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Membranous nephropathy: new pathogenic mechanisms and their clinical implications. Nat Rev Nephrol 2022; 18:466-478. [PMID: 35484394 DOI: 10.1038/s41581-022-00564-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 12/24/2022]
Abstract
Membranous nephropathy (MN) is characterized histomorphologically by the presence of immune deposits in the subepithelial space of the glomerular filtration barrier; its clinical hallmarks are nephrotic range proteinuria with oedema. In patients with primary MN, autoimmunity is driven by circulating autoantibodies that bind to one or more antigens on the surface of glomerular podocytes. Compared with other autoimmune kidney diseases, the understanding of the pathogenesis of MN has substantially improved in the past decade, thanks to the discovery of pathogenic circulating autoantibodies against phospholipase A2 receptor 1 (PLA2R1) and thrombospondin type 1 domain-containing protein 7A (THSD7A). The subsequent identification of more proteins associated with MN, some of which are also endogenous podocyte antigens, might further advance the clinical characterization of MN, including its diagnosis, treatment and prognosis. Insights from studies in patients with MN, combined with the development of novel in vivo and in vitro experimental models, have potential to improve the management of patients with MN. Characterizing the interaction between autoimmunity and local glomerular lesions provides an opportunity to develop more specific, pathogenesis-based treatments.
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Huang L, Zhao YJ, Dong QR, Hu GC. A study of altered calcium sensing system caused primary membranous nephropathy to end-stage renal failure. Biomed Pharmacother 2021; 141:111777. [PMID: 34246186 DOI: 10.1016/j.biopha.2021.111777] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 10/20/2022] Open
Abstract
PMN (primary membranous nephropathy) is the most prevalent source of idiopathic nephrotic syndrome, which further progressed to ESRD (end-stage renal disease) in non-diabetic adults worldwide. Autoantibodies circulating against podocyte membrane proteins PLA2R1 and THSD7A are present in approximately 75-80% of incidents. Furthermore, a research presented an unusual case of IgG4-RD correlated with elevated serum levels of calcium concluded that renal irregularities have been preceded and triggered by hypercalcemia. In-addition, previous research also indicates an elevated amount of calcium in the blood of PMN patients. However, we also found conflicting evidence from previous studies showing that autoantibodies that suppress the calcium-sensing receptor (CaSR) induce a high level of calcium in some cases of IgG4RD. Notably, the calcium ion plays a critical function not only as intracellular signaling molecule but binds extracellular receptor activity to intracellular events. Moreover, the raise in intracellular calcium levels during PMN is known as a crucial event involved in the activation of numerous nucleases, proteases and implicitly facilitates the release of prostaglandins, cytokines and superoxide radicals capable of causing cell damage and death. Thus, the precise mechanism of the PMN disease to renal failure is not fully clear and the disease incidence differs among patients. Therefore, we are hypothesizing the role of disrupted calcium signaling in PMN that progress to ESRD.
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Affiliation(s)
- Lan Huang
- Division of Nephrology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China.
| | - Ya-Juan Zhao
- Division of Nephrology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Qiao-Rong Dong
- Division of Nephrology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
| | - Gui-Cai Hu
- Division of Nephrology, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, China
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Hanset N, Aydin S, Demoulin N, Cosyns JP, Castanares-Zapatero D, Crott R, Cambier JF, Pochet JM, Gillerot G, Reginster F, Houssiau F, Debiec H, Ronco P, Jadoul M, Morelle J. Podocyte Antigen Staining to Identify Distinct Phenotypes and Outcomes in Membranous Nephropathy: A Retrospective Multicenter Cohort Study. Am J Kidney Dis 2020; 76:624-635. [PMID: 32668319 DOI: 10.1053/j.ajkd.2020.04.013] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/08/2020] [Indexed: 12/15/2022]
Abstract
RATIONALE & OBJECTIVE Membranous nephropathy (MN) is characterized by the deposition of immune complexes along glomerular basement membranes. M-Type phospholipase A2 receptor (PLA2R), thrombospondin type 1 domain-containing 7A (THSD7A), exostosin 1 and 2 (EXT1/2), and neural epidermal growth factor-like 1 protein (NELL-1) have been identified as established or potential podocyte antigens in MN. We investigated the association of podocyte antigen staining with MN clinical phenotype and outcomes. STUDY DESIGN Multicenter retrospective cohort study. SETTING & PARTICIPANTS 177 consecutive patients with MN unrelated to lupus erythematosus, identified after screening of 3,875 native kidney biopsies performed in the Belgian UCLouvain Kidney Disease Network from 2000 through 2018. PREDICTOR Positive immunostaining for podocyte antigens on archived kidney biopsy samples. OUTCOMES Association with different phenotypes (baseline characteristics of patients and pathologic findings on kidney biopsy), time to cancer and to kidney failure. ANALYTICAL APPROACH Kaplan-Meier estimates and Cox regression analyses to assess time to cancer and kidney failure. RESULTS 177 patients were followed up for a median of 4.0 (IQR, 1.3-8.0) years. Diagnosis of PLA2R-positive (PLA2R+), THSD7A+, and double-negative (PLA2R-/THSD7A-) MN was made in 117 (66.1%), 6 (3.4%), and 54 (30.5%) patients, respectively. Progression to kidney failure was similar in all groups. Although the number of patients with THSD7A+MN was small, they showed a higher incidence (50%) and increased risk for developing cancer during follow-up (adjusted HR, 5.0 [95% CI, 1.4-17.9]; P=0.01). 8% and 5% of patients with double-negative MN stained positively for EXT1/2 and NELL-1, respectively. Most patients with EXT1/2+MN were women, had features of systemic autoimmunity, and showed glomerular C1q deposits. LIMITATIONS Retrospective design; small number of patients in the THSD7A group; lack of evaluation of immunoglobulin G subclasses deposition. CONCLUSIONS Our real-world data describe the relative prevalence of subgroups of MN and support the hypothesis that a novel classification of MN based on podocyte antigen staining may be clinically relevant.
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Affiliation(s)
- Nicolas Hanset
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Selda Aydin
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium; Department of Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Nathalie Demoulin
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Jean-Pierre Cosyns
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium; Department of Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | | | - Ralph Crott
- Consultant in Biostatistics, Colombiers, France
| | | | - Jean-Michel Pochet
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Centre Hospitalier Universitaire UCLouvain-Namur, Namur, Belgium
| | | | | | - Frédéric Houssiau
- Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium; Division of Rheumatology, Cliniques universitaires Saint-Luc, Brussels, Belgium
| | - Hanna Debiec
- Sorbonne Université, Université Pierre et Marie Curie Paris 06, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Paris, France
| | - Pierre Ronco
- Sorbonne Université, Université Pierre et Marie Curie Paris 06, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Paris, France; Assistance Publique-Hôpitaux de Paris, Hôpital de Jour de Néphrologie, Hôpital Tenon, Paris, France
| | - Michel Jadoul
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium; Institut de Recherche Expérimentale et Clinique, UCLouvain, Brussels, Belgium.
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Abstract
PURPOSE OF REVIEW Continuous expansion of our knowledge in the pathogenesis of membranous nephropathy possible by the identification of antibodies recognized specific podocytes antigens results in unprecedent patient management strategy. RECENT FINDINGS Circulating anti-phospholipase A2 receptor (PLA2R) and anti-thrombospondin domain 7A (THSD7A) antibodies strongly relate with the modifications of podocytes biology leading to the new molecular diagnosis of membranous nephropathy. Immunization against THSD7A involves extra-renal mechanism. However, the pathway of anti-PLA2R immunization still remains unresolved. Experimental data highlight the crucial role of THSD7A in the attachment of podocytes to the glomerular basement membrane, rewarding the THSD7A pathogenicity, whereas the third of Koch's postulates is still not fulfilled for anti-PLA2R antibodies. The anti-PLA2R antibodies epitope spreading will possibly be even more specific marker improving the molecular classification of membranous nephropathy. Two immune epitopes have been identified in the N-terminal tail of THSD7A but without evidence of epitope spreading as for anti-PLA2R. SUMMARY In 2019, the Kidney Diseases: Improving Global Outcomes guidelines recognized anti-PLA2R antibodies (but not anti-THSD7A antibodies) as a valuable molecular risk factor for the pejorative evolution of kidney function and recommended their monitoring for the diagnosis and the assessment of membranous nephropathy immune activity. Screening for malignancy is particularly advised in THSD7A-mediated membranous nephropathy.
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Zipfel PF, Wiech T, Rudnick R, Afonso S, Person F, Skerka C. Complement Inhibitors in Clinical Trials for Glomerular Diseases. Front Immunol 2019; 10:2166. [PMID: 31611870 PMCID: PMC6776600 DOI: 10.3389/fimmu.2019.02166] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Accepted: 08/28/2019] [Indexed: 01/16/2023] Open
Abstract
Defective complement action is a cause of several human glomerular diseases including atypical hemolytic uremic syndrome (aHUS), anti-neutrophil cytoplasmic antibody mediated vasculitis (ANCA), C3 glomerulopathy, IgA nephropathy, immune complex membranoproliferative glomerulonephritis, ischemic reperfusion injury, lupus nephritis, membranous nephropathy, and chronic transplant mediated glomerulopathy. Here we summarize ongoing clinical trials of complement inhibitors in nine glomerular diseases and show which inhibitors are used in trials for these renal disorders (http://clinicaltrials.gov).
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Affiliation(s)
- Peter F Zipfel
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany.,Friedrich-Schiller-University, Jena, Germany
| | - Thorsten Wiech
- Institute of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Ramona Rudnick
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Sara Afonso
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
| | - Fermin Person
- Institute of Pathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Skerka
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Jena, Germany
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Abstract
The global burden of chronic kidney disease will increase during the next century. As NFκB, first described more than 30 years ago, plays a major role in immune and non-immune-mediated diseases and in inflammatory and metabolic disorders, this review article summarizes current knowledge on the role of NFκB in in vivo kidney injury and describes the new and so far not completely understood crosstalk between canonical and non-canonical NFκB pathways in T-lymphocyte activation in renal disease.
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Affiliation(s)
- Ning Song
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Friedrich Thaiss
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Linlin Guo
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Stahl RA, Reinhard L, Hoxha E. Characterization of autoantibodies in primary membranous nephropathy and their clinical significance. Expert Rev Clin Immunol 2018; 15:165-175. [PMID: 30433832 DOI: 10.1080/1744666x.2019.1548934] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Introduction: Membranous nephropathy (MN) is the most common cause of a nephrotic syndrome in Caucasian adults. The identification of target antigens in MN in the last decade has had a major impact on the clinical approach to these patients. Areas covered: Since the discoveries in animal models in the 1980s that circulating autoantibodies induce disease upon in situ binding to glomerular podocytes, many attempts have been undertaken to define the human antigens responsible for disease induction. Only in 2009 was Phospholipase A2 Receptor 1 described as the major antigen responsible for MN onset in about 70% of patients. Subsequently, in 2014, Thrombospondin Type-1 Domain-Containing 7A was identified as a second antigen, accounting for 2-3% of patients with MN. The knowledge of the role of these antibodies in MN has improved the diagnosis and management of patients and helped to better define the need for immunosuppressive treatment. Expert commentary: These discoveries over the last 10 years in the discipline of nephrology have clearly shown the improvements a better understanding of disease pathogenesis can bring for patient care.
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Affiliation(s)
- Rolf Ak Stahl
- a III. Department of Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Linda Reinhard
- a III. Department of Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
| | - Elion Hoxha
- a III. Department of Medicine , University Medical Center Hamburg-Eppendorf , Hamburg , Germany
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