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Li X, Shen Y, Li Y, Ma L, Sun Q. Clinicopathological characteristics and outcomes of PLA2R related idiopathic membranous nephropathy in patients with seronegative PLA2R antibodies. Ren Fail 2024; 46:2297015. [PMID: 38275176 PMCID: PMC10823883 DOI: 10.1080/0886022x.2023.2297015] [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: 08/31/2023] [Accepted: 12/14/2023] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) with deposits of phospholipase A2 receptor (PLA2R) antigen in glomerular tissue (GAg+) but no circulating serum PLA2R antibody (SAb-) has been reported. However, little is known about the clinicopathological characteristics and prognosis of this subtype. METHODS A total of 74 IMN patients with GAg + identified by kidney biopsy were enrolled in this study. We categorized patients into two groups based on the presence or absence of serum PLA2R antibody. Data on clinical features, pathological features, and outcomes were collected. Kaplan-Meier analysis of complete remission (CR) and partial remission (PR) comparing SAb-/GAg + and SAb+/GAg + patients. Cox proportional hazards models was used to examine factors associated with CR and PR. RESULTS Among 74 IMN patients, 14 were SAb-/GAg+. Compared with SAb+/GAg + patients, SAb-/GAg + patients presented with higher levels of albumin, lower levels of cholesterol and low density lipoprotein cholesterol (all p < .01), but similar pathological manifestations of kidney biopsy. Multivariate logistic analyses indicated that low albumin (0.79 [95%CI: 0.66-0.95], p = .01) and high cholesterol (1.81 [95%CI: 1.02-3.19], p = .04) were correlated with seropositivity of PLA2R antibody. SAb-/GAg + patients exhibited a significantly higher probability of CR (p = .03) than patients who were SAb+/GAg+. However, no difference was found in the PR rate. Cox regression analyses showed that compared to SAb+/GAg + patients, SAb-/GAg + was more predictive of complete remission (4.28 [95%CI: 1.01-18.17], p = .04). CONCLUSION IMN with PLA2R staining on kidney biopsy but without serum PLA2R antibody has milder clinical manifestations and a better prognosis.
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Affiliation(s)
- Xue Li
- Division of Nephrology, Department of Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yang Shen
- Division of Nephrology, Department of Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Yanchun Li
- Division of Nephrology, Department of Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Lijie Ma
- Division of Nephrology, Department of Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Qianmei Sun
- Division of Nephrology, Department of Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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Wang M, Yang J, Fang X, Lin W, Yang Y. Membranous nephropathy: pathogenesis and treatments. MedComm (Beijing) 2024; 5:e614. [PMID: 38948114 PMCID: PMC11214595 DOI: 10.1002/mco2.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 07/02/2024] Open
Abstract
Membranous nephropathy (MN), an autoimmune disease, can manifest at any age and is among the most common causes of nephrotic syndrome in adults. In 80% of cases, the specific etiology of MN remains unknown, while the remaining cases are linked to drug use or underlying conditions like systemic lupus erythematosus, hepatitis B virus, or malignancy. Although about one-third of patients may achieve spontaneous complete or partial remission with conservative management, another third face an elevated risk of disease progression, potentially leading to end-stage renal disease within 10 years. The identification of phospholipase A2 receptor as the primary target antigen in MN has brought about a significant shift in disease management and monitoring. This review explores recent advancements in the pathophysiology of MN, encompassing pathogenesis, clinical presentations, diagnostic criteria, treatment options, and prognosis, with a focus on emerging developments in pathogenesis and therapeutic strategies aimed at halting disease progression. By synthesizing the latest research findings and clinical insights, this review seeks to contribute to the ongoing efforts to enhance our understanding and management of this challenging autoimmune disorder.
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Affiliation(s)
- Mengqiong Wang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Jingjuan Yang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Xin Fang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Weiqiang Lin
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Yi Yang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
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3
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Zhang X, Dou J, Gao G, Sheng X, Shen Y, Feng Y, Wu X, Zhang Z, Cheng G. Comparison of tacrolimus with or without prednisone therapy in primary membranous nephropathy: a retrospective clinical study. Sci Rep 2024; 14:14214. [PMID: 38902302 PMCID: PMC11190188 DOI: 10.1038/s41598-024-64661-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/11/2024] [Indexed: 06/22/2024] Open
Abstract
Previous studies showed tacrolimus monotherapy and dual therapy with tacrolimus and prednisone as effective treatment modalities in managing membranous nephropathy. However, few studies have compared these therapeutic regimens. The patients were divided into two groups based on the treatment regimen: (1) tacrolimus and prednisone dual therapy (T + P group, n = 67) treatment group; and (2) tacrolimus monotherapy (T group, n = 65) or the control group. Propensity matching method and subgroup analysis to eliminate the bias in the relationship between the treatment regimen and the outcomes. The mean remission times were 20.33 ± 2.75 weeks at T group and 9.50 ± 1.81 weeks at T + P group. The T group had a remission rates of 73.33, 76.66 and 66.66% at 12weeks, 24weeks and 48weeks, while the T + P group had a remission rate of 81.66, 86.66, 91.66%; At the follow-up of 48 weeks, the relapse rate for the T group was 21.66%, and that for the T + P group was 5%. The anti-PLA2R ab is positive and therapy may be the independent risk factors for predicting remission. Tacrolimus and low-dose prednisone dual therapy is efficacious in managing MN and lowers the recurrence rate in clinical practice.
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Affiliation(s)
- Xinyue Zhang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingyu Dou
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ge Gao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaoxiao Sheng
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ya Shen
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuhua Feng
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xueying Wu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhen Zhang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Genyang Cheng
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.
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Hullekes F, Uffing A, Verhoeff R, Seeger H, von Moos S, Mansur J, Mastroianni-Kirsztajn G, Silva HT, Buxeda A, Pérez-Sáez MJ, Arias-Cabrales C, Collins AB, Swett C, Morená L, Loucaidou M, Kousios A, Malvezzi P, Bugnazet M, Russo LS, Muhsin SA, Agrawal N, Nissaisorakarn P, Patel H, Al Jurdi A, Akalin E, Neto ED, Agena F, Ventura C, Manfro RC, Bauer AC, Mazzali M, de Sousa MV, La Manna G, Bini C, Comai G, Reindl-Schwaighofer R, Berger S, Cravedi P, Riella LV. Recurrence of membranous nephropathy after kidney transplantation: A multicenter retrospective cohort study. Am J Transplant 2024; 24:1016-1026. [PMID: 38341027 DOI: 10.1016/j.ajt.2024.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
Membranous nephropathy (MN) is a leading cause of kidney failure worldwide and frequently recurs after transplant. Available data originated from small retrospective cohort studies or registry analyses; therefore, uncertainties remain on risk factors for MN recurrence and response to therapy. Within the Post-Transplant Glomerular Disease Consortium, we conducted a retrospective multicenter cohort study examining the MN recurrence rate, risk factors, and response to treatment. This study screened 22,921 patients across 3 continents and included 194 patients who underwent a kidney transplant due to biopsy-proven MN. The cumulative incidence of MN recurrence was 31% at 10 years posttransplant. Patients with a faster progression toward end-stage kidney disease were at higher risk of developing recurrent MN (hazard ratio [HR], 0.55 per decade; 95% confidence interval [CI], 0.35-0.88). Moreover, elevated pretransplant levels of anti-phospholipase A2 receptor (PLA2R) antibodies were strongly associated with recurrence (HR, 18.58; 95% CI, 5.37-64.27). Patients receiving rituximab for MN recurrence had a higher likelihood of achieving remission than patients receiving renin-angiotensin-aldosterone system inhibition alone. In sum, MN recurs in one-third of patients posttransplant, and measurement of serum anti-PLA2R antibody levels shortly before transplant could aid in risk-stratifying patients for MN recurrence. Moreover, patients receiving rituximab had a higher rate of treatment response.
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Affiliation(s)
- Frank Hullekes
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Groningen Transplant Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Audrey Uffing
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Groningen Transplant Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Rucháma Verhoeff
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Surgery, Erasmus Medical Center Transplant Institute, Erasmus University, Rotterdam, The Netherlands
| | - Harald Seeger
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Seraina von Moos
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | - Juliana Mansur
- Division of Nephrology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | | | | | - Anna Buxeda
- Division of Nephrology, Hospital del Mar, Barcelona, Spain
| | | | | | - A Bernard Collins
- Renal Pathology, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christie Swett
- Renal Pathology, Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Leela Morená
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Paolo Malvezzi
- Department of Nephrology, Dialysis, Apheresis and Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Mathilde Bugnazet
- Department of Nephrology, Dialysis, Apheresis and Transplantation, CHU Grenoble Alpes, Grenoble, France
| | - Luis Sanchez Russo
- Translational Transplant Research Center, Renal Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Saif A Muhsin
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikhil Agrawal
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Pitchaphon Nissaisorakarn
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Het Patel
- Division of Nephrology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ayman Al Jurdi
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Enver Akalin
- Einstein/Montefiore Transplant Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Elias David Neto
- Renal Transplant Service, Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Fabiana Agena
- Renal Transplant Service, Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Carlucci Ventura
- Renal Transplant Service, Division of Nephrology, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Roberto C Manfro
- Division of Nephrology, Hospital de clínicas de Porto Alegre/Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Andrea Carla Bauer
- Division of Nephrology, Hospital de clínicas de Porto Alegre/Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Marilda Mazzali
- Division of Nephrology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | | | - Gaetano La Manna
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Claudia Bini
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Giorgia Comai
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Stefan Berger
- Groningen Transplant Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Paolo Cravedi
- Translational Transplant Research Center, Renal Division, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Leonardo V Riella
- Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Nephrology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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5
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Ren W, Sun J, Zhang L, He W, Guo Z, Bian Q. Significance of the total renal chronicity score in predicting renal outcome in PLA2R-associated membranous nephropathy. J Nephrol 2024; 37:1051-1061. [PMID: 38512370 DOI: 10.1007/s40620-024-01893-z] [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: 07/09/2023] [Accepted: 01/07/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Phospholipase A2 receptor (PLA2R)-associated membranous nephropathy accounts for the majority of membranous nephropathy; however, few studies have determined the prognostic impact and clinical application of renal pathologic change on this disease. METHODS A retrospective cohort study of 262 patients with PLA2R-associated membranous nephropathy was conducted. The total renal chronicity score calculated according to the degree of glomerulosclerosis, interstitial fibrosis, tubular atrophy, and arteriosclerosis was applied to evaluate renal chronicity. Baseline bias was adjusted by inverse probability weight when assessing the prognostic impact of chronicity, and multiple parameters were used to evaluate the application value of renal chronicity. RESULTS During a median follow-up of 24.5 months, renal outcome (kidney function deterioration and/or end-stage kidney disease) was observed in 22 (8.40%) patients. Not only did a higher total renal chronicity score independently predict renal outcome [odds ratio (OR): 1.562, 95% confidence interval (CI) 1.073-2.273, P = 0.020], but non-minimal chronicity was also an independent risk factor for renal outcome (OR: 3.170, 95% CI 1.040-9.659, P = 0.042). Moreover, the membranous nephropathy risk classification in the Kidney Disease: Improving Global Outcomes (KDIGO) guideline integrated with non-minimal chronicity showed improvements in categorical net reclassification (0.174, 95% CI 0.012-0.335, P = 0.035), continuous net reclassification (0.462, 95% CI 0.087-0.838, P = 0.016), and integrated discrimination (0.019, 95% CI 0.003-0.035, P = 0.020) compared to the original classification. CONCLUSIONS Renal chronicity is closely associated with renal outcomes in PLA2R-associated membranous nephropathy, and combining the KDIGO risk classification with chronicity scores may provide a more accurate prognostic prediction.
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Affiliation(s)
- Weifu Ren
- Department of Nephrology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jing Sun
- Department of Nephrology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lingyan Zhang
- Department of Nephrology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Wei He
- Department of Nephrology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zhiyong Guo
- Department of Nephrology, Changhai Hospital, Naval Medical University, Shanghai, China.
| | - Qi Bian
- Department of Nephrology, Changhai Hospital, Naval Medical University, Shanghai, China.
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6
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Andeen NK, Hou J. Diagnostic Challenges and Emerging Pathogeneses of Selected Glomerulopathies. Pediatr Dev Pathol 2024:10935266241237656. [PMID: 38576387 DOI: 10.1177/10935266241237656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Recent progress in glomerular immune complex and complement-mediated diseases have refined diagnostic categories and informed mechanistic understanding of disease development in pediatric patients. Herein, we discuss selected advances in 3 categories. First, membranous nephropathy antigens are increasingly utilized to characterize disease in pediatric patients and include phospholipase A2 receptor (PLA2R), Semaphorin 3B (Sema3B), neural epidermal growth factor-like 1 (NELL1), and protocadherin FAT1, as well as the lupus membranous-associated antigens exostosin 1/2 (EXT1/2), neural cell adhesion molecule 1 (NCAM1), and transforming growth factor beta receptor 3 (TGFBR3). Second, we examine advances in techniques for paraffin and light chain immunofluorescence (IF), including the former's function as a salvage technique and their necessity for diagnosis in adolescent cases of membranous-like glomerulopathy with masked IgG kappa deposits (MGMID) and proliferative glomerulonephritis with monotypic Ig deposits (PGNMID), respectively. Finally, progress in understanding the roles of complement in pediatric glomerular disease is reviewed, with specific attention to overlapping clinical, histologic, and genetic or functional alternative complement pathway (AP) abnormalities among C3 glomerulopathy (C3G), infection-related and post-infectious GN, "atypical" post-infectious GN, immune complex mediated membranoproliferative glomerulonephritis (IC-MPGN), and atypical hemolytic uremic syndrome (aHUS).
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Affiliation(s)
- Nicole K Andeen
- Oregon Health & Science University, Department of Pathology and Laboratory Medicine, Portland, OR, USA
| | - Jean Hou
- Cedars-Sinai Medical Center, Department of Pathology, Los Angeles, CA, USA
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Sethi S, Fervenza FC. Membranous nephropathy-diagnosis and identification of target antigens. Nephrol Dial Transplant 2024; 39:600-606. [PMID: 37863839 DOI: 10.1093/ndt/gfad227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Indexed: 10/22/2023] Open
Abstract
Membranous nephropathy (MN) is a common cause of nephrotic syndrome in adults. MN is characterized by subepithelial accumulation of immune complexes along the glomerular basement membrane. The immune complexes are composed of immunoglobulin G and a target antigen. PLA2R is the target antigen in approximately 60% of MN cases, and MN is traditionally classified as PLA2R-positive or PLA2R-negative MN. Over the last 7 years, additional target antigens have been identified, which have specific disease associations, distinctive clinical and pathologic findings, and therapeutic implications. The newly discovered target antigens include NELL1, EXT1/EXT2, NCAM1, SEMA3B, PCDH7, FAT1, CNTN1, NTNG1, PCSK6 and NDNF. To group all these antigens into a generic 'PLA2R-negative' MN group is imprecise and un-informative. We propose a logical approach for detection of the target antigen which includes (i) currently available serology-based testing to detect anti-PLA2R and anti-THSD7A antibodies; and (ii) kidney biopsy testing to detect the target antigens. Determination of the antigen on kidney biopsy can be done by immunohistochemistry or immunofluorescence studies. Alternatively, laser capture microdissection (LCM) of glomeruli followed by mass spectrometry (MS) can be used to identify a target antigen. LCM/MS has the advantage of being a one-stop test and is particularly useful for detection of rare target antigens. At the current time, while it is possible to detect the newer antigens by immunohistochemistry/immunofluorescence/LCM/MS, serology-based tests to detect serum antibodies to the new antigens are not yet available. It is critical that serology-based tests should be developed not just for accurate diagnosis, but as a guide for treatment. We review the current methodology and propose an algorithm for diagnosis and detection of target antigens in MN that may shape the current practice in the future. Membranous nephropathy (MN) results from accumulation of subepithelial immune complexes along the glomerular basement membrane.PLA2R is the most common target antigen, but newly discovered target antigens have filled the void of PLA2R-negative MN.MN associated with the newly discovered target antigens have distinctive clinical and pathologic findings, treatment and prognostic implications. These include NELL1, EXT1/EXT2, NCAM1, PCDH7, SEMA3B, CNTN1, FAT1, NDNF and PCSK6.Immunohistochemistry/immunofluorescence methodology is currently in use for detecting target antigens in kidney biopsy tissue, although we anticipate laser capture microdissection of glomeruli followed by mass spectrometry will become available soon.Serologic testing is currently available for only detecting antibodies to PLA2R and THSD7A. It is critical that serologic tests become available for detecting antibodies to the newly discovered antigens.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Radhakrishnan Y, Zand L, Sethi S, Fervenza FC. Membranous nephropathy treatment standard. Nephrol Dial Transplant 2024; 39:403-413. [PMID: 37934599 DOI: 10.1093/ndt/gfad225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Indexed: 11/09/2023] Open
Abstract
Membranous nephropathy (MN) is characterized by deposition of immune complexes leading to thickening of glomerular basement membranes. Over time, the understanding of MN has evolved, with the identification of specific autoantibodies against novel podocyte antigens and the unraveling of intricate pathogenic pathways. Although the anti-CD20 monoclonal antibody rituximab is favored as part of the initial therapy in MN, a subgroup of MN patients may be resistant to rituximab necessitating the use of alternative agents such as cytotoxic therapies. In addition, newer agents such as novel anti-CD20 monoclonal antibodies, therapies targeting the CD38-positive plasma cells and anti-complement therapy are being studied in patients who are resistant to traditional treatment strategies. This manuscript furnishes a review of the novel developments in the pathophysiology of MN including the identification of target antigens and current treatment standards for MN, concentrating on evidenced-based interventions designed to attain remission and to prevent disease progression.
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Affiliation(s)
- Yeshwanter Radhakrishnan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ladan Zand
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sanjeev Sethi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Lu S, Xiao J, Liu D, Zhang Y, Dong Y, Zhao Z. Diagnostic value of renal biopsy in anti-phospholipase A2 receptor antibody-positive patients with proteinuria in China. Sci Rep 2024; 14:2907. [PMID: 38316889 PMCID: PMC10844597 DOI: 10.1038/s41598-024-53445-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 01/31/2024] [Indexed: 02/07/2024] Open
Abstract
Renal biopsy remains the gold standard for diagnosing membranous nephropathy (MN). Recent studies have suggested that renal biopsy can be replaced with the serum phospholipase A2 receptor (PLA2R) antibody test for MN diagnosis in patients with nephrotic syndrome. However, this test has not been validated in the Chinese population. In this study, we investigated whether renal biopsy provides additional diagnostic information on patients with proteinuria who are seropositive for PLA2R antibodies (SAb +). We retrospectively reviewed the clinicopathological characteristics of SAb + adult patients (aged ≥ 18 years) with proteinuria (≥ 0.5 g/24 h) assessed at the Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, from June 2021 to March 2022. Among a total of 801 SAb + patients who received renal biopsy, those with incomplete pathological data, diabetes or any potential cause of secondary MN were excluded. Among the 491 remaining patients, 474 had primary MN (PMN), 16 had atypical MN (AMN, 9 patients with "full house" and 2 patients with HBsAg + /HBcAg + immunofluorescence results), and 1 had focal segmental glomerulosclerosis. In patients with an eGFR of ≥ 60 mL/min/1.73 m2 (n = 451), 436 had PMN, and 71 (16.3%) exhibited additional biopsy findings, with obesity-related glomerulopathy being the most common. In patients with an impaired eGFR (n = 40), 38 had PMN, and 31 (81.6%) showed additional findings, with acute tubular injury being the most common. In conclusion, anti-PLA2R antibody positivity is highly predictive of PMN in Chinese adults but often coexists with other pathological diagnoses. The advantages of renal biopsy for detecting other pathologies should be weighed against the potential risks of the biopsy procedure.
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Affiliation(s)
- Shan Lu
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China.
| | - Jing Xiao
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China
| | - Dong Liu
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China
| | - Yan Zhang
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China
| | - Yijun Dong
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China
| | - Zhanzheng Zhao
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China
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10
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Wang B, Fu YQ, Xie LJ, Cao JY, Yang M, Li M, Chen TL, Zhang XL, Luo Q, Lv LL, Liu BC. Measurement of urinary exosomal phospholipase A2 receptor is a sensitive method for diagnosis of PLA2R-associated membranous nephropathy. Clin Kidney J 2024; 17:sfad191. [PMID: 38186888 PMCID: PMC10768785 DOI: 10.1093/ckj/sfad191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Indexed: 01/09/2024] Open
Abstract
Background The discovery of phospholipase A2 receptor (PLA2R) and its antibody (aPLA2Rab) has paved the way for diagnosing PLA2R-associated membranous nephropathy (PLA2R-MN) with a high specificity of 98%. However, the sensitivity was only 40% to 83.9%, and there is ongoing discussion around determining the optimal threshold for diagnosis. Recent advancements in the use of exosomes, a novel form of "liquid biopsy," have shown great promise in identifying markers for various medical conditions. Methods Protein mass spectrometry and western blot were applied to verify the existence of PLA2R antigen in the urine exosome. We then evaluated the efficacy of urinary exosomal PLA2R antigen alone or combined with serum aPLA2Rab level to diagnose PLA2R-MN. Results The urinary exosomes contained a high abundance of PLA2R antigen as evidenced by protein mass spectrometry and western blot in 85 PLA2R-MN patients vs the disease controls (14 secondary MN patients, 22 non-MN patients and 4 PLA2R-negative MN patients) and 20 healthy controls. Of note, urinary exosomal PLA2R antigen abundance also had a good consistency with the PLA2R antigen level in the renal specimens of PLA2R-MN patients. The sensitivity of urinary exosomal PLA2R for diagnosing PLA2R-MN reached 95.4%, whereas the specificity was 63.3%. Combining detection of the urinary exosomal PLA2R and serum aPLA2Rab could develop a more sensitive diagnostic method for PLA2R-MN, especially for patients with serum aPLA2Rab ranging from 2 to 20 RU/mL. Conclusions Measurement of urinary exosomal PLA2R could be a sensitive method for the diagnosis of PLA2R-MN.
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Affiliation(s)
- Bin Wang
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Yu-Qi Fu
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Li-jun Xie
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Jin-Yuan Cao
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
- Department of Nephrology, Fifth Affiliated Hospital of Nantong University, Taizhou, China
| | - Min Yang
- Department of Nephrology, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Min Li
- Department of Nephrology, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Tian-Lei Chen
- Department of Nephrology, the Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiao-Liang Zhang
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Qian Luo
- Bionic Sensing and Intelligence Center, Institute of Biomedical and Health Engineering, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Lin-Li Lv
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
| | - Bi-Cheng Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University School of Medicine, Nanjing, Jiangsu, China
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11
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Sethi S, Beck LH, Glassock RJ, Haas M, De Vriese AS, Caza TN, Hoxha E, Lambeau G, Tomas NM, Madden B, Debiec H, D'Agati VD, Alexander MP, Amer H, Appel GB, Barbour SJ, Caravaca-Fontan F, Cattran DC, Casal Moura M, D'Avila DO, Eick RG, Garovic VD, Greene EL, Herrera Hernandez LP, Jennette JC, Lieske JC, Markowitz GS, Nath KA, Nasr SH, Nast CC, Pani A, Praga M, Remuzzi G, Rennke HG, Ruggenenti P, Roccatello D, Soler MJ, Specks U, Stahl RAK, Singh RD, Theis JD, Velosa JA, Wetzels JFM, Winearls CG, Yandian F, Zand L, Ronco P, Fervenza FC. Mayo Clinic consensus report on membranous nephropathy: proposal for a novel classification. Kidney Int 2023; 104:1092-1102. [PMID: 37795587 DOI: 10.1016/j.kint.2023.06.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 10/06/2023]
Abstract
Membranous nephropathy (MN) is a pattern of injury caused by autoantibodies binding to specific target antigens, with accumulation of immune complexes along the subepithelial region of glomerular basement membranes. The past 20 years have brought revolutionary advances in the understanding of MN, particularly via the discovery of novel target antigens and their respective autoantibodies. These discoveries have challenged the traditional classification of MN into primary and secondary forms. At least 14 target antigens have been identified, accounting for 80%-90% of cases of MN. Many of the forms of MN associated with these novel MN target antigens have distinctive clinical and pathologic phenotypes. The Mayo Clinic consensus report on MN proposes a 2-step classification of MN. The first step, when possible, is identification of the target antigen, based on a multistep algorithm and using a combination of serology, staining of the kidney biopsy tissue by immunofluorescence or immunohistochemistry, and/or mass spectrometry methodology. The second step is the search for a potential underlying disease or associated condition, which is particularly relevant when knowledge of the target antigen is available to direct it. The meeting acknowledges that the resources and equipment required to perform the proposed testing may not be generally available. However, the meeting consensus was that the time has come to adopt an antigen-based classification of MN because this approach will allow for accurate and specific MN diagnosis, with significant implications for patient management and targeted treatment.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Laurence H Beck
- Section of Nephrology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California, USA
| | - Mark Haas
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
| | | | - Elion Hoxha
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gérard Lambeau
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, Valbonne Sophia Antipolis, France
| | - Nicola M Tomas
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Madden
- Mayo Clinic Proteomics Core, Mayo Clinic, Rochester, Minnesota, USA
| | - Hanna Debiec
- Sorbonne Université, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Paris, France
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Gerald B Appel
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fernando Caravaca-Fontan
- Department of Medicine, Complutense University, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Daniel C Cattran
- Toronto General Research Institute, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Marta Casal Moura
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Domingos O D'Avila
- Serviço de Nefrologia, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Renato G Eick
- Serviço de Nefrologia, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Eddie L Greene
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | | | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Karl A Nath
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cynthia C Nast
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Antonello Pani
- Nephrology, Dialysis and Transplantation, Arnas Brotzu, Cagliari, Italy; Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Manuel Praga
- Department of Medicine, Complutense University, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Helmut G Rennke
- Department of Pathology, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; Unit of Nephrology, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy; Center of Immuno-Rheumatology and Rare Diseases (CMID), Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Maria Jose Soler
- Department of Nephrology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, Barcelona, Spain; Centro de Referencia en Enfermedad, Glomerular Compleja del Sistema Nacional de Salud de España (CSUR), Barcelona, Spain
| | - Ulrich Specks
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rolf A K Stahl
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raman Deep Singh
- Renal Pathophysiology Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jorge A Velosa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack F M Wetzels
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Federico Yandian
- Department of Nephrology, Hospital de Clinicas Universidad de la Republica, Montevideo, Uruguay
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Pierre Ronco
- Sorbonne Université, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Paris, France; Division of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.
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12
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Hou X, Tian C, Liu W, Li Y, Li W, Wang Z. Construction of artificial intelligence non-invasive diagnosis model for common glomerular diseases based on hyperspectral and urine analysis. Photodiagnosis Photodyn Ther 2023; 44:103736. [PMID: 37597684 DOI: 10.1016/j.pdpdt.2023.103736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/26/2023] [Accepted: 08/04/2023] [Indexed: 08/21/2023]
Abstract
OBJECTIVE To develop a non-invasive fluid biopsy assisted diagnosis model for glomerular diseases based on hyperspectral, so as to solve the problem of poor compliance of patients with invasive examination and improve the early diagnosis rate of glomerular diseases. METHODS A total of 65 urine samples from patients who underwent renal biopsy from November 2020 to January 2022 in Qianfoshan Hospital of Shandong Province were collected.By simultaneously capturing spectral information of the above urine samples in the 400-1000 nm range, more obvious differences were found in the spectra of urine from patients with glomerular diseases between 650 nm and 680 nm. We obtained the original hyperspectral images in this wavelength range through digital scanning, and sampled pixel points at intervals on the original images. The two-dimensional digital image generated from each pixel point served as a member of the subsequent training and test sets. . After manually labeling the images according to different biopsy pathological types, they were randomly divided into training set (n = 58,800) and test set (n = 25,200). The training set was used for training learning and parameter iteration of artificial intelligence non-invasive liquid diagnosis model, and the test set for model recognition and interpretation. The evaluation indexes such as accuracy, sensitivity and specificity were calculated to evaluate the performance of the diagnosis model. RESULTS The model has an accuracy rate of 96% for early diagnosis of four glomerular diseases. CONCLUSION The auxiliary diagnosis model system has high accuracy. It is expected to be used as a non-invasive diagnostic method for glomerular diseases in clinic.
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Affiliation(s)
- Xiangyu Hou
- Department of Nephrology, Shandong Institute of Nephrology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, No. 16766 Jingshi Road, Jinan, Shandong 250014, China
| | - Chongxuan Tian
- Department of biomedical Engineering Institute, School of Control Science and Engineering, Shandong University, Jinan, Shandong, 250016, China
| | - Wen Liu
- Department of Nephrology, Shandong Institute of Nephrology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, No. 16766 Jingshi Road, Jinan, Shandong 250014, China
| | - Yang Li
- Department of Nephrology, Shandong Institute of Nephrology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, No. 16766 Jingshi Road, Jinan, Shandong 250014, China
| | - Wei Li
- Department of biomedical Engineering Institute, School of Control Science and Engineering, Shandong University, Jinan, Shandong, 250016, China.
| | - Zunsong Wang
- Department of Nephrology, Shandong Institute of Nephrology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, No. 16766 Jingshi Road, Jinan, Shandong 250014, China.
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13
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Peritore L, Labbozzetta V, Maressa V, Casuscelli C, Conti G, Gembillo G, Santoro D. How to Choose the Right Treatment for Membranous Nephropathy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1997. [PMID: 38004046 PMCID: PMC10673286 DOI: 10.3390/medicina59111997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 10/30/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023]
Abstract
Membranous nephropathy is an autoimmune disease affecting the glomeruli and is one of the most common causes of nephrotic syndrome. In the absence of any therapy, 35% of patients develop end-stage renal disease. The discovery of autoantibodies such as phospholipase A2 receptor 1, antithrombospondin and neural epidermal growth factor-like 1 protein has greatly helped us to understand the pathogenesis and enable the diagnosis of this disease and to guide its treatment. Depending on the complications of nephrotic syndrome, patients with this disease receive supportive treatment with diuretics, ACE inhibitors or angiotensin-receptor blockers, lipid-lowering agents and anticoagulants. After assessing the risk of progression of end-stage renal disease, patients receive immunosuppressive therapy with various drugs such as cyclophosphamide, steroids, calcineurin inhibitors or rituximab. Since immunosuppressive drugs can cause life-threatening side effects and up to 30% of patients do not respond to therapy, new therapeutic approaches with drugs such as adrenocorticotropic hormone, belimumab, anti-plasma cell antibodies or complement-guided drugs are currently being tested. However, special attention needs to be paid to the choice of therapy in secondary forms or in specific clinical contexts such as membranous disease in children, pregnant women and patients undergoing kidney transplantation.
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Affiliation(s)
- Luigi Peritore
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Vincenzo Labbozzetta
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Veronica Maressa
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Giovanni Conti
- Pediatric Nephrology Unit, AOU Policlinic “G Martino”, University of Messina, 98125 Messina, Italy;
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
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14
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Sethi S, Beck LH, Glassock RJ, Haas M, De Vriese AS, Caza TN, Hoxha E, Lambeau G, Tomas NM, Madden B, Debiec H, D'Agati VD, Alexander MP, Amer H, Appel GB, Barbour SJ, Caravaca-Fontan F, Cattran DC, Casal Moura M, D'Avila DO, Eick RG, Garovic VD, Greene EL, Herrera Hernandez LP, Jennette JC, Lieske JC, Markowitz GS, Nath KA, Nasr SH, Nast CC, Pani A, Praga M, Remuzzi G, Rennke HG, Ruggenenti P, Roccatello D, Soler MJ, Specks U, Stahl RAK, Singh RD, Theis JD, Velosa JA, Wetzels JFM, Winearls CG, Yandian F, Zand L, Ronco P, Fervenza FC. Mayo Clinic Consensus Report on Membranous Nephropathy: Proposal for a Novel Classification. Mayo Clin Proc 2023; 98:1671-1684. [PMID: 37804268 DOI: 10.1016/j.mayocp.2023.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 10/09/2023]
Abstract
Membranous nephropathy (MN) is a pattern of injury caused by autoantibodies binding to specific target antigens, with accumulation of immune complexes along the subepithelial region of glomerular basement membranes. The past 20 years have brought revolutionary advances in the understanding of MN, particularly via the discovery of novel target antigens and their respective autoantibodies. These discoveries have challenged the traditional classification of MN into primary and secondary forms. At least 14 target antigens have been identified, accounting for 80%-90% of cases of MN. Many of the forms of MN associated with these novel MN target antigens have distinctive clinical and pathologic phenotypes. The Mayo Clinic consensus report on MN proposes a 2-step classification of MN. The first step, when possible, is identification of the target antigen, based on a multistep algorithm and using a combination of serology, staining of the kidney biopsy tissue by immunofluorescence or immunohistochemistry, and/or mass spectrometry methodology. The second step is the search for a potential underlying disease or associated condition, which is particularly relevant when knowledge of the target antigen is available to direct it. The meeting acknowledges that the resources and equipment required to perform the proposed testing may not be generally available. However, the meeting consensus was that the time has come to adopt an antigen-based classification of MN because this approach will allow for accurate and specific MN diagnosis, with significant implications for patient management and targeted treatment.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Laurence H Beck
- Section of Nephrology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California, USA
| | - Mark Haas
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
| | | | - Elion Hoxha
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gérard Lambeau
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, Valbonne Sophia Antipolis, France
| | - Nicola M Tomas
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Madden
- Mayo Clinic Proteomics Core, Mayo Clinic, Rochester, Minnesota, USA
| | - Hanna Debiec
- Sorbonne Université, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Paris, France
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Gerald B Appel
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fernando Caravaca-Fontan
- Department of Medicine, Complutense University, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Daniel C Cattran
- Toronto General Research Institute, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Marta Casal Moura
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Domingos O D'Avila
- Serviço de Nefrologia, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Renato G Eick
- Serviço de Nefrologia, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Eddie L Greene
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | | | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Karl A Nath
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cynthia C Nast
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Antonello Pani
- Nephrology, Dialysis and Transplantation, Arnas Brotzu, Cagliari, Italy; Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Manuel Praga
- Department of Medicine, Complutense University, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Helmut G Rennke
- Department of Pathology, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; Unit of Nephrology, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy; Center of Immuno-Rheumatology and Rare Diseases (CMID), Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Maria Jose Soler
- Department of Nephrology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, Barcelona, Spain; Centro de Referencia en Enfermedad, Glomerular Compleja del Sistema Nacional de Salud de España (CSUR), Barcelona, Spain
| | - Ulrich Specks
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rolf A K Stahl
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raman Deep Singh
- Renal Pathophysiology Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jorge A Velosa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack F M Wetzels
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Federico Yandian
- Department of Nephrology, Hospital de Clinicas Universidad de la Republica, Montevideo, Uruguay
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Pierre Ronco
- Sorbonne Université, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Paris, France; Division of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.
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15
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Nath KA, Erickson LA, Garovic VD. Primary and Secondary Diagnoses in Medicine: Insights From Mayo Clinic Consensus Report on Membranous Nephropathy--Executive Summary. Mayo Clin Proc 2023; 98:1599-1601. [PMID: 37804269 DOI: 10.1016/j.mayocp.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 08/14/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Karl A Nath
- Division of Nephrology & Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Lori A Erickson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Vesna D Garovic
- Division of Nephrology & Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
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16
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Chen Y, Xu Y, Chen S, Yu Y, Zhu X, Chen J. The application of podocyte antigen PLA2R and anti-PLA2R antibody in the diagnosis and treatment of membranous nephropathy. Ren Fail 2023; 45:2264939. [PMID: 37814415 PMCID: PMC10566392 DOI: 10.1080/0886022x.2023.2264939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND The application of podocyte antigen M-type phospholipase A2 receptor (PLA2R, GAg) and serum anti-PLA2R antibody (SAb) in predicting the prognosis of membrane nephropathy (MN) was controversial. METHOD 328 biopsy-proven MN patients were divided into three phenotypes, 182 MN patients with GAg+/SAb+, 118 MN patients with GAg+/SAb-, and 28 MN patients with GAg-/SAb-. The baseline clinicopathological characteristics, therapy response, and prognosis were compared among the three groups. Cox regression analysis was performed to assess predictors of remission. Anti-PLA2R antibody was analyzed by receiver operating characteristic curve to find the optimal titer for MN diagnosis. RESULT Lower eGFR (p = 0.009), higher UPCR (p < 0.001), and lower serum albumin (p < 0.001) were observed in GAg+/SAb+ MN patients, compared to GAg+/SAb- MN patients. More GAg+/SAb+ MN patients received cyclophosphamide (CTX) combined with glucocorticoids and calcineurin inhibitors (CNI) based therapy than the other two groups (p = 0.015 and p = 0.023, respectively). No significant difference was observed among the three groups in terms of complete remission, relapse, and developing ESRD. SAb+ status was an independent predictor for no remission (hazard ratio 1.378, 95% confidence interval 1.023 to 1.855; p = 0.035). The optimal cutoff value for anti-PLA2R antibody to predict MN was 2.055 RU/mL (sensibility 0.802, specificity 0.970). CONCLUSION GAg+/SAb+ MN patients were related to more severe clinical manifestations and more requisition of immunosuppressive treatment. Positive anti-PLA2R antibody was an independent predictor for no remission. An anti-PLA2R antibody above 2.055 RU/mL can be a suggestive indicator of MN diagnosis in patients with proteinuria.
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Affiliation(s)
- Yang Chen
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang China
| | - Ying Xu
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang China
| | - Siyu Chen
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang China
| | - Yedong Yu
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang China
- Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang, China
| | - Xueling Zhu
- The Department of Infectious Diseases, State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, Zhejiang, China
- National Key Clinical Department of Kidney Diseases, Hangzhou, Zhejiang, China
- Institute of Nephrology, Zhejiang University, Hangzhou, Zhejiang, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, Zhejiang China
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Geng C, Huang L, Li Q, Li G, Li Y, Zhang P, Feng Y. A nomogram prediction model for treatment failure in primary membranous nephropathy. Ren Fail 2023; 45:2265159. [PMID: 37795790 PMCID: PMC10557540 DOI: 10.1080/0886022x.2023.2265159] [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: 05/22/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Primary membranous nephropathy (PMN) has a heterogeneous natural course. Immunosuppressive therapy is recommended for PMN patients at moderate or high risk of renal function deterioration. Prediction models for the treatment failure of PMN have rarely been reported. METHODS This study retrospectively studied patients diagnosed as PMN by renal biopsy at Sichuan Provincial People's Hospital from January 2017 to December 2020. Information on clinical characteristics, laboratory test results, pathological examination, and treatment was collected. The outcome was treatment failure, defined as the lack of complete or partial remission at the end of 12 months. Simple logistic regression was used to identify candidate predictive variables. Forced-entry stepwise multivariable logistic regression was used to develop the prediction model, and performance was evaluated using C-statistic, calibration plot, and decision curve analysis. Internal validation was performed by bootstrapping. RESULTS In total, 310 patients were recruited for this study. 116 patients achieved the outcome. Forced-entry stepwise multivariable logistic regression indicated that PLA2Rab titer (OR = 1.002, 95% CI: 1.001-1.004, p = 0.003), inflammatory cells infiltration (OR = 2.753, 95% CI: 1.468-5.370, p = 0.002) and C3 deposition on immunofluorescence (OR = 0.217, 95% CI: 0.041-0.964, p = 0.049) were the three independent risk factors for treatment failure of PMN. The final prediction model had a C-statistic (95% CI) of 0.653 (0.590-0.717) and a net benefit of 23%-77%. CONCLUSIONS PLA2R antibody, renal interstitial inflammation infiltration, and C3 deposition on immunofluorescence were the three independent risk factors for treatment failure in PMN. Our prediction model might help identify patients at risk of treatment failure; however, the performance awaits improvement.
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Affiliation(s)
- Chanyu Geng
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Liming Huang
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Qiang Li
- Renal and Metabolic Division, The George Institute for Global Health, Sydney, Australia
| | - Guisen Li
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yi Li
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Ping Zhang
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yunlin Feng
- Department of Nephrology, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
- Renal and Metabolic Division, The George Institute for Global Health, Sydney, Australia
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He HG, Huang YY, Liang QQ, Ye QR, Li AD, Ye K, Wu QX, You YW. Calcineurin inhibitors or cyclophosphamide in the treatment of membranous nephropathy superimposed with FSGS lesions: a retrospective study from China. Ren Fail 2023; 45:2253930. [PMID: 37724535 PMCID: PMC10512924 DOI: 10.1080/0886022x.2023.2253930] [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: 04/11/2023] [Accepted: 08/25/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Cyclophosphamide (CTX) and calcineurin inhibitors (CNIs) based regimens are recommended as immunosuppressive therapies for patients with idiopathic membranous nephropathy (IMN). Focal and segmental glomerular sclerosis (FSGS) lesions, which are common in membranous nephropathy (MN), are poor predictors of outcome. This study compared the differences of prognosis between two regimens in patients with IMN combined with FSGS lesions. METHODS This retrospective study enrolled 108 patients with biopsy-proven IMN, accompanied with FSGS lesions, nephrotic syndrome and an estimated glomerular filtration rate (eGFR)≥60 mL/min/1.73 m2 who were treated with CTX or CNIs. We used propensity score matching (PSM) for balancing the confounding variables. RESULTS During follow-up, 10 patients (10/55 [18.2%]; nine males) in the CNIs group showed a 50% decline in eGFR; eight had a not otherwise specified variant. Patients initially treated with CNIs had a significantly higher risk of progression to the primary outcome and a lower probability of complete or total remission. The relapse rate was higher in patients who initially received CNIs- than in those who received CTX-based treatment. Before PSM, age and 24-h urine protein level differed significantly between the groups. The PSM model included data from 72 patients. Worse outcomes were also noted among patients who initially received CNIs than those who received CTX-based treatments after matching. CONCLUSIONS Patients with MN combined with FSGS lesions have a higher risk of renal functional decline and a higher rate of relapse after CNIs than after CTX therapy.
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Affiliation(s)
- Hong-Guang He
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yi-Yun Huang
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Qin-Qing Liang
- Department of Pathology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Qiu-Rong Ye
- Department of Pathology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - An-Dong Li
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Kun Ye
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Qiu-Xia Wu
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yan-Wu You
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
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Stefan G, Balcan GT, Petre N, Cinca S, Zugravu A, Stancu S. Anti-phospholipase A2 receptor positive membranous nephropathy: investigating the link between electron microscopy stages and clinical outcome. Ultrastruct Pathol 2023; 47:365-372. [PMID: 37449497 DOI: 10.1080/01913123.2023.2236225] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
This retrospective, observational study sought to examine the relationship between Ehrenreich-Churg electron microscopy (EM) stages and long-term outcomes in anti-PLA2R membranous nephropathy (MN). Seventy-one patients with anti-PLA2R MN (median titer 185.7RU/mL) were followed for a median of 46 months, with end-stage kidney disease (ESKD) as the primary endpoint, and response to treatment as a secondary endpoint. Patients were grouped into stages I-II (41 patients) and stages III-IV (30 patients) for analytical purposes. Notably, the III-IV group demonstrated a lower eGFR, lower anti-PLA2R titer, but a higher chronicity score. Kaplan-Meier analysis showed shorter mean kidney survival time in stages III-IV compared to I-II (p 0.03). However, multivariate analysis using Cox regression indicated that Ehrenreich-Churg stages did not significantly influence kidney survival, but lower eGFR at diagnosis and higher histopathological chronicity score did. Remission was achieved by 64% of patients and no relationship between Ehrenreich-Churg stages and treatment response was found. The only identified risk factor for not achieving remission was the severity of hyposerinemia at diagnosis. In conclusion, while EM stages III-IV are associated with more chronic lesions and stages I-II with more active immunologic disease, the histological chronicity score seems to be a stronger predictor of long-term outcomes.
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Affiliation(s)
- Gabriel Stefan
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Nephrology Department, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - George Terinte Balcan
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Ultrastructural Pathology Laboratory, "Victor Babes" National Institute of Pathology, Bucharest, Romania
| | - Nicoleta Petre
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Nephrology Department, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Simona Cinca
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Nephrology Department, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Adrian Zugravu
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Nephrology Department, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Simona Stancu
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Nephrology Department, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
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20
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Kakhsurueva PA, Kamyshova ES, Bobkova IN, Stavrovskaya EV, Rudenko TE, Andreeva EY. [Clinical significance of the determination of antibodies to thrombospondin type 1 containing domain 7A (THSD7A) in membranous nephropathy]. TERAPEVT ARKH 2023; 95:462-467. [PMID: 38158964 DOI: 10.26442/00403660.2023.06.202268] [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: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Membranous nephropathy (MN) is an immunocomplex glomerular disease, which is the most common cause of nephrotic syndrome in adults. Numerous studies have established that autoantibodies against the target podocyte autoantigens, including the thrombospondin type 1 domain containing 7A (THSD7A), play a leading role in the development of idiopathic MN. AIM To evaluate the prevalence of anti-THSD7A autoantibodies (anti-THSD7A AB) in a group of Russian patients with MN. MATERIALS AND METHODS Serum titers of anti-THSD7A AB were tested in 61 patients with biopsy-proven MN and 12 healthy controls. RESULTS The prevalence of anti-THSD7A AB was not differing significantly in patients with MN and in the control group (110.9 [71.63; 210.62] and 159.25 [125.64; 231.97] pg/ml, respectively; p=0.111). When comparing subgroups of anti-PLA2R-negative patients and patients who did not receive immunosuppressive therapy with the control group, there were also no statistically significant differences in the Anti-THSD7A AB levels (p>0.05). In the MN group, 1 (1.6%) patient was anti-THSD7A-positive: a 60-year-old man with anti-PLA2R-negative MN and the presence of hormonally inactive adenomas of both adrenal glands and colon polyps (villous adenoma with focal moderate dysplasia, tubulo-villous and tubular adenoma with focal moderate severe dysplasia). CONCLUSION THSD7-associated MN is a rare variant of MN and is usually detected in PLA2R-negative patients. Screening for malignancies in THSD7A-positive MN patients is proposed.
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Affiliation(s)
- P A Kakhsurueva
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E S Kamyshova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - I N Bobkova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E V Stavrovskaya
- Sechenov First Moscow State Medical University (Sechenov University)
| | - T E Rudenko
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E Y Andreeva
- Sechenov First Moscow State Medical University (Sechenov University)
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21
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Bajcsi D, Bitó L, Turkevi-Nagy S, Nyári T, Kemény É, Légrády P, Ábrahám G, Iványi B. The value of PLA2R antigen and IgG subclass staining relative to anti-PLA2R seropositivity in the differential diagnosis of membranous nephropathy. BMC Nephrol 2023; 24:230. [PMID: 37550626 PMCID: PMC10408061 DOI: 10.1186/s12882-023-03273-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 07/19/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND The diagnostic performance of PLA2R and IgG subclass staining of kidney biopsies relative to anti-PLA2R seropositivity in the differentiation of primary and secondary membranous nephropathy (pMN, sMN) was examined. Besides PLA2R staining - which has a lower specificity than anti-PLA2R antibody serology - there is insufficient knowledge to decide which IgG1-4 subtype immunohistological patterns (IgG4-dominance, IgG4-dominance/IgG1-IgG4-codominance or IgG4-dominance/IgG4-codominance with any IgG subtype) could be used to distinguish between pMN and sMN. METHODS 87 consecutive Hungarian patients (84 Caucasians, 3 Romas) with the biopsy diagnosis of MN were classified clinically as pMN (n = 63) or sMN (n = 24). The PLA2R and IgG subclass staining was part of the diagnostic protocol. Anti-PLA2R antibodies were determined by an indirect immunofluorescence test in 74 patients with disease activity. RESULTS For pMN, the sensitivity of anti-PLA2R seropositivity was 61.1%, and the specificity was 90.0%; and similar values for PLA2R staining were 81.0%, and 66.7%, respectively. In all stages of pMN, IgG4-dominance was the dominant subclass pattern, while the second most frequent was IgG3/IgG4-codominance. The sensitivity and specificity scores were: IgG4-dominance 52.2% and 91.7%, IgG4-dominance/IgG3-IgG4-codominance 76.2% and 87.5%, IgG4-dominance/IgG1-IgG4-codominance 64.2% and 75%, and IgG4-dominance/codominance with any IgG subclass 92.1% and 70.8%, respectively. Anti-PLA2R seropositivity, glomerular PLA2R, and IgG4-dominance/codominance significantly correlated with each other. The IgG4 subclass was rarely encountered in sMN. CONCLUSION In our series, IgG4-dominance had the highest specificity in the differentiation of MN, just as high as that for anti-PLA2R seropositivity. The specificity values of PLA2R staining and IgG4-dominance/codominance with any IgG subclass or IgG4-dominance/IgG1-IgG4 codominance were ≤ 75%. Apart from IgG4 dominance, IgG4-dominance/IgG3-IgG4-codominance also had good statistical value in differentiating pMN from sMN. As IgG subclass switching during the progression of pMN was not the feature of our cohort, pMN in Hungarian patients is presumed to be an IgG4-related disorder right from the start. Although anti-PLA2R seropositivity has become the cornerstone for diagnosing pMN, if a kidney biopsy evaluation is conducted, besides the staining of PLA2R antigen, the evaluation of IgG subclasses provides relevant information for a differential diagnosis. Even in cases with IgG4-dominance, however, malignancy should be thoroughly checked.
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Affiliation(s)
- Dóra Bajcsi
- Szent-Györgyi Albert Health Center, University of Szeged, Szeged, Hungary.
| | - László Bitó
- Szent-Györgyi Albert Health Center, University of Szeged, Szeged, Hungary
| | | | - Tibor Nyári
- Szent-Györgyi Albert Health Center, University of Szeged, Szeged, Hungary
| | - Éva Kemény
- Szent-Györgyi Albert Health Center, University of Szeged, Szeged, Hungary
| | - Péter Légrády
- Szent-Györgyi Albert Health Center, University of Szeged, Szeged, Hungary
| | - György Ábrahám
- Szent-Györgyi Albert Health Center, University of Szeged, Szeged, Hungary
| | - Béla Iványi
- Szent-Györgyi Albert Health Center, University of Szeged, Szeged, Hungary
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22
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Beck LH, Ayoub I, Caster D, Choi MJ, Cobb J, Geetha D, Rheault MN, Wadhwani S, Yau T, Whittier WL. KDOQI US Commentary on the 2021 KDIGO Clinical Practice Guideline for the Management of Glomerular Diseases. Am J Kidney Dis 2023; 82:121-175. [PMID: 37341661 DOI: 10.1053/j.ajkd.2023.02.003] [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: 12/21/2022] [Accepted: 02/20/2023] [Indexed: 06/22/2023]
Abstract
The KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases represents the first update to this set of recommendations since the initial set of KDIGO guideline recommendations was published in 2012. The pace of growth in our molecular understanding of glomerular disease has quickened and a number of newer immunosuppressive and targeted therapies have been introduced since the original set of guideline recommendations, making such an update necessary. Despite these updates, many areas of controversy remain. In addition, further updates since the publication of KDIGO 2021 have occurred which this guideline does not encompass. With this commentary, the KDOQI work group has generated a chapter-by-chapter companion opinion article that provides commentary specific to the implementation of the KDIGO 2021 guideline in the United States.
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Affiliation(s)
- Laurence H Beck
- Division of Nephrology, Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Isabelle Ayoub
- Department of Medicine, Division of Nephrology, Wexner Medical, The Ohio State University, Columbus, Ohio
| | - Dawn Caster
- Department of Medicine, School of Medicine, University of Louisville, Louisville, Kentucky
| | | | - Jason Cobb
- Division of Renal Medicine, Department of Medicine, School of Medicine, Emory University, Atlanta, Georgia
| | - Duvuru Geetha
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland
| | - Michelle N Rheault
- Department of Pediatrics, Division of Pediatric Nephrology, Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Shikha Wadhwani
- Division of Nephrology and Hypertension, Northwestern University, Chicago, Illinois
| | - Timothy Yau
- Division of Nephrology, Department of Medicine, School of Medicine, Washington University, St. Louis, Missouri
| | - William L Whittier
- Division of Nephrology, Rush University Medical Center, Chicago, Illinois
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Ragy O, Bate S, Bukhari S, Hiremath M, Samani S, Khwaja A, Rao A, Kanigicherla DAK. PLA2R Antibody Does Not Outperform Conventional Clinical Markers in Predicting Outcomes in Membranous Nephropathy. Kidney Int Rep 2023; 8:1605-1615. [PMID: 37547510 PMCID: PMC10403689 DOI: 10.1016/j.ekir.2023.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction The prognostic value of PLA2R antibody (Ab) test in clinical practice remains unclear. We aimed to evaluate its ability in predicting hard outcomes in primary membranous nephropathy (PMN) after adjustments to conventional markers of disease activity. Methods A total of 222 patients diagnosed with PMN from January 2003 to July 2019 having had a serum PLA2R Ab test, were included from 3 centers in the north of England. Baseline conventional markers, PLA2R-Ab-status (positive vs. negative), Ab-titer (high vs. low), and time of testing (pre-PLA2R era vs. PLA2R era) were evaluated for association with outcomes. Primary outcome was time to progression (composite of doubling of creatinine, stage 5 chronic kidney disease, or death). Secondary outcomes were time to partial remission (PR) and time to immunosuppression. Cox proportional hazard testing was used. Results During a median follow-up of 5.26 years, progression was seen in 65 (29.3%) and PR in 179 of 222 patients (80.6%). There was a clear association of estimated glomerular filtration rate (eGFR) (standardized hazard ratio [HRZ] = 0.767, P < 0.05) and urine protein-to-creatinine ratio (uPCR) (HRZ = 1.44, P < 0.005) with time to progression among all patients, and eGFR (HRZ = 0.606, P < 0.005) in Ab-positive patients. Baseline Ab-positivity was not associated with time to progression (adjusted hazard ratio [aHR] = 0.93, P = 0.71) or time to PR (aHR = 0.84, P = 0.13). Similarly, baseline high Ab-titer was not associated with time to progression (aHR = 1.07, P = 0.77) or time to PR (aHR = 0.794, P = 0.08). Conclusion Once adjusted to conventional markers of disease activity, baseline PLA2R Ab-positivity or Ab-titer do not predict disease progression or time to PR. Further studies are needed to harness the utility of PLA2R Ab test in prognostication in PMN.
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Affiliation(s)
- Omar Ragy
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Sebastian Bate
- Manchester Academic Health Science Centre, Research and Innovation, Manchester University NHS Foundation Trust, Manchester, UK
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Samar Bukhari
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Mrityunjay Hiremath
- Nephrology Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Syazril Samani
- Nephrology Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Arif Khwaja
- Sheffield Kidney Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Anirudh Rao
- Nephrology Department, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Durga Anil K. Kanigicherla
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
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24
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McDonnell T, Wu HHL, Sinha S, Chinnadurai R. The Role of PLA2R in Primary Membranous Nephropathy: Do We Still Need a Kidney Biopsy? Genes (Basel) 2023; 14:1343. [PMID: 37510247 PMCID: PMC10380005 DOI: 10.3390/genes14071343] [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: 05/31/2023] [Revised: 06/24/2023] [Accepted: 06/24/2023] [Indexed: 07/30/2023] Open
Abstract
Membranous nephropathy (MN) is the most prevalent cause of nephrotic syndrome amongst the non-diabetic adult population. A fifth of idiopathic nephrotic syndrome cases can be attributed to MN, rising to more than 40% in older patients over 60 years. Most MN cases are classified as being of a primary cause, where there is absence of a secondary disease process explaining its manifestation. Traditionally, the standard approach of diagnosing MN involves performing a kidney biopsy as histological evaluation offers not only conclusive evidence of the diagnosis but also provides valuable information regarding disease chronicity and the presence of any other kidney histopathological features. Nevertheless, kidney biopsy is an invasive procedure which poses risks for the patient including bleeding and pain and bears greater costs for the health system. The identification of the phospholipase A2 receptor (PLA2R) antigen in 2009 was a landmark discovery, one which has evolved our understanding of the disease processes in MN and subsequently our management approach of this condition. Antibodies against PLA2R (PLA2RAb) have since emerged as an attractive non-invasive test option to be applied for the diagnosis and prognostication of primary MN. However, much debate and unknowns remain about the accuracy and reliability of testing for PLA2RAb across various primary MN scenarios. We provide a review summarizing the historical journey of PLA2R in relation to its significance in primary MN and, more importantly, evidence emerging over the years which contemplated the role of PLA2RAb as a diagnostic and prognostic tool in primary MN.
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Affiliation(s)
- Thomas McDonnell
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (T.M.); (S.S.); (R.C.)
| | - Henry H. L. Wu
- Renal Research Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, The University of Sydney, Sydney, NSW 2065, Australia
| | - Smeeta Sinha
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (T.M.); (S.S.); (R.C.)
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (T.M.); (S.S.); (R.C.)
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK
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Duan S, Chen S, Lu F, Zhou M, Jiang L, Chen C, Geng L, Sun R, Xu Y, Huang Z, Zhang C, Zhang B, Mao H, Xing C, Yuan Y. Serum 25-hydroxyvitamin D as a predictive biomarker of clinical outcomes in patients with primary membranous nephropathy. Front Nutr 2023; 10:1171216. [PMID: 37181155 PMCID: PMC10167293 DOI: 10.3389/fnut.2023.1171216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/27/2023] [Indexed: 05/16/2023] Open
Abstract
Background Primary membranous nephropathy (PMN) is an immune-related disease with increased morbidity and the most common cause of adult nephrotic syndrome (NS). The serum 25-hydroxyvitamin D [25(OH)D)], a biomarker of vitamin D (VD) status, tends to decline in patients with kidney disease. However, the relationship between 25(OH)D and PMN is still unclear. Therefore, this study aims to clarify the association between 25(OH)D and disease severity and therapy response of PMN. Methods A total of 490 participants diagnosed with PMN by biopsy from January 2017 to April 2022 were recruited at the First Affiliated Hospital of Nanjing Medical University. The correlations between baseline 25(OH)D and manifestations of nephrotic syndrome (NS) or seropositivity of anti-PLA2R Ab were confirmed by univariate and multivariate logistic analyses. Spearman's correlations were used to examine the associations between baseline 25(OH)D and other clinical parameters. In the follow-up cohort, Kaplan-Meier analysis was used to assess remission outcomes among groups with low, medium, and high levels of 25(OH)D. Furthermore, the independent risk factors for non-remission (NR) were explored by COX regression analysis. Results At baseline, 25(OH)D was negatively related to 24-h urinary protein and serum anti-PLA2R Ab. The lower level of baseline 25(OH)D was associated with an increased risk for the incidence of NS in PMN (model 2, OR 6.8, 95% CI 4.4, 10.7, P < 0.001) and seropositivity of anti-PLA2R Ab (model 2, OR 2.4, 95% CI 1.6, 3.7, P < 0.001). Furthermore, the lower level of 25(OH)D during follow-up was demonstrated as an independent risk factor for NR even after adjusting age, gender, MBP, 24 h UP, serum anti-PLA2R Ab, serum albumin, and serum C3 [25(OH)D (39.2-62.3 nmol/L): HR 4.90, 95% CI 1.02, 23.53 P = 0.047; 25(OH)D < 39.2 nmol/L: HR 17.52, 95% CI 4.04, 76.03 P < 0.001); vs. 25(OH)D ≥ 62.3 nmol/L]. The Kaplan-Meier survival analysis also demonstrated that the higher level of follow-up 25(OH)D had a higher possibility of remission than the lower one (log-rank test, P < 0.001). Conclusion Baseline 25(OH)D was significantly correlated with nephrotic proteinuria and seropositivity of anti-PLA2R Ab in PMN. As an independent risk factor for NR, a low level of 25(OH)D during follow-up might serve as a prognostic tool for sensitively identifying cases with a high probability of poor treatment response.
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Dantas M, Silva LBB, Pontes BTM, dos Reis MA, de Lima PSN, Moysés M. Membranous nephropathy. J Bras Nefrol 2023; 45:229-243. [PMID: 37527529 PMCID: PMC10627124 DOI: 10.1590/2175-8239-jbn-2023-0046en] [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: 04/03/2023] [Accepted: 05/31/2023] [Indexed: 08/03/2023] Open
Abstract
Membranous nephropathy is a glomerulopathy, which main affected target is the podocyte, and has consequences on the glomerular basement membrane. It is more common in adults, especially over 50 years of age. The clinical presentation is nephrotic syndrome, but many cases can evolve with asymptomatic non-nephrotic proteinuria. The mechanism consists of the deposition of immune complexes in the subepithelial space of the glomerular capillary loop with subsequent activation of the complement system. Great advances in the identification of potential target antigens have occurred in the last twenty years, and the main one is the protein "M-type phospholipase-A2 receptor" (PLA2R) with the circulating anti-PLA2R antibody, which makes it possible to evaluate the activity and prognosis of this nephropathy. This route of injury corresponds to approximately 70% to 80% of cases of membranous nephropathy characterized as primary. In the last 10 years, several other potential target antigens have been identified. This review proposes to present clinical, etiopathogenic and therapeutic aspects of membranous nephropathy in a didactic manner, including cases that occur during kidney transplantation.
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Affiliation(s)
- Márcio Dantas
- Universidade de São Paulo, Faculdade de Medicina, Hospital das
Clínicas, Ribeirão Preto, SP, Brazil
| | | | | | - Marlene Antônia dos Reis
- Universidade Federal do Triângulo Mineiro, Patologia Geral, Centro
de Pesquisa em Rim, Uberaba, MG, Brazil
| | | | - Miguel Moysés
- Universidade de São Paulo, Faculdade de Medicina, Hospital das
Clínicas, Ribeirão Preto, SP, Brazil
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Fernández-Juárez G, Ronco P, Jha V. Personalized Treatment of PLA2R-Related Membranous Nephropathy. Clin J Am Soc Nephrol 2023; 18:530-532. [PMID: 36747312 PMCID: PMC10103204 DOI: 10.2215/cjn.0000000000000086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/06/2023] [Indexed: 01/28/2023]
Affiliation(s)
- Gema Fernández-Juárez
- Department of Nephrology, Instituto de Investigación de la Paz (IdIPAZ), Hospital Universitario La Paz, Madrid, Spain
| | - Pierre Ronco
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Sorbonne Université, Paris, France
- Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India
- School of Public Health, Imperial College, London, United Kingdom
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
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Allinovi M, Lugli G, Rossi F, Palterer B, Almerigogna F, Caroti L, Antognoli G, Cirami C. Accuracy of serum PLA2R antibody detected by indirect immunofluorescence in diagnosing biopsy-proven primary membranous nephropathy: a single-center experience and a systematic review of the literature. J Nephrol 2023; 36:281-283. [PMID: 36462140 DOI: 10.1007/s40620-022-01528-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 11/17/2022] [Indexed: 12/05/2022]
Affiliation(s)
- Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy.
| | - Gianmarco Lugli
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Federica Rossi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
| | - Boaz Palterer
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
| | - Fabio Almerigogna
- Immunoallergology Unit, Careggi University Hospital, Florence, Italy
| | - Leonardo Caroti
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Giulia Antognoli
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
| | - Calogero Cirami
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, Florence, Italy
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Ragy O, Rautemaa V, Smith A, Brenchley P, Kanigicherla D, Hamilton P. Can use of the serum anti-PLA2R antibody negate the need for a renal biopsy in primary membranous nephropathy? PLoS One 2023; 18:e0281726. [PMID: 36827283 PMCID: PMC9955960 DOI: 10.1371/journal.pone.0281726] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Since the emergence of the anti-PLA2R antibody (PLA2R-Ab) test, nephrology practice has not changed dramatically, with most nephrologists still relying on a kidney biopsy to diagnose membranous nephropathy. In this study, we examined the clinical accuracy of the anti-PLA2R antibody test using ELISA in routine clinical care. METHODS We conducted a retrospective analysis of PLA2R-Ab testing in 187 consecutive patients seen at a single UK centre between 2003 and 2020. We compared the kidney biopsy findings with the PLA2R-ab antibody test. Patients' demography, urine protein creatinine ratios, serum albumin, and treatment characteristics including supportive and immunosuppressive treatment were recorded. The clinical accuracy of the test (e.g. sensitivity and specificity, positive [PPV] and negative [NPV] predictive values) was calculated using the kidney biopsy findings as the diagnostic reference. RESULTS Mean levels of PLA2R-Ab titre in primary membranous nephropathy were 217RU/ml in comparison to 3RU/ml for both secondary membranous nephropathy and other diagnoses. Most patients with a positive PLA2R-Ab test had a confirmed renal biopsy diagnosis of primary membranous nephropathy with: PPV of 97.3%, sensitivity 75.5%, NPV was 79.8% and specificity was 97.8% at a cut-off threshold of >20 RU/ml. CONCLUSION The anti-PLA2R antibody test is a highly specific test for diagnosing membranous nephropathy, and the test has the potential to allow for the diagnosis and treatment in up to 75% of PMN cases without the need for a renal biopsy. Nevertheless, patients with negative PLA2R-Ab tests will still require a biopsy to confirm their diagnosis.
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Affiliation(s)
- Omar Ragy
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Wellcome Centre for Cell-Matrix Research, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Vilma Rautemaa
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Alison Smith
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Paul Brenchley
- Wellcome Centre for Cell-Matrix Research, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, United Kingdom
| | - Durga Kanigicherla
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Wellcome Centre for Cell-Matrix Research, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Patrick Hamilton
- Manchester Institute of Nephrology and Transplantation, Manchester University NHS Foundation Trust, Manchester, United Kingdom
- Wellcome Centre for Cell-Matrix Research, Division of Cell Matrix Biology and Regenerative Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
- Manchester Academic Health Science Centre (MAHSC), The University of Manchester, Manchester, United Kingdom
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Ge L, Liu J, Lin B, Qin X. Progress in understanding primary glomerular disease: insights from urinary proteomics and in-depth analyses of potential biomarkers based on bioinformatics. Crit Rev Clin Lab Sci 2023:1-20. [PMID: 36815270 DOI: 10.1080/10408363.2023.2178378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Chronic kidney disease (CKD) has become a global public health challenge. While primary glomerular disease (PGD) is one of the leading causes of CKD, the specific pathogenesis of PGD is still unclear. Accurate diagnosis relies largely on invasive renal biopsy, which carries risks of bleeding, pain, infection and kidney vein thrombosis. Problems with the biopsy procedure include lack of glomeruli in the tissue obtained, and the sampling site not being reflective of the overall lesion in the kidney. Repeated renal biopsies to monitor disease progression cannot be performed because of the significant risks of bleeding and kidney vein thrombosis. On the other hand, urine collection, a noninvasive method, can be performed repeatedly, and urinary proteins can reflect pathological changes in the urinary system. Advancements in proteomics technologies, especially mass spectrometry, have facilitated the identification of candidate biomarkers in different pathological types of PGD. Such biomarkers not only provide insights into the pathogenesis of PGD but also are important for diagnosis, monitoring treatment, and prognosis. In this review, we summarize the findings from studies that have used urinary proteomics, among other omics screens, to identify potential biomarkers for different types of PGD. Moreover, we performed an in-depth bioinformatic analysis to gain a deeper understanding of the biological processes and protein-protein interaction networks in which these candidate biomarkers may participate. This review, including a description of an integrated analysis method, is intended to provide insights into the pathogenesis, noninvasive diagnosis, and personalized treatment efforts of PGD and other associated diseases.
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Affiliation(s)
- Lili Ge
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China.,Liaoning Clinical Research Center for Laboratory Medicine, Shenyang, China
| | - Jianhua Liu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China.,Liaoning Clinical Research Center for Laboratory Medicine, Shenyang, China
| | - Baoxu Lin
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China.,Liaoning Clinical Research Center for Laboratory Medicine, Shenyang, China
| | - Xiaosong Qin
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China.,Liaoning Clinical Research Center for Laboratory Medicine, Shenyang, China
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31
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Hoxha E, Reinhard L, Castedello T, Becker JU. False positivity for PLA 2R1 antibody measured by ELISA in a nephrotic patient with no membranous nephropathy. Kidney Int 2023; 103:411-415. [PMID: 36208829 DOI: 10.1016/j.kint.2022.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 09/18/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Elion Hoxha
- III. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Linda Reinhard
- III. Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jan U Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany.
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32
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Qin Y, Wu Q, Sheng H, Li T, Liu X, Yang X, Lin B, Zhou X, Jin J, Wang L, Huang B, He Q, Hu Z. Quantitative detection of anti-PLA2R antibodies targeting different epitopes and its clinical application in primary membranous nephropathy. Clin Chem Lab Med 2023; 61:251-259. [PMID: 36351699 DOI: 10.1515/cclm-2022-0720] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aimed to establish time-resolved fluorescence immunoassays to quantitatively detect the autoantibodies targeting different epitopes of M-type phospholipase A2 receptor (PLA2R) and evaluate its clinical application in primary membranous nephropathy (PMN). METHODS PLA2R and its reactive epitope-specific IgG/IgG4 time-resolved fluorescence immunoassays (TRFIAs) were established using europium-labeled anti-human IgG/IgG4 antibodies, recombinant proteins, and patient serum. The levels of IgG/IgG4 targeting PLA2R and its epitopes in PMN patient serum were detected, and the relationship between epitope spreading of PLA2R and the severity of patients with PMN was evaluated. RESULTS The TRFIAs established in this study could quantitatively detect PLA2R and its epitope-specific IgG and IgG4. Sera from 59 patients with PMN were subjected to detection using anti-PLA2R IgG and anti-PLA2R IgG4. Among them, 46 and 54 patients were found positive for PLA2R antibodies, respectively. Moreover, the levels of PLA2R antibodies were strongly correlated with the severity of patients with PMN. Patients who were detected to have two or more epitopes had more serious renal injury. CONCLUSIONS PLA2R domain-specific IgG/IgG4 TRFIAs were established in this study, and detection with anti-PLA2R IgG4 could more sensitively screen the reactivity of patients to the PLA2R domain. Moreover, detection epitope spreading of PLA2R was confirmed which is related to the severity of patients with PMN.
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Affiliation(s)
- Yuan Qin
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Qingqing Wu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Huiming Sheng
- Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Ting Li
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Xiaobin Liu
- Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, P.R. China
| | - Xue Yang
- Wuxi Children's Hospital, Wuxi, P.R. China
| | - Bo Lin
- Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, P.R. China
| | - Xiumei Zhou
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Juan Jin
- Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, P.R. China
| | - Liang Wang
- Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, P.R. China
| | - Biao Huang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Qiang He
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, P.R. China
| | - Zhigang Hu
- Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, P.R. China
- Wuxi Children's Hospital, Wuxi, P.R. China
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Ye M, Tang D, Li W, Ma C, Zeng Z, Liao S, Song Z, Meng Y, Liu F, Luan S, Yin L, Dai Y. Serum metabolomics analysis reveals metabolite profile and key biomarkers of idiopathic membranous nephropathy. PeerJ 2023; 11:e15167. [PMID: 37041975 PMCID: PMC10083006 DOI: 10.7717/peerj.15167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/13/2023] [Indexed: 04/13/2023] Open
Abstract
Background Idiopathic membranous nephropathy (IMN) is an organ-specific autoimmune disease with multiple and complex pathogenic mechanisms. Currently, renal biopsy is considered the gold standard for diagnosing membranous nephropathy. However, there were limitations to the renal puncture biopsy, such as the relatively high cost, longer time consuming, and the risk of invasive procedures. We investigated the profile of serum metabolites in IMN patients based on the UHPLC-QE-MS metabolomics technique for exploring the potential disease biomarkers and clinical implementation. Methods In our research, we collected serum samples from healthy control (n = 15) and IMN patients (n = 25) to perform metabolomics analysis based on the UHPLC-QE-MS technique. Result We identified 215 differentially expressed metabolites (DEMs) between the IMN and healthy control (HC) groups. Furthermore, these DEMs were significantly identified in histidine metabolism, arginine and proline metabolism, pyrimidine metabolism, purine metabolism, and steroid hormone biosynthesis. Several key DEMs were significantly correlated with the level of clinical parameters, such as serum albumin, IgG, UTP, and cholesterol. Among them, dehydroepiandrosterone sulfate (DHEAS) was considered the reliable diagnostic biomarker in the IMN group. There was an increased abundance of actinobacteria, phylum proteobacteria, and class gammaproteobacterial in IMN patients for host-microbiome origin analysis. Conclusion Our study revealed the profiles of DEMs from the IMN and HC groups. The result demonstrated that there were disorders of amino acids, nucleotides, and steroids hormones metabolism in IMN patients. The down-regulation of DHEAS may be associated with the imbalance of the immune environment in IMN patients. In host-microbiome origin analysis, the gut microbiota and metabolite disturbances were present in IMN patients.
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Affiliation(s)
- Mingjun Ye
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen, Guangdong, China
- Institute of Nephrology and Blood Purification, the First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
| | - Donge Tang
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen, Guangdong, China
| | - Weilong Li
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Chiyu Ma
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen, Guangdong, China
| | - Zhipeng Zeng
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen, Guangdong, China
| | - Shengyou Liao
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen, Guangdong, China
| | - Zhuoheng Song
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Yu Meng
- Institute of Nephrology and Blood Purification, the First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
| | - Fanna Liu
- Institute of Nephrology and Blood Purification, the First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
| | - Shaodong Luan
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen, China
| | - Lianghong Yin
- Institute of Nephrology and Blood Purification, the First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
| | - Yong Dai
- Clinical Medical Research Center, The Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen, Guangdong, China
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Development and validation of a novel nomogram to predict diabetic kidney disease in patients with type 2 diabetic mellitus and proteinuric kidney disease. Int Urol Nephrol 2023; 55:191-200. [PMID: 35870041 DOI: 10.1007/s11255-022-03299-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 07/07/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Differentiating between diabetic kidney disease (DKD) and non-diabetic kidney disease (NDKD) in patients with Type 2 diabetes mellitus (T2DM) is important due to implications on treatment and prognosis. Clinical methods to accurately distinguish DKD from NDKD are lacking. We aimed to develop and validate a novel nomogram to predict DKD in patients with T2DM and proteinuric kidney disease to guide decision for kidney biopsy. METHODS A hundred and two patients with Type 2 Diabetes Mellitus (T2DM) who underwent kidney biopsy from 1st January 2007 to 31st December 2016 were analysed. Univariate and multivariate analyses were performed to identify predictive variables and construct a nomogram. The discriminative ability of the nomogram was assessed by calculating the area under the receiver operating characteristic curve (AUROC), while calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test and calibration plot. Internal validation of the nomogram was assessed using bootstrap resampling. RESULTS Duration of T2DM, HbA1c, absence of hematuria, presence of diabetic retinopathy and absence of positive systemic biomarkers were found to be independent predictors of DKD in multivariate analysis and were represented as a nomogram. The nomogram showed excellent discrimination, with a bootstrap-corrected C statistic of 0.886 (95% CI 0.815-0.956). Both the calibration curve and the Hosmer-Lemeshow goodness-of-fit test (p = 0.242) showed high degree of agreement between the prediction and actual outcome, with the bootstrap bias-corrected curve similarly indicating excellent calibration. CONCLUSIONS A novel nomogram incorporating 5 clinical parameters is useful in predicting DKD in type 2 diabetes mellitus patients with proteinuric kidney disease.
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So BYF, Chan GCW, Yap DYH, Chan TM. The role of the complement system in primary membranous nephropathy: A narrative review in the era of new therapeutic targets. Front Immunol 2022; 13:1009864. [PMID: 36353636 PMCID: PMC9639362 DOI: 10.3389/fimmu.2022.1009864] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 10/12/2022] [Indexed: 11/14/2022] Open
Abstract
Primary membranous nephropathy (MN) is an important cause of nephrotic syndrome and chronic kidney disease (CKD) in the adult population. Although the discovery of different autoantibodies against glomerular/podocytic antigens have highlighted the role of B cells in the pathogenesis of MN, suboptimal response or even resistance to B cell-directed therapies occurs, suggesting that other pathophysiological mechanisms are involved in mediating podocyte injury. The complement system plays an important role in the innate immune response to infection, and dysregulation of the complement system has been observed in various kidney diseases. There is compelling evidence of complement cascade activation in primary MN, with the mannose-binding lectin (MBL) and alternative pathways particularly implicated. With appropriate validation, assays of complements and associated activation products could hold promise as adjunctive tools for non-invasive disease monitoring and prognostication. While there is growing interest to target the complement system in MN, there is concern regarding the risk of infection due to encapsulated organisms and high treatment costs, highlighting the need for clinical trials to identify patients most likely to benefit from complement-directed therapies.
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Huang Y, Zhou J, Zhou K, Huang B, Xue J, Zhang X, Liu B, Zhang Z, Zhou L, Cai T, Zhang Y, Hu Z, Wang L, Liu X. PLA2R-IgG4 antibody as a predictive biomarker of treatment effectiveness and prognostic evaluation in patients with idiopathic membranous nephropathy: a retrospective study. PeerJ 2022; 10:e14193. [PMID: 36248712 PMCID: PMC9559058 DOI: 10.7717/peerj.14193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/15/2022] [Indexed: 01/24/2023] Open
Abstract
Background The Kidney Disease Improving Global Outcomes (KDIGO) 2021 guidelines recommend Rituximab (RTX) as the first-line therapy and phospholipase A2 receptor (PLA2R) antibody as a biomarker for remission and prognosis in patients with idiopathic membranous nephropathy (IMN). Methods This study was a retrospective analysis of 70 patients with IMN treated with either rituximab (RTX) or cyclophosphamide (CTX) and steroid. Quantitative detection of PLA2R-IgG and PLA2R-IgG4 antibodies at sixth month after treatment, determined using time-resolved fluoroimmunoassay (TRFIA), were used for treatment effectiveness analysis and prognostic evaluation in patients with IMN. Results After 12 months of therapy, the remission rate of proteinuria, including complete remission (CR) and partial remission (PR) in the RTX group and the CTX group, were 74% versus 67.5% (P = 0.114), respectively. Both PLA2R-IgG and PLA2R-IgG4 levels were decreased in patients with remission of proteinuria after 6 months of therapy. Receiver operating characteristic curve (ROC) curve analysis exhibited that the AUC of PLA2R-IgG4 and the PLA2R-IgG as laboratory criteria for proteinuria remission were 0.970 versus 0.886 (P = 0.0516), respectively, after 6 months of treatment. The cut-off value of PLA2R-IgG4 was 7.67 RU/mL and the sensitivity and specificity of remission rate at 6th month were 90.9% and 100%, respectively. Furthermore, the AUC of the PLA2R-IgG4 and PLA2R-IgG to predict the outcome after 12 months of treatment were 0.922 versus 0.897 (P = 0.3270), respectively. With the cut-off value of PLA2R-IgG4 being 22.985 RU/mL, the sensitivity and specificity of remission rate at 12th month were 100% and 87.1%, respectively. Logistic regression analysis revealed that the PLA2R-IgG4 level (P = 0.023), the rate of decrease of PLA2R-IgG4 level (P = 0.034), and eGFR level (P = 0.012) were significantly associated with remission. Conclusions We found that the patients in the RTX group and CTX group achieved effective remission of proteinuria after 12 months of treatment. PLA2R-IgG4 may be a more effective biomarker for treatment effectiveness analysis and prognostic assessment, compared with anti-PLA2R-IgG for PLA2R associated IMN.
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Affiliation(s)
- Yiqing Huang
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Junyi Zhou
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Kezhi Zhou
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Biao Huang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Jing Xue
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Xiran Zhang
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Bin Liu
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Zhijian Zhang
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Leting Zhou
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Ting Cai
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Yi Zhang
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, China
| | - Zhigang Hu
- Medical Laboratory, The Affiliated Wuxi Children’s Hospital of Nanjing Medical University, Wuxi, China
| | - Liang Wang
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Xiaobin Liu
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi, China
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Wang B, Zhu Z, Huang F, Huang H, Tu L, Wang Y, Zheng L, Zhou J, Wei X. Anti-phospholipase A2 receptor antibody levels at diagnosis predicts outcome of TAC-based treatment for idiopathic membranous nephropathy patients. BMC Nephrol 2022; 23:306. [PMID: 36068486 PMCID: PMC9450429 DOI: 10.1186/s12882-022-02914-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 08/10/2022] [Indexed: 11/27/2022] Open
Abstract
Background Idiopathic membranous nephropathy (iMN) is recognized as an organ-specific autoimmune disease, mainly caused by anti-PLA2R antibody. This study aimed to study between anti-PLA2R antibody level at diagnosis and the response to tacrolimus (TAC)-based treatment in iMN patients. Methods This was a retrospective cohort study including 94 kidney biopsy-proven MN patients with positive anti-PLA2R antibody at diagnosis from May 2017 to September 2021 in our center. All iMN patients received the TAC regimen as the initial immunosuppressive therapy. All patients were divided into two groups according to anti-PLA2R antibody titer at diagnosis: high-level group (> 150 RU/ml; n = 42) and low-level group (≤ 150 RU/ml; n = 52). The association between anti-PLA2R antibody levels and clinical outcomes was assessed using the Kaplan–Meier method. Results The low density lipoprotein in the high-level group was significantly higher than low-level group at diagnosis, otherwise, serum albumin was significantly lower than low-level group; however, there was no significant difference in creatinine levels between two groups. The remission rates were significantly higher in the low-level group than high-level group after treatment with TAC for 12, 18, or 24 months (all P < 0.05). After 12 months of treatment with TAC, 82.7% of the patients in the low-level group achieved complete remission (CR) or partial remission (PR) (mean, 6.52 ± 0.53 months). However, 38.1% of the patients in high-level group achieved CR or PR (mean, 9.86 ± 0.51 months). Moreover, CR rate at 12 months in the high-level group was only 4.7% (mean, 11.88 ± 0.63 months). The infection frequency in the high-level group (35.6%) was higher than the low-level group (20%) during the TAC treatment, although there was no significant difference (P = 0.065). There were 19% patients who had end-stage kidney disease (ESKD), and 7.1% of patients died of ESKD in the high-level group during the follow-up period. Conclusion Anti-PLA2R antibody level above 150 RU/ml at diagnosis can predict a poor treatment response and outcome of TAC treatment in iMN patients, who may not benefit from TAC or other calcineurin inhibitor regimens as the initial treatment.
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Affiliation(s)
- Bihua Wang
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, 17 Yongwai Zhengjie, Nanchang City, 330006, Jiangxi, China.,Nanchang University, Nanchang City, 330006, China
| | - Zhidan Zhu
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, 17 Yongwai Zhengjie, Nanchang City, 330006, Jiangxi, China.,Nanchang University, Nanchang City, 330006, China
| | - Feng Huang
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, 17 Yongwai Zhengjie, Nanchang City, 330006, Jiangxi, China.,Nanchang University, Nanchang City, 330006, China
| | - Haowen Huang
- Department of Nephrology, People's Hospital of Ganjiang New District, Nanchang City, 330006, Jiangxi, China
| | - Luxia Tu
- Pathology Department, The First Affiliated Hospital of Nanchang University, Nanchang City, China
| | - Ying Wang
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, 17 Yongwai Zhengjie, Nanchang City, 330006, Jiangxi, China
| | - Linfeng Zheng
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, 17 Yongwai Zhengjie, Nanchang City, 330006, Jiangxi, China
| | - Jing Zhou
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, 17 Yongwai Zhengjie, Nanchang City, 330006, Jiangxi, China
| | - Xin Wei
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, 17 Yongwai Zhengjie, Nanchang City, 330006, Jiangxi, China.
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Luo J, Yuan Y, Tian J, Zhou Z, Su C, Yang F, Wang G. Clinicopathological Characteristics and Outcomes of PLA 2R-Associated Membranous Nephropathy in Seropositive Patients Without PLA 2R Staining on Kidney Biopsy. Am J Kidney Dis 2022; 80:364-372. [PMID: 35288217 DOI: 10.1053/j.ajkd.2022.01.426] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/05/2022] [Indexed: 01/27/2023]
Abstract
RATIONALE & OBJECTIVE Phospholipase A2 receptor (PLA2R)-associated membranous nephropathy (MN) with circulating serum autoantibodies to PLA2R (SAb+) but no deposits of PLA2R antigen in glomerular tissue by immunofluorescence (GAg-) has been reported. However, little is known about the clinicopathological characteristics or prognosis of this subtype of MN. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS 130 SAb+ patients in China with biopsy-proven MN who had follow-up data and received immunosuppressive therapy. The median follow-up was 16 (IQR, 9-25) months. PREDICTOR PLA2R antigen detection by immunofluorescence staining of kidney biopsy specimens. OUTCOMES Complete remission (CR) was defined as proteinuria levels <0.3 g/d and a >50% decrease compared with a previously established baseline. Partial remission (PR) was defined as proteinuria levels <3.5 g/d and a >50% decrease compared with a previously established baseline. The kidney function outcome was defined as a >40% decrease in estimated glomerular filtration rate (eGFR) at the end of the study compared with baseline. ANALYTICAL APPROACH Kaplan-Meier analysis of PR and CR comparing SAb+/GAg+ and SAb+/GAg- patients. Cox proportional hazards models to examine these associations were adjusted for confounders. RESULTS Among 130 SAb+ patients with PLA2R-associated MN, 18 were GAg-. Compared with SAb+/GAg+ patients, those who were SAb+/GAg- presented with more severe kidney injury as evidenced by higher SAb titer, greater proteinuria, lower serum albumin concentrations, lower eGFR (all P < 0.05), and more severe disease with higher chronicity scores (P < 0.001) on kidney biopsies. SAb+/GAg- patients exhibited a significantly lower probability of PR (P < 0.001) and CR (P = 0.03) and were more likely to experience a >40% decrease in eGFR (P = 0.008) than patients who were SAb+/GAg+. After adjusting for clinical and pathologic variables available at the time of biopsy, compared with SAb+/GAg+ patients, SAb+/GAg- patients had a lower rate of experiencing remission (hazard ratio, 0.32 [95% CI, 0.15-0.68]; P = 0.003) and a higher rate of the >40% eGFR decrease outcome (hazard ratio, 7.66 [95% CI, 1.54-38.08]; P = 0.01). LIMITATIONS Retrospective study, small sample size, and lack of a uniform approach to treatment. CONCLUSIONS Seropositive PLA2R-associated MN without PLA2R staining on kidney biopsy may represent a distinct clinical subtype with more severe disease and a worse prognosis. GAg- is independently associated with poor response to treatment and >40% eGFR decrease in seropositive PLA2R-associated MN.
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Affiliation(s)
- Jiao Luo
- Renal Division, Nanfang Hospital, Southern Medical University, The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou, China
| | - Ye Yuan
- Renal Division, Nanfang Hospital, Southern Medical University, The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou, China
| | - Jianwei Tian
- Renal Division, Nanfang Hospital, Southern Medical University, The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou, China
| | - Zhanmei Zhou
- Renal Division, Nanfang Hospital, Southern Medical University, The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou, China
| | - Cailing Su
- Renal Division, Nanfang Hospital, Southern Medical University, The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou, China
| | - Fang Yang
- Renal Division, Nanfang Hospital, Southern Medical University, The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou, China
| | - Guobao Wang
- Renal Division, Nanfang Hospital, Southern Medical University, The National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Guangdong Provincial Clinical Research Center for Kidney Disease, Guangzhou, China.
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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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Wang T, Yu W, Wu F, Zhang Y, Shang J, Zhao Z. Construction of a Nomogram Discriminating Malignancy-Associated Membranous Nephropathy From Idiopathic Membranous Nephropathy: A Retrospective Study. Front Oncol 2022; 12:914092. [PMID: 35912251 PMCID: PMC9329587 DOI: 10.3389/fonc.2022.914092] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/23/2022] [Indexed: 11/17/2022] Open
Abstract
Background Based on the etiology, membranous nephropathy (MN) can be categorized into idiopathic membranous nephropathy (IMN) and secondary membranous nephropathy. Malignancy-associated membranous nephropathy (MMN) is a common type of secondary MN. Its incidence is only second to that of lupus nephritis. As the treatment and prognosis of MMN differ significantly from those of other MNs, the identification of MMN is crucial for clinical practice. The purpose of this study was to develop a model that could efficiently discriminate MMN, to guide more precise selection of therapeutic strategies. Methods A total of 385 with IMN and 62 patients with MMN, who were hospitalized at the First Affiliated Hospital of Zhengzhou University between January 2017 and December 2020 were included in this study. We constructed a discriminant model based on demographic information and laboratory parameters for distinguishing MMN and IMN. To avoid an increased false positivity rate resulting from the large difference in sample numbers between the two groups, we matched MMN and IMN in a 1:3 ratio according to gender. Regression analysis was subsequently performed and a discriminant model was constructed. The calibration ability and clinical utility of the model were assessed via calibration curve and decision curve analysis. Results We constructed a discriminant model based on age, CD4+ T cell counts, levels of cystatin C, albumin, free triiodothyronine and body mass index, with a diagnostic power of 0.860 and 0.870 in the training and test groups, respectively. The model was validated to demonstrate good calibration capability and clinical utility. Conclusion In clinical practice, patients demonstrating higher scores after screening with this model should be carefully monitored for the presence of tumors in order to improve their outcome.
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Affiliation(s)
- Ting Wang
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wei Yu
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Feng Wu
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yiding Zhang
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jin Shang
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Laboratory Animal Platform of Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
- *Correspondence: Zhanzheng Zhao, ; Jin Shang,
| | - Zhanzheng Zhao
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- Laboratory Animal Platform of Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
- *Correspondence: Zhanzheng Zhao, ; Jin Shang,
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Dong L, Li YQ, Guo SM, Xu G, Wei W, Han M. Hypercholesterolemia Correlates With Glomerular Phospholipase A2 Receptor Deposit and Serum Anti-Phospholipase A2 Receptor Antibody and Predicts Proteinuria Outcome in Idiopathic Membranous Nephropathy. Front Immunol 2022; 13:905930. [PMID: 35784308 PMCID: PMC9248763 DOI: 10.3389/fimmu.2022.905930] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background The anti-phospholipase A2 receptor (PLA2R) antibody is a non-invasive diagnostic tool and prognosis predictor of idiopathic membranous nephropathy (IMN). Baseline hypercholesterolemia independently predicts proteinuria outcomes in IMN patients. Thus, we investigated whether hyperlipidemia is correlated with anti-PLA2R and pathological indicators. Methods A total of 495 IMN patients identified by kidney biopsy in Wuhan Tongji Hospital, China, from January 2016 through December 2020 were enrolled in this study. Data on clinical features, pathology findings, and outcomes were collected. Results Total cholesterol (TC), non-high-density lipoprotein cholesterol (non-HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglyceride (TG) were positively related to proteinuria, indicating damage to the renal glomerulus [Spearman’s rank correlation coefficient = 0.432, 0.462, 0.315, and 0.289, respectively, P < 0.001 for all]. In univariate logistic regression, low HDL-C [odds ratio (OR): 0.856; 95% CI: 0.778–0.939; P = 0.001] and high TG [OR: 1.025; 95% CI: 1.006–1.044; P = 0.011] were correlated with tubular atrophy, suggesting lesions on tubules. Increased TC [adjusted OR: 1.285; 95% CI: 1.119–1.475; P < 0.001], non-HDL-C [adjusted OR: 1.284; 95% CI: 1.113–1.482; P = 0.001], and LDL-C [adjusted OR: 1.178; 95% CI: 1.009–1.376; P = 0.039] independently predicted glomerular PLA2R deposit; similar results were observed for lipids in predicting the seropositivity of anti-PLA2R antibodies. After treatment, increased HDL-C [adjusted hazard ratio (HR): 1.764; 95% CI: 1.241–2.507; P = 0.002] and decreased non-HDL-C [adjusted HR: 0.884; 95% CI: 0.795–0.983; P = 0.022] independently predicted proteinuria remission. Conclusion Hypercholesterolemia is a potentially useful biomarker for disease severity, serum anti-PLA2R antibody, glomerular PLA2R deposit, and proteinuria outcome of IMN.
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Affiliation(s)
- Lei Dong
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue-Qiang Li
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shui-Ming Guo
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Xu
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wang Wei
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Han
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Wu M, Chen Y, Chiu I, Wu M. Genetic Insight into Primary Glomerulonephritis. Nephrology (Carlton) 2022; 27:649-657. [DOI: 10.1111/nep.14074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/18/2022] [Accepted: 06/06/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Mei‐Yi Wu
- Division of Nephrology, Department of Internal Medicine Taipei Medical University‐Shuang Ho Hospital New Taipei City Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine Taipei Medical University Taipei Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health National Taiwan University Taipei Taiwan
- TMU Research Center of Urology and Kidney Taipei Medical University Taipei Taiwan
| | - Ying‐Chun Chen
- Division of Nephrology, Department of Internal Medicine Taipei Medical University‐Shuang Ho Hospital New Taipei City Taiwan
| | - I‐Jen Chiu
- Division of Nephrology, Department of Internal Medicine Taipei Medical University‐Shuang Ho Hospital New Taipei City Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine Taipei Medical University Taipei Taiwan
- TMU Research Center of Urology and Kidney Taipei Medical University Taipei Taiwan
| | - Mai‐Szu Wu
- Division of Nephrology, Department of Internal Medicine Taipei Medical University‐Shuang Ho Hospital New Taipei City Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine Taipei Medical University Taipei Taiwan
- TMU Research Center of Urology and Kidney Taipei Medical University Taipei Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine Taipei Medical University Taipei Taiwan
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Sethi S, Madden B, Casal Moura M, Nasr SH, Klomjit N, Gross L, Negron V, Charlesworth MC, Alexander MP, Leung N, Specks U, Fervenza FC, Haas M. Hematopoietic Stem Cell Transplant-Membranous Nephropathy Is Associated with Protocadherin FAT1. J Am Soc Nephrol 2022; 33:1033-1044. [PMID: 35321939 PMCID: PMC9063902 DOI: 10.1681/asn.2021111488] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/25/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Membranous nephropathy (MN) is a common cause of proteinuria in patients receiving a hematopoietic stem cell transplant (HSCT). The target antigen in HSCT-associated MN is unknown. METHODS We performed laser microdissection and tandem mass spectrometry (MS/MS) of glomeruli from 250 patients with PLA2R-negative MN to detect novel antigens in MN. This was followed by immunohistochemical (IHC)/immunofluorescence (IF) microscopy studies to localize the novel antigen. Western blot analyses using serum and IgG eluted from frozen biopsy specimen to detect binding of IgG to new 'antigen'. RESULTS MS/MS detected a novel protein, protocadherin FAT1 (FAT1), in nine patients with PLA2R-negative MN. In all nine patients, MN developed after allogeneic HSCT (Mayo Clinic discovery cohort). Next, we performed MS/MS in five patients known to have allogeneic HSCT-associated MN (Cedar Sinai validation cohort). FAT1 was detected in all five patients by MS/MS. The total spectral counts for FAT1 ranged from 8 to 39 (mean±SD, 20.9±10.1). All 14 patients were negative for known antigens of MN, including PLA2R, THSD7A, NELL1, PCDH7, NCAM1, SEMA3B, and HTRA1. Kidney biopsy specimens showed IgG (2 to 3+) with mild C3 (0 to 1+) along the GBM; IgG4 was the dominant IgG subclass. IHC after protease digestion and confocal IF confirmed granular FAT1 deposits along the GBM. Lastly, Western blot analyses detected anti-FAT1 IgG and IgG4 in the eluate obtained from pooled frozen kidney biopsy tissue and in the serum of those with FAT1-asssociated MN, but not from those with PLA2R-associated MN. CONCLUSIONS FAT1-associated MN appears to be a unique type of MN associated with HSCT. FAT1-associated MN represents a majority of MN associated with HSCT.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Benjamin Madden
- Medical Genome Facility, Proteomics Core, Mayo Clinic, Rochester, Minnesota
| | - Marta Casal Moura
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Samih H. Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Nattawat Klomjit
- Division of Nephrology and Hypertension, Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - LouAnn Gross
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Vivian Negron
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | | | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - Ulrich Specks
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Mark Haas
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
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Suthar KS, Vanikar AV, Patel RD, Kanodia KV, Nigam LA, Gandhi PA, Mehta AH. Anti-phospholipase A2 Receptor Antibody in Differentiation and Prognostication of Membranous Nephropathy. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:280-287. [PMID: 37417180 DOI: 10.4103/1319-2442.379026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023] Open
Abstract
Anti-M-type phospholipase A2 receptor (anti-PLA2R) antibody is believed to be associated with primary membranous nephropathy (pMN) and absent in secondary MN (sMN). There are few data regarding utility of anti-PLA2R antibody as a prognosticator. Our study aimed to compare the incidence of positive serum anti-PLA2R antibody titer in pMN versus sMN and correlation with clinical outcome. From August 2015 to July 2019, patients with biopsy-proven MN were evaluated for serum anti-PLA2R antibody titers by the enzyme-linked immunosorbent assay. The subset of cases was repeated to monitor the clinical response in terms of 24 h proteinuria. A total of 169 patients, 65 pMN and 104 sMN were studied. Anti-PLA2R antibody was found in 41 (63.08%) pMN with mean titer, 232.62 RU/mL, and 40 (38.46%) sMN with mean titer 253.59 RU/mL. Out of positive antiPLA2R antibody titer in pMN cases, 15 were retested twice to 5 times with mean titers of 78.95, 36.27, 13.9, and 15.45 RU/mL, respectively. Out of positive anti-PLA2R antibody in sMN cases, 11 were retested twice to five times with mean titers of 104.42, 122.49, 12.33, and 17.2 RU/mL, respectively. All patients with decreasing anti-PLA2R antibody titer in both groups had clinical remission, with a decrease in mean 24 h proteinuria from 7.11 g to 3.36 g in pMN and 5.97 g to 3.41 g in sMN. Ten pMN and 11 sMN patients without remission showed persistent positive anti- PLA2R antibody titer. Anti-PLA2R antibody titer may be elevated in pMN/sMN. It can also be used as a noninvasive prognostic marker for MN.
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Affiliation(s)
- Kamlesh S Suthar
- Department of Pathology, Lab Medicine, Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, India
| | - Aruna V Vanikar
- Department of Pathology, Lab Medicine, Transfusion Services and Immunohematology; Department of Regenerative Medicine and Cell Therapy, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, India
| | - Rashmi D Patel
- Department of Pathology, Lab Medicine, Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, India
| | - Kamal V Kanodia
- Department of Pathology, Lab Medicine, Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, India
| | - Lovelesh A Nigam
- Department of Pathology, Lab Medicine, Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, India
| | - Paulin A Gandhi
- Department of Pathology, Lab Medicine, Transfusion Services and Immunohematology, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, India
| | - Aanal H Mehta
- Department of Bio-Statistics, G. R. Doshi and K. M. Mehta Institute of Kidney Diseases and Research Center and Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, India
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Stefan G, Stancu S, Zugravu A, Popa O, Zubidat D, Petre N, Mircescu G. Negative anti-phospholipase A2 receptor antibody status at three months predicts remission in primary membranous nephropathy. Ren Fail 2022; 44:258-268. [PMID: 35172682 PMCID: PMC8863379 DOI: 10.1080/0886022x.2022.2033265] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background The value of anti-phospholipase A2 receptor antibody (anti-PLA2R ab) monitoring at 3 months after diagnosis in membranous nephropathy (MN) remains uncertain. Methods We retrospectively examined the outcome on 1 August 2020 of 59 adult patients (age 54 (44, 68) years, 69% male, SCr 1.0 (0.9, 1.3) mg/dL) diagnosed with MN (kidney biopsy, positive serum anti-PLA2R ab). The outcomes were: kidney survival; partial and/or complete remission. Results Most of the studied patients (97%) received immunosuppression, cyclophosphamide regimens were the most frequent (87%), followed by cyclosporine (10%). The median time to remission was 12.0 months and the cumulative remission rates were 34% at 6, 54% at 12, and 73% at 24 months. Forty (69%) patients had negative anti-PLA2R ab at 3 months, they had similar age, serum creatinine, albumin, proteinuria, and treatment with the group with positive ab at 3 months. In the Cox proportional hazard model, three months anti-PLA2R ab negativization (HR 0.4 (95%CI 0.1, 0.9)) was an independent predictor for remission, while baseline hypoalbuminemia (HR 3.0 (95%CI 1.5, 5.7)) was associated with absence of remission. Six (10%) patients died, mostly due to cardiovascular disease and infections. A total of five (9%) patients started dialysis. Mean kidney survival time was 50.3 months and there was no survival difference in relation to baseline anti-PLA2R ab titer (p .09) or 3 months negativization (p .8). Conclusions Three months anti-PLA2R ab negativization seems to be a late predictor of remission, and lower serum albumin at diagnosis is an early marker for remission absence. Abbreviations: anti-P LA2R ab, anti-phospholipase A2 receptor antibody; eGFR, estimated glomerular filtration rate; ESKD, end stage kidney disease; MN, membranous nephropathy; NELL-1, neural epidermal growth factor-like 1 protein; RAAS: renin–angiotensin–aldosterone system; RBC: red blood cells; RRT, renal replacement therapy; T HSD7A, thrombospondin type-1 domain containing 7A
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Affiliation(s)
- Gabriel Stefan
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Simona Stancu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Adrian Zugravu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Otilia Popa
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Dalia Zubidat
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Nicoleta Petre
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gabriel Mircescu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
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Deng ZL, Yang WL, Zhao XY, Tang ZY, Zheng DX, Wang Y. Simultaneous subacute interstitial nephritis and anticoagulant-related nephropathy related to novel oral anticoagulants use. Ren Fail 2022; 44:30-33. [PMID: 35086437 PMCID: PMC8803099 DOI: 10.1080/0886022x.2021.2014338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Introduction: Interstitial nephritis related to novel oral anticoagulants was only reported in sporadic case reports and none was accompanied by anticoagulants related nephropathy (ARN).Case Report: We presented here a case of biopsy-proven subacute interstitial nephritis (SubAIN) accompanied by ARN after oral dabigatran to alarm clinicians. This case manifested with gross hematuria, acute kidney injury, slightly prolonged thrombin time, moderate anemia, moderate proteinuria, a large quantity of intratubular hemoglobin casts confirmed by hemoglobin antibody immunohistochemical staining which presumed to occur around 1 week after dabigatran and subacute interstitial nephritis accompanied by focal proliferative glomerulonephritis. Serum creatinine level did not continue to elevate after discontinuation of the oral anticoagulant. With the subsequent supportive therapy, it decreased to some extent then reduced to normal with the help of prednisone (half of the full dose).Conclusions: When we came across a patient who manifested as hematuria or acute kidney injury with a history of anticoagulants usage, we should think of ARN and pay more attention on history collection. Secondly, subacute interstitial nephritis may coexist with ARN. Thirdly, hemoglobin immunohistochemical staining may be helpful to make it clear whether the intra-tubular protein casts came from red blood cells. In addition, for those patients who may have decreased kidney function, anticoagulants dose should be reduced to prevent the occurrence of ARN.
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Affiliation(s)
- Zhen-Ling Deng
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Wen-Ling Yang
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Xin-Yue Zhao
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Zi-Yong Tang
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Dan-Xia Zheng
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Yue Wang
- Department of Nephrology, Peking University Third Hospital, Beijing, China
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Dong Z, Dai H, Liu W, Jiang H, Feng Z, Liu F, Zhao Q, Rui H, Liu WJ, Liu B. Exploring the Differences in Molecular Mechanisms and Key Biomarkers Between Membranous Nephropathy and Lupus Nephritis Using Integrated Bioinformatics Analysis. Front Genet 2022; 12:770902. [PMID: 35047003 PMCID: PMC8762271 DOI: 10.3389/fgene.2021.770902] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 12/06/2021] [Indexed: 01/16/2023] Open
Abstract
Background: Both membranous nephropathy (MN) and lupus nephritis (LN) are autoimmune kidney disease. In recent years, with the deepening of research, some similarities have been found in the pathogenesis of these two diseases. However, the mechanism of their interrelationship is not clear. The purpose of this study was to investigate the differences in molecular mechanisms and key biomarkers between MN and LN. Method: The expression profiles of GSE99325, GSE99339, GSE104948 and GSE104954 were downloaded from GEO database, and the differentially expressed genes (DEGs) of MN and LN samples were obtained. We used Gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) for enrichment analysis of DEGs. A protein-protein interaction (PPI) network of DEGs was constructed using Metascape. We filtered DEGs with NetworkAnalyst. Finally, we used receiver operating characteristic (ROC) analysis to identify the most significant DEGs for MN and LN. Result: Compared with LN in the glomerulus, 14 DEGs were up-regulated and 77 DEGs were down-regulated in MN. Compared with LN in renal tubules, 21 DEGs were down-regulated, but no up-regulated genes were found in MN. According to the result of GO and KEGG enrichment, PPI network and Networkanalyst, we screened out six genes (IFI6, MX1, XAF1, HERC6, IFI44L, IFI44). Interestingly, among PLA2R, THSD7A and NELL1, which are the target antigens of podocyte in MN, the expression level of NELL1 in MN glomerulus is significantly higher than that of LN, while there is no significant difference in the expression level of PLA2R and THSD7A. Conclusion: Our study provides new insights into the pathogenesis of MN and LN by analyzing the differences in gene expression levels between MN and LN kidney samples, and is expected to be used to prepare an animal model of MN that is more similar to human.
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Affiliation(s)
- Zhaocheng Dong
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Renal Research Institution of Beijing University of Chinese Medicine, and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Haoran Dai
- Shunyi Branch, Beijing Traditional Chinese Medicine Hospital, Beijing, China
| | - Wenbin Liu
- Beijing University of Chinese Medicine, Beijing, China
| | - Hanxue Jiang
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Zhendong Feng
- Beijing Chinese Medicine Hospital Pinggu Hospital, Beijing, China
| | - Fei Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Beijing University of Chinese Medicine, Beijing, China
| | - Qihan Zhao
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Capital Medical University, Beijing, China
| | - Hongliang Rui
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Wei Jing Liu
- Renal Research Institution of Beijing University of Chinese Medicine, and Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Baoli Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.,Shunyi Branch, Beijing Traditional Chinese Medicine Hospital, Beijing, China
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Ronco P, Plaisier E, Debiec H. The role of PLA2R antibody monitoring: what we know and what we don't know. Nephrol Dial Transplant 2021; 38:826-833. [PMID: 34910212 DOI: 10.1093/ndt/gfab356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Indexed: 11/14/2022] Open
Abstract
For a long time, kidney biopsy was the only diagnostic mean for membranous nephropathy (MN), and proteinuria and serum creatinine the only markers of disease activity. The discovery of PLA2R antibody in 2009 has induced a paradigm shift in both the diagnostic and monitoring of patients. Two serological tests are routinely used: the ELISA which is quantitative and the immunofluorescence assay (IFA) which is more sensitive. In centers where the 2 assays are available, the recommendation is to use IFA for screening and diagnostic of immunological remission, and ELISA for monitoring effectiveness of therapy. In patients with positive PLA2R antibody serology, normal kidney function and no evidence for an underlying disease, a kidney biopsy is not mandatory given the almost 100% specificity of the assays. Because MN has different phases, one cannot base a clinical or therapeutic decision on a single measurement of PLA2R antibody at baseline. Risk evaluation of disease progression is a dynamic process that should be performed repeatedly to capture the trajectory of the disease based on both the traditional biomarkers (proteinuria, serum creatinine) and PLA2R antibody levels. Effectiveness of therapy is also evaluated on the PLA2R antibody trajectory, particularly during the first 6 months. Finally, PLA2R antibody monitoring has transformed the management of patients with a kidney allograft. Future studies are needed to develop more subtle immunological tests, including monitoring of antigen-specific memory B cells.
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Affiliation(s)
- Pierre Ronco
- Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
- Sorbonne Université, and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1155, Paris, France
| | - Emmanuelle Plaisier
- Sorbonne Université, and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1155, Paris, France
- Department of Nephrology, AURA Paris Plaisance, Paris, France
| | - Hanna Debiec
- Sorbonne Université, and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1155, Paris, France
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Ronco P, Plaisier E. Time to Abandon Kidney Biopsy to Diagnose Membranous Nephropathy? Clin J Am Soc Nephrol 2021; 16:1787-1789. [PMID: 34782362 PMCID: PMC8729492 DOI: 10.2215/cjn.11180821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Pierre Ronco
- Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France,Unité Mixte de Recherche S1155, Sorbonne Université and Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Emmanuelle Plaisier
- Unité Mixte de Recherche S1155, Sorbonne Université and Institut National de la Santé et de la Recherche Médicale, Paris, France,Department of Nephrology, Association pour l'Utilisation du Rein Artificiel Paris Plaisance, Paris, France
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50
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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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