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Bartoli G, Dello Strologo A, Grandaliano G, Pesce F. Updates on C3 Glomerulopathy in Kidney Transplantation: Pathogenesis and Treatment Options. Int J Mol Sci 2024; 25:6508. [PMID: 38928213 PMCID: PMC11204074 DOI: 10.3390/ijms25126508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/01/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024] Open
Abstract
C3 glomerulopathy is a rare disease, characterized by an abnormal activation of the complement's alternative pathway that leads to the accumulation of the C3 component in the kidney. The disease recurs in more than half of kidney transplant recipients, with a significant impact on graft survival. Recurrence of the primary disease represents the second cause of graft loss after organ rejection. In C3 glomerulopathy, there are several risk factors which can promote a recurrence during transplantation, such as delayed graft function, infection and monoclonal gammopathy. All these events can trigger the alternative complement pathway. In this review, we summarize the impact of C3 glomerulopathy on kidney grafts and present the latest treatment options. The most widely used treatments for the disease include corticosteroids and mycophenolate mofetil, which are already used chronically by kidney transplant recipients; thus, additional treatments for C3 glomerulopathy are required. Currently, several studies using anti-complement drugs (i.e., eculizumab, Ravalizumab, avacopan) for C3 glomerulopathy in kidney transplant patients are ongoing with encouraging results.
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Affiliation(s)
- Giulia Bartoli
- Department of Translational Medicine and Surgery, Università Cattolica dl Sacro Cuore, 00168 Rome, Italy; (G.B.); (A.D.S.); (G.G.)
| | - Andrea Dello Strologo
- Department of Translational Medicine and Surgery, Università Cattolica dl Sacro Cuore, 00168 Rome, Italy; (G.B.); (A.D.S.); (G.G.)
| | - Giuseppe Grandaliano
- Department of Translational Medicine and Surgery, Università Cattolica dl Sacro Cuore, 00168 Rome, Italy; (G.B.); (A.D.S.); (G.G.)
- Nephrology, Dialysis and Transplantation Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Francesco Pesce
- Department of Translational Medicine and Surgery, Università Cattolica dl Sacro Cuore, 00168 Rome, Italy; (G.B.); (A.D.S.); (G.G.)
- Division of Renal Medicine, “Ospedale Isola Tiberina—Gemelli Isola”, 00186 Rome, Italy
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Diagnostic and Prognostic Comparison of Immune-Complex-Mediated Membranoproliferative Glomerulonephritis and C3 Glomerulopathy. Cells 2023; 12:cells12050712. [PMID: 36899849 PMCID: PMC10000503 DOI: 10.3390/cells12050712] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023] Open
Abstract
Membranoproliferative glomerulonephritis (MPGN) is subdivided into immune-complex-mediated glomerulonephritis (IC-MPGN) and C3 glomerulopathy (C3G). Classically, MPGN has a membranoproliferative-type pattern, but other morphologies have also been described depending on the time course and phase of the disease. Our aim was to explore whether the two diseases are truly different, or merely represent the same disease process. All 60 eligible adult MPGN patients diagnosed between 2006 and 2017 in the Helsinki University Hospital district, Finland, were reviewed retrospectively and asked for a follow-up outpatient visit for extensive laboratory analyses. Thirty-seven (62%) had IC-MPGN and 23 (38%) C3G (including one patient with dense deposit disease, DDD). EGFR was below normal (≤60 mL/min/1.73 m2) in 67% of the entire study population, 58% had nephrotic range proteinuria, and a significant proportion had paraproteins in their serum or urine. A classical MPGN-type pattern was seen in only 34% of the whole study population and histological features were similarly distributed. Treatments at baseline or during follow-up did not differ between the groups, nor were there significant differences observed in complement activity or component levels at the follow-up visit. The risk of end-stage kidney disease and survival probability were similar in the groups. IC-MPGN and C3G have surprisingly similar characteristics, kidney and overall survival, which suggests that the current subdivision of MPGN does not add substantial clinical value to the assessment of renal prognosis. The high proportion of paraproteins in patient sera or in urine suggests their involvement in disease development.
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Ahmad SB, Bomback AS. C3 Glomerulopathy: Pathogenesis and Treatment. Adv Chronic Kidney Dis 2020; 27:104-110. [PMID: 32553242 DOI: 10.1053/j.ackd.2019.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/13/2019] [Accepted: 12/13/2019] [Indexed: 12/18/2022]
Abstract
C3 glomerulopathy (C3G) is a rare set of kidney diseases with 2 patterns: C3 glomerulonephritis (C3GN) and dense deposit disease. Pathogenesis of both diseases is due to complement dysregulation in the alternative pathway. Acquired or genetic alterations of the regulatory proteins of the complement pathway result in C3G. Although the disease is characterized by low C3 levels in serum and C3-dominant staining by immunofluorescence on biopsy, other disease entities such as infection-related glomerulonephritis and masked monoclonal deposits can present similarly. Both the C3GN and dense deposit disease variants of C3G are progressive and recur in transplanted kidneys. Although no direct treatment is available, complement blockers are either available or in the clinical trial phase. This review will survey the pathogenesis of C3GN and current treatment options.
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Abstract
Glomerulonephritis (GN) refers to a group of renal diseases affecting the glomeruli due to the damage mediated by immunological mechanisms. A large proportion of the disease manifestations are caused by disturbances in the complement system. They can be due to genetic errors, autoimmunity, microbes or abnormal immunoglobulins, like modified IgA or paraproteins. The common denominator in most of the problems is an overactive or misdirected alternative pathway complement activation. An assessment of kidney function, amount of proteinuria and hematuria are crucial elements to evaluate, when glomerulonephritis is suspected. However, the cornerstones of the diagnoses are renal biopsy and careful examination of the complement abnormality. Differential diagnostics between the various forms of GN is not possible based on clinical features, as they may vary greatly. This review describes the known mechanisms of complement dysfunction leading to different forms of primary GN (like IgA glomerulonephritis, dense deposit disease, C3 glomerulonephritis, post-infectious GN, membranous GN) and differences to atypical hemolytic uremic syndrome. It also covers the basic elements of etiology-directed therapy and prognosis of the most common forms of GN. Common principles in the management of GN include treatment of hypertension and reduction of proteinuria, some require immunomodulating treatment. Complement inhibition is an emerging treatment option. A thorough understanding of the basic disease mechanism and a careful follow-up are needed for optimal therapy.
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Affiliation(s)
- Kati Kaartinen
- Department of Nephrology, Abdominal Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Adrian Safa
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Bacteriology and Immunology, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | - Soumya Kotha
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Bacteriology and Immunology, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | - Giorgio Ratti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Bacteriology and Immunology, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | - Seppo Meri
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Bacteriology and Immunology, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland; HUSLAB, Helsinki University Central Hospital, Helsinki, Finland.
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Frangou E, Varnavidou-Nicolaidou A, Petousis P, Soloukides A, Theophanous E, Savva I, Michael N, Toumasi E, Georgiou D, Stylianou G, Mean R, Anastasiadou N, Athanasiou Y, Zavros M, Kyriacou K, Deltas C, Hadjianastassiou V. Clinical course and outcome after kidney transplantation in patients with C3 glomerulonephritis due to CFHR5 nephropathy. Nephrol Dial Transplant 2019; 34:1780-1788. [PMID: 30844074 DOI: 10.1093/ndt/gfz021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/17/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Complement factor H-related protein 5 (CFHR5) nephropathy is an inherited renal disease characterized by microscopic and synpharyngitic macroscopic haematuria, C3 glomerulonephritis and renal failure. It is caused by an internal duplication of exons 2-3 within the CFHR5 gene resulting in dysregulation of the alternative complement pathway. The clinical characteristics and outcomes of transplanted patients with this rare familial nephropathy remain unknown. METHODS This is a retrospective case series study of 17 kidney transplant patients with the established founder mutation, followed-up over a span of 30 years. RESULTS The mean (±SD) age of patients at the time of the study and at transplantation was 58.6 ± 9.9 and 46.7 ± 8.8 years, respectively. The 10- and 15-year patient survival rates were 100 and 77.8%, respectively. Proteinuria was present in 33.3% and microscopic haematuria in 58.3% of patients with a functional graft. Serum complement levels were normal in all. 'Confirmed' and 'likely' recurrence of CFHR5 nephropathy were 16.6 and 52.9%, respectively; however, 76.5% of patients had a functional graft after a median of 120 months post-transplantation. Total recurrence was not associated with graft loss (P = 0.171), but was associated with the presence of microscopic haematuria (P = 0.001) and proteinuria (P = 0.018). Graft loss was associated with the presence of proteinuria (P = 0.025). CONCLUSIONS We describe for the first time the clinical characteristics and outcome of patients with CFHR5 nephropathy post-transplantation. Despite the recurrence of CFHR5 nephropathy, we provide evidence for a long-term favourable outcome and support the continued provision of kidney transplantation as a renal replacement option in patients with CFHR5 nephropathy.
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Affiliation(s)
- Eleni Frangou
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Cyprus, Nicosia, Cyprus.,Biomedical Research Foundation, Academy of Athens, Athens, Greece
| | | | | | - Andreas Soloukides
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Cyprus, Nicosia, Cyprus
| | - Elena Theophanous
- Department of Histopathology, Nicosia General Hospital, Nicosia, Cyprus
| | - Isavella Savva
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Molecular Medicine Research Center, Department of Biological Sciences, University of Cyprus, Nicosia, Cyprus
| | - Nicos Michael
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Nicosia, Nicosia, Cyprus
| | - Elpida Toumasi
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Cyprus, Nicosia, Cyprus
| | - Dora Georgiou
- Histocompatibility and Immunogenetics Laboratory, Nicosia General Hospital, Nicosia, Cyprus
| | - Galatia Stylianou
- Histocompatibility and Immunogenetics Laboratory, Nicosia General Hospital, Nicosia, Cyprus
| | - Richard Mean
- Histocompatibility and Immunogenetics Laboratory, Nicosia General Hospital, Nicosia, Cyprus
| | | | - Yiannis Athanasiou
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Cyprus, Nicosia, Cyprus
| | - Michalis Zavros
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus
| | - Kyriacos Kyriacou
- Department of Electron Microscopy, Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Constantinos Deltas
- Molecular Medicine Research Center, Department of Biological Sciences, University of Cyprus, Nicosia, Cyprus
| | - Vassilis Hadjianastassiou
- Department of Nephrology and Transplantation, Nicosia General Hospital, Nicosia, Cyprus.,Medical School, University of Nicosia, Nicosia, Cyprus
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