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Uchida T, Oda T. The Prevalence, Characteristics, and Putative Mechanisms of Dual Antigen-Positive Membranous Nephropathy: The Underestimated Condition. Int J Mol Sci 2024; 25:5931. [PMID: 38892120 PMCID: PMC11172907 DOI: 10.3390/ijms25115931] [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: 04/08/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Following the discovery of podocyte phospholipase A2 receptor and thrombospondin type-1 domain-containing 7A, various potential target antigens for membranous nephropathy (MN) have been reported one after another. MN target antigens have now been identified in a significant proportion of patients, and a new classification framework classifies patients with MN based on the detected antigen and associated disease phenotype. A serology-based approach that does not require a histological diagnosis for patients suspected of having MN has also been proposed. However, there have been cases in which dual positivity for MN antigens and/or corresponding antibodies has been shown. Importantly, some of them showed a transition of the affected patient's immune responses to MN antigens, suggesting that serological diagnosis changes depending on the timing of the analysis. In this review, we provide detailed information on these cases and present an overview of our recent understanding of their putative mechanisms involved in these cases. Greater awareness is required to adequately recognize and develop appropriate therapeutic strategies for this condition.
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Affiliation(s)
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji 193-0998, Japan;
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Andeen NK, Kung VL, Avasare RS. NELL1 membranous nephropathy: clinical associations provide mechanistic clues. FRONTIERS IN NEPHROLOGY 2024; 4:1323432. [PMID: 38596642 PMCID: PMC11002321 DOI: 10.3389/fneph.2024.1323432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 03/04/2024] [Indexed: 04/11/2024]
Abstract
Neural epidermal growth factor-like 1 (NELL1) membranous nephropathy (MN) is notable for its segmental deposit distribution, IgG1 dominant deposits, and comparatively high rate of spontaneous remission. It has been associated with a variety of exposures and secondary conditions, specifically use of thiol-containing medications - including lipoic acid, bucillamine, and tiopronin - as well as traditional indigenous medications (TIM) particularly those with high mercury content, and non-steroid anti-inflammatory drugs (NSAIDs). Malignancies, graft vs. host disease (GVHD), infection, and autoimmune conditions have also been associated with NELL1 MN. Herein, we provide a detailed summary of the clinicopathologic features of NELL1 and associations with underlying conditions, with a focus on treatment and outcomes. Rare cases of dual NELL1 and phospholipase A2 receptor (PLA2R) positive MN are reviewed. Genome-wide association study of NELL1, role of NELL1 in other physiologic and pathologic processes, and connection between NELL1 MN and malignancy with relevance of NELL1 tumor staining are examined. Finally, relationships and potential disease mechanisms of thiol- and mercury- associated NELL1 MN are discussed.
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Affiliation(s)
- Nicole K. Andeen
- Department of Pathology and Laboratory Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Vanderlene L. Kung
- Department of Pathology and Laboratory Medicine, Oregon Health & Science University, Portland, OR, United States
| | - Rupali S. Avasare
- Department of Medicine, Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, OR, United States
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Avasare R, Andeen N, Beck L. Novel Antigens and Clinical Updates in Membranous Nephropathy. Annu Rev Med 2024; 75:219-332. [PMID: 37552894 DOI: 10.1146/annurev-med-050522-034537] [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] [Indexed: 08/10/2023]
Abstract
Membranous nephropathy (MN), an autoimmune kidney disease and leading cause of nephrotic syndrome, leads to kidney failure in up to one-third of affected individuals. Most MN cases are due to an autoimmune reaction against the phospholipase A2 receptor (PLA2R) located on kidney podocytes. Serum PLA2R antibody quantification is now part of routine clinical practice because antibody titers correlate with disease activity and treatment response. Recent advances in target antigen detection have led to the discovery of more than 20 other podocyte antigens, yet the clinical impact of additional antigen detection remains unknown and is under active investigation. Here we review recent findings and hypothesize how current research will inform future care of patients with MN.
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Affiliation(s)
- Rupali Avasare
- Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, Oregon, USA;
| | - Nicole Andeen
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA;
| | - Laurence Beck
- Section of Nephrology, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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Yang L, Wang G, Ye N, Xu X, Cheng W, Sun L, Dong H, Kong L, Zhao X, Geng Y, Cheng H. Clinicopathological and prognostic characteristics of idiopathic membranous nephropathy with dual antigen positivity. Front Immunol 2024; 14:1297107. [PMID: 38250076 PMCID: PMC10796489 DOI: 10.3389/fimmu.2023.1297107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Background Idiopathic membranous nephropathy (IMN) is the most common pathological type in adults with nephrotic syndrome. Many target antigens have been discovered. However, dual antigen-positive IMN patients are very rare, with only a few such cases being briefly described in various studies. There is no specific study on the clinicopathological and prognostic characteristics of dual antigen-positive IMN patients, and the disease characteristics of such patients remain unclear. Methods Immunohistochemical staining of PLA2R, THSD7A, and NELL-1 was conducted on kidney tissue samples obtained from patients diagnosed with IMN. Simultaneously, the presence of corresponding serum antibodies was determined. Patients exhibiting positivity for dual antigens were included in the study, identified either through tissue staining or serum antibody detection. We retrospectively collected their clinical, pathological, and follow-up data and measured their serum antibody levels at multiple time points. Additionally, the same type of dual antigen-positive IMN cases reported in the literature were reviewed to extract clinical, pathological, and prognostic information. We compared the data for all of the above dual antigen-positive and PLA2R single-positive IMN cases at our center. Results We identified 6 IMN patients with dual antigen positivity at our center, approximately 0.7% of whole MN series; the previous literature reports 43 IMN patients with dual antigen positivity, the proportion ranged from 0.2% to 2.8%. The IgG1 positivity rate in the renal tissue of the dual antigen-positive patients at our center was significantly lower than that of dual antigen-positive patients previously reported (16.7% vs. 100.0%, p=0.015), but there was no significant difference in clinical or prognostic aspects. Patients with dual antigen positivity reported at our center and in the literature were combined and compared with PLA2R single-positive IMN reported at our center. Compared with PLA2R single-positive IMN patients, dual antigen-positive IMN patients had a higher renal tissue IgG1 positivity rate (58.3% vs. 22.3%, p=0.016), and the time required to achieve remission was longer [13.5 (3.3,35.0) vs. 3.0 (1.0,8.0), p=0.052]. Overall, The changes in urine protein were consistent with the changes in serum PLA2R antibody levels in dual antigen-positive IMN patients. Conclusions For patients with primary membranous nephropathy who did not attain remission following prolonged treatment, multiple target antigen staining should still be actively performed, even with positivity for the PLA2R target antigen.
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Affiliation(s)
- Lei Yang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Guoqin Wang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Ye
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoyi Xu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wenrong Cheng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lijun Sun
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongrui Dong
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lingqiang Kong
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoyi Zhao
- Division of Nephrology, Affiliated Hospital of Chifeng University, Neimenggu, China
| | - Yanqiu Geng
- Division of Nephrology, The Third Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Hong Cheng
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Sivagnanam H, Anand M, Senthikumar PK, Velu KB, Vishwanathan R. A Case of Pla2r and Exostosin 1 Positive Membranous Nephropathy - The Diagnostic and Therapeutic Dilemma. Cureus 2023; 15:e43619. [PMID: 37719621 PMCID: PMC10504682 DOI: 10.7759/cureus.43619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
Membranous nephropathy is an immune disease that commonly presents as nephrotic syndrome. The understanding of the pathogenesis of membranous nephropathy has rapidly evolved over the past few years due to the discovery of newer antigens. Exostosin 1 and exostosin 2 are antigens discovered in 2019 and found to be specific for membranous nephropathy secondary to autoimmune disease and are usually not seen in M-type phospholipase A2-associated membranous nephropathy. However, fewer clinical and pathological details of exostosin 1 and 2 related nephropathies are known, owing to the novelty of the antigen. Here we report a 24-year-old female who presented with nephrotic range proteinuria. Initial blood investigations revealed a doubtful autoimmune disease background. A subsequent renal biopsy revealed membranous nephropathy with both PLA2r and exostosin 1 positivity, which posed challenges in both diagnosis and treatment. Immunoglobulin G staining and electron microscopy were performed to differentiate if it was a PLA2r-associated or a exostosin 1/ exostosin 2-related membranous nephropathy. Electron microscopy revealed subepithelial deposits and immunoglobulin G stained for immunoglobulin G4, signifying possible PLA2r-associated membranous nephropathy with exostosin deposits. The patient was treated with rituximab and had a good treatment response. Only one similar case has been reported with both PLA2R and exostosin positivity. The pathophysiologic mechanism of this unique association is still unclear.
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Affiliation(s)
| | - Murugesh Anand
- Nephrology, Tirunelveli Medical College, Tirunelveli, IND
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Huang G, Liu F, Yu L, Wang J, Chen J, Mao J. Pediatric membranous nephropathy: In the novel antigens era. Front Immunol 2022; 13:962502. [PMID: 36016931 PMCID: PMC9396344 DOI: 10.3389/fimmu.2022.962502] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/21/2022] [Indexed: 01/10/2023] Open
Abstract
Membranous nephropathy (MN) falls within the scope of a glomerular disease. MN exhibits subepithelial immune- complex deposition and capillary wall thickening which could occur in all age groups. In comparison with adult patients with MN, MN in pediatric population has a lower incidence and more secondary factors (e.g., systemic lupus erythematosus, infection, malignancy, or drug toxicity). Two target antigens for the immune complexes, PLA2R (identified in 2009) and THSD7A (in 2014), found in previous studies and first presented in adult MN, are found in pediatric patients suffering from MN and their antibodies are now an effective tool for diagnosis and monitoring in children and adolescents. Several novel antigens have been identified (e.g., EXT1/EXT2, NELL1, Sema3B, PCDH7, HTRA1, and NCAM1) over the past few years. Each of them represents different clinical and pathologic findings. In-depth research should be conducted to gain insights into the outcomes and pathophysiology of the above novel antigen-associated MN. Targeted treatment opinions for different novel antigen-related MN are under development both in adults and pediatric patients.
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Bobart SA, Han H, Tehranian S, De Vriese AS, Roman JCL, Sethi S, Zand L, Andrades Gomez C, Giesen CD, Soler MJ, Bomback AS, Fervenza FC. Noninvasive Diagnosis of PLA2R-Associated Membranous Nephropathy: A Validation Study. Clin J Am Soc Nephrol 2021; 16:1833-1839. [PMID: 34782349 PMCID: PMC8729491 DOI: 10.2215/cjn.05480421] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Kidney biopsy is the current gold standard to diagnose membranous nephropathy. Approximately 70%-80% of patients with primary membranous nephropathy have circulating anti-phospholipase A2 receptor antibodies. We previously demonstrated that in proteinuric patients with preserved eGFR and absence of associated conditions (e.g., autoimmunity, malignancy, infection, drugs, and paraproteinemia), a positive anti-phospholipase A2 receptor antibody test by ELISA and immunofluorescence assay confirms the diagnosis of membranous nephropathy noninvasively. These data have not been externally validated. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The clinical and pathologic characteristics of patients with a positive anti-phospholipase A2 receptor antibody test at the Mayo Clinic, the University Hospital Vall D'Hebron (Barcelona), and the Columbia University Medical Center (New York) were retrospectively reviewed. Biopsy findings and presence or absence of a potential associated condition were assessed. RESULTS From a total of 276 patients with positive anti-phospholipase A2 receptor serology, previously reported patients (n=33), kidney transplant recipients (n=9), pediatric patients (n=2), and patients without kidney biopsy (n=69) were excluded. Among the 163 remaining patients, associated conditions were identified in 47 patients, and 15 patients had diabetes mellitus. All 101 patients of the final cohort had a primary diagnosis of membranous nephropathy on kidney biopsy. In the 79 patients with eGFR≥60 ml/min per 1.73 m2, none of the biopsy findings altered diagnosis or management. Among the 22 patients with decreased eGFR, additional findings included superimposed acute interstitial nephritis (n=1). CONCLUSIONS In patients with preserved eGFR and absence of associated conditions or diabetes, a positive anti-phospholipase A2 receptor test by either ELISA >20 RU/ml or a positive immunofluorescence assay confirms the diagnosis of membranous nephropathy, precluding the requirement for a kidney biopsy.
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Affiliation(s)
- Shane A. Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- Department of Nephrology and Hypertension, Cleveland Clinic Florida, Weston, Florida
| | - Heedeok Han
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Shahrzad Tehranian
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - An S. De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | | | - Callen D. Giesen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Maria Jose Soler
- Nephrology Department, University Hospital Vall D’Hebron, Barcelona, Spain
| | - Andrew S. Bomback
- Division of Nephrology, Columbia University Medical Center, New York, New York
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