus nephritis.
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Affiliation(s)
- Anthony Chang
- Department of Pathology, University of Chicago, Chicago, IL 60637
| | - Marcus R. Clark
- Section of Rheumatology, Department of Medicine and Gwenn Knapp Center for Lupus and Immunology Research, University of Chicago, Chicago, IL 60637
| | - Kichul Ko
- Section of Rheumatology, Department of Medicine and Gwenn Knapp Center for Lupus and Immunology Research, University of Chicago, Chicago, IL 60637
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202
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Hirooka Y, Nozaki Y. Interleukin-18 in Inflammatory Kidney Disease. Front Med (Lausanne) 2021; 8:639103. [PMID: 33732720 PMCID: PMC7956987 DOI: 10.3389/fmed.2021.639103] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/08/2021] [Indexed: 12/29/2022] Open
Abstract
Interleukin (IL)-18, a member of the IL-1 superfamily, is a pro-inflammatory cytokine that is structurally similar to IL-1β. IL-18 promotes the production of interferon gamma (IFN-γ) and strongly induces a Th1 response. IL-18 drives the same myeloid differentiation factor 88 (MyD88)/nuclear factor kappa B (NF-κB) signaling pathway as IL-1β. In physiological conditions, IL-18 is regulated by the endogenous inhibitor IL-18 binding protein (IL-18BP), and the activity of IL-18 is balanced. It is reported that in several inflammatory diseases, the IL-18 activity is unbalanced, and IL-18 neutralization by IL-18BP is insufficient. IL-18 acts synergistically with IL-12 to induce the production of IFN-γ as a Th1 cytokine, and IL-18 acts alone to induce the production of Th2 cytokines such as IL-4 and IL-13. In addition, IL-18 alone enhances natural killer (NK) cell activity and FAS ligand expression. The biological and pathological roles of IL-18 have been studied in many diseases. Here we review the knowledge regarding IL-18 signaling and the role of IL-18 in inflammatory kidney diseases. Findings on renal injury in coronavirus disease 2019 (COVID-19) and its association with IL-18 will also be presented.
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Affiliation(s)
- Yasuaki Hirooka
- Department of Rheumatology, Kindai University Nara Hospital, Nara, Japan
| | - Yuji Nozaki
- Department of Hematology and Rheumatology, Kindai University School of Medicine, Osaka, Japan
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203
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Hu L, Hu J, Chen L, Zhang Y, Wang Q, Yang X. Interleukin-22 From Type 3 Innate Lymphoid Cells Aggravates Lupus Nephritis by Promoting Macrophage Infiltration in Lupus-Prone Mice. Front Immunol 2021; 12:584414. [PMID: 33717066 PMCID: PMC7953152 DOI: 10.3389/fimmu.2021.584414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 01/21/2021] [Indexed: 12/15/2022] Open
Abstract
Lupus nephritis (LN) is one of the most severe manifestations of systemic lupus erythematosus (SLE). Our previous studies demonstrated increased serum and renal Interleukin (IL)-22 in LN patients and MRL/lpr mice. This study investigated the role of IL-22 and its mechanism in LN. Here, we found that IL-22 was mainly produced by type 3 innate lymphoid cells (ILC3) in kidney of MRL/lpr mice. The systemic illness and local renal lesion were significantly alleviated in IL-22 or IL-22R gene knockout (KO) mice (IL-22 KO or IL-22R KO MRL/lpr mice) than control mice (MRL/lpr mice). IL-22 KO or IL-22R KO MRL/lpr mice had significantly slighter infiltration of macrophage in kidney than MRL/lpr mice. Consistently, by RNA-Seq, the expression of (CC motif) ligand 2 (CCL2) and (CXC motif) ligand 10 (CXCL10) was decreased in kidney of KO mice compared with control mice. By immunoblotting, significantly increased levels of STAT3 phosphorylation were found in the kidney of control mice compared to KO mice. In vitro, primary kidney epithelial cells from control mouse stimulated with recombinant IL-22 (rIL-22) expressed higher levels of CCL2, CXCL10, and phosphorylated STAT3. At the same time, when primary kidney epithelial cells were treated with rIL-22, transwell assay demonstrated their supernatant recruited more macrophages. In human kidney epithelial cell line (HK2) cells, when treated with rIL-22, we observed similar results with primary mouse kidney epithelial cells. Moreover, when cells were stimulated with rIL-22 following pre-treatment with STAT3 pathway inhibitor, the expression of CCL2 and CXCL10 were significantly reversed. Our findings demonstrate that IL-22 binding to IL-22R in kidney epithelial cells activated the STAT3 signaling pathway, enhanced the chemokine secretion and then promoted macrophage infiltration to the kidney of MRL/lpr mice, thus aggravated LN in lupus-prone mice. These findings indicate that IL-22 may play a pathogenic role in LN and may provide a promising novel therapeutic target for LN.
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Affiliation(s)
- Lingzhen Hu
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Jingyi Hu
- Laboratory of Immunology, College of Medicine, Institute of Basic Medical Sciences, Zhejiang University, Hangzhou, China
| | - Liheng Chen
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Yi Zhang
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Department of Rheumatology, Hangzhou Dingqiao Hospital, Hangzhou, China
| | - Qingqing Wang
- Laboratory of Immunology, College of Medicine, Institute of Basic Medical Sciences, Zhejiang University, Hangzhou, China
| | - Xuyan Yang
- Department of Rheumatology, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
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204
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Luís MSF, Bultink IEM, da Silva JAP, Voskuyl AE, Inês LS. Early predictors of renal outcome in patients with proliferative lupus nephritis: a 36-months cohort study. Rheumatology (Oxford) 2021; 60:5134-5141. [PMID: 33560332 DOI: 10.1093/rheumatology/keab126] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 01/22/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To identify predictors of complete renal response (CRR) and renal flares in SLE patients with active proliferative lupus nephritis (LN). METHODS Retrospective cohort study over 36 months including patients with biopsy-proven proliferative LN (class III/IV), from two European tertiary centers. CRR and renal flare were defined as proteinuria <0.5g/day with normal renal function and proteinuria >1g/day after CRR attainment, respectively. Demographic, clinical and analytic parameters were evaluated as early predictors of renal outcome, using survival analysis. Candidate variables were tested as predictors for CRR at time 0, 3 and 6 months after starting induction treatment. Potential predictors for renal flare were evaluated at time of reaching CRR. Variables with p < 0.10 on univariate analysis with Log-Rank tests were further tested with multivariate Cox proportional hazards regression models. RESULTS We included 104 patients (81.7% female, age at baseline 32.0±13.3 years). Over follow-up, 91.7% reached CRR, within a median time of 6.0 months. Proteinuria <2g/day at baseline (HR = 1.80, CI 95% 1.16-2.79, p < 0.01) and 3 months (HR = 2.32, 95%CI 1.24-4.32, p < 0.01) after starting induction therapy were independent predictors of CRR. Renal flares occurred in 18.4% of patients reaching CRR, after a mean time of 16.5±8.6 months. Age up to 25 years at time of LN diagnosis (HR = 5.41, 95%CI 1.72-16.97, p < 0.01) and positive anti-RNP (HR = 3.52, 95%CI 1.21-10.20, p = 0.02) were independent predictors of renal flares. CONCLUSION In patients with SLE and proliferative LN, factors assessed at baseline and 3 months from starting induction treatment can predict CRR and renal flares once CRR is achieved.
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Affiliation(s)
- Mariana S F Luís
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Institute for Clinical and Biomedical Research - i.CBR, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Irene E M Bultink
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - José A P da Silva
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Institute for Clinical and Biomedical Research - i.CBR, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Alexandre E Voskuyl
- Department of Rheumatology and Clinical Immunology, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Luís S Inês
- Rheumatology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
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205
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Pryor KP, Xu C, Collins JE, Costenbader KH, Feldman CH. Predictors of Initial Hydroxychloroquine Receipt among Medicaid Beneficiaries with Incident Systemic Lupus Erythematosus. Arthritis Care Res (Hoboken) 2021; 74:1263-1268. [PMID: 33555101 PMCID: PMC8349369 DOI: 10.1002/acr.24572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/28/2020] [Accepted: 02/02/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Although hydroxychloroquine/chloroquine (HCQ/CQ) form the cornerstone of systemic lupus erythematosus (SLE) treatment, not all patients receive this, which may contribute to disparities in outcomes. We investigated factors associated with first dispensing of HCQ/CQ. METHODS Using Medicaid insurance claims from 2000-2010, we identified individuals age 18-65 years with incident SLE (≥3 SLE ICD-9 codes separated by ≥30 days without prior SLE codes or HCQ/CQ use for 24 months.) The primary outcome was first dispensing of HCQ/CQ within 24 months of the first SLE code. We used Cox proportional hazards regression models to examine the association between sociodemographic factors, comorbidities, health care utilization and medication use and HCQ/CQ dispensing within 24 months of diagnosis. RESULTS We identified 9560 Medicaid beneficiaries with incident SLE; 41% received HCQ (N=3949) or CQ (N=14) within 24 months of diagnosis. Younger patients were more likely to receive HCQ/CQ. Black, Asian, Hispanic and American Indian/Alaska Native individuals were more likely to receive HCQ/CQ than White individuals. Alcohol, opioid, and nicotine use, diabetes, and end-stage renal disease were associated with lower dispensing. Outpatient appointments and preventive care services were associated with higher rates; more hospitalizations with lower rates. CONCLUSION Only 41% of Medicaid beneficiaries with SLE received HCQ/CQ within 24 months of diagnosis. Greater outpatient and preventive care increased receipt. All non-White race/ethnicities had higher rates of first dispensing. Time to initial HCQ/CQ dispensing may not explain racial/ethnic disparities in adverse outcomes, highlighting the need to consider other care quality-related issues and medication adherence challenges.
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Affiliation(s)
- Katherine P Pryor
- Department of Medicine, Brigham and Women's Hospital (BWH), Boston, MA, United States
| | - Chang Xu
- Division of Rheumatology, Inflammation and Immunity, BWH/Harvard Medical School, United States
| | - Jamie E Collins
- OrACORe, Department of Orthopedic Surgery, BWH/Harvard Medical School.,VERITY Methodology Core, BWH/Harvard Medical School
| | - Karen H Costenbader
- Division of Rheumatology, Inflammation and Immunity, BWH/Harvard Medical School, United States
| | - Candace H Feldman
- Division of Rheumatology, Inflammation and Immunity, BWH/Harvard Medical School, United States
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206
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Cicalese PA, Mobiny A, Shahmoradi Z, Yi X, Mohan C, Van Nguyen H. Kidney Level Lupus Nephritis Classification Using Uncertainty Guided Bayesian Convolutional Neural Networks. IEEE J Biomed Health Inform 2021; 25:315-324. [PMID: 33206612 DOI: 10.1109/jbhi.2020.3039162] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The kidney biopsy based diagnosis of Lupus Nephritis (LN) is characterized by low inter-observer agreement, with misdiagnosis being associated with increased patient morbidity and mortality. Although various Computer Aided Diagnosis (CAD) systems have been developed for other nephrohistopathological applications, little has been done to accurately classify kidneys based on their kidney level Lupus Glomerulonephritis (LGN) scores. The successful implementation of CAD systems has also been hindered by the diagnosing physician's perceived classifier strengths and weaknesses, which has been shown to have a negative effect on patient outcomes. We propose an Uncertainty-Guided Bayesian Classification (UGBC) scheme that is designed to accurately classify control, class I/II, and class III/IV LGN (3 class) at both the glomerular-level classification task (26,634 segmented glomerulus images) and the kidney-level classification task (87 MRL/lpr mouse kidney sections). Data annotation was performed using a high throughput, bulk labeling scheme that is designed to take advantage of Deep Neural Network's (or DNNs) resistance to label noise. Our augmented UGBC scheme achieved a 94.5% weighted glomerular-level accuracy while achieving a weighted kidney-level accuracy of 96.6%, improving upon the standard Convolutional Neural Network (CNN) architecture by 11.8% and 3.5% respectively.
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207
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Calcineurin and Systemic Lupus Erythematosus: The Rationale for Using Calcineurin Inhibitors in the Treatment of Lupus Nephritis. Int J Mol Sci 2021; 22:ijms22031263. [PMID: 33514066 PMCID: PMC7865978 DOI: 10.3390/ijms22031263] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 12/18/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with a broad spectrum of clinical presentations that can affect almost all organ systems. Lupus nephritis (LN) is a severe complication that affects approximately half of the systemic erythematosus lupus (SLE) patients, which significantly increases the morbidity and the mortality risk. LN is characterized by the accumulation of immune complexes, ultimately leading to renal failure. Aberrant activation of T cells plays a critical role in the pathogenesis of both SLE and LN and is involved in the production of inflammatory cytokines, the recruitment of inflammatory cells to the affected tissues and the co-stimulation of B cells. Calcineurin is a serine-threonine phosphatase that, as a consequence of the T cell hyperactivation, induces the production of inflammatory mediators. Moreover, calcineurin is also involved in the alterations of the podocyte phenotype, which contribute to proteinuria and kidney damage observed in LN patients. Therefore, calcineurin inhibitors have been postulated as a potential treatment strategy in LN, since they reduce T cell activation and promote podocyte cytoskeleton stabilization, both being key aspects in the development of LN. Here, we review the role of calcineurin in SLE and the latest findings about calcineurin inhibitors and their mechanisms of action in the treatment of LN.
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208
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Farinha F, Pepper RJ, Oliveira DG, McDonnell T, Isenberg DA, Rahman A. Outcomes of membranous and proliferative lupus nephritis - analysis of a single-centre cohort with more than 30 years of follow-up. Rheumatology (Oxford) 2021; 59:3314-3323. [PMID: 32303057 PMCID: PMC7590413 DOI: 10.1093/rheumatology/keaa103] [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: 11/13/2019] [Revised: 02/11/2020] [Indexed: 01/28/2023] Open
Abstract
Objectives To compare membranous lupus nephritis (MLN) and proliferative lupus nephritis (PLN) with respect to survival, demographic, clinical and laboratory characteristics; and to investigate predictors of renal and patient survival. Methods Single-centre retrospective observational study. Patients with biopsy-proven PLN, MLN and mixed lupus nephritis were included. Groups were compared using appropriate statistical tests and survival was analysed through the Kaplan-Meier method. Cox regression analysis was performed to investigate predictors of renal and patient survival. Results A total of 187 patients with biopsy-proven lupus nephritis (135 with PLN, 38 with MLN and 14 with mixed LN) were followed for up to 42 years (median 12 years). There was a higher proportion of MLN amongst Afro-Caribbeans than amongst Caucasians (31% vs 15%, P = 0.010). Patients with MLN had significantly lower anti-dsDNA antibodies (P = 0.001) and higher C3 levels (P = 0.018) at diagnosis. Cumulative renal survival rates at 5, 10, 15 and 20 years were 91, 81, 75 and 66% for PLN and 100, 97, 92 and 84% for MLN, respectively (P = 0.028). Cumulative patient survival at 5, 10, 15 and 20 years was 94, 86, 80 and 76%, with no difference between PLN and MLN. Urinary protein-creatinine ratio above 42 mg/mmol and eGFR below 76 ml/min/1.73 m2, one year after the diagnosis of LN, were the strongest predictors of progression to end-stage renal disease. eGFR below 77 ml/min/1.73 m2, at one year, development of end-stage renal disease and Afro-Caribbean ethnicity were associated with higher mortality. Conclusion Patients with MLN and PLN differ significantly regarding serological profiles and renal survival, suggesting different pathogenesis. Renal function at year one predicts renal and patient survival.
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Affiliation(s)
| | - Ruth J Pepper
- Centre for Nephrology, University College London - Royal Free Campus, London, UK
| | - Daniel G Oliveira
- Internal Medicine Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
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Lorenzo-Vizcaya A, Isenberg D. Analysis of trends and causes of death in SLE patients over a 40-years period in a cohort of patients in the United Kingdom. Lupus 2021; 30:702-706. [PMID: 33472522 DOI: 10.1177/0961203320988607] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Systemic Lupus Erythematosus (SLE) an autoimmune rheumatic disease with a complex pathogenesis, remains potentially life-threatening. SLE patients have increased morbidity and premature mortality compared to non-SLE patients. The five-year survival rate has improved from <50% in the 1950s to >90% in the 1980s. Lupus patients still have a mortality risk three times that of the general population. OBJECTIVES To provide a detailed analysis of the causes of death, main characteristics and trends in the management of the deceased SLE patients from the lupus clinic at the University College London Hospital (UCLH); during the past four decades. METHODS This was a non-interventional, retrospective study based on historical real-world data from paper and electronic records of patients followed up at UCLH. The analysis focused on data collected between 1st January 1978 and 31th December 2018. We collected the: causes of death, duration of disease, key laboratory and clinical parameters and the treatment received. We compared the results from the four decades to ascertain trends in the causes of mortality. All statistical analyses were performed using the Statistical Package for Social Sciences (SPSS), version 22.0. The 95% confidence intervals for the means of data were calculated. RESULTS 111 SLE patients (15%), died during follow-up. Their median age was 51 years (interquartile range (IQR) = 38-63 years) and the median duration of disease, 15 years (IQR = 8.5-24 years). The main causes of death in the past 40 years were infection (31.7%), cancer (26.7%) and cardiovascular disease (CVD) (21.8%). 93.6% of these patients were immunosupressed. During the 40-year period, there were several therapeutic developments notably the introduction of mycophenolate mofetil (MMF) and rituximab; the latter initially only given to patients when more conventional inmunosupressants had failed, but more recently offered to patients at diagnosis. There was a statistically significant increase in the use of hydroxycloroquine (HCQ), MMF and rituximab. In contrast, the use of Azathioprine (AZA) and steroids, hardly changed over time. CONCLUSIONS This retrospective review shows how epidemiological factors, causes of death and treatment of SLE patients have changed during the last 40 years in the UCLH cohort.
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Affiliation(s)
- Ana Lorenzo-Vizcaya
- Department of Internal Medicine, Hospital Universitario De Ourense, Ourense, Spain
| | - David Isenberg
- Department of Rheumatology, Division of Medicine, University College London, London, UK
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210
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Abstract
Systemic lupus erythematosus is a rare lifelong multi-systemic autoimmune condition. Juvenile-onset SLE (JSLE) is recognized to have a more active disease course when compared with adult-onset disease and patients have a worse long-term survival. Kidney involvement occurs in over 50% of children and treatment decisions are guided by the histological classification. Several international groups have produced treatment protocols that rely on an intense period of immunosuppression to halt the acute kidney inflammatory process, followed by maintenance therapy with close observation for disease improvement and prompt evaluation of disease flares. A reduced glomerular filtration rate at presentation is predictive of later stage chronic kidney disease (CKD) in multivariate analysis. Kidney remission remains suboptimal with only 40-60% of patients achieving complete remission. Kidney flares are seen in over a third of patients. The rate of CKD 5 is reported to be up to 15% and the presence of lupus nephritis (LN) has an established link with an associated increase in mortality. In established kidney failure, transplantation seems to be the optimal kidney replacement modality for this group of patients, ideally after a period of disease quiescence. Modified outcome measures in clinical trials have demonstrated that biologic agents can be effective in this disease. Current biologic agents under investigation include obinutuzimab, belimumab, atacicept, anifrolumab, tocilizumab, eculizumab, dapirolizumab, and abatacept. Future research should focus on discovering early disease biomarkers, including surrogates for later cardiovascular disease, and evaluating biological agents as adjuncts to improve the rates of complete remission and subsequently influence the kidney outcome. The aim of this review article is to summarize the current kidney outcomes for this disease with a view to identifying key areas that may help to reduce the risk of long-term CKD.
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211
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Xiong ZH, Cao XS, Guan HL, Zheng HL. Immunotherapies application in active stage of systemic lupus erythematosus in pregnancy: A case report and review of literature. World J Clin Cases 2020; 8:6396-6407. [PMID: 33392323 PMCID: PMC7760451 DOI: 10.12998/wjcc.v8.i24.6396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/27/2020] [Accepted: 10/26/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Pregnancy in the setting of systemic lupus erythematosus can worsen the condition from the stable to active stage, with quality of life and fertility desire being particular concerns. Pregnancy in the active stage of systemic lupus erythematosus (ASLE), although rare and complicated to manage, can be treated favorably with immunotherapies ifs used properly. Here we report such a success case.
CASE SUMMARY A 31-year-old primigravida patient, diagnosed with SLE seven years ago, was induced ASLE after a cold at 21 + weeks. The patient’s vital signs on presentation were normal. Her laboratory exam was remarkable for significant proteinuria, liver and renal dysfunction, and low C3 and C4 levels. Infectious work-up was negative. The patient was diagnosed with ASLE. She was given immunosuppressive agents (methylprednisolone, gamma globulin and azathioprine etc.) and plasma adsorption therapy, monitoring blood pressure every 8 h, fetal heart rate twice a day, and liver and renal function at least twice a week. Successful maternal and fetal outcomes are presented here.
CONCLUSION Child-bearing in ASLE has become more promising, even for this difficult case of ASLE with multiple organ damage. Thorough antepartum counseling, cautious maternal-fetal monitoring, and multi-organ function monitoring by multidisciplinary specialties are keys to favorable pregnancy outcomes.
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Affiliation(s)
- Zhi-Hui Xiong
- Department of Obstetrics, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
| | - Xiao-Song Cao
- Department of Medical Clinic, Lanxi No. 5 Middle School, Lanxi 321100, Zhejiang Province, China
| | - Hai-Lian Guan
- Department of Obstetrics, Tongde Hospital of Zhejiang Province, Hangzhou 310012, Zhejiang Province, China
| | - Hui-Ling Zheng
- Department of Obstetrics, The Second Affiliated Hospital of Zhejiang University of Traditional Chinese Medicine, Hangzhou 310005, Zhejiang Province, China
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Gasparotto M, Gatto M, Binda V, Doria A, Moroni G. Lupus nephritis: clinical presentations and outcomes in the 21st century. Rheumatology (Oxford) 2020; 59:v39-v51. [PMID: 33280015 PMCID: PMC7751166 DOI: 10.1093/rheumatology/keaa381] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/28/2020] [Indexed: 01/17/2023] Open
Abstract
Lupus nephritis (LN) is a frequent and severe manifestation of SLE. Along the decades, the epidemiology of LN and its clinical presentation have been changing. However, even though retrospective cohort studies report a decreased mortality rate and an improvement in the disease prognosis, the percentage of patients progressing into end stage renal disease (ESRD) keeps steady despite the improvements in therapeutic strategies. Current in-use medications have been available for decades now, yet over the years, regimens for optimizing their efficacy and minimizing toxicity have been developed. Therapeutic research is now moving towards the direction of precision medicine and several new drugs, targeting selectively different pathogenetic pathways, are currently under evaluation with promising results. In this review, we address the main changes and persistent unmet needs in LN management throughout the past decades, with a focus on prognosis and upcoming treatments.
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Affiliation(s)
| | - Mariele Gatto
- Rheumatology Unit, Department of Medicine, University of Padua
| | - Valentina Binda
- Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine, University of Padua
| | - Gabriella Moroni
- Nephrology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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Arnaud L, Tektonidou MG. Long-term outcomes in systemic lupus erythematosus: trends over time and major contributors. Rheumatology (Oxford) 2020; 59:v29-v38. [PMID: 33280012 PMCID: PMC7719040 DOI: 10.1093/rheumatology/keaa382] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/03/2020] [Indexed: 12/20/2022] Open
Abstract
SLE is a chronic autoimmune rheumatic disorder of high heterogeneity in clinical presentation, treatment response and prognosis. Long-term outcomes in SLE have been dramatically improved over the past decades, however, increased morbidity and mortality, especially among young individuals, still exists. Unmet needs include residual disease activity and frequent flares, glucocorticoid treatment dependency and toxicity, comorbidity burden, reduced health-related quality of life, health disparities and damage. The main determinants of long-term outcomes in SLE are age, sex, race/ethnicity, genetic profile, environmental factors including smoking, disease activity, major organ involvement such as lupus nephritis and CNS involvement, comorbidities including cardiovascular disease and serious infections, coexistence with APS, treatment adherence, socio-economic factors and access to care. In this review we discuss trends in long-term outcomes in SLE over the years and major contributors such as genetic, disease-related, treatment, comorbidity, socio-economic and other factors.
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Affiliation(s)
- Laurent Arnaud
- Department of Rheumatology, Hôpitaux Universitaires de Strasbourg, INSERM UMR-S 1109, Centre National de Référence des Maladies Auto-immunes Systémiques Rares (RESO), Strasbourg, France
| | - Maria G Tektonidou
- Rheumatology Unit, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Joint Rheumatology Program, Laiko Hospital, Athens, Greece
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Atisha-Fregoso Y, Malkiel S, Harris KM, Byron M, Ding L, Kanaparthi S, Barry WT, Gao W, Ryker K, Tosta P, Askanase AD, Boackle SA, Chatham WW, Kamen DL, Karp DR, Kirou KA, Sam Lim S, Marder B, McMahon M, Parikh SV, Pendergraft WF, Podoll AS, Saxena A, Wofsy D, Diamond B, Smilek DE, Aranow C, Dall'Era M. Phase II Randomized Trial of Rituximab Plus Cyclophosphamide Followed by Belimumab for the Treatment of Lupus Nephritis. Arthritis Rheumatol 2020; 73:121-131. [PMID: 32755035 PMCID: PMC7839443 DOI: 10.1002/art.41466] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 07/22/2020] [Indexed: 12/28/2022]
Abstract
Objective To assess the safety, mechanism of action, and preliminary efficacy of rituximab followed by belimumab in the treatment of refractory lupus nephritis (LN). Methods In a multicenter, randomized, open‐label clinical trial, 43 patients with recurrent or refractory LN were treated with rituximab, cyclophosphamide (CYC), and glucocorticoids followed by weekly belimumab infusions until week 48 (RCB group), or treated with rituximab and CYC but no belimumab infusions (RC group). Patients were followed up until week 96. Percentages of total and autoreactive B cell subsets in the patients’ peripheral blood were analyzed by flow cytometry. Results Treatment with belimumab did not increase the incidence of adverse events in patients with refractory LN. At week 48, a complete or partial renal response occurred in 11 (52%) of 21 patients receiving belimumab, compared to 9 (41%) of 22 patients in the RC group who did not receive belimumab (P = 0.452). Lack of improvement in or worsening of LN was the major reason for treatment failure. B cell depletion occurred in both groups, but the percentage of B cells remained lower in those receiving belimumab (geometric mean number of B cells at week 60, 53 cells/μl in the RCB group versus 11 cells/μl in the RC group; P = 0.0012). Percentages of total and autoreactive transitional B cells increased from baseline to week 48 in both groups. However, percentages of total and autoreactive naive B cells decreased from baseline to week 48 in the belimumab group compared to the no belimumab RC group (P = 0.0349), a finding that is consistent with the observed impaired maturation of naive B cells and enhanced censoring of autoreactive B cells. Conclusion The addition of belimumab to a treatment regimen with rituximab and CYC was safe in patients with refractory LN. This regimen diminished maturation of transitional to naive B cells during B cell reconstitution, and enhanced the negative selection of autoreactive B cells. Clinical efficacy was not improved with rituximab and CYC in combination with belimumab when compared to a therapeutic strategy of B cell depletion alone in patients with LN.
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Affiliation(s)
| | - Susan Malkiel
- Feinstein Institute for Medical Research, Manhasset, New York
| | | | | | - Linna Ding
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | | | | | - Wendy Gao
- National Institute of Allergy and Infectious Diseases, NIH, Bethesda, Maryland
| | | | - Patti Tosta
- Immune Tolerance Network, Bethesda, Maryland
| | | | | | | | | | | | | | | | | | | | - Samir V Parikh
- Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | | | | | - Betty Diamond
- Feinstein Institute for Medical Research, Manhasset, New York
| | | | - Cynthia Aranow
- Feinstein Institute for Medical Research, Manhasset, New York
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215
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Li T, Lee I, Jayakumar D, Huang X, Xie Y, Eisen S, Ranganathan P. Development and validation of lupus nephritis case definitions using United States veterans affairs electronic health records. Lupus 2020; 30:518-526. [PMID: 33176569 DOI: 10.1177/0961203320973267] [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] [Indexed: 11/16/2022]
Abstract
OBJECTIVE International Classification of Diseases (ICD) codes are commonly used to identify patients with rare diseases in electronic health records (EHRs). However, misclassification is common, impacting the validity of study results. In this study, we compared the accuracies of several ICD-based case definitions of lupus nephritis (LN) in identifying United States veterans with LN. METHODS Using the Department of Veterans Affairs (VA) EHR, we identified all veterans with ≥1 ICD-9 or 10 diagnostic codes for systemic lupus erythematosus (SLE) between October 1, 1999 and September 30, 2017. A cohort was randomly selected for diagnostic validation and 9 ICD-based LN case definitions were applied to this cohort. The diagnostic accuracy of each definition was assessed against gold standard criterion of biopsy-proven LN. RESULTS 18,420 veterans had ≥1 ICD-9 or 10 diagnostic codes for SLE; 981 were randomly selected for diagnostic validation. 95 veterans (9.7%) had biopsy-proven LN. The case definitions had high specificity and NPV but variable sensitivity and PPV. The definition containing ≥2 ICD -9 codes for SLE and ≥2 nephritis indicators had the highest combination of sensitivity and specificity (87.4% and 94.6% respectively). ICD-10 code for LN had high specificity (99.8%) and PPV (93.9%). CONCLUSION ICD-based case definitions of LN in the VA population have high specificity and NPV but variable sensitivity and PPV. Our results may help guide the design of future LN studies in VA cohorts. The choice of specific case definitions depends on the relative importance of different accuracy measures to individual studies.
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Affiliation(s)
- Tingting Li
- Division of Nephrology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA.,Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, MO, USA.,Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO, USA
| | - Iris Lee
- Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO, USA.,Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Divya Jayakumar
- Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO, USA.,Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Xinliang Huang
- Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO, USA.,Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Yan Xie
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, MO, USA
| | - Seth Eisen
- Clinical Epidemiology Center, VA Saint Louis Health Care System, Saint Louis, MO, USA.,Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO, USA.,Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
| | - Prabha Ranganathan
- Research and Education Service, VA Saint Louis Health Care System, Saint Louis, MO, USA.,Division of Rheumatology, Department of Medicine, Washington University School of Medicine, Saint Louis, MO, USA
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216
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Li B, Tang Y, Ni X, Chen W. Immune Cell Landscape Identification Associates Intrarenal Mononuclear Phagocytes With Onset and Remission of Lupus Nephritis in NZB/W Mice. Front Genet 2020; 11:577040. [PMID: 33304383 PMCID: PMC7693546 DOI: 10.3389/fgene.2020.577040] [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: 06/28/2020] [Accepted: 10/07/2020] [Indexed: 12/17/2022] Open
Abstract
Objective A challenging issue in the clinical management of lupus nephritis (LN) is the resistance to immunosuppressive therapy. We postulated that perturbed intrarenal immune cell landscape affected LN onset and remission induction, and shedding light on the characteristics of intrarenal immune cell infiltration could cultivate more efficient treatment regimens. Materials and Methods Genome-wide expression profiles of microarray datasets were downloaded from the Gene Expression Omnibus database. The CIBERSORT algorithm was used to analyze the intrarenal immune cell landscape, followed by Pearson correlation analysis and principal component analysis. The differentially expressed genes were identified and subjected to Gene Ontology (GO) enrichment analyses and protein-protein interaction network establishment, being visualized by Cytoscape and further analyzed by CytoHubba to extract hub genes. Hub genes were also validated in the genomic dataset from kidney biopsy-proven LN patients. Results In addition to memory B cells, monocytes and M1 macrophages were identified as two predominantly increased intrarenal immune cell types in LN-prone NZB/W mice upon nephritis onset. Most interestingly, apart from memory B cells, monocytes and M1 macrophages proportions in kidney tissue were significantly lower in early remission mice compared with late remission mice. Furthermore, GO analysis showed that intrarenal mononuclear phagocytes triggered nephritis onset mainly via the initiation of adaptive immune response and inflammatory reaction, but this functional involvement was mitigated upon remission induction. Hub genes related to LN onset in NZB/W mice were validated in the genomic dataset from kidney biopsy-proven LN patients. Conclusion LN characterizes aberrant mononuclear phagocytes abundance and signature upon disease onset, of which the reversal is associated with early remission induction in LN-prone NZB/W mice. Mononuclear phagocytes might be an adjunctive histology marker for monitoring disease onset and stratifying LN patients in terms of response to remission induction therapy.
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Affiliation(s)
- Bin Li
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
| | - Yanlai Tang
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xuhao Ni
- Department of Pancreato-Biliary Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Key Laboratory of Nephrology, National Health Commission and Guangdong Province, Guangzhou, China
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217
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Creatinine clearance rate predicts prognosis of patients with systemic lupus erythematosus: a large retrospective cohort study. Clin Rheumatol 2020; 40:2221-2231. [PMID: 33155157 DOI: 10.1007/s10067-020-05485-7] [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: 07/03/2020] [Revised: 10/06/2020] [Accepted: 10/26/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To explore the association between the creatinine clearance rate (Ccr) and the prognosis of patients, and compared with estimated glomerular filtration rate (eGFR). METHODS We retrospectively collected information of patients with SLE who were first hospitalized between 1999 and 2009 in Jiangsu Province, China, and followed up in 2010 and 2015. Ccr was calculated and dichotomized into normal group (Ccr ≥ 70) and decreasing group (Ccr < 70). The clinical characteristics of the two groups were compared and Cox proportional-hazards regression models were used to calculate hazard ratio (HR) and 95% confidence interval (CI). RESULTS Among 1990 SLE patients, we observed 437 (22.0%) with decreased Ccr, including 237 cases (11.9%) with mild renal dysfunction, 136 cases (6.8%) with moderate renal dysfunction, and 64 cases (3.2%) with severe renal dysfunction. Compared to normal Ccr, decreasing Ccr had a higher risk for mortality with adjusted HR (95% CI) of 2.21 (1.59-3.06). Dose-response relationships were significantly found between increased mortality of SLE and decreased Ccr (p for trend < 0. 001), as well as eGFR. Positive associations were consistently observed in subgroups, such as systemic lupus disease activity index (SLEDAI) ≥ 15, without comorbidities and abnormal laboratory indexes. Decreasing Ccr was positively associated with mortality from infection and renal failure with HR (95% CI) of 1.80 (1.02-3.19) and 6.84 (3.05-15.36). CONCLUSIONS A significant association has been observed between decreased Ccr and increased risk for mortality of SLE patients. Early clinical interventions to modulate the Ccr of SLE patients may be beneficial to their survival. Key points • Decreasing creatinine clearance rate (Ccr) was positively associated with an overall mortality of SLE patients, with a dose-response relationship. • Moreover, decreasing Ccr was associated with elevated mortality primarily due to infection and renal failure.
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218
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Disparities in Lupus and Lupus Nephritis Care and Outcomes Among US Medicaid Beneficiaries. Rheum Dis Clin North Am 2020; 47:41-53. [PMID: 34042053 DOI: 10.1016/j.rdc.2020.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Systemic lupus erythematosus (SLE) is a serious chronic autoimmune disease with substantial morbidity and mortality. Although improved diagnostics and therapeutics have contributed to declining mortality rates, important disparities exist in SLE survival rates by race, ethnicity, gender, age, country, and social disadvantage. This review highlights the burden of SLE and lupus nephritis among Medicaid beneficiaries, outlines barriers in access to high-quality SLE care and medication adherence in the Medicaid SLE population, and summarizes disparities in adverse outcomes among SLE patients enrolled in Medicaid.
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219
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Gamez-Nava JI, Diaz-Rizo V, Perez-Guerrero EE, Muñoz-Valle JF, Saldaña-Cruz AM, Fajardo-Robledo NS, Jacobo-Cuevas H, Nava-Valdivia CA, Alcaraz-Lopez MF, Trujillo X, Huerta M, Cardona-Muñoz EG, Gonzalez-Lopez L. Assessment of serum macrophage migration inhibitory factor (MIF), adiponectin, and other adipokines as potential markers of proteinuria and renal dysfunction in lupus nephritis: a cross-sectional study. Biomark Res 2020; 8:55. [PMID: 33133605 PMCID: PMC7594329 DOI: 10.1186/s40364-020-00236-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/15/2020] [Indexed: 12/15/2022] Open
Abstract
Background To date, the association of serum macrophage migration inhibitory factor (MIF) and serum adipokines with lupus nephritis is controversial. Objective To assess the utility of serum MIF, leptin, adiponectin and resistin levels as markers of proteinuria and renal dysfunction in lupus nephritis. Methods Cross-sectional study including 196 systemic lupus erythematosus (SLE) patients and 52 healthy controls (HCs). Disease activity was assessed by Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Renal SLE involvement was investigated by renal-SLEDAI. MIF, adiponectin, leptin and resistin levels were quantified by ELISA. We assessed the correlations of quantitative variables by Spearman correlation (rs). Multivariable linear regression adjusted the variables associated with the severity of proteinuria. Results SLE patients had higher MIF (p = 0.02) and adiponectin (p < 0.001) than HCs. Patients with renal SLE involvement (n = 43) had higher adiponectin (19.0 vs 13.3 μg/mL, p = 0.002) and resistin (10.7 vs 8.9 ng/mL, p = 0.01) than patients with non-renal SLE (n = 153). Proteinuria correlated with high adiponectin (rs = 0.19, p < 0.009) and resistin (rs = 0.26, p < 0.001). MIF (rs = 0.27, p = 0.04). Resistin correlated with increased creatinine (rs = 0.18, p = 0.02). High renal-SLEDAI correlated with adiponectin (rs = 0.21, p = 0.004). Multiple linear regression showed that elevated adiponectin (p = 0.02), younger age (p = 0.04) and low MIF (p = 0.02) were associated with the severity of proteinuria. Low MIF and high adiponectin levels interacted to explain the association with the severity of proteinuria (R2 = 0.41). Conclusions High adiponectin combined with low MIF concentrations int+eract to explain the severity of proteinuria in renal SLE. These findings highlight the relevance of adiponectin, resistin and MIF as markers of LN.
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Affiliation(s)
- Jorge Ivan Gamez-Nava
- Programa de Doctorado en Farmacología del Departamento de Fisiología y Programa de Doctorado en Salud del Pública Depatamento de Salud Pública, Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, Sierra Mojada 950, Colonia Independencia, 44340 Guadalajara, Jalisco Mexico.,Centro Medico Nacional de Occidente, Unidad de Investigacion Biomedica 02, Instituto Mexicano del Seguro Social, Hospital de Especialidades, 44340 Guadalajara, Jalisco Mexico
| | - Valeria Diaz-Rizo
- Departamento de Disciplinas Filosófico, Metodológico e Instrumentales, Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, 44340 Guadalajara, Jalisco Mexico
| | - Edsaul Emilio Perez-Guerrero
- Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, Instituto de Investigación en Ciencias Biomédicas, 44340 Guadalajara, Jalisco Mexico
| | - Jose Francisco Muñoz-Valle
- Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, Instituto de Investigación en Ciencias Biomédicas, 44340 Guadalajara, Jalisco Mexico
| | - Ana Miriam Saldaña-Cruz
- Departamento de Fisiología, Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, Sierra Mojada 950, Colonia Independencia, 44340 Guadalajara, Jalisco Mexico
| | - Nicte Selene Fajardo-Robledo
- Laboratorio de Investigación y Desarrollo Farmacéutico, Universidad de Guadalajara, Centro Universitario de Ciencias Exactas e Ingenierías, 44430 Guadalajara, Mexico
| | - Heriberto Jacobo-Cuevas
- Programa de Doctorado en Farmacología del Departamento de Fisiología y Programa de Doctorado en Salud del Pública Depatamento de Salud Pública, Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, Sierra Mojada 950, Colonia Independencia, 44340 Guadalajara, Jalisco Mexico
| | - Cesar Arturo Nava-Valdivia
- Departamento de Microbiología y Patología, Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, 44340 Guadalajara, Jalisco Mexico
| | | | - Xochitl Trujillo
- Universidad de Colima, Centro Universitario de Investigaciones Biomédicas, 28040 Colima, Mexico
| | - Miguel Huerta
- Universidad de Colima, Centro Universitario de Investigaciones Biomédicas, 28040 Colima, Mexico
| | - Ernesto German Cardona-Muñoz
- Departamento de Fisiología, Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, Sierra Mojada 950, Colonia Independencia, 44340 Guadalajara, Jalisco Mexico
| | - Laura Gonzalez-Lopez
- Programa de Doctorado en Farmacología del Departamento de Fisiología y Programa de Doctorado en Salud del Pública Depatamento de Salud Pública, Universidad de Guadalajara, Centro Universitario de Ciencias de la Salud, Sierra Mojada 950, Colonia Independencia, 44340 Guadalajara, Jalisco Mexico.,Departamento de Medicina InternaReumatología, Instituto Mexicano del Seguro Social (IMSS), Hospital General Regional 110, 44716 Guadalajara, Jalisco Mexico
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220
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Chedid A, Rossi GM, Peyronel F, Menez S, Atta MG, Bagnasco SM, Arend LJ, Rosenberg AZ, Fine DM. Low-Level Proteinuria in Systemic Lupus Erythematosus. Kidney Int Rep 2020; 5:2333-2340. [PMID: 33305127 PMCID: PMC7710831 DOI: 10.1016/j.ekir.2020.09.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/02/2020] [Accepted: 09/08/2020] [Indexed: 12/23/2022] Open
Abstract
Introduction In patients with systemic lupus erythematosus (SLE) without concurrent active urinary sediment or unexplained acute kidney injury (AKI), current guidelines recommend performing a kidney biopsy in those with at least 500 mg/24-hour (European League Against Rheumatism/European Renal Association-European Dialysis and Transplant Association [EULAR/ERA-EDTA]) or 1000 mg/24-hour (American College of Rheumatology [ACR]) proteinuria. To evaluate the relevance of these indications, we studied histopathologic findings in patients with SLE with proteinuria below these cutoffs. Methods We retrospectively reviewed the clinical, laboratory and histological characteristics of patients with SLE with <1000 mg/24-hour proteinuria (or mg/g urinary protein-to-creatinine ratio [UPCR]) who underwent their first kidney biopsy between 2003 and 2018. Results We identified 87 patients with SLE with proteinuria less than 1000 mg/24-hour (or mg/g UPCR); 52 of 87 (60%) with isolated proteinuria, that is, without AKI or active urinary sediment (hematuria). Histologic evidence of lupus nephritis (LN) was present in 40 of 52 (76%). Of the 40 patients with LN, 12 had class I or II, 14 had class III or IV, 8 had class V, 6 had a combined proliferative and membranous LN. Non-lupus diagnoses included focal segmental glomerulosclerosis, acute interstitial nephritis, and others. Patient’s age, low C3, low C4, and positivity for anti-double-stranded DNA (anti-dsDNA) antibodies predicted the histological diagnosis of LN on univariate logistic regression; however, a multivariate model including these parameters as independent covariates failed to predict LN. Conclusions Patients with SLE with low-level proteinuria may have significant lupus- or non–lupus-related kidney disease with management implications. There was a significant burden of severe forms of LN. The presence of LN was not predicted by laboratory abnormalities. Based on our findings, we suggest current guidelines be revised to expand kidney biopsy indications to include isolated proteinuria of any grade.
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Affiliation(s)
- Alice Chedid
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Giovanni M Rossi
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
- Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Francesco Peyronel
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
- Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
| | - Steven Menez
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mohamed G Atta
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Serena M Bagnasco
- Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Lois J Arend
- Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Avi Z Rosenberg
- Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Derek M Fine
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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221
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Furie R, Rovin BH, Houssiau F, Malvar A, Teng YKO, Contreras G, Amoura Z, Yu X, Mok CC, Santiago MB, Saxena A, Green Y, Ji B, Kleoudis C, Burriss SW, Barnett C, Roth DA. Two-Year, Randomized, Controlled Trial of Belimumab in Lupus Nephritis. N Engl J Med 2020; 383:1117-1128. [PMID: 32937045 DOI: 10.1056/nejmoa2001180] [Citation(s) in RCA: 443] [Impact Index Per Article: 110.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In adults with active lupus nephritis, the efficacy and safety of intravenous belimumab as compared with placebo, when added to standard therapy (mycophenolate mofetil or cyclophosphamide-azathioprine), are unknown. METHODS In a phase 3, multinational, multicenter, randomized, double-blind, placebo-controlled, 104-week trial conducted at 107 sites in 21 countries, we assigned adults with biopsy-proven, active lupus nephritis in a 1:1 ratio to receive intravenous belimumab (at a dose of 10 mg per kilogram of body weight) or matching placebo, in addition to standard therapy. The primary end point at week 104 was a primary efficacy renal response (a ratio of urinary protein to creatinine of ≤0.7, an estimated glomerular filtration rate [eGFR] that was no worse than 20% below the value before the renal flare (pre-flare value) or ≥60 ml per minute per 1.73 m2 of body-surface area, and no use of rescue therapy), and the major secondary end point was a complete renal response (a ratio of urinary protein to creatinine of <0.5, an eGFR that was no worse than 10% below the pre-flare value or ≥90 ml per minute per 1.73 m2, and no use of rescue therapy). The time to a renal-related event or death was assessed. RESULTS A total of 448 patients underwent randomization (224 to the belimumab group and 224 to the placebo group). At week 104, significantly more patients in the belimumab group than in the placebo group had a primary efficacy renal response (43% vs. 32%; odds ratio, 1.6; 95% confidence interval [CI], 1.0 to 2.3; P = 0.03) and a complete renal response (30% vs. 20%; odds ratio, 1.7; 95% CI, 1.1 to 2.7; P = 0.02). The risk of a renal-related event or death was lower among patients who received belimumab than among those who received placebo (hazard ratio, 0.51; 95% CI, 0.34 to 0.77; P = 0.001). The safety profile of belimumab was consistent with that in previous trials. CONCLUSIONS In this trial involving patients with active lupus nephritis, more patients who received belimumab plus standard therapy had a primary efficacy renal response than those who received standard therapy alone. (Funded by GlaxoSmithKline; BLISS-LN ClinicalTrials.gov number, NCT01639339.).
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Affiliation(s)
- Richard Furie
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Brad H Rovin
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Frédéric Houssiau
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Ana Malvar
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Y K Onno Teng
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Gabriel Contreras
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Zahir Amoura
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Xueqing Yu
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Chi-Chiu Mok
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Mittermayer B Santiago
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Amit Saxena
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Yulia Green
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Beulah Ji
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Christi Kleoudis
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Susan W Burriss
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - Carly Barnett
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
| | - David A Roth
- From the Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Great Neck, NY (R.F.); the Division of Nephrology, Ohio State University, Columbus (B.H.R.); Pôle de Pathologies Rhumatismales Inflammatoires et Systémiques, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, and Service de Rhumatologie, Cliniques Universitaires Saint-Luc - both in Brussels (F.H.); Organización Médica de Investigación, Buenos Aires (A.M.); the Department of Internal Medicine, Section of Nephrology, Leiden University Medical Center, Leiden, the Netherlands (Y.K.O.T.); the Division of Nephrology, Division of Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami (G.C.); Sorbonne Université, INSERM Unité 1135 (Z.A.), and Assistance Publique-Hôpitaux de Paris Sorbonne Université, Service de Médecine Interne 2, Institut Endocrinologie, Maladies Métaboliques et Médecine Interne, Centre de Référence National du Lupus et Syndrome des Antiphospholipides, Hôpital Pitié-Salpêtrière (Z.A.) - both in Paris; the Department of Nephrology, Guangdong Provincial People's Hospital and Guangdong Academy of Medical Sciences, Guangzhou (X.Y.), and the Department of Medicine, Tuen Mun Hospital, Hong Kong (C.C.M.) - both in China; Escola Bahiana de Medicina e Saúde Pública, Salvador, Brazil (M.B.S.); the Division of Rheumatology, New York University School of Medicine, New York (A.S.); GlaxoSmithKline, Stockley Park, Uxbridge, United Kingdom (Y.G., B.J.); Parexel, Durham, NC (C.K.); and GlaxoSmithKline, Collegeville, PA (S.W.B., C.B., D.A.R.)
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Ramanujam M, Steffgen J, Visvanathan S, Mohan C, Fine JS, Putterman C. Phoenix from the flames: Rediscovering the role of the CD40-CD40L pathway in systemic lupus erythematosus and lupus nephritis. Autoimmun Rev 2020; 19:102668. [PMID: 32942031 DOI: 10.1016/j.autrev.2020.102668] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/15/2020] [Indexed: 12/11/2022]
Abstract
Lupus nephritis (LN) is a significant complication of systemic lupus erythematosus (SLE), increasing its morbidity and mortality. Although the current standard of care helps suppress disease activity, it is associated with toxicity and ultimately does not cure SLE. At present, there are no therapies specifically indicated for the treatment of LN and there is an unmet need in this disease where treatment remains a challenge. The CD40-CD40L pathway is central to SLE pathogenesis and the generation of autoantibodies and their deposition in the kidneys, resulting in renal injury in patients with LN. CD40 is expressed on immune cells (including B cells, monocytes and dendritic cells) and also non-haematopoietic cells. Interactions between CD40L on T cells and CD40 on B cells in the renal interstitium are critical for the local expansion of naive B cells and autoantibody-producing B cells in LN. CD40L-mediated activation of myeloid cells and resident kidney cells, including endothelial cells, proximal tubular epithelial cells, podocytes and mesangial cells, further amplifies the inflammatory milieu in the interstitium and the glomeruli. Several studies have highlighted the upregulated expression of CD40 in LN kidney biopsies, and preclinical data have demonstrated the importance of the CD40-CD40L pathway in murine SLE and LN. Blocking this pathway is expected to ameliorate inflammation driven by infiltrating immune cells and resident kidney cells. Initial experimental therapeutic interventions targeting the CD40-CD40L pathway, based on CD40L antibodies, were associated with an increased incidence of thrombosis. However, this safety issue has not been observed with second-generation CD40/CD40L antibodies that have been engineered to prevent platelet activation. With these advancements, together with recent preclinical and clinical findings, it is anticipated that selective blockade of the CD40-CD40L pathway may address the unmet treatment needs in SLE, LN and other autoimmune diseases.
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Affiliation(s)
- Meera Ramanujam
- Immunology & Respiratory Diseases Research, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA; Institute of Infection, Immunity and Inflammation, University of Glasgow, UK.
| | - Jürgen Steffgen
- TA Inflammation Medicine, Boehringer Ingelheim, International GmbH, Biberach, Germany; Department of Nephrology and Rheumatology, Georg-August University of Göttingen, Göttingen, Germany
| | - Sudha Visvanathan
- Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Chandra Mohan
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Jay S Fine
- Immunology & Respiratory Diseases Research, Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA
| | - Chaim Putterman
- Albert Einstein College of Medicine, Bronx, NY, USA; Azrieli School of Medicine, Bar-Ilan Universtiy, Zefat, Israel; Research Institute, Galilee Medical Center, Nahariya, Israel.
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Tselios K, Gladman DD, Su J, Urowitz MB. Advanced Chronic Kidney Disease in Lupus Nephritis: Is Dialysis Inevitable? J Rheumatol 2020; 47:1366-1373. [PMID: 32238519 DOI: 10.3899/jrheum.191064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Advanced chronic kidney disease (CKD) carries an increased risk for progression to endstage renal disease (ESRD). We aimed to determine the rate of progression and the factors that drive the decline of renal function in lupus nephritis (LN). METHODS Patients with advanced LN-related CKD were identified from our longterm longitudinal cohort. Advanced CKD was defined as stage 3b [estimated glomerular filtration rate (eGFR) = 30-44 ml/min/1.73 m2] and stage 4 (eGFR = 15-29 ml/min/1.73 m2). All individuals were followed until progression to ESRD or the last visit and were divided into "progressors" and "non- progressors." Demographic, clinical, immunological, and therapeutic variables were compared at baseline. Multivariable Cox regression analysis (both time-dependent and independent) was performed to identify predictors for progression. RESULTS One hundred eighteen patients (74 CKD 3b and 44 CKD 4) were included. Forty-five patients progressed (29 to ESRD and 16 from CKD 3b to CKD 4) after 6 years on average. No significant decline in the renal function was observed in 73 patients ("non-progressors") after 10 years on average. Active serology (high anti-dsDNA titers and low complements C3/C4) at the time of CKD diagnosis and any increase of the daily prednisone dose after baseline were strongly associated with progression. Treatment with renin angiotensin system (RAS) blockers was associated with less risk for progression. CONCLUSION Dialysis is not inevitable in LN-related advanced CKD because 62% of our patients did not progress over 10 years of followup on average. Certain predictors were identified to affect progression to ESRD.
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Affiliation(s)
- Konstantinos Tselios
- From the Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network, Toronto, Ontario, Canada.,K. Tselios, MD, PhD; D.D. Gladman, MD, FRCPC; J. Su, MB, MSc; M.B. Urowitz, MD, FRCPC, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network
| | - Dafna D Gladman
- From the Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network, Toronto, Ontario, Canada.,K. Tselios, MD, PhD; D.D. Gladman, MD, FRCPC; J. Su, MB, MSc; M.B. Urowitz, MD, FRCPC, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network
| | - Jiandong Su
- From the Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network, Toronto, Ontario, Canada.,K. Tselios, MD, PhD; D.D. Gladman, MD, FRCPC; J. Su, MB, MSc; M.B. Urowitz, MD, FRCPC, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network
| | - Murray B Urowitz
- From the Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network, Toronto, Ontario, Canada. .,K. Tselios, MD, PhD; D.D. Gladman, MD, FRCPC; J. Su, MB, MSc; M.B. Urowitz, MD, FRCPC, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Lupus Clinic, University Health Network.
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Albirdisi MR, Al-Homood IA. Characteristics of lupus nephritis in Saudi lupus patients: A retrospective observational study. Lupus 2020; 29:1638-1643. [PMID: 32741304 DOI: 10.1177/0961203320947151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Systemic lupus erythematosus (SLE) is a chronic autoimmune multi-systemic disorder of the connective tissue, characterized mainly by involvement of the skin, joints, kidneys, and serosal membranes. It affects females particularly at childbearing age more commonly than males. Lupus nephritis affects around half of patients with SLE. Data about SLE and lupus nephritis in Saudi Arabia are still scarce. In this study, we aimed to evaluate the prevalence, clinical and laboratory findings of SLE and different histological types of lupus nephritis among Saudi patients at King Fahad Medical City. METHODS This is a retrospective study for adult patients who have been evaluated at king Fahad medical city between 2014 and 2019 and fulfilled the Systemic Lupus International Collaborating Clinics classification criteria (SLICC). RESULTS 112 patients, 103 (92%) females and 9 (8%) males, with confirmed diagnoses of SLE were reviewed. Skin rash (69.6%), photosensitivity (61.6%), mucosal ulcerations (45.9%), arthralgia and/or arthritis (44.6%) are the most common clinical features. Ninety seven (86.6%) out of 112 patients had a recorded first visit 24 hour urine protein level, out of those only 26 (23.2) patients presented with significant proteinuria of more than 0.5grams per day. Forty four (39.2%) have undergone kidney biopsy. Class IV and III lupus nephritis are the most common reported biopsy results (43.18% and 27.28% respectively). During the study period, three patients (2.7%) developed end-stage kidney disease requiring dialysis and five (4.5%) had renal transplant. CONCLUSION Our study provided insight on the demographics, characteristics and presentation of SLE patients and the outcome of lupus nephritis in Saudi Arabia.
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Affiliation(s)
- Majed R Albirdisi
- Rheumatology Section, Medical Specialties Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ibrahim A Al-Homood
- Rheumatology Section, Medical Specialties Department, King Fahad Medical City, Riyadh, Saudi Arabia
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Ichinose K, Kitamura M, Sato S, Fujikawa K, Horai Y, Matsuoka N, Tsuboi M, Nonaka F, Shimizu T, Sumiyoshi R, Koga T, Kawashiri SY, Iwamoto N, Igawa T, Tamai M, Nakamura H, Origuchi T, Nishino T, Kawakami A. Comparison of complete renal response and mortality in early- and late-onset lupus nephritis: a multicenter retrospective study of a Japanese cohort. Arthritis Res Ther 2020; 22:175. [PMID: 32698892 PMCID: PMC7374914 DOI: 10.1186/s13075-020-02271-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 07/14/2020] [Indexed: 11/24/2022] Open
Abstract
Background Most patients with systemic lupus erythematosus (SLE) progress to lupus nephritis (LN) within 5 years of their SLE diagnosis, although it is not uncommon for LN to develop at later time points. Here we evaluated the clinical features of early- and late-onset LN. Patients and methods We retrospectively analyzed the cases of 184 of the 201 patients who underwent a renal biopsy at Nagasaki University Hospital and associated community hospitals between 1990 and 2016 and were diagnosed as having LN. Early onset was defined as the development of LN within the first 5 years after the patient’s SLE diagnosis, and late onset was defined as LN development > 5 years post-diagnosis. We analyzed the complete renal response (CR) at 6 and 12 months after induction therapy, the classification of renal pathology, and the mortality of the early- and late-onset LN groups. Results The mean follow-up duration after the renal biopsy was 123 ± 85 months. There were 113 (61.4%) early-onset patients and 71 (38.6%) late-onset patients. A multivariate analysis revealed that the following factors were predictive of CR: at 6 months: female sex (odds ratio [OR] 3.93, 95% confidence interval [CI] 1.31–11.77, p = 0.010), proteinuria (OR 0.83, 95% CI 0.71–0.97, p = 0.009), index of activity (0–24) (OR 0.83, 95% CI 0.70–0.99, p = 0.030), and early-onset LN (OR 2.39, 95% CI 1.15–4.98, p = 0.018); at 12 months: female sex (OR 3.60, 95% CI 1.32–9.83, p = 0.013), mixed LN (OR 0.18, 95% CI 0.04–0.80, p = 0.024), index of activity (0–24) (OR 0.80, 95% CI 0.68–0.94, p = 0.007), and early-onset LN (OR 2.10, 95% CI 1.05–4.23, p = 0.035). In a Cox proportional hazards and Fine-Gray regression model, the early-onset LN group had a significantly better mortality rate than the late-onset LN group (p = 0.038 and p = 0.043, respectively). Conclusions In our cohort, early-onset LN was a better predictor of CR at 6 and 12 months than late-onset LN. Our results suggest that early-onset LN patients had lower mortality than late-onset LN patients.
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Affiliation(s)
- Kunihiro Ichinose
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Mineaki Kitamura
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Keita Fujikawa
- Department of Rheumatology, JCHO Isahaya General Hospital, Isahaya, Japan
| | - Yoshiro Horai
- Department of Rheumatology, Clinical Research Center, NHO Nagasaki Medical Center, Omura, Japan
| | - Naoki Matsuoka
- Nagasaki Medical Hospital of Rheumatology, Nagasaki, Japan
| | | | - Fumiaki Nonaka
- Department of Internal Medicine, Sasebo City General Hospital, Sasebo, Japan
| | - Toshimasa Shimizu
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Remi Sumiyoshi
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tomohiro Koga
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shin-Ya Kawashiri
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Naoki Iwamoto
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Takashi Igawa
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Mami Tamai
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hideki Nakamura
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tomoki Origuchi
- Department of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Bartels-Peculis L, Sharma A, Edwards AM, Sanyal A, Connolly-Strong E, Nelson WW. Treatment Patterns and Health Care Costs of Lupus Nephritis in a United States Payer Population. Open Access Rheumatol 2020; 12:117-124. [PMID: 32607019 PMCID: PMC7319534 DOI: 10.2147/oarrr.s248750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/21/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To describe the characteristics, treatment patterns, health care resource utilization (HCRU), and cost of care for members of a large United States (US) health insurance plan with lupus nephritis (LN). Methods A retrospective observational study was conducted using a health insurance plan database to identify adult members with a diagnosis of LN. Medical and pharmacy claims were used to describe demographics, comorbidities, HCRU, and cost patterns over a 12-month follow-up period for each patient, between January 1, 2014, and December 31, 2016. All study variables were examined descriptively. Results A total of 1039 patients were available for analysis (median age, 47 years; 83% female). The median Charlson Comorbidity Index (CCI) was 3.3. Less than half (41%) of patients received immunosuppressive therapies commonly used to treat LN. Evidence indicated that 58% of the study population were prescribed corticosteroid therapy, in most cases (73%) for more than 60 days. Adverse events known to be associated with corticosteroid therapy were recorded in 58% of patients. Guideline-recommended preventive therapy with hydroxychloroquine was prescribed for 54% of members with LN. Nearly half (47%) of members with LN did not see a nephrologist and more than one-third (36%) did not see a rheumatologist over 1 year of follow-up. Rates of all-cause hospitalization and emergency department (ED) use were 25% and 35%, respectively. The mean all-cause per-member-per-month (PMPM) medical cost for the study population was $2801, with LN-specific costs accounting for $1147 PMPM. Conclusion Patients with LN who are insured through a large US health plan appeared to underutilize outpatient specialist services and guideline-recommended hydroxychloroquine therapy. Corticosteroid use and adverse events known to be associated with corticosteroids were common in this cohort.
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Moraes-Fontes MF, Ferreira AC, Riso N, Viana H, Carvalho F. Rubrics for mortality: a real-world observational long-term lupus nephritis cohort. Lupus 2020; 29:1616-1622. [PMID: 32605529 DOI: 10.1177/0961203320937472] [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] [Indexed: 12/15/2022]
Abstract
In this study, we aimed to evaluate long-term patient survival according to demographic data, clinical manifestations of systemic lupus erythematosus (SLE) and previous and current treatments, collected retrospectively. Patient selection required a minimum of four American College of Rheumatology revised criteria for SLE, biopsy-proven lupus nephritis (LN) available for reclassification according to the modified National Institutes of Health proposal for activity and chronicity indices and a minimum follow-up of at least three years since the last renal biopsy. Selection criteria were fulfilled in 25 patients followed for a median of 21 years. Based on the last renal biopsy, an equal number of patients were thus classified as class I/II and IV (n=8) and class III and V (n = 4). The mortality rate for LN was 14%. Having ever been diagnosed with glomerulonephritis (GN) type III or type IV but not class IV alone (p = 0.046), a higher histological chronicity index at the last renal biopsy (p = 0.022), not attaining renal remission one year after induction therapy (p = 0.004), end-stage renal disease on dialysis (p = 0.033) and the extra-renal Systemic Lupus International Collaborating Clinics Damage Index score (p = 0.017) were all significantly associated with mortality. Our results may provide important clues for strict observation protocols in particular categories of LN patients with long-standing disease.
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Affiliation(s)
- Maria Francisca Moraes-Fontes
- Unidade de Doenças Auto-imunes, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Ana Carolina Ferreira
- Unidade de Doenças Auto-imunes, Hospital Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal.,Serviço de Medicina Interna, Hospital do Divino Espírito Santo de Ponta Delgada, São Miguel, Açores, Portugal
| | - Nuno Riso
- Serviço de Medicina Interna, Hospital do Divino Espírito Santo de Ponta Delgada, São Miguel, Açores, Portugal
| | - Helena Viana
- Laboratório de Nefropatologia, Serviço de Nefrologia, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
| | - Fernanda Carvalho
- Laboratório de Nefropatologia, Serviço de Nefrologia, Hospital de Curry Cabral, Centro Hospitalar Universitário de Lisboa Central, Lisbon, Portugal
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Wise LM, Stohl W. Belimumab and Rituximab in Systemic Lupus Erythematosus: A Tale of Two B Cell-Targeting Agents. Front Med (Lausanne) 2020; 7:303. [PMID: 32695790 PMCID: PMC7338653 DOI: 10.3389/fmed.2020.00303] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022] Open
Abstract
Given the centrality of B cells to systemic lupus erythematosus (SLE), it stands to reason that a candidate therapeutic agent that targets B cells could be efficacious. Both rituximab, a monoclonal antibody (mAb) that binds to CD20 on the surface of B cells, and belimumab, a mAb that binds and neutralizes the B cell survival factor BAFF, have been extensively studied for the treatment of SLE. Despite the greater ability of rituximab to deplete B cells than that of belimumab, randomized controlled trials of rituximab in SLE failed to reach their primary clinical endpoints, whereas the primary clinical endpoints were reached in four independent phase-III clinical trials of belimumab in SLE. Accordingly, belimumab has been approved for treatment of SLE, whereas use of rituximab in SLE remains off-label. Nevertheless, several case series of rituximab have pointed to some utility for rituximab in treating SLE. In this review, we provide a concise summary of the factors that led to belimumab's success in SLE as well an analysis of the elements that may have contributed to the lack of success seen in the rituximab randomized controlled trials in SLE.
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Affiliation(s)
- Leanna M Wise
- Division of Rheumatology, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
| | - William Stohl
- Division of Rheumatology, Department of Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA, United States
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Kraaij T, Arends EJ, van Dam LS, Kamerling SWA, van Daele PLA, Bredewold OW, Ray A, Bakker JA, Scherer HU, Huizinga TJW, Rabelink TJ, van Kooten C, Teng YKO. Long-term effects of combined B-cell immunomodulation with rituximab and belimumab in severe, refractory systemic lupus erythematosus: 2-year results. Nephrol Dial Transplant 2020; 36:1474-1483. [PMID: 32591783 PMCID: PMC8311580 DOI: 10.1093/ndt/gfaa117] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Indexed: 01/04/2023] Open
Abstract
Background Anti-CD20 B-cell depletion has not shown superior efficacy to standard immunosuppression in patients with systemic lupus erythematosus (SLE). Besides trial design, potential explanations are incomplete B-cell depletion in relation to substantial surges in B-cell-activating factor (BAFF). To improve B-cell targeting strategies, we conducted the first study in SLE patients aimed at investigating immunological effects and feasibility of combining rituximab (RTX; anti-CD20) and belimumab (BLM; anti-BAFF). Methods Reported is the long-term follow-up of a Phase 2 proof-of-concept study in 15 patients with SLE including 12 (80%) with lupus nephritis (LN). Results In 10/15 (67%) patients, a clinical response was observed by achievement of lupus low disease activity state, of which 8 (53%) continued treatment (BLM + ≤7.5 mg prednisolone) for the complete 2 years of follow-up. Five patients (33%) were referred to as ‘non-responders’ due to persistent LN, major flare or repetitive minor flares. Out of 12 LN patients, 9 (75%) showed a renal response including 8 (67%) complete renal responders. All anti-dsDNA+ patients converted to negative, and both anti-C1q and extractable nuclear antigen autoantibodies showed significant reductions. CD19+ B cells showed a median decrease from baseline of 97% at 24 weeks, with a persistent reduction of 84% up to 104 weeks. When comparing responders with non-responders, CD20+ B cells were depleted significantly less in non-responders and double-negative (DN) B cells repopulated significantly earlier. Conclusions Combined B-cell targeted therapy with RTX and BLM prevented full B-cell repopulation including DN B cells, with concomitant specific reduction of SLE-relevant autoantibodies. The observed immunological and clinical benefits in a therapy-refractory SLE population prompt further studies on RTX + BLM.
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Affiliation(s)
- Tineke Kraaij
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Eline J Arends
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Laura S van Dam
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Sylvia W A Kamerling
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Paul L A van Daele
- Department of Clinical Immunology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Obbo W Bredewold
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Argho Ray
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jaap A Bakker
- Department of Clinical Chemistry & Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans U Scherer
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Tom J W Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ton J Rabelink
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Cees van Kooten
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
| | - Y K Onno Teng
- Department of Nephrology, Leiden University Medical Center, Leiden, the Netherlands
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Wang D, Yang J, Fan J, Chen W, Nikolic‐Paterson DJ, Li J. Omics technologies for kidney disease research. Anat Rec (Hoboken) 2020; 303:2729-2742. [PMID: 32592293 DOI: 10.1002/ar.24413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/31/2019] [Accepted: 02/17/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Dan Wang
- Department of NephrologyThe First Affiliated Hospital, Sun Yat‐sen University Guangzhou China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province Guangzhou China
| | - Jiayi Yang
- Department of NephrologyThe First Affiliated Hospital, Sun Yat‐sen University Guangzhou China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province Guangzhou China
| | - Jinjin Fan
- Department of NephrologyThe First Affiliated Hospital, Sun Yat‐sen University Guangzhou China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province Guangzhou China
| | - Wei Chen
- Department of NephrologyThe First Affiliated Hospital, Sun Yat‐sen University Guangzhou China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province Guangzhou China
| | | | - Jinhua Li
- Department of NephrologyThe First Affiliated Hospital, Sun Yat‐sen University Guangzhou China
- Key Laboratory of Nephrology, National Health Commission and Guangdong Province Guangzhou China
- Shunde Women and Children Hospital, Guangdong Medical University Shunde Guangdong China
- The Second Clinical College, Guangdong Medical University Dongguan Guangdong China
- Department of Anatomy and Developmental BiologyMonash Biomedicine Discovery Institute, Monash University Clayton Victoria Australia
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Mahajan A, Amelio J, Gairy K, Kaur G, Levy RA, Roth D, Bass D. Systemic lupus erythematosus, lupus nephritis and end-stage renal disease: a pragmatic review mapping disease severity and progression. Lupus 2020; 29:1011-1020. [PMID: 32571142 PMCID: PMC7425376 DOI: 10.1177/0961203320932219] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Objective The understanding of systemic lupus erythematosus (SLE) and lupus nephritis (LN) pathogenesis remains incomplete. This review assessed LN development in SLE, within-LN progression and progression to end-stage renal disease (ESRD). Methods A keyword-based literature search was conducted, and 26 publications were included. Results Overall, 7–31% of patients had LN at SLE diagnosis; 31–48% developed LN after SLE diagnosis, most within 5 years. Class IV was the most commonly found LN class and had the worst prognosis. Histological transformation occurred in 40–76% of patients, more frequently from non-proliferative rather than proliferative lesions. Cumulative 5- and 10-year ESRD incidences in patients with SLE were 3% and 4%, respectively, and 3–11% and 6–19%, respectively, in patients with SLE and LN. Conclusions Elevated serum creatinine was identified as a predictor of worsening disease state, and progression within LN classes and from SLE/LN to ESRD. This review highlights the substantial risk for developing LN and progressing to ESRD amongst patients with SLE.
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Affiliation(s)
| | - Justyna Amelio
- GlaxoSmithKline, Real World Evidence and Epidemiology, Stevenage, UK
| | - Kerry Gairy
- GlaxoSmithKline, Value Evidence and Outcomes, Brentford, UK
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Plüß M, Tampe B, Niebusch N, Zeisberg M, Müller GA, Korsten P. Clinical Efficacy of Routinely Administered Belimumab on Proteinuria and Neuropsychiatric Lupus. Front Med (Lausanne) 2020; 7:222. [PMID: 32537456 PMCID: PMC7267006 DOI: 10.3389/fmed.2020.00222] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/01/2020] [Indexed: 12/12/2022] Open
Abstract
Background and Objectives: Belimumab (BEL) is a monoclonal antibody approved for the treatment of active systemic lupus erythematosus (SLE) but not for lupus nephritis (LN) and neuropsychiatric systemic lupus erythematosus (NPSLE). We aimed to assess BEL's effects on these severe, potentially life-threatening manifestations. Methods: Retrospective observational cohort study using routine clinical data in a case series of patients with SLE receiving BEL. Results: Sixteen patients received BEL therapy for active SLE. Nine were excluded because they had no LN or NPSLE. Six suffered from LN, and one patient had NPSLE. All LN patients received BEL in addition to standard therapy including glucocorticoids, hydroxychloroquine, and mycophenolate mofetil in five cases, and tacrolimus in one case. Three patients with proteinuria >1,000 mg/g creatinine responded well (one complete, two partial renal responses); all other patients had decreasing proteinuria and a reduction in anti-dsDNA levels. The patient with NPSLE who had failed previous therapies had persistent clinical improvement of cutaneous and neuropsychiatric manifestations. There was one mild allergic reaction and one lower respiratory tract infection, but no other adverse events. One patient discontinued therapy due to a lack of improvement in clinical symptoms, another because of clinical remission. Conclusions: In our series, BEL led to a decrease of proteinuria in patients with proteinuria of more than 1,000 mg/g creatinine despite standard of care treatment, and led to a marked clinical improvement in one patient with NPSLE. No adverse events were observed. Routinely administered BEL shows clinical efficacy on non-approved manifestations, but careful patient selection is warranted.
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Affiliation(s)
- Marlene Plüß
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Björn Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Noah Niebusch
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Michael Zeisberg
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Gerhard A Müller
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
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Liu P, Li P, Peng Z, Xiang Y, Xia C, Wu J, Yang B, He Z. Predictive value of the neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, platelet-to-neutrophil ratio, and neutrophil-to-monocyte ratio in lupus nephritis. Lupus 2020; 29:1031-1039. [PMID: 32501169 DOI: 10.1177/0961203320929753] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Objective To evaluate the role of neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-neutrophil ratio (PNR), platelet-to-monocyte ratio (PMR), and neutrophil-to-monocyte ratio (NMR) as predictors for lupus nephritis (LN) patients without infection or as biomarkers for distinguishing between infection or flare with LN patients. Methods LN patients were divided into three groups: LN without infection, LN with infection, and LN with flare. A total of 57 healthy subjects were enrolled as controls. The differentiation was analyzed between LN without infection and control group, and LN with infection and LN with flare. Correlations among variables were assessed in the LN group without infection. Receiver operating characteristic curves were constructed in two comparable groups. Results NLR, PLR, and MLR were increased significantly in the LN group without infection as compared with those in healthy controls. NLR (area under the curve (AUC): 0.75) and MLR (AUC: 0.79) were useful for distinguishing between LN patients without infection and healthy subjects. In differentiating LN patients without infection from the controls, optimal cutoffs of NLR and MLR were 3.43 (sensitivity: 45.6%, specificity: 96.5%, and overall accuracy: 68.8%) and 0.24 (sensitivity: 75.0%, specificity: 73.7%, and overall accuracy: 73.6%), respectively. In addition, NLR ( r = 0.322, p = 0.011) and PLR ( r = 0.283, p = 0.026) were positively correlated with CRP. Importantly, NLR and NMR were increased while PNR was decreased in the LN group with infection in comparison with those in the LN group with flare. NLR (AUC: 0.80), NMR (AUC: 0.78), and PNR (AUC: 0.74) were useful in differentiating LN patients with infection and flare, and their optimal cutoffs were 4.02 (sensitivity: 82.6%, specificity: 69.6%, and overall accuracy: 75.5%), 12.19 (sensitivity: 80.4%, specificity: 73.9%, and overall accuracy: 77.5%), and 28.26 (sensitivity: 65.2%, specificity: 76.8%, and overall accuracy: 71.6%), respectively. Conclusions We demonstrated, for the first time, that MLR or NMR had the best accuracy in differentiating LN patients without infection from healthy subjects, or differentiating infection from flare in LN patients, respectively. Our results implied that NLR, MLR, PNR, and NMR may be useful biomarkers in predicting LN.
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Affiliation(s)
- Peng Liu
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Peiyuan Li
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Zhong Peng
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Yazhou Xiang
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Chenqi Xia
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Juan Wu
- Department of Gastroenterology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Bo Yang
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
| | - Zhangxiu He
- Department of Nephrology, The First Affiliated Hospital of University of South China, Hengyang, China
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Abstract
PURPOSE OF REVIEW Update on the diagnosis, treatment, and monitoring of lupus nephritis. RECENT FINDINGS The recent criteria enable the earlier classification of lupus nephritis based on kidney biopsy and compatible serology. Treatment of active nephritis includes low-dose intravenous cyclophosphamide or mycophenolate, followed by maintenance immunosuppression. Recent trials have suggested superiority of regimens combining mycophenolate with either calcineurin inhibitor or belimumab, although their long-term benefit/risk ratio has not been determined. Encouraging results with novel anti-CD20 antibodies confirm the effectiveness of B cell depletion. Achievement of low-grade proteinuria (< 700-800 mg/24 h) at 12-month post-induction is linked to favorable long-term outcomes and could be considered in a treat-to-target strategy. Also, repeat kidney biopsy can guide the duration of maintenance immunosuppression. Lupus nephritis has increased cardiovascular disease burden necessitating risk-reduction strategies. An expanding spectrum of therapies coupled with ongoing basic/translational research can lead to individualized medical care and improved outcomes in lupus nephritis.
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Affiliation(s)
- Myrto Kostopoulou
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Christina Adamichou
- 4th Department of Internal Medicine, Hippokration University Hospital, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Rheumatology, Clinical Rheumatology and Allergy, University of Crete Medical School, 71008 Voutes-Stavrakia, Heraklion, Greece
| | - George Bertsias
- Department of Rheumatology, Clinical Rheumatology and Allergy, University of Crete Medical School, 71008 Voutes-Stavrakia, Heraklion, Greece.
- Laboratory of Rheumatology, Autoimmunity and Inflammation, Institute of Molecular Biology and Biotechnology-FORTH, Heraklion, Greece.
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235
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Argolini LM, Frontini G, Elefante E, Saccon F, Binda V, Tani C, Scotti I, Carli L, Gatto M, Esposito C, Gerosa M, Caporali R, Doria A, Messa P, Mosca M, Moroni G. Multicentric study comparing cyclosporine, mycophenolate mofetil and azathioprine in the maintenance therapy of lupus nephritis: 8 years follow up. J Nephrol 2020; 34:389-398. [PMID: 32462476 DOI: 10.1007/s40620-020-00753-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 05/11/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND The ideal long-term maintenance therapy of Lupus Nephritis (LN) is still a matter of debate. The present study was aimed at comparing the efficacy/safety profile of cyclosporine (CsA), mycophenolate mofetil (MMF) and azathioprine (AZA) in long-term maintenance therapy of LN. METHODS We performed a retrospective study of patients with biopsy-proven active LN. After induction therapy, all patients received maintenance therapy with CsA, MMF or AZA based on medical decision. Primary endpoint was complete renal remission (CRR) after 8 years (defined as proteinuria < 0.5 g/24 h, eGFR > 60 ml/min/1.73 mq); secondary endpoints were: CRR after 1 year, renal and extrarenal flares, progression of chronic kidney disease (CKD stage 3 or above) and side-effects. RESULTS Out of 106 patients, 34 received CsA, 36 MMF and 36 AZA. Clinical and histological characteristics at start of induction therapy were comparable among groups. At start of maintenance therapy, CsA patients had significantly higher proteinuria (P = 0.004) or nephrotic syndrome (P = 0.024) and significantly lower CRR (23.5% vs 55.5% on MMF and 41.7% on AZA, P = 0.024). At one year, CRR was similar in the three groups (79.4% on CsA, 63.8% on MMF, 58.3% on AZA, P = 0.2). At 8 years, the primary endpoint was achieved by 79.4% of CsA vs 83.3% of MMF and 77.8% of AZA patients (P = 0.83); 24 h proteinuria, serum creatinine, eGFR were similar. CKD stage 3 or above developed in 8.8% of CsA, in 8.3% of MMF and in 8.3% of AZA patients (P = 0.92). Flares-free survival curves and incidence of side-effects were not different. CONCLUSIONS This is the first study comparing CsA, MMF and AZA on long-term LN maintenance therapy. All treatments had similar efficacy in achieving and maintaining CRR, despite more severe baseline clinical features in patients treated with CsA.
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Affiliation(s)
| | - Giulia Frontini
- Divisione di Nefrologia e Dialisi-Padiglione Croff, Fondazione Ca' Granda IRCCS Ospedale Maggiore Policlinico Milano, Via della Commenda 15, 20122, Milano, Italy
| | - Elena Elefante
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Francesca Saccon
- Division of Rheumatology, Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Valentina Binda
- Divisione di Nefrologia e Dialisi-Padiglione Croff, Fondazione Ca' Granda IRCCS Ospedale Maggiore Policlinico Milano, Via della Commenda 15, 20122, Milano, Italy
| | - Chiara Tani
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Isabella Scotti
- Division of Clinical Rheumatology, ASST Istituto Gaetano Pini - CTO, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, ASST Istituto Gaetano Pini - CTO, Milan, Italy
| | - Linda Carli
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Mariele Gatto
- Division of Rheumatology, Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Ciro Esposito
- Unit of Nephrology and Dialysis, University of Pavia, ICS Maugeri S.P.a., Pavia, Italia
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Istituto Gaetano Pini - CTO, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, ASST Istituto Gaetano Pini - CTO, Milan, Italy
| | - Roberto Caporali
- Division of Clinical Rheumatology, ASST Istituto Gaetano Pini - CTO, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, ASST Istituto Gaetano Pini - CTO, Milan, Italy
| | - Andrea Doria
- Division of Rheumatology, Department of Medicine, DIMED, University of Padua, Padua, Italy
| | - Piergiorgio Messa
- Divisione di Nefrologia e Dialisi-Padiglione Croff, Fondazione Ca' Granda IRCCS Ospedale Maggiore Policlinico Milano, Via della Commenda 15, 20122, Milano, Italy
| | - Marta Mosca
- Department of Clinical and Experimental Medicine, Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Gabriella Moroni
- Divisione di Nefrologia e Dialisi-Padiglione Croff, Fondazione Ca' Granda IRCCS Ospedale Maggiore Policlinico Milano, Via della Commenda 15, 20122, Milano, Italy.
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AlYousef A, AlSahow A, AlHelal B, Alqallaf A, Abdallah E, Abdellatif M, Nawar H, Elmahalawy R. Glomerulonephritis Histopathological Pattern Change. BMC Nephrol 2020; 21:186. [PMID: 32423387 PMCID: PMC7236312 DOI: 10.1186/s12882-020-01836-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 04/30/2020] [Indexed: 12/03/2022] Open
Abstract
Background Glomerulonephritides (GN) are relatively rare kidney diseases with substantial morbidity and mortality. They are often difficult to treat, sometimes with no cure, and can lead to chronic kidney disease (CKD) and end stage kidney disease (ESKD). Kidney biopsy is the diagnostic procedure of choice with variable indications from center to center. It helps in identifying the exact specific diagnosis, assessing the level of disease activity and severity, and hence aids in proper therapy and helps predicting prognosis. There is a global change of pattern of glomerular disease over the last five decades. Methods Retrospective analysis of all kidney biopsies (545 cases) that were done in patients over 12 year-old over last six years in four major hospitals in Kuwait. The indications for kidney biopsy were categorized into six clinical syndromes: nephrotic syndrome, sub-nephrotic proteinuria, nephrotic syndrome plus acute kidney injury (AKI), sub-nephrotic proteinuria plus AKI, isolated hematuria, and Unexplained renal impairment. We calculated the incidence of each type of kidney disease and indication of biopsy. Results most common indication of kidney biopsy was sub-nephrotic proteinuria associated with AKI in 179 cases (32.8%). Primary Glomerulonephritis was the main diagnosis that was reported in 356 cases (65.3%). Immunoglobulin A Nephropathy (IgAN) was the commonest lesion in primary glomerulonephritis in 85 (23.9%) cases. Secondary Glomerulonephritis was diagnosed in 134 cases (24.6%), 56 (41.8%) of them were reported as lupus nephritis cases. In young adults (below 18 years of age) there were 31 cases reviews, 35.5% were found to have minimal change disease (MCD). Conclusion IgAN is the commonest glomerulonephritis in primary nephrotic syndromes in Kuwait over the past six years. Lupus nephritis is the leading secondary glomerulonephritis diagnosis.
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Affiliation(s)
- Anas AlYousef
- Farwaniya Hospital, Department of Internal Medicine, Nephrology Unit, Sabah Al Nasser, Kuwait.
| | - Ali AlSahow
- Al Jahra Hospital, Department of Internal Medicine, Nephrology Unit, Al Jahra, Kuwait
| | - Bassam AlHelal
- Al Adan Hospital, Department of Internal Medicine, Nephrology Unit, Hadiya, Kuwait
| | - Ahmed Alqallaf
- Mubarak Al-Kabeer Hospital, Department of Internal Medicine, Nephrology Unit, Jabriya, Kuwait
| | - Emad Abdallah
- Al Adan Hospital, Department of Internal Medicine, Nephrology Unit, Hadiya, Kuwait
| | - Mohammed Abdellatif
- Farwaniya Hospital, Department of Internal Medicine, Nephrology Unit, Sabah Al Nasser, Kuwait
| | - Hani Nawar
- Al Jahra Hospital, Department of Internal Medicine, Nephrology Unit, Al Jahra, Kuwait
| | - Riham Elmahalawy
- Mubarak Al-Kabeer Hospital, Department of Internal Medicine, Nephrology Unit, Jabriya, Kuwait
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237
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Zhang J, Chen C, Fu H, Yu J, Sun Y, Huang H, Tang Y, Shen N, Duan Y. MicroRNA-125a-Loaded Polymeric Nanoparticles Alleviate Systemic Lupus Erythematosus by Restoring Effector/Regulatory T Cells Balance. ACS NANO 2020; 14:4414-4429. [PMID: 32203665 DOI: 10.1021/acsnano.9b09998] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Systemic lupus erythematosus (SLE), a common lethal autoimmune disease, is characterized by effector/regulatory T cells imbalance. Current therapies are either inefficient or have severe side effects. MicroRNA-125a (miR-125a) can stabilize Treg-mediated self-tolerance by targeting effector programs, but it is significantly downregulated in peripheral T cells of patients with SLE. Therefore, overexpression of miR-125a may have therapeutic potential to treat SLE. Considering the stability and targeted delivery of miRNA remains a major challenge in vivo, we constructed a monomethoxy (polyethylene glycol)-poly(d,l-lactide-co-glycolide)-poly(l-lysine) (mPEG-PLGA-PLL) nanodelivery system to deliver miR-125a into splenic T cells. Results demonstrate that miR-125a-loaded mPEG-PLGA-PLL (PEALmiR-125a) nanoparticles (NPs) exhibit good biocompatibility and protect miR-125a from degradation, thereby prolonging the circulatory time of miRNA in vivo. In addition, PEALmiR-125a NPs are preferentially enriched in a pathological spleen and efficiently deliver miR-125a into the splenic T cells in SLE mice models. The PEALmiR-125a NPs treatment significantly alleviates SLE disease progression by reversing the imbalance of effector/regulatory T cells. Collectively, the PEALmiR-125a NPs show excellent therapeutic efficacy and safety, which may provide an effective treatment for SLE.
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Affiliation(s)
- Jiali Zhang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200032, China
| | - Chuanrong Chen
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200032, China
| | - Hao Fu
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200032, China
| | - Jian Yu
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200032, China
| | - Ying Sun
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200032, China
| | - Hui Huang
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200032, China
| | - Yuanjia Tang
- Shanghai Institute of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Nan Shen
- Shanghai Institute of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
- Institute of Health Sciences, Shanghai Jiao Tong University School of Medicine and Shanghai Institutes for Biological Sciences (SIBS), University of Chinese Academy of Sciences, Chinese Academy of Sciences (CAS), Shanghai 200031, China
- Center for Autoimmune Genomics and Etiology (CAGE), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, United States
| | - Yourong Duan
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200032, China
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Webber D, Cao J, Dominguez D, Gladman DD, Levy DM, Ng L, Paterson AD, Touma Z, Urowitz MB, Wither JE, Silverman ED, Hiraki LT. Association of systemic lupus erythematosus (SLE) genetic susceptibility loci with lupus nephritis in childhood-onset and adult-onset SLE. Rheumatology (Oxford) 2020; 59:90-98. [PMID: 31236574 DOI: 10.1093/rheumatology/kez220] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 05/08/2019] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE LN is one of the most common and severe manifestations of SLE. Our aim was to test the association of SLE risk loci with LN risk in childhood-onset SLE (cSLE) and adult-onset SLE (aSLE). METHODS Two Toronto-based tertiary care SLE cohorts included cSLE (diagnosed <18 years) and aSLE patients (diagnosed ⩾18 years). Patients met ACR and/or SLICC SLE criteria and were genotyped on the Illumina Multi-Ethnic Global Array or Omni1-Quad arrays. We identified those with and without biopsy-confirmed LN. HLA and non-HLA additive SLE risk-weighted genetic risk scores (GRSs) were tested for association with LN risk in logistic models, stratified by cSLE/aSLE and ancestry. Stratified effect estimates were meta-analysed. RESULTS Of 1237 participants, 572 had cSLE (41% with LN) and 665 had aSLE (30% with LN). Increasing non-HLA GRS was significantly associated with increased LN risk [odds ratio (OR) = 1.26; 95% CI 1.09, 1.46; P = 0.0006], as was increasing HLA GRS in Europeans (OR = 1.55; 95% CI 1.07, 2.25; P = 0.03). There was a trend for stronger associations between both GRSs and LN risk in Europeans with cSLE compared with aSLE. When restricting cases to proliferative LN, the magnitude of these associations increased for both the non-HLA (OR = 1.30; 95% CI 1.10, 1.52; P = 0.002) and HLA GRS (OR = 1.99; 95% CI 1.29, 3.08; P = 0.002). CONCLUSION We observed an association between known SLE risk loci and LN risk in children and adults with SLE, with the strongest effect observed among Europeans with cSLE. Future studies will include SLE-risk single nucleotide polymorphisms specific to non-European ancestral groups and validate findings in an independent cohort.
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Affiliation(s)
- Declan Webber
- Division of Rheumatology, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Jingjing Cao
- Genetics & Genome Biology, Research Institute, SickKids Hospital, Toronto, Canada
| | - Daniela Dominguez
- Division of Rheumatology, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Dafna D Gladman
- Krembil Research Institute, Toronto Western Hospital, Toronto, Canada
| | - Deborah M Levy
- Division of Rheumatology, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Lawrence Ng
- Division of Rheumatology, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Andrew D Paterson
- Genetics & Genome Biology, Research Institute, SickKids Hospital, Toronto, Canada
| | - Zahi Touma
- Krembil Research Institute, Toronto Western Hospital, Toronto, Canada
| | - Murray B Urowitz
- Krembil Research Institute, Toronto Western Hospital, Toronto, Canada
| | - Joan E Wither
- Krembil Research Institute, Toronto Western Hospital, Toronto, Canada
| | - Earl D Silverman
- Division of Rheumatology, Department of Pediatrics, University of Toronto, Toronto, Canada.,Division of Translational Medicine Research Institute, Toronto, Canada
| | - Linda T Hiraki
- Division of Rheumatology, Department of Pediatrics, University of Toronto, Toronto, Canada.,Child Health Evaluative Sciences, Research Institute, SickKids Hospital, Toronto, Canada
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Fanouriakis A, Kostopoulou M, Cheema K, Anders HJ, Aringer M, Bajema I, Boletis J, Frangou E, Houssiau FA, Hollis J, Karras A, Marchiori F, Marks SD, Moroni G, Mosca M, Parodis I, Praga M, Schneider M, Smolen JS, Tesar V, Trachana M, van Vollenhoven RF, Voskuyl AE, Teng YKO, van Leew B, Bertsias G, Jayne D, Boumpas DT. 2019 Update of the Joint European League Against Rheumatism and European Renal Association-European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of lupus nephritis. Ann Rheum Dis 2020; 79:713-723. [PMID: 32220834 DOI: 10.1136/annrheumdis-2020-216924] [Citation(s) in RCA: 404] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To update the 2012 EULAR/ERA-EDTA recommendations for the management of lupus nephritis (LN). METHODS Following the EULAR standardised operating procedures, a systematic literature review was performed. Members of a multidisciplinary Task Force voted independently on their level of agreeement with the formed statements. RESULTS The changes include recommendations for treatment targets, use of glucocorticoids and calcineurin inhibitors (CNIs) and management of end-stage kidney disease (ESKD). The target of therapy is complete response (proteinuria <0.5-0.7 g/24 hours with (near-)normal glomerular filtration rate) by 12 months, but this can be extended in patients with baseline nephrotic-range proteinuria. Hydroxychloroquine is recommended with regular ophthalmological monitoring. In active proliferative LN, initial (induction) treatment with mycophenolate mofetil (MMF 2-3 g/day or mycophenolic acid (MPA) at equivalent dose) or low-dose intravenous cyclophosphamide (CY; 500 mg × 6 biweekly doses), both combined with glucocorticoids (pulses of intravenous methylprednisolone, then oral prednisone 0.3-0.5 mg/kg/day) is recommended. MMF/CNI (especially tacrolimus) combination and high-dose CY are alternatives, for patients with nephrotic-range proteinuria and adverse prognostic factors. Subsequent long-term maintenance treatment with MMF or azathioprine should follow, with no or low-dose (<7.5 mg/day) glucocorticoids. The choice of agent depends on the initial regimen and plans for pregnancy. In non-responding disease, switch of induction regimens or rituximab are recommended. In pure membranous LN with nephrotic-range proteinuria or proteinuria >1 g/24 hours despite renin-angiotensin-aldosterone blockade, MMF in combination with glucocorticoids is preferred. Assessment for kidney and extra-renal disease activity, and management of comorbidities is lifelong with repeat kidney biopsy in cases of incomplete response or nephritic flares. In ESKD, transplantation is the preferred kidney replacement option with immunosuppression guided by transplant protocols and/or extra-renal manifestations. Treatment of LN in children follows the same principles as adult disease. CONCLUSIONS We have updated the EULAR recommendations for the management of LN to facilitate homogenization of patient care.
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Affiliation(s)
- Antonis Fanouriakis
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece.,Department of Rheumatology, "Asklepieion" General Hospital, Athens, Greece
| | - Myrto Kostopoulou
- Department of Nephrology, "G. Gennimatas" General Hospital, Athens, Greece
| | - Kim Cheema
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, University Hospital LMU Munich, Munich, Germany
| | - Martin Aringer
- Division of Rheumatology, Department of Medicine III, University Medical Center & Faculty of Medicine Carl Gustav Carus at the TU Dresden, Dresden, Germany
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - John Boletis
- Nephrology Department and Renal Transplantation Unit, "Laikon" Hospital, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Eleni Frangou
- Department of Nephrology, Limassol General Hospital, Limassol, Cyprus
| | - Frederic A Houssiau
- Cliniques Universitaires Saint-Luc, Université catholique de Louvain, Brussels, Belgium
| | - Jane Hollis
- Lupus nurse specialist, Addenbrooke's Hospital, Cambridge, UK
| | - Adexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | | | - Stephen D Marks
- University College London Great Ormond Street Institute of Child Health, NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Gabriella Moroni
- Nephrology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Ioannis Parodis
- Division of Rheumatology, Department of Medicine Solna, Karolinska Institutet and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Manuel Praga
- Nephrology Department, Research Institute Hospital Universitario 12 de Octubre (i+12), Department of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Matthias Schneider
- Department of Rheumatology & Hiller Research Unit Rheumatology, UKD, Heinrich-Heine University, Duesseldorf, Germany
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Vladimir Tesar
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Maria Trachana
- Pediatric Immunology and Rheumatology Referral Center, First Pediatric Clinic, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Alexandre E Voskuyl
- Rheumatology and Immunology Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Y K Onno Teng
- Centre of expertise for Lupus-, Vasculitis- and Complement-mediated Systemic autoimmune diseases, Department of Internal Medicine - section Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - George Bertsias
- Rheumatology, Clinical Immunology and Allergy, University Hospital of Heraklion, Heraklion, Greece
| | - David Jayne
- Department of Medicine, Cambridge University, Cambridge, UK
| | - Dimitrios T Boumpas
- Rheumatology and Clinical Immunology Unit, "Attikon" University Hospital, Athens, Greece .,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
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Mejia-Vilet JM, Parikh SV, Song H, Fadda P, Shapiro JP, Ayoub I, Yu L, Zhang J, Uribe-Uribe N, Rovin BH. Immune gene expression in kidney biopsies of lupus nephritis patients at diagnosis and at renal flare. Nephrol Dial Transplant 2020; 34:1197-1206. [PMID: 29800348 DOI: 10.1093/ndt/gfy125] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Up to 50% of lupus nephritis (LN) patients experience renal flares after their initial episode of LN. These flares contribute to poor renal outcomes. We postulated that intrarenal immune gene expression is different in flares compared with de novo LN, and conducted these studies to test this hypothesis. METHODS Glomerular and tubulointerstitial immune gene expression was evaluated in 14 patients who had a kidney biopsy to diagnose LN and another biopsy at their first LN flare. Ten healthy living kidney donors were included as controls. RNA was extracted from laser microdissected formalin-fixed paraffin-embedded kidney biopsies. Gene expression was analyzed using the Nanostring nCounter® platform and validated by quantitative real-time polymerase chain reaction. Differentially expressed genes were analyzed by the Ingenuity Pathway Analysis and Panther Gene Ontology tools. RESULTS Over 110 genes were differentially expressed between LN and healthy control kidney biopsies. Although there was considerable molecular heterogeneity between LN biopsies at diagnosis and flare, for about half the LN patients gene expression from the first LN biopsy clustered with the repeated LN biopsy. However, in all patients, a set of eight interferon alpha-controlled genes had a significantly higher expression in the diagnostic biopsy compared with the flare biopsy. In contrast, nine tumor necrosis factor alpha-controlled genes had higher expression in flare biopsies. CONCLUSIONS There is significant heterogeneity in immune-gene expression of kidney tissue from LN patients. There are limited but important differences in gene expression between LN flares, which may influence treatment decisions.
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Affiliation(s)
- Juan M Mejia-Vilet
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA.,Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Samir V Parikh
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA
| | - Huijuan Song
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA
| | - Paolo Fadda
- Genomics Shared Resource (GSR)-Comprehensive Cancer Center (CCC)
| | - John P Shapiro
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA
| | - Isabelle Ayoub
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA
| | - Lianbo Yu
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jianying Zhang
- Center for Biostatistics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Norma Uribe-Uribe
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Brad H Rovin
- Division of Nephrology, Department of Internal Medicine, Davis Heart and Lung Research Institute, Ohio State University Medical Center, Columbus, OH, USA
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241
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Nikolopoulos D, Kostopoulou M, Pieta A, Karageorgas T, Tseronis D, Chavatza K, Flouda S, Rapsomaniki P, Banos A, Kremasmenou E, Tzavara V, Katsimbri P, Fanouriakis A, Boumpas DT. Evolving phenotype of systemic lupus erythematosus in Caucasians: low incidence of lupus nephritis, high burden of neuropsychiatric disease and increased rates of late-onset lupus in the 'Attikon' cohort. Lupus 2020; 29:514-522. [PMID: 32106788 PMCID: PMC7168806 DOI: 10.1177/0961203320908932] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study aimed to analyse the phenotype of systemic lupus erythematosus (SLE) at first presentation and during follow-up in a newly established SLE cohort based at 'Attikon' University Hospital. The hospital combines primary, secondary and tertiary care for the region of Western Attica, Greece. METHODS This study comprised a mixed prevalent and incident cohort of 555 Caucasian patients diagnosed with SLE according to American College of Rheumatology 1997 criteria and/or the Systemic Lupus Erythematosus International Collaborating Clinics (SLICC) 2012 criteria. Demographic and clinical characteristics, patterns of severity, treatments and SLICC damage index were recorded for each patient at the time of diagnosis and at last evaluation. RESULTS The mean age at lupus diagnosis was 38.3 years (standard deviation = 15.6 years), with a median disease duration at last follow-up of two years (interquartile range 1-11). At initial presentation, the most common 'classification' manifestations were arthritis (73.3%), acute cutaneous lupus (65%) and unexplained fever (25%), while among symptoms not included in any criteria set, Raynaud's phenomenon (33%) was the most common. Kidney and neuropsychiatric involvement as presenting manifestations were present in 10.3% and 11.5% cases, respectively. Irreversible damage accrual was present in 17.8% within six months of disease diagnosis, attributed mainly to thrombotic and neuropsychiatric disease. At last evaluation, 202 (36.4%) patients had developed severe disease, of whom more than half were treated with pulse cyclophosphamide. CONCLUSION In this cohort of Caucasian patients, lupus nephritis is not as common as in older cohorts, while neuropsychiatric disease is emerging as a major frontier in lupus prevention and care. These data may help to document changes in the natural history and treatment of SLE over time and may have implications for its early recognition and management.
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Affiliation(s)
- D Nikolopoulos
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - M Kostopoulou
- Department of Nephrology, 'Georgios Gennimatas' Hospital, Athens, Greece
| | - A Pieta
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - T Karageorgas
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - D Tseronis
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - K Chavatza
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - S Flouda
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - P Rapsomaniki
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - A Banos
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - E Kremasmenou
- 3rd Department of Internal Medicine, 'Red Cross' Hospital, Athens, Greece
| | - V Tzavara
- Laboratory of Immunology, 'Red Cross' Hospital, Athens, Greece
| | - P Katsimbri
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - A Fanouriakis
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece.,Department of Rheumatology, 'Asklepieion' General Hospital, Athens, Greece
| | - D T Boumpas
- 4th Department of Internal Medicine, Attikon University Hospital, Joint Rheumatology Program, National and Kapodistrian University of Athens Medical School, Athens, Greece.,Laboratory of Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece.,Medical School, University of Cyprus, Nicosia, Cyprus
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242
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Wu CY, Hua KF, Chu CL, Yang SR, Arbiser JL, Yang SS, Lin YC, Liu FC, Yang SM, Ka SM, Chen A. Tris DBA Ameliorates Accelerated and Severe Lupus Nephritis in Mice by Activating Regulatory T Cells and Autophagy and Inhibiting the NLRP3 Inflammasome. THE JOURNAL OF IMMUNOLOGY 2020; 204:1448-1461. [PMID: 32060137 DOI: 10.4049/jimmunol.1801610] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 01/10/2020] [Indexed: 12/20/2022]
Abstract
Tris (dibenzylideneacetone) dipalladium (Tris DBA), a small-molecule palladium complex, has been shown to inhibit cell growth and proliferation in pancreatic cancer, lymphocytic leukemia, and multiple myeloma. In the current study, we examined the therapeutic effects of Tris DBA on glomerular cell proliferation, renal inflammation, and immune cells. Treatment of accelerated and severe lupus nephritis (ASLN) mice with Tris DBA resulted in improved renal function, albuminuria, and pathology, including measurements of glomerular cell proliferation, cellular crescents, neutrophils, fibrinoid necrosis, and tubulointerstitial inflammation in the kidneys as well as scoring for glomerulonephritis activity. The treated ASLN mice also showed significantly decreased glomerular IgG, IgM, and C3 deposits. Furthermore, the compound was able to 1) inhibit bone marrow-derived dendritic cell-mediated T cell functions and reduce serum anti-dsDNA autoantibody levels; 2) differentially regulate autophagy and both the priming and activation signals of the NLRP3 inflammasome; and 3) suppress the phosphorylation of JNK, ERK, and p38 MAPK signaling pathways. Tris DBA improved ASLN in mice through immunoregulation by blunting the MAPK (ERK, JNK)-mediated priming signal of the NLRP3 inflammasome and by regulating the autophagy/NLRP3 inflammasome axis. These results suggest that the pure compound may be a drug candidate for treating the accelerated and deteriorated type of lupus nephritis.
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Affiliation(s)
- Chung-Yao Wu
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan 114
| | - Kuo-Feng Hua
- Department of Biotechnology and Animal Science, National Ilan University, Yilan, Taiwan 260
| | - Ching-Liang Chu
- Graduate Institute of Immunology, National Taiwan University College of Medicine, Taipei, Taiwan 106;
| | - Shin-Ruen Yang
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan 114
| | - Jack L Arbiser
- Department of Dermatology, Emory School of Medicine, Atlanta, GA 30322.,Winship Cancer Institute, Emory School of Medicine, Atlanta, GA 30322.,Atlanta Veterans Administration Medical Center, Decatur, GA 30033
| | - Sung-Sen Yang
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan 114;
| | - Yu-Chuan Lin
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan 114
| | - Feng-Cheng Liu
- Division of Rheumatology/Immunology and Allergy, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan 114
| | - Shun-Min Yang
- Institute of Physics, Academia Sinica, Taipei, Taiwan 114
| | - Shuk-Man Ka
- Graduate Institute of Aerospace and Undersea Medicine, Academy of Medicine, National Defense Medical Center, Taipei, Taiwan 114; and
| | - Ann Chen
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan 114; .,Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan 114
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243
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Zoshima T, Hara S, Mizushima I, Nishioka R, Ito K, Fujii H, Yamada K, Nomura H, Kawano M. Wire-loop lesion is associated with serological immune abnormality, but not renal prognosis, in lupus nephritis. Lupus 2020; 29:407-412. [PMID: 32041502 DOI: 10.1177/0961203320905652] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Wire-loop lesion (WL) is one of the active lesions of lupus nephritis (LN). However, few reports have focused on the clinicopathological relationships of WL to serological immune abnormality and renal prognosis. METHODS We enrolled 126 Japanese LN patients subjected to renal biopsy in 11 hospitals from 2000 to 2018. In patients with class III or IV of the International Society of Nephrology/Renal Pathology Society classification, we retrospectively compared clinicopathological findings between those with WL (WL+ group) and without WL (WL- group) to detect factors associated with WL. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate of <60 mL/min/1.73m2 for more than three months. We also compared these findings between those with CKD (CKD+ group) and without CKD (CKD- group) at the last visit to investigate factors associated with renal prognosis. RESULTS Of 126 patients, 100 (79.4%) were classified as class III or IV. WL was found in 36 (36.0%) of them. Although the renal function did not differ, the WL+ group had a higher titre of serum anti-dsDNA antibodies and lower serum complement 3 levels than the WL- group. Linear regression analysis revealed a significant association only between anti-dsDNA antibodies and WL (β = 0.27, 95% confidence interval (CI) 0.001-0.100, p = 0.01). Of these patients, 69 were tracked for 59.6 ± 55.1 months. Kaplan-Meier analysis showed no difference in renal prognosis between these groups. Next, the CKD+ group included 15 (22.1%) patients. They were older and had higher frequencies of hypertension and hyperuricaemia, serum creatinine (Cr) level, glomerulosclerosis, interstitial inflammation, interstitial fibrosis and tubular atrophy than the CKD- group at the time of renal biopsy. The frequency of WL was not significantly different. Cox regression analysis revealed significant associations of CKD with hypertension, hyperuricaemia, serum Cr level at the time of renal biopsy clinically and with tubular atrophy histologically. CONCLUSIONS WL was associated with serum anti-dsDNA antibodies but not with renal prognosis, suggesting that WL reflects immune abnormality but is not an independent factor predictive of renal prognosis in LN.
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Affiliation(s)
- T Zoshima
- Department of Rheumatology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - S Hara
- Department of Rheumatology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - I Mizushima
- Department of Rheumatology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - R Nishioka
- Department of Rheumatology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - K Ito
- Department of Rheumatology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - H Fujii
- Department of Rheumatology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - K Yamada
- Department of Hematology and Immunology, Kanazawa Medical University, Kanazawa, Japan
| | - H Nomura
- Department of General Medicine, Kanazawa University Hospital, Kanazawa, Japan
| | - M Kawano
- Department of Rheumatology, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
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244
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Nusbaum JS, Mirza I, Shum J, Freilich RW, Cohen RE, Pillinger MH, Izmirly PM, Buyon JP. Sex Differences in Systemic Lupus Erythematosus: Epidemiology, Clinical Considerations, and Disease Pathogenesis. Mayo Clin Proc 2020; 95:384-394. [PMID: 32029091 DOI: 10.1016/j.mayocp.2019.09.012] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 08/17/2019] [Accepted: 09/20/2019] [Indexed: 12/12/2022]
Abstract
Systemic lupus erythematosus (SLE) is a chronic, multiorgan, systemic autoimmune disease that is more common in women than men and is typically diagnosed during reproductive age, necessitating sex-specific considerations in care. In women there is no substantive evidence to suggest that SLE reduces fertility, but subfertility may occur as a result of active disease, immunosuppressive drugs, and age-related declines in fertility related to delays in childbearing. Although pregnancy outcomes have improved, SLE still poses risks in pregnancy that contribute to poorer maternal and fetal outcomes. Cyclophosphamide, an important agent for the treatment of severe or life-threatening lupus, may adversely affect fertility, particularly with increases in dose and patient age. Fertility preservation techniques are therefore an important consideration for women and men before cytotoxic treatment. There is mixed evidence as to whether exogenous estrogen in the form of oral contraceptive pills or hormone replacement therapy may increase the risk for the development of SLE, but among women with SLE already diagnosed, combined oral contraceptive pills and hormone replacement therapy do not confer risk for severe flare and remain important in reproductive care. The higher incidence of SLE in women may nonetheless be attributable to effects of endogenous estrogen, as well as failures in X chromosome inactivation, increased Toll-like receptor gene products, and changes in microRNA function. A greater appreciation of the biological underpinnings and consequences of sex differences in SLE may lead to more targeted treatments and improved outcomes for patients with SLE.
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Affiliation(s)
- Julie S Nusbaum
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York.
| | - Ibraheem Mirza
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Justine Shum
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Robert W Freilich
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Rebecca E Cohen
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Michael H Pillinger
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Peter M Izmirly
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
| | - Jill P Buyon
- Division of Rheumatology, Department of Medicine, New York University School of Medicine, New York
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245
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Abstract
Lupus nephritis (LN) is a form of glomerulonephritis that constitutes one of the most severe organ manifestations of the autoimmune disease systemic lupus erythematosus (SLE). Most patients with SLE who develop LN do so within 5 years of an SLE diagnosis and, in many cases, LN is the presenting manifestation resulting in the diagnosis of SLE. Understanding of the genetic and pathogenetic basis of LN has improved substantially over the past few decades. Treatment of LN usually involves immunosuppressive therapy, typically with mycophenolate mofetil or cyclophosphamide and with glucocorticoids, although these treatments are not uniformly effective. Despite increased knowledge of disease pathogenesis and improved treatment options, LN remains a substantial cause of morbidity and death among patients with SLE. Within 10 years of an initial SLE diagnosis, 5-20% of patients with LN develop end-stage kidney disease, and the multiple comorbidities associated with immunosuppressive treatment, including infections, osteoporosis and cardiovascular and reproductive effects, remain a concern. Clearly, early and accurate diagnosis of LN and prompt initiation of therapy are of vital importance to improve outcomes in patients with SLE.
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246
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Hanly JG, Urowitz MB, Gordon C, Bae SC, Romero-Diaz J, Sanchez-Guerrero J, Bernatsky S, Clarke AE, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley MA, Ramsey-Goldman R, Manzi S, Jönsen A, Alarcón GS, van Vollenhoven RF, Aranow C, Mackay M, Ruiz-Irastorza G, Lim S, Inanc M, Kalunian KC, Jacobsen S, Peschken CA, Kamen DL, Askanase A, Farewell V. Neuropsychiatric events in systemic lupus erythematosus: a longitudinal analysis of outcomes in an international inception cohort using a multistate model approach. Ann Rheum Dis 2020; 79:356-362. [PMID: 31915121 DOI: 10.1136/annrheumdis-2019-216150] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 12/11/2019] [Accepted: 12/11/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Using a reversible multistate model, we prospectively examined neuropsychiatric (NP) events for attribution, outcome and association with health-related quality of life (HRQoL), in an international, inception cohort of systemic lupus erythematosus (SLE) patients. METHODS Annual assessments for 19 NP events attributed to SLE and non-SLE causes, physician determination of outcome and patient HRQoL (short-form (SF)-36 scores) were measured. Time-to-event analysis and multistate modelling examined the onset, recurrence and transition between NP states. RESULTS NP events occurred in 955/1827 (52.3%) patients and 592/1910 (31.0%) unique events were attributed to SLE. In the first 2 years of follow-up the relative risk (95% CI) for SLE NP events was 6.16 (4.96, 7.66) and non-SLE events was 4.66 (4.01, 5.43) compared with thereafter. Patients without SLE NP events at initial assessment had a 74% probability of being event free at 10 years. For non-SLE NP events the estimate was 48%. The majority of NP events resolved over 10 years but mortality was higher in patients with NP events attributed to SLE (16%) versus patients with no NPSLE events (6%) while the rate was comparable in patients with non-SLE NP events (7%) compared with patients with no non-SLE events (6%). Patients with NP events had lower SF-36 summary scores compared with those without NP events and resolved NP states (p<0.001). CONCLUSIONS NP events occur most frequently around the diagnosis of SLE. Although the majority of events resolve they are associated with reduced HRQoL and excess mortality. Multistate modelling is well suited for the assessment of NP events in SLE.
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Affiliation(s)
- John G Hanly
- Division of Rheumatology, Department of Medicine and Department of Pathology, Queen Elizabeth ll Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Murray B Urowitz
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Caroline Gordon
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Sang-Cheol Bae
- Department of Rheumatology, Hanyang University Hospital for Rheumatic Diseases, Seoul, Republic of Korea
| | | | - Jorge Sanchez-Guerrero
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sasha Bernatsky
- Divisions of Rheumatology and Clinical Epidemiology, Department of medicine, McGill University, Montreal, Quebec, Canada
| | - Ann E Clarke
- Divisions of Rheumatology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Daniel J Wallace
- Cedars-Sinai/David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - David A Isenberg
- Centre for Rheumatology Research, Department of Medicine, University College, London, UK
| | - Anisur Rahman
- Centre for Rheumatology Research, Department of Medicine, University College, London, UK
| | - Joan T Merrill
- Department of Clinical Pharmacology, Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Paul R Fortin
- Division of Rheumatology, Department of Medicine, CHU de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Dafna D Gladman
- Center for Prognosis Studies in the Rheumatic Diseases, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ian N Bruce
- Arthritis Research UK Epidemiology Unit, Faculty of Biology Medicine and Health, Manchester Academic Health Sciences Centre, The University of Manchester, and NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Michelle Petri
- Department of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ellen M Ginzler
- Department of Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Mary Anne Dooley
- Thurston Arthritis Research Centre, University of North Carolina, Chapel Hill, NC, USA
| | | | - Susan Manzi
- Lupus Center of Excellence, Allegheny Health Network, Pittsburgh, PA, USA
| | - Andreas Jönsen
- Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund, Sweden
| | - Graciela S Alarcón
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ronald F van Vollenhoven
- Department of Rheumatology and Clinical Immunology, University Medical Centres, Amsterdam, The Netherlands
| | - Cynthia Aranow
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Meggan Mackay
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Guillermo Ruiz-Irastorza
- Autoimmune Diseases Research Unit, Department of Internal Medicine, BioCruces Bizkaia Health Research Institute, Hospital Universitario Cruces, University of the Basque Country, Barakaldo, Spain
| | - Sam Lim
- Emory University, Department of Medicine, Division of Rheumatology, Atlanta, Georgia, USA
| | - Murat Inanc
- Division of Rheumatology, Department of Internal Medicine, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | | | - Søren Jacobsen
- Copenhagen Lupus and Vasculitis Clinic, 4242, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Diane L Kamen
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Anca Askanase
- Hospital for Joint Diseases, NYU, Seligman Centre for Advanced Therapeutics, New York, NY, USA
| | - Vernon Farewell
- MRC Biostatistics Unit, Cambridge Institute of Public Health, University of Cambridge, Cambridge, UK
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247
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Delfino J, Dos Santos TAFG, Skare TL. Comparison of lupus patients with early and late onset nephritis: a study in 71 patients from a single referral center. Adv Rheumatol 2020; 60:5. [PMID: 31900216 DOI: 10.1186/s42358-019-0105-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 12/23/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Nephritis occurs frequently in systemic lupus erythematosus (SLE) and may worsen disease morbidity and mortality. Knowing all characteristics of this manifestation helps to a prompt recognition and treatment. AIM To compare the differences in clinical data, serological profile and treatment response of nephritis of early and late onset. METHODS Retrospective study of 71 SLE patients with biopsy proven nephritis divided in early nephritis group (diagnosis of nephritis in the first 5 years of the disease) and late nephritis (diagnosis of nephritis after 5 years). Epidemiological, serological, clinical and treatment data were collected from charts and compared. RESULTS In this sample, 70. 4% had early onset nephritis and 29.6% had late onset. No differences were noted in epidemiological, clinical, serological profile, SLICC and SLEDAI, except that late onset nephritis patients were older at nephritis diagnosis (p = 0.01). Regarding renal biopsy classification, C3 and C4 levels, serum creatinine, 24 h proteinuria and response rate to treatment the two groups were similar (p = NS). Patients with early onset had lower levels of hemoglobin at nephritis onset than those of late onset (p = 0.02). CONCLUSIONS Most of SLE patients had nephritis in the first 5 years of disease. No major differences were noted when disease profile or treatment outcome of early and late onset nephritis were compared.
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Affiliation(s)
- Juliana Delfino
- Mackenzie Evangelical University Hospital, Curitiba, PR, Brazil.
| | | | - Thelma L Skare
- Mackenzie Evangelical University Hospital, Curitiba, PR, Brazil
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Hanly JG, Li Q, Su L, Urowitz MB, Gordon C, Bae SC, Romero-Diaz J, Sanchez-Guerrero J, Bernatsky S, Clarke AE, Wallace DJ, Isenberg DA, Rahman A, Merrill JT, Fortin PR, Gladman DD, Bruce IN, Petri M, Ginzler EM, Dooley MA, Steinsson K, Ramsey-Goldman R, Zoma AA, Manzi S, Nived O, Jonsen A, Khamashta MA, Alarcón GS, Svenungsson E, van Vollenhoven RF, Aranow C, Mackay M, Ruiz-Irastorza G, Ramos-Casals M, Lim SS, Inanc M, Kalunian KC, Jacobsen S, Peschken CA, Kamen DL, Askanase A, Theriault C, Farewell V. Peripheral Nervous System Disease in Systemic Lupus Erythematosus: Results From an International Inception Cohort Study. Arthritis Rheumatol 2020; 72:67-77. [PMID: 31390162 PMCID: PMC6935421 DOI: 10.1002/art.41070] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the frequency, clinical characteristics, associations, and outcomes of different types of peripheral nervous system (PNS) disease in a multiethnic/multiracial, prospective inception cohort of systemic lupus erythematosus (SLE) patients. METHODS Patients were evaluated annually for 19 neuropsychiatric (NP) events including 7 types of PNS disease. SLE disease activity, organ damage, autoantibodies, and patient and physician assessment of outcome were measured. Time to event and linear regressions were used as appropriate. RESULTS Of 1,827 SLE patients, 88.8% were female, and 48.8% were white. The mean ± SD age was 35.1 ± 13.3 years, disease duration at enrollment was 5.6 ± 4.2 months, and follow-up was 7.6 ± 4.6 years. There were 161 PNS events in 139 (7.6%) of 1,827 patients. The predominant events were peripheral neuropathy (66 of 161 [41.0%]), mononeuropathy (44 of 161 [27.3%]), and cranial neuropathy (39 of 161 [24.2%]), and the majority were attributed to SLE. Multivariate Cox regressions suggested longer time to resolution in patients with a history of neuropathy, older age at SLE diagnosis, higher SLE Disease Activity Index 2000 scores, and for peripheral neuropathy versus other neuropathies. Neuropathy was associated with significantly lower Short Form 36 (SF-36) physical and mental component summary scores versus no NP events. According to physician assessment, the majority of neuropathies resolved or improved over time, which was associated with improvements in SF-36 summary scores for peripheral neuropathy and mononeuropathy. CONCLUSION PNS disease is an important component of total NPSLE and has a significant negative impact on health-related quality of life. The outcome is favorable for most patients, but our findings indicate that several factors are associated with longer time to resolution.
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Affiliation(s)
- John G Hanly
- Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Qiuju Li
- University of Cambridge, Cambridge, UK
| | - Li Su
- University of Cambridge, Cambridge, UK
| | - Murray B Urowitz
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Caroline Gordon
- University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Sang-Cheol Bae
- Hanyang University Hospital for Rheumatic Diseases, Seoul, Korea
| | | | | | | | - Ann E Clarke
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Daniel J Wallace
- Cedars-Sinai and University of California, Los Angeles School of Medicine
| | | | | | | | - Paul R Fortin
- CHU de Québec and Université Laval, Québec City, Québec, Canada
| | - Dafna D Gladman
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Ian N Bruce
- Arthritis Research UK Epidemiology Unit, University of Manchester, NIHR Manchester Musculoskeletal Biomedical Research Centre, and Manchester University NHS Foundation Trust, Manchester, UK
| | - Michelle Petri
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - M A Dooley
- University of North Carolina, Chapel Hill, North Carolina
| | | | | | | | - Susan Manzi
- Allegheny Health Network, Pittsburgh, Pennsylvania
| | | | | | - Munther A Khamashta
- St. Thomas' Hospital and King's College London School of Medicine, London, UK
| | | | | | | | - Cynthia Aranow
- Feinstein Institute for Medical Research, Manhasset, New York
| | - Meggan Mackay
- Feinstein Institute for Medical Research, Manhasset, New York
| | | | - Manuel Ramos-Casals
- Institut d'Investigacions Biomèdiques August Pi i Sunyer and Hospital Clínic de Barcelona, Barcelona, Spain
| | - S Sam Lim
- Emory University School of Medicine, Atlanta, Georgia
| | | | | | - Soren Jacobsen
- Rigshospitalet and Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | | | - Chris Theriault
- Queen Elizabeth II Health Sciences Center and Dalhousie University, Halifax, Nova Scotia, Canada
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Rao DA, Arazi A, Wofsy D, Diamond B. Design and application of single-cell RNA sequencing to study kidney immune cells in lupus nephritis. Nat Rev Nephrol 2019; 16:238-250. [PMID: 31853010 DOI: 10.1038/s41581-019-0232-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2019] [Indexed: 11/09/2022]
Abstract
The immune mechanisms that cause tissue injury in lupus nephritis have been challenging to define. The advent of high-dimensional cellular analyses, such as single-cell RNA sequencing, has enabled detailed characterization of the cell populations present in small biopsy samples of kidney tissue. In parallel, the development of methods that cryopreserve kidney biopsy specimens in a manner that preserves intact, viable cells, has enabled the uniform analysis of tissue samples collected at multiple sites and across many geographic areas and demographic cohorts with high-dimensional platforms. The application of these methods to kidney biopsy samples from patients with lupus nephritis has begun to define the phenotypes of both infiltrating and resident immune cells, as well as parenchymal cells, present in nephritic kidneys. The detection of similar immune cell populations in urine suggests that it might be possible to non-invasively monitor immune activation in kidneys. Once applied to large patient cohorts, these high-dimensional studies might enable patient stratification according to patterns of immune cell activation in the kidney or identify disease features that can be used as surrogate measures of efficacy in clinical trials. Applied broadly across multiple inflammatory kidney diseases, these studies promise to enormously expand our understanding of renal inflammation in the next decade.
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Affiliation(s)
- Deepak A Rao
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Arnon Arazi
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - David Wofsy
- Rheumatology Division and Russell/Engleman Research Center, University of California San Francisco, San Francisco, CA, USA
| | - Betty Diamond
- Center for Autoimmune, Musculoskeletal and Hematopoietic Diseases, The Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.
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250
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Funes SC, Ríos M, Gómez‐Santander F, Fernández‐Fierro A, Altamirano‐Lagos MJ, Rivera‐Perez D, Pulgar‐Sepúlveda R, Jara EL, Rebolledo‐Zelada D, Villarroel A, Roa JC, Mackern‐Oberti JP, Kalergis AM. Tolerogenic dendritic cell transfer ameliorates systemic lupus erythematosus in mice. Immunology 2019; 158:322-339. [PMID: 31509246 PMCID: PMC6856940 DOI: 10.1111/imm.13119] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 08/28/2019] [Accepted: 09/05/2019] [Indexed: 12/11/2022] Open
Abstract
Current treatments for systemic autoimmune diseases partially improve the health of patients displaying low pharmacological efficacy and systemic immunosuppression. Here, the therapeutic potential of transferring tolerogenic dendritic cells (tolDCs) generated with heme-oxygenase inductor cobalt (III) protoporphyrin IX (CoPP), dexamethasone and rosiglitazone for the treatment of systemic autoimmunity was evaluated in two murine models of systemic lupus erythematosus (SLE), MRL-Faslpr and NZM2410 mice. Dendritic cells treated ex vivo with these drugs showed a stable tolerogenic profile after lipopolysaccharide stimulation. Regular doses of tolDCs were administered to anti-nuclear antibody-positive mice throughout 60-70 days, and the clinical score was evaluated. Long-term treatment with these tolDCs was well tolerated and effective to improve the clinical score on MRL-Faslpr lupus-prone mice. Additionally, decreased levels of anti-nuclear antibodies in NZM2410 mice were observed. Although tolDC treatment increased regulatory T cells, no significant reduction of renal damage or glomerulonephritis could be found. In conclusion, these results suggest that the transfer of histone-loaded tolDCs could improve only some SLE symptoms and reduced anti-nuclear antibodies. This is the first study to evaluate antigen-specific tolDC administration to treat SLE. Our report strengthens the clinical relevance of tolDC generation with CoPP, dexamethasone and rosiglitazone and the use of these modified cells as a therapy for systemic autoimmunity.
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Affiliation(s)
- Samanta C. Funes
- Millennium Institute on Immunology and ImmunotherapyDepartamento de Genética Molecular y MicrobiologíaFacultad de Ciencias BiológicasPontificia Universidad Católica de ChileSantiagoChile
| | - Mariana Ríos
- Millennium Institute on Immunology and ImmunotherapyDepartamento de Genética Molecular y MicrobiologíaFacultad de Ciencias BiológicasPontificia Universidad Católica de ChileSantiagoChile
| | - Felipe Gómez‐Santander
- Millennium Institute on Immunology and ImmunotherapyDepartamento de Genética Molecular y MicrobiologíaFacultad de Ciencias BiológicasPontificia Universidad Católica de ChileSantiagoChile
| | - Ayleen Fernández‐Fierro
- Millennium Institute on Immunology and ImmunotherapyDepartamento de Genética Molecular y MicrobiologíaFacultad de Ciencias BiológicasPontificia Universidad Católica de ChileSantiagoChile
| | - María J. Altamirano‐Lagos
- Millennium Institute on Immunology and ImmunotherapyDepartamento de Genética Molecular y MicrobiologíaFacultad de Ciencias BiológicasPontificia Universidad Católica de ChileSantiagoChile
| | - Daniela Rivera‐Perez
- Millennium Institute on Immunology and ImmunotherapyDepartamento de Genética Molecular y MicrobiologíaFacultad de Ciencias BiológicasPontificia Universidad Católica de ChileSantiagoChile
| | - Raul Pulgar‐Sepúlveda
- Millennium Institute on Immunology and ImmunotherapyDepartamento de Genética Molecular y MicrobiologíaFacultad de Ciencias BiológicasPontificia Universidad Católica de ChileSantiagoChile
| | - Evelyn L. Jara
- Millennium Institute on Immunology and ImmunotherapyDepartamento de Genética Molecular y MicrobiologíaFacultad de Ciencias BiológicasPontificia Universidad Católica de ChileSantiagoChile
- Present address:
Facultad de CienciasDepartamento de Ciencias BásicasUniversidad Santo TomásTemucoChile
| | - Diego Rebolledo‐Zelada
- Millennium Institute on Immunology and ImmunotherapyDepartamento de Genética Molecular y MicrobiologíaFacultad de Ciencias BiológicasPontificia Universidad Católica de ChileSantiagoChile
| | - Alejandra Villarroel
- Departamento de Anatomía PatológicaFacultad de MedicinaPontificia Universidad Católica de ChileSantiagoChile
| | - Juan C. Roa
- Departamento de Anatomía PatológicaFacultad de MedicinaPontificia Universidad Católica de ChileSantiagoChile
| | - Juan P. Mackern‐Oberti
- Instituto de Medicina y Biología Experimental de CuyoIMBECU CCT Mendoza‐ CONICETMendozaArgentina
- Instituto de FisiologíaFacultad de Ciencias MédicasUniversidad Nacional de CuyoMendozaArgentina
| | - Alexis M. Kalergis
- Millennium Institute on Immunology and ImmunotherapyDepartamento de Genética Molecular y MicrobiologíaFacultad de Ciencias BiológicasPontificia Universidad Católica de ChileSantiagoChile
- Departamento de EndocrinologíaEscuela de Medicina, Facultad de MedicinaPontificia Universidad Católica de ChileSantiagoChile
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