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Martin Capon I, Gutierrez E, Huerta A, Viera E, Alvarez Nadal M, Fernández-Lucas M, Villacorta J. Relapse treatment with low-dose steroids in steroid-sensitive minimal change disease. FRONTIERS IN NEPHROLOGY 2024; 4:1426156. [PMID: 39055858 PMCID: PMC11269268 DOI: 10.3389/fneph.2024.1426156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024]
Abstract
Background The treatment of minimal change disease (MCD) consists of a high dose of steroids for several months, implying significant drug toxicity. Nevertheless, relapses of steroid-sensitive MCD usually respond to lower doses of steroids. Methods The objective of this study was to analyze whether a low dose of steroids (LDS) is effective for the treatment of MCD relapses. Since 2018, new relapses of steroid-sensitive adult patients with MCD in three Spanish centers have been treated with LDS. The cumulative dose of steroids, the time to remission, and the relapse-free time were compared between relapses treated with LDS and previous relapses of the same patients treated with a standard dose of steroids (SDS). Results A total of 51 relapses in 31 patients were treated with LDS and compared with 48 historical relapses of the same patients treated with SDS. The mean doses of prednisone adjusted by weight for the initial treatment were 0.45 mg/kg (0.40-0.51 mg/kg) in the relapses treated with LDS and 0.88 mg/kg (0.81-1.00 mg/kg) in those treated with SDS. The mean cumulative doses of prednisone in LDS- and SDS-treated relapses were 1,191 mg (801-1,890 mg) and 3,700 mg (2,755-5,800 mg), respectively. The duration of treatment was 63 days (42-117 days) in the LDS group and was 140 days (65-195 days) in the SDS group. All patients achieved complete remission within 1 month after steroid therapy in both groups. The times to remission of the LDS and SDS groups were 19.10 ± 12.80 and 18.93 ± 12.98 days, respectively (p = 0.95). Conclusion Among the steroid-sensitive patients with MCD, relapse therapy with LDS (0.5 mg/kg) appears effective and allows minimization of the steroid cumulative dose.
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Affiliation(s)
- Irene Martin Capon
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Eduardo Gutierrez
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
- Instituto de Investigación del Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Elizabeth Viera
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Marta Alvarez Nadal
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Milagros Fernández-Lucas
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de investigación Sanitaria (IRYCIS), Madrid, Spain
| | - Javier Villacorta
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de investigación Sanitaria (IRYCIS), Madrid, Spain
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Li S, Yao S, Tie X, Shi X, Feng R, Su X, Wang L. Enteric-coated Mycophenolate Sodium therApy versus cyclophosphamide for induction of Remission in Microscopic PolyAngiitis (EMSAR-MPA trial): study protocol for a randomised controlled trial. BMJ Open 2024; 14:e074662. [PMID: 38471694 PMCID: PMC10936518 DOI: 10.1136/bmjopen-2023-074662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 02/22/2024] [Indexed: 03/14/2024] Open
Abstract
INTRODUCTION Several studies have demonstrated that mycophenolate mofetil (MMF) may be an excellent alternative to cyclophosphamide (CYC) or rituximab for the induction of remission in non-life-threatening anti-neutrophil cytoplasmic antibodies associated vasculitis because of its strong immunosuppressive potency and low toxicity profile. Enteric-coated mycophenolate sodium (EC-MPS) was introduced to reduce gastrointestinal adverse reactions of MMF. This study will evaluate the efficacy and safety of EC-MPS combined with glucocorticoid in patients with active and non-life-threatening microscopic polyangiitis (MPA). METHODS AND ANALYSIS This study is a multicentre, open-label, randomised controlled, non-inferiority trial. A total of 110 patients with active and non-life-threatening MPA from 11 hospitals in Shanxi Province of China will be recruited and randomised in a 1:1 ratio to receive either EC-MPS or CYC. All patients will receive the same glucocorticoid plan. We will compare oral EC-MPS (720-1440 mg/day) with intravenous pulsed CYC (7.5-15 mg/kg) administered for 3-6 months. All patients will be switched from their assigned treatment (EC-MPS or CYC) to oral azathioprine (2 mg/kg/day) after remission has been achieved, between 3 and 6 months. Azathioprine will be continued until the study ends at 18 months. The primary end point of efficacy is the remission rate at 6 months. Follow-up will continue for 18 months in order to detect an influence of induction regimen on subsequent relapse rates. ETHICS AND DISSEMINATION This study has received approval from the Ethics Committee of the Second Hospital of Shanxi Medical University (2022YX-026). All participants are required to provide written informed consent and no study-related procedures will be performed until consent is obtained. The results of this trial will be published in peer-reviewed journals and presented at conferences. TRIAL REGISTRATION NUMBER ChiCTR2200063823.
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Affiliation(s)
- Sijia Li
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Shulei Yao
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Xuan Tie
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Xiaojing Shi
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Rongrong Feng
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Xiaole Su
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
| | - Lihua Wang
- Division of Nephrology, Shanxi Medical University Second Hospital, Shanxi Kidney Disease Institute, Taiyuan, Shanxi, People's Republic of China
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Morel A, Remy P, Sakhi H, El Karoui K, Sahali D, Audard V, Moktefi A. CD44 staining in parietal epithelial cells and early steroid response in patients with minimal change disease. Clin Kidney J 2023; 16:1355-1358. [PMID: 37529642 PMCID: PMC10387389 DOI: 10.1093/ckj/sfad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Indexed: 08/03/2023] Open
Affiliation(s)
- Antoine Morel
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare «Syndrome Néphrotique Idiopathique», Fédération Hospitalo-Universitaire “Innovative Therapy for Immune Disorders”, Créteil, France
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Philippe Remy
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare «Syndrome Néphrotique Idiopathique», Fédération Hospitalo-Universitaire “Innovative Therapy for Immune Disorders”, Créteil, France
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Hamza Sakhi
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare «Syndrome Néphrotique Idiopathique», Fédération Hospitalo-Universitaire “Innovative Therapy for Immune Disorders”, Créteil, France
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Khalil El Karoui
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare «Syndrome Néphrotique Idiopathique», Fédération Hospitalo-Universitaire “Innovative Therapy for Immune Disorders”, Créteil, France
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Dil Sahali
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare «Syndrome Néphrotique Idiopathique», Fédération Hospitalo-Universitaire “Innovative Therapy for Immune Disorders”, Créteil, France
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Vincent Audard
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare «Syndrome Néphrotique Idiopathique», Fédération Hospitalo-Universitaire “Innovative Therapy for Immune Disorders”, Créteil, France
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
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Windpessl M, Odler B, Bajema IM, Geetha D, Säemann M, Lee JM, Vaglio A, Kronbichler A. Glomerular Diseases Across Lifespan: Key Differences in Diagnostic and Therapeutic Approaches. Semin Nephrol 2023; 43:151435. [PMID: 37945450 DOI: 10.1016/j.semnephrol.2023.151435] [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: 11/12/2023]
Abstract
Glomerular diseases are common causes of chronic kidney disease in childhood, adolescence, and adulthood. The epidemiology of glomerular diseases differs between different age groups, with minimal change disease being the leading cause of nephrotic syndrome in childhood, while membranous nephropathy and focal segmental glomerulosclerosis are more common in adulthood. IgA vasculitis is also more common in childhood. Moreover, there is a difference in disease severity with more children presenting with a relapsing form of nephrotic syndrome and a more acute presentation of antineutrophil cytoplasmic antibody-associated vasculitis and concomitant glomerulonephritis, as highlighted by the higher percentage of cellular crescents on kidney biopsy specimens in comparison with older patients. There is also a female preponderance in antineutrophil cytoplasmic antibody-associated vasculitis and more children present with tracheobroncholaryngeal disease. This article aims to summarize differences in the presentation of different glomerular diseases that are encountered commonly by pediatric and adult nephrologists and potential differences in the management.
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Affiliation(s)
- Martin Windpessl
- Section of Nephrology, Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria; Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Balazs Odler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ingeborg M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands; Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria; Sigmund Freud University, Medical School, Vienna, Austria
| | - Jiwon M Lee
- Division of Rare Disease Management, Korea Disease Control and Prevention Agency, Cheongju-si, Republic of Korea
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Firenze, Nephrology Unit, Meyer Children's Hospital, Firenze, Italy
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria.
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Azukaitis K, Palmer SC, Strippoli GF, Hodson EM. Interventions for minimal change disease in adults with nephrotic syndrome. Cochrane Database Syst Rev 2022; 3:CD001537. [PMID: 35230699 PMCID: PMC8887628 DOI: 10.1002/14651858.cd001537.pub5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Steroids have been used widely since the early 1970s for the treatment of adult-onset minimal change disease (MCD). Recently, newer agents have been used in adult MCD aiming to reduce the risk of adverse effects. The response rates to immunosuppressive agents in adult MCD are more variable than in children. The optimal agent, dose, and duration of treatment for the first episode of nephrotic syndrome, or for disease relapse(s) have not been determined. This is an update of a review first published in 2008. OBJECTIVES We aimed to 1) evaluate the benefits and harms of different agents, including both immunosuppressive and non-immunosuppressive agents, in adults with MCD causing the nephrotic syndrome; and 2) evaluate the efficacy of interventions on 'time-to-remission' of nephrotic syndrome, in adults with MCD causing the nephrotic syndrome. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 21 July 2021 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of any intervention for MCD with nephrotic syndrome in adults over 18 years were included. Studies comparing different types, routes, frequencies, and duration of immunosuppressive agents and non-immunosuppressive agents were assessed. DATA COLLECTION AND ANALYSIS Two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random-effects model and results were expressed as a risk ratio (RR) for dichotomous outcomes, or mean difference (MD) for continuous data with 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Fifteen RCTs (769 randomised participants) were identified; four studies evaluated different prednisolone regimens, eight studies evaluated the calcineurin inhibitors (CNIs) (tacrolimus or cyclosporin), two studies evaluated enteric-coated mycophenolate sodium (EC-MPS) and one study evaluated levamisole. In all but two studies of non-corticosteroid agents, reduced-dose prednisolone was given with the treatment agent and the comparator was high-dose prednisolone. In the risk of bias assessment, 11 and seven studies were at low risk of bias for sequence generation and allocation concealment, respectively. No studies were at low risk of performance bias and eight studies were at low risk of detection bias. Thirteen, 10 and six studies were at low risk of attrition bias, reporting bias and other bias, respectively. Compared with no specific treatment, it is uncertain whether prednisolone increases the number with complete remission (1 study, 28 participants: RR 1.44, 95% CI 0.95 to 2.19), complete or partial remission (1 study, 28 participants: RR 1.38, 95% CI 0.98 to 1.95), subsequent relapse (1 study, 28 participants: RR 0.75, 95% CI 0.48 to 1.17), or reduces the adverse effects because the certainty of the evidence is very low. Compared with oral prednisolone alone, it is uncertain whether intravenous methylprednisolone and prednisolone increase the number with complete remission (2 studies, 35 participants: RR 1.76, 95% CI 0.17 to 18.32; I² = 90%), relapse (two studies, 19 participants. RR 1.18, 95% CI 0.65 to 2.15; I² = 0%) or adverse events because the certainty of the evidence is very low. Compared with prednisolone alone, CNIs with reduced-dose prednisolone or without prednisolone probably make little or no difference to the number achieving complete remission (8 studies; 492 participants: RR 0.99, 95% CI 0.93 to 1.05; I² = 0%), complete or partial remission (4 studies, 269 participants: RR 1.01, 95% CI 0.96 to 1.05; I² = 0%), or relapse (7 studies; 422 participants: RR 0.73, 95% CI 0.51 to 1.03; I² = 0%) (moderate certainty evidence), may reduce the risk of obesity or Cushing's Syndrome (5 studies; 388 participants: RR 0.11, 95% CI 0.02 to 0.59; I² = 45%) and the risk of acne (4 studies; 270 participants: RR 0.15, 95% CI 0.03 to 0.67; I² = 0%) (low certainty evidence); and had uncertain effects on diabetes or hyperglycaemia, hypertension, and acute kidney injury (AKI) (low certainty evidence). Compared with prednisolone alone, EC-MPS with reduced-dose prednisolone probably make little or no difference to the number undergoing complete remission at 4 weeks (1 study, 114 participants: RR 1.12, 95% CI 0.84 to 1.50), and at 24 weeks probably make little or no difference to the number undergoing complete remission (2 studies, 134 participants: RR 1.12, 95% CI 0.84 to 1.38; I² = 0%) (moderate certainty evidence), complete or partial remission (2 studies 134 participants: RR 0.92, 95% CI 0.75 to 1.12; I² = 0%), relapse (2 studies, 83 participants: RR 0.50, 95% CI 0.07 to 3.74; I² = 56%) (low certainty evidence); or to the adverse events of new-onset glucose intolerance, death, or AKI (low certainty evidence). One study (24 participants) compared levamisole and prednisolone with prednisolone in patients with relapsing disease. The authors identified no differences in mean relapse rate or adverse effects but no standard deviations were provided. AUTHORS' CONCLUSIONS This updated review has identified evidence for the efficacy and adverse effects of CNIs and EC-MPS with or without reduced-dose prednisolone compared with prednisolone alone for the induction of remission in adults with MCD and nephrotic syndrome with some reductions in steroid-associated adverse events. RCT data on the efficacy and adverse effects of rituximab in adults with MCD are awaited. Further, adequately powered RCTs are required to determine the relative efficacies of CNIs and EC-MPS and to evaluate these medications in patients with relapsing or steroid-resistant disease.
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Affiliation(s)
- Karolis Azukaitis
- Clinic of Pediatrics, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Suetonia C Palmer
- Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - Giovanni Fm Strippoli
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | - Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Colucci M, Oniszczuk J, Vivarelli M, Audard V. B-Cell Dysregulation in Idiopathic Nephrotic Syndrome: What We Know and What We Need to Discover. Front Immunol 2022; 13:823204. [PMID: 35140723 PMCID: PMC8819007 DOI: 10.3389/fimmu.2022.823204] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 01/04/2022] [Indexed: 11/18/2022] Open
Abstract
The therapeutic efficacy of B-cell depletion by anti-CD20 treatment in pediatric and, more recently, in adult idiopathic nephrotic syndrome patients suggests a key role of B cells in the pathogenesis of the disease. However, their exact role is still unclear. B cells are able to secrete a large variety of antibodies that can protect against infections. However, B-cell dysregulation is well-established in a variety of autoimmune diseases. In parallel with their ability to produce antibodies, pathogenic B cells display altered effector functions by expressing activating surface molecules, which can strongly modify the immune homeostasis, or by producing specific cytokines, which can directly affect either podocyte structure and functions or modulate T-cell homeostasis. Herein, we report the most relevant clinical and experimental evidences of a pathogenic role of B cells in idiopathic nephrotic syndrome. We further highlight similarities and differences between children and adults affected by non-genetic forms of the disease and discuss what needs to be investigated in order to define the exact mechanisms underlying the pathogenic role of B cells and to identify more tailored therapeutic approaches.
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Affiliation(s)
- Manuela Colucci
- Renal Diseases Research Unit, Genetics and Rare Diseases Research Area, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- *Correspondence: Manuela Colucci,
| | - Julie Oniszczuk
- Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Henri-Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare “Syndrome Néphrotique Idiopathique”, Fédération Hospitalo-Universitaire, Innovative Therapy for Immune Disorders, Créteil, France
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Marina Vivarelli
- Division of Nephrology, Department of Pediatric Subspecialties, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Vincent Audard
- Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Henri-Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare “Syndrome Néphrotique Idiopathique”, Fédération Hospitalo-Universitaire, Innovative Therapy for Immune Disorders, Créteil, France
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 780] [Impact Index Per Article: 260.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Koirala A, Jefferson JA. Steroid Minimization in Adults with Minimal Change Disease. GLOMERULAR DISEASES 2021; 1:237-249. [PMID: 36751385 PMCID: PMC9677715 DOI: 10.1159/000517626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/30/2021] [Indexed: 11/19/2022]
Abstract
Background Minimal change disease (MCD) causes approximately 10% of nephrotic syndrome in adults. While glucocorticoids (GCs) effectively induce remission in MCD, the disease has a high relapse rate (50-75%), and repeated exposure to GCs is often required. The adverse effects of GCs are well recognized and commonly encountered with the high doses and recurrent courses used in MCD. Summary In this review, we will discuss the standard therapy of MCD in adults and then describe new therapeutic options in induction therapy and treatment of relapses in MCD, minimizing the exposure to GCs. Key Messages Steroid minimization strategies may decrease adverse effects in the treatment of MCD.
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Oniszczuk J, Beldi-Ferchiou A, Audureau E, Azzaoui I, Molinier-Frenkel V, Frontera V, Karras A, Moktefi A, Pillebout E, Zaidan M, El Karoui K, Delfau-Larue MH, Hénique C, Ollero M, Sahali D, Mahévas M, Audard V. Circulating plasmablasts and high level of BAFF are hallmarks of minimal change nephrotic syndrome in adults. Nephrol Dial Transplant 2021; 36:609-617. [PMID: 33241414 DOI: 10.1093/ndt/gfaa279] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The recent success achieved with the use of B cell-depleting agents in some patients with minimal change nephrotic syndrome (MCNS) suggests an unexpected role for B lymphocytes in the pathogenesis of this immune-mediated glomerular disease. Nevertheless, no extensive B-cell phenotyping analysis has ever been performed in untreated adult patients soon after MCNS diagnosis. METHODS We investigated the distribution of the different B-cell subpopulations in 22 untreated adult patients with biopsy-proven MCNS [MCNS relapse (MCNS-Rel)]. We compared these data with those for 24 healthy controls, 13 MCNS patients in remission (with no specific treatment) and 19 patients with idiopathic membranous nephropathy (IMN). RESULTS Patients with MCNS-Rel or IMN had higher proteinuria and lower serum albumin and gammaglobulin levels (P < 0.0001 for all comparisons) than MCNS patients in remission. Plasmablasts were the only B-cell subsets present at significantly higher levels in MCNS-Rel patients than in the patients of the other three groups (P < 0.05 for all comparisons). The lower albumin levels and higher proteinuria levels were positively correlated with the percentage of circulating plasmablasts (Spearman test's ρ = -0.54, P = 0.01 and ρ = 0.65, P = 0.002, respectively). Similarly, the increase of immunoglobulin M (IgM) and the decrease of IgG levels were significantly associated with the percentage of plasmablasts in MCNS-Rel patients (Spearman's ρ = 0.36, P = 0.01 and Spearman's ρ = -0.60, P = 0.01, respectively). Increased production of interleukin (IL)-21, IL-6 and B-cell activating factor (BAFF) in the serum of MCNS-Rel patients was found significantly correlated with the percentage of plasmablasts (ρ = 0.72, P = 0.0002, ρ = 0.49, P = 0.04 and ρ = 0.62, P = 0.009, respectively). CONCLUSIONS An increase in the proportion of circulating plasmablasts seems to be a hallmark of untreated MCNS in adult patients. Further studies are required to more precisely determine the phenotype and functions of these cells.
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Affiliation(s)
- Julie Oniszczuk
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare « Syndrome Néphrotique Idiopathique », Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Asma Beldi-Ferchiou
- AP-HP, Hôpitaux Universitaires Henri Mondor, Département d'Hématologie et Immunologie Biologiques, Créteil, France.,Univ Paris Est Créteil, INSERM U955, IMRB, Equipe Immunorégulation et Biothérapie, Créteil, France
| | - Etienne Audureau
- AP-HP, Hôpitaux Universitaires Henri Mondor, Service de Santé Publique, Unité de Recherche Clinique, Université Paris Est Créteil, INSERM U955, IMRB, Equipe CEPIA, Créteil, France
| | - Imane Azzaoui
- Univ Paris Est Créteil, INSERM U955, IMRB, Equipe 2, Créteil, France
| | - Valérie Molinier-Frenkel
- AP-HP, Hôpitaux Universitaires Henri Mondor, Département d'Hématologie et Immunologie Biologiques, Créteil, France.,Univ Paris Est Créteil, INSERM U955, IMRB, Equipe Immunorégulation et Biothérapie, Créteil, France
| | - Vincent Frontera
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Alexandre Karras
- AP-HP, Hôpital Européen Georges Pompidou, Service de Néphrologie, Paris, France.,Faculté de Médecine Paris-Descartes, Université de Paris, Paris, France
| | - Anissa Moktefi
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France.,AP-HP, Hôpitaux Universitaires Henri Mondor, Département de Pathologie, Créteil, France
| | - Evangeline Pillebout
- Service de Néphrologie et Transplantation, AP-HP, Hôpital Saint Louis, Paris, France
| | - Mohamad Zaidan
- AP-HP, Hôpitaux Universitaires du Kremlin Bicêtre, Service de Néphrologie-Dialyse-Transplantation, Le Kremlin-Bicêtre, France
| | - Khalil El Karoui
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare « Syndrome Néphrotique Idiopathique », Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Marie-Hélène Delfau-Larue
- AP-HP, Hôpitaux Universitaires Henri Mondor, Département d'Hématologie et Immunologie Biologiques, Créteil, France.,Univ Paris Est Créteil, INSERM U955, IMRB, Equipe 9, Créteil, France
| | - Carole Hénique
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Mario Ollero
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Dil Sahali
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare « Syndrome Néphrotique Idiopathique », Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - Matthieu Mahévas
- Univ Paris Est Créteil, INSERM U955, IMRB, Equipe 2, Créteil, France.,AP-HP, Hôpitaux Universitaires Henri Mondor, Service de Médecine interne, Centre de Référence Maladie Rare « Cytopénies Auto-immunes », Créteil, France
| | - Vincent Audard
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare « Syndrome Néphrotique Idiopathique », Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », Créteil, France.,Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
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10
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Moret L, Ganea A, Dao M, Hummel A, Knebelman B, Subra JF, Noble J, Mariat C, Jourde-Chiche N, Toure F, Garrouste C, Laurent C, Adeline L, Delmas Y, Cez A, Fritz O, Mousson C, Pouteau LM, Moranne O, Halimi JM, Audard V. Apheresis in Adult With Refractory Idiopathic Nephrotic Syndrome on Native Kidneys. Kidney Int Rep 2021; 6:2134-2143. [PMID: 34386662 PMCID: PMC8343786 DOI: 10.1016/j.ekir.2021.04.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 04/22/2021] [Accepted: 04/26/2021] [Indexed: 11/30/2022] Open
Abstract
Background Apheresis is the gold standard for idiopathic nephrotic syndrome (INS) relapse after transplantation, but it remains unknown whether such treatment is useful for adults with refractory INS on native kidneys. Methods This retrospective study included patients older than 16 years with biopsy-proven refractory (persistent nephrotic syndrome on corticosteroids plus at least 1 immunosuppressive drug) INS treated by apheresis and followed for at least 3 months. Results Between September 1997 and January 2020, 21 patients (focal segmental glomerulosclerosis: 12, minimal change nephrotic syndrome: 9, men: 67%, median age: 34 years) were identified. At last follow-up (12 months), 7 of 21 patients were in complete or partial remission. Remission was associated with older age (51 vs. 30 years, P = 0.05), lower proteinuria (3.9 vs. 7.3 g/d, P = 0.03), and lower estimated glomerular filtration rate (eGFR) (28.0 vs. 48.5 ml/min per 1.73 m2, P = 0.05) at apheresis. The need for dialysis before apheresis (odds ratio [OR] 22.0 [1.00–524], P = 0.026), age ≥50 years (OR: 22.6 [1.00–524], P = 0.006), a marked (>4.5 g/d) decrease in proteinuria (OR: 9.17 [1.15–73.2], P = 0.041), and a short (<12 months) time between diagnosis and apheresis (OR: 10.8 [1–117], P = 0.043) were significantly associated with remission. Three of 7 patients in remission who were initially on dialysis became dialysis-free; by contrast, none of the 14 patients without remission was initially on dialysis, but 5 of 14 had become dialysis-dependent (P = 0.01). Conclusion Apheresis may result in remission in adult patients with refractory INS, particularly in those at risk of renal failure, with limited sensitivity to medical treatments, if apheresis is initiated within a year of diagnosis.
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Affiliation(s)
- Léa Moret
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, CHRU Tours, Tours, France
| | | | - Myriam Dao
- Service de Néphrologie, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Necker, Paris, France
| | - Aurélie Hummel
- Service de Néphrologie, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Necker, Paris, France
| | - Bertrand Knebelman
- Service de Néphrologie, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Necker, Paris, France
| | - Jean François Subra
- Service de Néphrologie-Dialyse-Transplantation, CHU d'Angers, Angers, France
| | - Johan Noble
- Service de Néphrologie, Hémodialyse, Aphérèses et Transplantation Rénale, CHU Grenoble-Alpes, Grenoble, France
| | - Christophe Mariat
- CHU Saint-Etienne, Hôpital Nord Avenue Albert Raimond, Saint Priest en Jarez, France
| | - Noémie Jourde-Chiche
- Aix-Marseille University, C2VN, INSERM, INRAE, AP-HM, Centre de Néphrologie et Transplantation Rénale, Marseille, France
| | - Fatouma Toure
- Service de Néphrologie-Dialyse-Transplantation Rénale, CHU Limoges, Limoges, France
| | - Cyril Garrouste
- Service de Néphrologie-Dialyse et Transplantation, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | - Lacraz Adeline
- Service Néphrologie Hémodialyse, CH de la côte Basque, Bayonne, France
| | - Yahsou Delmas
- Service de Néphrologie, Transplantation et Dialyse, CHU Bordeaux, Bordeaux, France
| | - Alexandre Cez
- Service de Néphrologie, AP-HP, Hôpital Tenon, Paris, France
| | - Olivier Fritz
- Service de Néphrologie, Centre Hospitalier de La Rochelle, La Rochelle, France
| | | | - Lise Marie Pouteau
- Service de Néphrologie et Hémodialyse, Centre Hospitalier de Laval, Laval, France
| | - Olivier Moranne
- Service de Néphrologie-Dialyses-Aphérèse, Hôpital Caremeau, CHU Nîmes, Nîmes, France
| | - Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation Rénale, CHRU Tours, Tours, France.,EA4245, Université François-Rabelais, Tours, France.,INI-CRCT, Vandœuvre-lès-Nancy, France
| | - Vincent Audard
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare « Syndrome Néphrotique Idiopathique », Fédération Hospitalo-Universitaire « Innovative Therapy for Immune Disorders », AP-HP, Hôpitaux Universitaires Henri Mondor, Créteil, France.,University of Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
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11
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Chin HJ, Chae DW, Kim YC, An WS, Ihm C, Jin DC, Kim SG, Kim YL, Kim YS, Kim YG, Koo HS, Lee JE, Lee KW, Oh J, Park JH, Jiang H, Lee H, Lee SK. Comparison of the Efficacy and Safety of Tacrolimus and Low-Dose Corticosteroid with High-Dose Corticosteroid for Minimal Change Nephrotic Syndrome in Adults. J Am Soc Nephrol 2021; 32:199-210. [PMID: 33168602 PMCID: PMC7894664 DOI: 10.1681/asn.2019050546] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 09/08/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Tacrolimus is used as a steroid-sparing immunosuppressant in adults with minimal change nephrotic syndrome. However, combined treatment with tacrolimus and low-dose steroid has not been compared with high-dose steroid for induction of clinical remission in a large-scale randomized study. METHODS In this 24-week open-label noninferiority study, we randomized 144 adults with minimal change nephrotic syndrome to receive 0.05 mg/kg twice-daily tacrolimus plus once-daily 0.5 mg/kg prednisolone, or once-daily 1 mg/kg prednisolone alone, for up to 8 weeks or until achieving complete remission. Two weeks after complete remission, we tapered the steroid to a maintenance dose of 5-7.5 mg/d in both groups until 24 weeks after study drug initiation. The primary end point was complete remission within 8 weeks (urine protein: creatinine ratio <0.2 g/g). Secondary end points included time until remission and relapse rates (proteinuria and urine protein: creatinine ratio >3.0 g/g) after complete remission to within 24 weeks of study drug initiation. RESULTS Complete remission within 8 weeks occurred in 53 of 67 patients (79.1%) receiving tacrolimus and low-dose steroid and 53 of 69 patients (76.8%) receiving high-dose steroid; this difference demonstrated noninferiority, with an upper confidence limit below the predefined threshold (20%) in both intent-to-treat (11.6%) and per-protocol (17.0%) analyses. Groups did not significantly differ in time until remission. Significantly fewer patients relapsed on maintenance tacrolimus (3-8 ng/ml) plus tapered steroid versus tapered steroid alone (5.7% versus 22.6%, respectively; P=0.01). There were no clinically relevant safety differences. CONCLUSIONS Combined tacrolimus and low-dose steroid was noninferior to high-dose steroid for complete remission induction in adults with minimal change nephrotic syndrome. Relapse rates were significantly lower with maintenance tacrolimus and steroid compared with steroid alone. No clinically-relevant differences in safety findings were observed.
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Affiliation(s)
- Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Dong-Wan Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong Chul Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Won Suk An
- Department of Internal Medicine, Dong-A University College of Medicine, Busan, South Korea
| | - ChunGyoo Ihm
- Department of Nephrology, Kyunghee University Medical Center, Seoul, South Korea
| | - Dong-Chan Jin
- Department of Internal Medicine, St Vincent Hospital, Suwon, South Korea
| | - Sung Gyun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Yong-Soo Kim
- Department of Internal Medicine, The Catholic University of Korea, Seoul St. Mary’s Hospital, Seoul, South Korea
| | - Yoon-Goo Kim
- Department of Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ho Seok Koo
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, South Korea
| | - Jung Eun Lee
- Department of Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kang Wook Lee
- Department of Nephrology, Chungnam National University Hospital, Daejeon, South Korea
| | - Jieun Oh
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, Seoul, South Korea
| | - Jung Hwan Park
- Department of Internal Medicine, Konkuk University Medical Center, Seoul, South Korea
| | - Hongsi Jiang
- Medical Affairs Asia Oceania, Astellas Pharma Singapore Pte. Ltd., Singapore
| | - Hyuncheol Lee
- Clinical Research, Astellas Pharma Korea Inc., Seoul, South Korea
| | - Sang Koo Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan, Seoul, South Korea
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12
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Gauckler P, Shin JI, Alberici F, Audard V, Bruchfeld A, Busch M, Cheung CK, Crnogorac M, Delbarba E, Eller K, Faguer S, Galesic K, Griffin S, Hrušková Z, Jeyabalan A, Karras A, King C, Kohli HS, Maas R, Mayer G, Moiseev S, Muto M, Odler B, Pepper RJ, Quintana LF, Radhakrishnan J, Ramachandran R, Salama AD, Segelmark M, Tesař V, Wetzels J, Willcocks L, Windpessl M, Zand L, Zonozi R, Kronbichler A. Rituximab in adult minimal change disease and focal segmental glomerulosclerosis - What is known and what is still unknown? Autoimmun Rev 2020; 19:102671. [PMID: 32942039 DOI: 10.1016/j.autrev.2020.102671] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/06/2020] [Indexed: 02/07/2023]
Abstract
Primary forms of minimal change disease and focal segmental glomerulosclerosis are rare podocytopathies and clinically characterized by nephrotic syndrome. Glucocorticoids are the cornerstone of the initial immunosuppressive treatment in these two entities. Especially among adults with minimal change disease or focal segmental glomerulosclerosis, relapses, steroid dependence or resistance are common and necessitate re-initiation of steroids and other immunosuppressants. Effective steroid-sparing therapies and introduction of less toxic immunosuppressive agents are urgently needed to reduce undesirable side effects, in particular for patients whose disease course is complex. Rituximab, a B cell depleting monoclonal antibody, is increasingly used off-label in these circumstances, despite a low level of evidence for adult patients. Hence, critical questions concerning drug-safety, long-term efficacy and the optimal regimen for rituximab-treatment remain unanswered. Evidence in the form of large, multicenter studies and randomized controlled trials are urgently needed to overcome these limitations.
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Affiliation(s)
- Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; Division of Pediatric Nephrology, Severance Children's Hospital, Seoul 03722, Republic of Korea; Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Federico Alberici
- Nephrology Unit, ASST Spedali Civili di Brescia, Brescia, Italy; Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Vincent Audard
- Department of Nephrology and Transplantation, Rare French Disease Centre "Idiopathic Nephrotic syndrome", Henri-Mondor/Albert-Chenevier Hospital Assistance Publique-Hôpitaux de Paris, Inserm U955, Team 21, Paris-East University, 94000 Créteil, France
| | - Annette Bruchfeld
- Department of Renal Medicine, CLINTEC, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Martin Busch
- Department of Internal Medicine III, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany
| | - Chee Kay Cheung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom; John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Matija Crnogorac
- Department of Nephrology and Dialysis, Dubrava University Hospital, Avenija Gojka Suska 6, 10 000 Zagreb, Croatia
| | - Elisa Delbarba
- Department of Nephrology, University of Brescia, Hospital of Montichiari, Brescia, Italy
| | - Kathrin Eller
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Centre Hospitalier Universitaire de Toulouse, 31000 Toulouse, France; Institut National de la Santé et de la Recherche Médicale, U1048 (Institut des Maladies Cardiovasculaires et Métaboliques-équipe 12), 31000 Toulouse, France
| | - Kresimir Galesic
- Department of Nephrology and Dialysis, Dubrava University Hospital, Avenija Gojka Suska 6, 10 000 Zagreb, Croatia
| | - Siân Griffin
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, UK
| | - Zdenka Hrušková
- Department of Nephrology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Anushya Jeyabalan
- Division of Nephrology, Columbia University Medical Center, NY, New York, USA
| | - Alexandre Karras
- Service de Néphrologie, Hôpital Européen-Georges Pompidou, Assistance Publique des Hôpitaux de Paris, 75015 Paris, France
| | - Catherine King
- Centre for Translational Inflammation Research University of Birmingham Research Laboratories, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Harbir Singh Kohli
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rutger Maas
- Department of Nephrology, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, Netherlands
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Masahiro Muto
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Balazs Odler
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ruth J Pepper
- University College London Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Luis F Quintana
- Department of Nephrology and Renal Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), Department of Medicine, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Jai Radhakrishnan
- Division of Nephrology, Columbia University Medical Center, NY, New York, USA
| | - Raja Ramachandran
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Alan D Salama
- University College London Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Mårten Segelmark
- Department of Clinical Sciences Lund, University, Skane University Hospital, Nephrology Lund, Lund, Sweden
| | - Vladimír Tesař
- Department of Nephrology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, PO Box 9101, 6500, HB, Nijmegen, Netherlands
| | - Lisa Willcocks
- Department of Renal Medicine, Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Reza Zonozi
- Division of Nephrology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, 101 Merrimac Street, Boston, MA 02114, USA
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria.
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13
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Van den Berge BT, Maas RJ. Nephron Number as Predictor of Corticosteroid Response in Adult Minimal Change Disease. Kidney Med 2020; 2:520-522. [PMID: 33090125 PMCID: PMC7568060 DOI: 10.1016/j.xkme.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Bartholomeus T Van den Berge
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands.,Department of Pathology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rutger J Maas
- Department of Nephrology, Radboud University Medical Center, Nijmegen, the Netherlands
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14
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Abstract
Podocytopathies are kidney diseases in which direct or indirect podocyte injury drives proteinuria or nephrotic syndrome. In children and young adults, genetic variants in >50 podocyte-expressed genes, syndromal non-podocyte-specific genes and phenocopies with other underlying genetic abnormalities cause podocytopathies associated with steroid-resistant nephrotic syndrome or severe proteinuria. A variety of genetic variants likely contribute to disease development. Among genes with non-Mendelian inheritance, variants in APOL1 have the largest effect size. In addition to genetic variants, environmental triggers such as immune-related, infection-related, toxic and haemodynamic factors and obesity are also important causes of podocyte injury and frequently combine to cause various degrees of proteinuria in children and adults. Typical manifestations on kidney biopsy are minimal change lesions and focal segmental glomerulosclerosis lesions. Standard treatment for primary podocytopathies manifesting with focal segmental glomerulosclerosis lesions includes glucocorticoids and other immunosuppressive drugs; individuals not responding with a resolution of proteinuria have a poor renal prognosis. Renin-angiotensin system antagonists help to control proteinuria and slow the progression of fibrosis. Symptomatic management may include the use of diuretics, statins, infection prophylaxis and anticoagulation. This Primer discusses a shift in paradigm from patient stratification based on kidney biopsy findings towards personalized management based on clinical, morphological and genetic data as well as pathophysiological understanding.
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15
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Lee ACH, Riedl M, Frommer L, Diana T, Kahaly GJ. Systemic safety analysis of mycophenolate in Graves' orbitopathy. J Endocrinol Invest 2020; 43:767-777. [PMID: 31834613 DOI: 10.1007/s40618-019-01161-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE The dual antiproliferative mechanism of mycophenolate appears to be beneficial in Graves' orbitopathy (GO). METHODS Safety data from the two published mycophenolate trials and the original database of the European Group on Graves' Orbitopathy (EUGOGO) trial were systematically analyzed. Treatment efficacy stratified by individual visual parameters of activity and severity were compared. RESULTS A total of 129 adverse events (AE) involving 50 patients (29.4%) were noted among all mycophenolate-treated patients. Mycophenolate sodium plus intravenous glucocorticoid (MPS + GC) group of the EUGOGO trial recorded significantly more AE (55.4% versus 4.6% of patients affected) and serious adverse events (SAE) (12.5% versus 0%) than mycophenolate mofetil (MMF) group of the Chinese trial. None of those SAE was side effect (SE). Most SE in MPS + GC group were mild. Gastrointestinal disorders, infection and liver dysfunction affected 8.8%, 7.1% and 1.2% of all mycophenolate-treated patients (versus 5.4%, 5.4% and 1.2% of all patients on GC monotherapy, respectively). MPS + GC did not significantly increase the risk of infection or liver dysfunction when compared to GC monotherapy. No cytopenia, serious infection or treatment-related mortality was reported. The much higher AE rates of mycophenolate trials in other autoimmune diseases or transplantations suggested that major mycophenolate toxicities were mostly dose- and duration dependent. Mycophenolate, either as monotherapy or as combination, achieved better overall response than GC monotherapy. CONCLUSION The risk-benefit ratio of low-dose mycophenolate treatment in active moderate-to-severe GO is highly favorable given its reassuring safety profile with low rate of mild-to-moderate SE and promising efficacy.
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Affiliation(s)
- A C H Lee
- Department of Medicine I, Johannes-Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - M Riedl
- Department of Medicine I, Johannes-Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - L Frommer
- Department of Medicine I, Johannes-Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - T Diana
- Department of Medicine I, Johannes-Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany
| | - G J Kahaly
- Department of Medicine I, Johannes-Gutenberg University Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany.
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16
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Colliou E, Karras A, Boffa JJ, Ribes D, Garrouste C, Quintrec ML, Daugas E, Huart A, Ducloux D, Hummel A, Ferrandiz I, Demoulin N, Jourde-Chiche N, Chauveau D, Audard V, Faguer S. Outcomes of Older Patients (≥60 years) with New-Onset Idiopathic Nephrotic Syndrome Receiving Immunosuppressive Regimen: A Multicentre Study of 116 Patients. J Clin Med 2019; 8:jcm8030298. [PMID: 30832362 PMCID: PMC6463053 DOI: 10.3390/jcm8030298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/20/2019] [Accepted: 02/26/2019] [Indexed: 12/29/2022] Open
Abstract
Because of its rarity, renal presentation and outcomes of idiopathic nephrotic syndrome (INS; minimal changes disease or focal and segmental glomerulosclerosis) has poorly been described in elderly patients, precluding an individualized therapy procedure. Whether immunosuppressive regimens formerly designed in children and young adults are safe and efficient in elderly remains elusive. In a large multicentric retrospective study that included 116 patients with INS and onset ≥ 60 years of age, we showed that cumulative incidence of renal response was 95% after frontline therapy, with an age-dependent median time-to-response (60 days before 70 years of age at the onset vs. 120 days after; p = 0.03). Cumulative incidence of relapse was 90% at 7 years, with relapse occurring continuously over time. After a median follow-up of 34 months (IQR (12; 57)), 7 patients had died (6%) and 5 reached end-stage renal disease. Complications were highly prevalent: diabetes mellitus (23.3%), hypertension (24.1%), infection requiring hospitalization (21.6%) and acute kidney injury (9.5%). Thus, in older patients with INS and receiving steroids, renal response is delayed and relapse is the rule. Alternative immunosuppressive regimens, including B-cells depleting agents as frontline therapy, should be tested in this subset of patients to improve the mid- to long-term outcomes.
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Affiliation(s)
- Eloïse Colliou
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Centre Hospitalier Universitaire de Toulouse, 31000 Toulouse, France.
| | - Alexandre Karras
- Service de Néphrologie, Hôpital Européen-Georges Pompidou, Assistance Publique des Hôpitaux de Paris, 75015 Paris, France.
| | - Jean-Jacques Boffa
- Service de Néphrologie, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, 75020 Paris, France.
| | - David Ribes
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Centre Hospitalier Universitaire de Toulouse, 31000 Toulouse, France.
| | - Cyril Garrouste
- Service de Néphrologie et Transplantation Rénale, Centre Hospitalier Universitaire de Clermont-Ferrand, 63000 Clermont-Ferrand, France.
| | - Moglie Le Quintrec
- Service de Néphrologie et Transplantation Rénale, Centre Hospitalier Universitaire de Montpellier, 34000 Montpellier, France.
| | - Eric Daugas
- Service de Néphrologie et Transplantation Rénale, Hôpital Bichat, Assistance Publique des Hôpitaux de Paris, 75018 Paris, France.
| | - Antoine Huart
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Centre Hospitalier Universitaire de Toulouse, 31000 Toulouse, France.
| | - Didier Ducloux
- Service de Néphrologie et Transplantation Rénale, Centre Hospitalier Universitaire de Besançon, 25000 Besançon, France.
| | - Aurélie Hummel
- Service de Néphrologie-Dialyse, Hôpital Necker, Assistance Publique des Hôpitaux de Paris, 75015 Paris, France.
| | - Inès Ferrandiz
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Centre Hospitalier Universitaire de Toulouse, 31000 Toulouse, France.
| | - Nathalie Demoulin
- Département de Néphrologie, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1348 Louvain, Belgique.
| | - Noémie Jourde-Chiche
- Université d'Aix-Marseille C2VN, INSERM 1263, INRA 1260; AP-HM, Centre de Néphrologie et Transplantation rénale, 13000 Marseille, France.
| | - Dominique Chauveau
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Centre Hospitalier Universitaire de Toulouse, 31000 Toulouse, France.
- Institut National de la Santé et de la Recherche Médicale, U1048 (Institut des Maladies Cardiovasculaires et Métaboliques-équipe 12), 31000 Toulouse, France.
| | - Vincent Audard
- Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Hôpital Mondor, Assistance Publique des Hôpitaux de Paris, Université Paris-Est Créteil (UPEC), INSERM U955, équipe 21, 94000 Créteil, France.
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Centre Hospitalier Universitaire de Toulouse, 31000 Toulouse, France.
- Institut National de la Santé et de la Recherche Médicale, U1048 (Institut des Maladies Cardiovasculaires et Métaboliques-équipe 12), 31000 Toulouse, France.
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