1
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Kim D, Lv J, Hladunewich M, Jha V, Hooi LS, Monaghan H, Shan S, Reich HN, Barbour S, Billot L, Zhang H, Perkovic V, Wong MG. The Efficacy and Safety of Reduced-Dose Oral Methylprednisolone in High-Risk Immunoglobulin A Nephropathy. Kidney Int Rep 2024; 9:2168-2179. [PMID: 39081761 PMCID: PMC11284425 DOI: 10.1016/j.ekir.2024.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/19/2024] [Accepted: 03/25/2024] [Indexed: 08/02/2024] Open
Abstract
Introduction The therapeutic effects of steroids in immunoglobulin A nephropathy (IgAN) global (TESTING) study reported that methylprednisolone reduces the risk of major kidney events in individuals with IgAN at high risk of disease progression compared to supportive care alone but is associated with increased serious adverse events (SAEs) primarily with full-dose therapy. The risk benefit balance of the reduced-dose methylprednisolone regimen is examined in this prespecified analysis of the reduced-dose cohort of the TESTING trial. Methods Between 2017 and 2019, patients with IgAN, proteinuria ≥1 g/d despite 3 months of renin-angiotensin-system blockade and estimated glomerular filtration rate (eGFR) 30 to 120 ml/min per 1.73 m2 were randomized to reduced-dose methylprednisolone 0.4 mg/kg/d or placebo. The primary outcome was a composite of a 40% eGFR decline, kidney failure, or death due to kidney disease. Results A total of 241 participants were randomized and followed-up with for a median of 2.5 years (mean age: 37 years; baseline eGFR: 65 ml/min per 1.73 m2; proteinuria: 2.48 g/d). Methylprednisolone was associated with fewer primary outcome events compared to placebo (7/121 vs. 22/120; hazard ratio [HR]: 0.24; 95% confidence interval [CI]: 0.10-0.58, P = 0.002), lowered proteinuria, and reduced eGFR rate of decline from baseline. The mean difference between methylprednisolone and placebo in proteinuria and eGFR from baseline was -1.15 g/d and 7.9 ml/min per 1.73 m2 (P < 0.001) at 12 months, respectively; however, these benefits were lost over time. There were 7 versus 3 SAEs in the methylprednisolone versus placebo group (HR: 1.97; 95% CI: 0.49-7.90), including 5 versus 2 infections. Conclusion Reduced-dose methylprednisolone is effective in improving kidney outcomes in high risk IgAN; however, it is associated with a modestly higher number of SAEs compared to placebo.
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Affiliation(s)
- Dana Kim
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Michelle Hladunewich
- Sunnybrook Health Sciences Center, University of Toronto, Toronto, Ontario, Canada
| | - Vivekanand Jha
- The George Institute for Global Health India, UNSW, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
- The George Institute for Global Health, School of Public Health, Imperial College London, UK
| | | | - Helen Monaghan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Sana Shan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Heather N. Reich
- Division of Nephrology, University Health Network, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sean Barbour
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Muh Geot Wong
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
- Department of Renal Medicine, Concord Repatriation General Hospital, Australia
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Keskinis C, Moysidou E, Christodoulou M, Pateinakis P, Stangou M. Diagnosing and Treating IgAN: Steroids, Budesonide, or Maybe Both? Diagnostics (Basel) 2024; 14:512. [PMID: 38472984 DOI: 10.3390/diagnostics14050512] [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: 12/27/2023] [Revised: 01/24/2024] [Accepted: 02/21/2024] [Indexed: 03/14/2024] Open
Abstract
IgA nephropathy (IgAN), the most common primary glomerulonephritis worldwide, is characterized by a mesangial IgA deposit and a variety of histological lesions, as described by the Oxford classification system. Despite the well-described "four-hit hypothesis", there are still plenty of less or undescribed mechanisms that participate in the disease pathogenesis, such as B-cell priming, which seems to be initiated by different antigens in the intestinal microbiota. Diagnosis of the disease is currently based on kidney biopsy findings, as the sensitivity and specificity of the many serum and urinary biomarkers described so far do not seem to have diagnostic accuracy. Therapeutic strategies consist of the initial step of non-immune medication, aiming to reduce both the intraglomerular pressure and proteinuria to below 0.5 g/day, followed by systemic corticosteroid administration in patients who remain at high risk for progressive chronic kidney disease despite the maximum non-immune treatment. The 6-month systemic corticosteroid treatment reduces proteinuria levels; however, the increased possibility of adverse events and increased relapse rate after treatment raises the need for a new therapeutic approach. Targeted-release budesonide is a therapeutic modality that aims to inhibit disease pathogenetic pathways at early stages; it has minor systemic absorption and proven beneficial effects on renal function and proteinuria. In the present systemic review, the benefits and adverse events of steroids and budesonide are described, and the possibility of combined treatment is questioned in selected cases with active histologic lesions.
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Affiliation(s)
| | - Eleni Moysidou
- 1st Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | - Michalis Christodoulou
- 1st Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
| | | | - Maria Stangou
- 1st Department of Nephrology, Hippokration Hospital, School of Medicine, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece
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Kawamura T, Hirano K, Koike K, Nishikawa M, Shimizu A, Joh K, Katafuchi R, Hashiguchi A, Matsuzaki K, Maruyama S, Tsuboi N, Narita I, Yano Y, Yokoo T, Suzuki Y. Associations of corticosteroid therapy and tonsillectomy with kidney survival in a multicenter prospective study for IgA nephropathy. Sci Rep 2023; 13:18455. [PMID: 37891208 PMCID: PMC10611761 DOI: 10.1038/s41598-023-45514-4] [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: 06/04/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
Efficacy of systemic corticosteroid therapy (CS) for long-term kidney survival in patients with IgA nephropathy (IgAN) is controversial. Therefore, prospective studies evaluating targeted therapies to lymphatic tissues in mucosal immune system responsible for production of nephritogenic IgA have been desired worldwide. Here, we aimed to evaluate the associations of CS and combination therapy of CS and tonsillectomy (CS + Tx) with kidney survival, using database from a nationwide multicenter prospective cohort study on IgAN. Primary outcome was a 50% increase in serum creatinine from baseline or dialysis induction. The analysis included 941 patients (CS/CS + Tx/non-CS 239/364/338), 85 (9.0%) of whom reached outcomes during median follow-up of 5.5 (interquartile range 2.0-8.0) years. On overlap weighting analysis with balanced baseline characteristics, CS and CS + Tx were associated with lower risk of kidney events when compared with non-CS (hazard ratio [HR] 0.51, 95% confidence interval [CI] 0.29-0.88 and HR 0.20, 95%CI 0.09-0.44, respectively). Notably, when compared with the CS, CS + Tx was associated with a lower risk of kidney events (HR 0.40, 95%CI 0.18-0.91). Present study demonstrated, keeping with favorable association of systemic CS with kidney survival, concurrent tonsillectomy as one of targeted interventions to lymphatic tissues may provide additional improvement to kidney survival in patients with IgAN.
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Affiliation(s)
- Tetsuya Kawamura
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan.
| | - Keita Hirano
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
- Division of Nephrology, Department of Internal Medicine, Japanese Red Cross Ashikaga Hospital, Ashikaga, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Masako Nishikawa
- Clinical Research Support Center, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Kensuke Joh
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
| | - Ritsuko Katafuchi
- National Hospital Organization Fukuoka-Higashi Medical Center, Fukuoka, Japan
- Division of Nephrology, Department of Internal Medicine, Kano Hospital, Fukuoka, Japan
| | - Akinori Hashiguchi
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Matsuzaki
- Department of Public Health, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yuichiro Yano
- Department of Advanced Epidemiology, Noncommunicable Disease (NCD) Epidemiology Research Center, Shiga University of Medical Science, Ōtsu, Shiga, Japan
- The Department of Family Medicine and Community Health, Duke University, Durham, NC, USA
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8 Nishi-Shinbashi, Minato-Ku, Tokyo, 105-8461, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
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Noor SM, Abuazzam F, Mathew R, Zhang Z, Abdipour A, Norouzi S. IgA nephropathy: a review of existing and emerging therapies. FRONTIERS IN NEPHROLOGY 2023; 3:1175088. [PMID: 37675358 PMCID: PMC10479631 DOI: 10.3389/fneph.2023.1175088] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/03/2023] [Indexed: 09/08/2023]
Abstract
IgA nephropathy (IgAN) is the most common form of primary glomerulonephritis worldwide. Recently, there have been multiple advances in the understanding of IgAN pathophysiology and therapeutic options. Despite the advent of new treatment options, individual risk stratification of the disease course and choosing the best treatment strategy for the patient remains challenging. A multitude of clinical trials is ongoing, opening multiple opportunities for enrollment. In this brief review we discuss the current approach to the management of IgAN and highlight the ongoing clinical trials.
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Affiliation(s)
| | | | | | | | | | - Sayna Norouzi
- Department of Nephrology, Loma Linda University, Loma Linda, CA, United States
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Kim D, Wong MG. Corticosteroid Therapy in Immunoglobulin A Nephropathy: A Friend or Foe? Kidney Blood Press Res 2023; 48:392-404. [PMID: 36972570 DOI: 10.1159/000530285] [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: 09/22/2022] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND The administration of corticosteroids in addition to supportive care to delay progressive immunoglobulin A nephropathy (IgAN), the most common primary glomerulonephritis worldwide, remains controversial. This is partly due to the paucity of well-designed randomized controlled trials and well-known corticosteroid-related side effects. As a result, clinical equipoise in corticosteroid therapy exists depending on geographical regions and the clinician's preference. SUMMARY Better understanding around the pathogenesis of IgAN has prompted several clinical trials exploring the effects of immunosuppressive agents including corticosteroids. Earlier studies of corticosteroids were limited by suboptimal study designs, inadequate implementation of standard of care, and inconsistent adverse event data collection. Two well-designed, adequately powered, multi-centre randomized controlled trials, the STOP-IgAN and TESTING studies, have reported contrasting kidney outcomes that have further fuelled the clinical conundrum regarding the efficacy of corticosteroids. Both studies independently reported greater adverse events with corticosteroids. A novel targeted release formulation of budesonide, which has been hypothesized to reduce the adverse events associated with systemic corticosteroids, has shown promising results in the Phase 3 NefigaRD trial. Studies of treatments targeting B cells and the complement cascade are currently underway, and early data appear encouraging. This review provides an overview of the current literature around the understanding of the pathomechanisms and benefits and harm of corticosteroid use in IgAN. KEY MESSAGES Recent evidence suggests the use of corticosteroids in a selected cohort of people with IgAN at high risk of disease progression can improve kidney outcomes but comes with an associated risk of treatment-related adverse events, particularly with higher doses. Management decisions should therefore follow an informed patient-clinician discussion.
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Affiliation(s)
- Dana Kim
- Renal and Metabolic Division, The George Institute for Global Health, Newtown, New South Wales, Australia
- Concord Clinical School, University of Sydney, Concord, New South Wales, Australia
| | - Muh Geot Wong
- Concord Clinical School, University of Sydney, Concord, New South Wales, Australia
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia
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6
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Neuen BL, Tighiouart H, Heerspink HJ, Vonesh EF, Chaudhari J, Miao S, Chan TM, Fervenza FC, Floege J, Goicoechea M, Herrington WG, Imai E, Jafar TH, Lewis JB, Li PKT, Locatelli F, Maes BD, Perrone RD, Praga M, Perna A, Schena FP, Wanner C, Wetzels JF, Woodward M, Xie D, Greene T, Inker LA. Acute Treatment Effects on GFR in Randomized Clinical Trials of Kidney Disease Progression. J Am Soc Nephrol 2022; 33:291-303. [PMID: 34862238 PMCID: PMC8819983 DOI: 10.1681/asn.2021070948] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/28/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Acute changes in GFR can occur after initiation of interventions targeting progression of CKD. These acute changes complicate the interpretation of long-term treatment effects. METHODS To assess the magnitude and consistency of acute effects in randomized clinical trials and explore factors that might affect them, we performed a meta-analysis of 53 randomized clinical trials for CKD progression, enrolling 56,413 participants with at least one estimated GFR measurement by 6 months after randomization. We defined acute treatment effects as the mean difference in GFR slope from baseline to 3 months between randomized groups. We performed univariable and multivariable metaregression to assess the effect of intervention type, disease state, baseline GFR, and albuminuria on the magnitude of acute effects. RESULTS The mean acute effect across all studies was -0.21 ml/min per 1.73 m2 (95% confidence interval, -0.63 to 0.22) over 3 months, with substantial heterogeneity across interventions (95% coverage interval across studies, -2.50 to +2.08 ml/min per 1.73 m2). We observed negative average acute effects in renin angiotensin system blockade, BP lowering, and sodium-glucose cotransporter 2 inhibitor trials, and positive acute effects in trials of immunosuppressive agents. Larger negative acute effects were observed in trials with a higher mean baseline GFR. CONCLUSION The magnitude and consistency of acute GFR effects vary across different interventions, and are larger at higher baseline GFR. Understanding the nature and magnitude of acute effects can help inform the optimal design of randomized clinical trials evaluating disease progression in CKD.
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Affiliation(s)
- Brendon L. Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands
| | - Edward F. Vonesh
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Fernando C. Fervenza
- Division of Nephrology and Hypertension and Department of Medicine, Mayo Clinic Rochester, Minnesota
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - William G. Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Julia B. Lewis
- Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Philip Kam-Tao Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Bart D. Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | | | - Manuel Praga
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P. Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Jack F.M. Wetzels
- Department of Nephrology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Imperial College London, United Kingdom
| | - Di Xie
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Steiger S, Rossaint J, Zarbock A, Anders HJ. Secondary Immunodeficiency Related to Kidney Disease (SIDKD)-Definition, Unmet Need, and Mechanisms. J Am Soc Nephrol 2022; 33:259-278. [PMID: 34907031 PMCID: PMC8819985 DOI: 10.1681/asn.2021091257] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Kidney disease is a known risk factor for poor outcomes of COVID-19 and many other serious infections. Conversely, infection is the second most common cause of death in patients with kidney disease. However, little is known about the underlying secondary immunodeficiency related to kidney disease (SIDKD). In contrast to cardiovascular disease related to kidney disease, which has triggered countless epidemiologic, clinical, and experimental research activities or interventional trials, investments in tracing, understanding, and therapeutically targeting SIDKD have been sparse. As a call for more awareness of SIDKD as an imminent unmet medical need that requires rigorous research activities at all levels, we review the epidemiology of SIDKD and the numerous aspects of the abnormal immunophenotype of patients with kidney disease. We propose a definition of SIDKD and discuss the pathogenic mechanisms of SIDKD known thus far, including more recent insights into the unexpected immunoregulatory roles of elevated levels of FGF23 and hyperuricemia and shifts in the secretome of the intestinal microbiota in kidney disease. As an ultimate goal, we should aim to develop therapeutics that can reduce mortality due to infections in patients with kidney disease by normalizing host defense to pathogens and immune responses to vaccines.
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Affiliation(s)
- Stefanie Steiger
- Division of Nephrology, Department of Medicine IV, Ludwig Maximilians University Hospital of Munich, Munich, Germany
| | - Jan Rossaint
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, Ludwig Maximilians University Hospital of Munich, Munich, Germany
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Huerta A, Mérida E, Medina L, Fernandez M, Gutierrez E, Hernandez E, Lopez P, Sevillano A, Portolés J, Trimarchi H, Praga M. Corticosteroids and mycophenolic acid analogs in IgA nephropathy with progressive decline in kidney function. Clin Kidney J 2021; 15:771-777. [PMID: 35371455 PMCID: PMC8967683 DOI: 10.1093/ckj/sfab244] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
A randomized controlled trial (RCT) demonstrated a beneficial effect of corticosteroids (CS) plus cyclophosphamide followed by azathioprine in progressive IgA nephropathy (IgAN). Although treatment with CS and mycophenolic acid analogs (MPAA) remains controversial in IgAN, there is no information about their effect in progressive IgAN.
Methods
Patients with progressive IgAN, defined by a decrease in estimated glomerular filtration rate (eGFR) of at least 10 ml/min/1.73 m2 in the 12 months prior to the start of treatment, proteinuria ≥ 0.75 g/24h despite maximum tolerated doses of renin-angiotensin system blockers (RASB) and persistent hematuria, who had received treatment with CS+MPAA were included in this retrospective study. The main outcome was the difference between the eGFR slope from the start of treatment with CS+MPAA to the last visit with this treatment with respect to the eGFR slope during the 12 months prior to start of treatment.
Results
Twenty-five patients were included in the study. Mean duration of CS+MPAA treatment was 24.7±15.2 months. In the 12 months prior to treatment the median rate of kidney function decline was -23 [-32 to -16] ml/min/1.73 m2 per year. After the onset of treatment, the median eGFR slope was +5 [+3 to +9] ml/min/1.73 m2 per year (P = 0.001 with respect to the 12 months prior to treatment). Proteinuria decreased from 1.8 (1.0-2.5) g/day at baseline to 0.6 (0.3-1.2) g/day at the end of treatment (P = 0.01) and hematuria disappeared in 40% of the patients. There were no serious adverse effects requiring treatment discontinuation.
Conclusions
CS + MPAA is an effective treatment in IgAN patients with a sustained decline in kidney function accompanied by persistent proteinuria and hematuria despite optimized conservative treatment. Prospective studies are needed to confirm these results.
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Affiliation(s)
- Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta del Hierro Majadahonda, Madrid, Spain
- REDInREN ISCIII 016/009, Spain
| | - Eva Mérida
- REDInREN ISCIII 016/009, Spain
- Department of Nephrology, Hospital Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Laura Medina
- Department of Nephrology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Maria Fernandez
- Department of Nephrology, Hospital Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Eduardo Gutierrez
- REDInREN ISCIII 016/009, Spain
- Department of Nephrology, Hospital Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Eduardo Hernandez
- REDInREN ISCIII 016/009, Spain
- Department of Nephrology, Hospital Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Paula Lopez
- Department of Nephrology, Hospital Universitario Puerta del Hierro Majadahonda, Madrid, Spain
| | - Angel Sevillano
- REDInREN ISCIII 016/009, Spain
- Department of Nephrology, Hospital Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Jose Portolés
- Department of Nephrology, Hospital Universitario Puerta del Hierro Majadahonda, Madrid, Spain
- REDInREN ISCIII 016/009, Spain
| | - Hernan Trimarchi
- Department of Nephrology, Hospital Británico de Buenos Aires, Argentina
| | - Manuel Praga
- REDInREN ISCIII 016/009, Spain
- Research Institute Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
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Murali S, Shenoy SV, Prabhu RA, Nagaraju SP. Hypertensive emergency and seizures during haemodialysis. BMJ Case Rep 2021; 14:e242471. [PMID: 34548293 PMCID: PMC8458320 DOI: 10.1136/bcr-2021-242471] [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] [Accepted: 08/26/2021] [Indexed: 11/04/2022] Open
Abstract
Intracranial abscesses are uncommon, serious and life-threatening infections. A brain abscess is caused by inflammation and collection of infected material, coming from local or remote infectious sources. Patients with chronic kidney disease on dialysis are prone to invasive bacterial infections like methicillin-resistant Staphylococcus aureus (MRSA) especially in the presence of central venous catheters or arteriovenous grafts. However, intracranial abscess formation due to MRSA is rare. Here, we present a case of MRSA brain abscess with an atypical clinical presentation in the absence of traditional risk factors.Intracranial abscesses are uncommon, serious, and life-threatening infections. A Brain abscess is caused by inflammation and collection of infected material, coming from local or remote infectious sources. Patients with chronic kidney disease on dialysis are prone to invasive bacterial infections like methicillin-resistant staphylococcus aureus (MRSA) especially in the presence of central venous catheters or arterio-venous grafts. However intracranial abscess formation due to MRSA is rare. Here we present a case of MRSA brain abscess with an atypical clinical presentation in the absence of traditional risk factors. A 46-year-old male with chronic kidney disease (CKD) secondary to chronic glomerulonephritis, on haemodialysis for 4 years through a left brachio-cephalic AVF developed an episode of generalised tonic-clonic seizures lasting 2 min during his scheduled dialysis session. He reported no complaints before entry to the dialysis. On clinical examination, he was drowsy with the absence of any focal motor deficits. His blood pressure was recorded to be 200/120 mm Hg. He was managed in the intensive care unit with mechanical ventilation, intravenous nitroglycerine for blood pressure control, levetiracetam for seizures and empirical vancomycin. Radiological evaluation showed a brain abscess in the midline involving bosth basi-frontal lobes. After medical optimization, the abscess was drained surgically, and the pus cultured. As culture grew Methicillin Resistant Staphylococcus aureus, he was treated with intravenous vancomycin for 6 weeks. On follow up, the abscess had resolved and the patient recovered without any neurological deficits.
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Affiliation(s)
| | | | - Ravindra Attur Prabhu
- Department of Nephrology, Kasturba Medical College Manipal, Manipal, Karnataka, India
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Abstract
IgA nephropathy (IgAN) is the most common type of glomerulonephritis in Asia and the Western world. In most patients, it follows an asymptomatic to oligosymptomatic course and GFR loss, if any, is slow. The mainstay of therapy therefore is optimized supportive care, i.e., measures that lower blood pressure, reduce proteinuria, minimize lifestyle risk factors, and otherwise help to reduce non-specific insults to the kidneys. The value of immunosuppression has become controversial and if at all, systemic high-dose corticosteroid therapy should be considered for a few months taking into account patient characteristics that would caution against or preclude such therapy. In addition, adverse events related to corticosteroid therapy markedly increase as GFR declines. Beyond corticosteroids, there is little evidence that any additional immunosuppression is helpful, with the exception of mycophenolate mofetil in patients of Asian descent. A considerable number of clinical trials ranging from enteric coated budesonide to blockade of B-cell function to complement inhibitors are currently ongoing and will hopefully allow a more targeted therapy of high-risk patients with progressive IgAN in the future.
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11
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Inker LA, Heerspink HJL, Tighiouart H, Chaudhari J, Miao S, Diva U, Mercer A, Appel GB, Donadio JV, Floege J, Li PKT, Maes BD, Locatelli F, Praga M, Schena FP, Levey AS, Greene T. Association of Treatment Effects on Early Change in Urine Protein and Treatment Effects on GFR Slope in IgA Nephropathy: An Individual Participant Meta-analysis. Am J Kidney Dis 2021; 78:340-349.e1. [PMID: 33775708 PMCID: PMC8384669 DOI: 10.1053/j.ajkd.2021.03.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 03/03/2021] [Indexed: 01/18/2023]
Abstract
RATIONALE & OBJECTIVE An early change in proteinuria is considered a reasonably likely surrogate end point in immunoglobulin A nephropathy (IgAN) and can be used as a basis for accelerated approval of therapies, with verification in a postmarketing confirmatory trial. Glomerular filtration rate (GFR) slope is a recently validated surrogate end point for chronic kidney disease progression and may be considered as the end point used for verification. We undertook a meta-analysis of clinical trials in IgAN to compare treatment effects on change in proteinuria versus change in estimated GFR (eGFR) slope. STUDY DESIGN Individual patient-level meta-analysis. SETTING & STUDY POPULATIONS Individual data of 1,037 patients from 12 randomized trials. SELECTION CRITERIA FOR STUDIES Randomized trials of IgAN with proteinuria measurements at baseline and 6 (range, 2.5-14) months and at least a further 1 year of follow-up for the clinical outcome. ANALYTICAL APPROACH For each trial, we estimated the treatment effects on proteinuria and on the eGFR slope, computed as the total slope starting at baseline or the chronic slope starting 3 months after randomization. We used a Bayesian mixed-effects analysis to relate the treatment effects on proteinuria to effects on GFR slope across these studies and developed a prediction model for the treatment effect on the GFR slope based on the effect on proteinuria. RESULTS Across all studies, treatment effects on proteinuria accurately predicted treatment effects on the total slope at 3 years (median R2 = 0.88; 95% Bayesian credible interval [BCI], 0.06-1) and on the chronic slope (R2 = 0.98; 95% BCI, 0.29-1). For future trials, an observed treatment effect of approximately 30% reduction in proteinuria would confer probabilities of at least 90% for nonzero treatment benefits on the total and chronic slopes of eGFR. We obtained similar results for proteinuria at 9 and 12 months and total slope at 2 years. LIMITATIONS Study population restricted to 12 trials of small sample size, leading to wide BCIs. There was heterogeneity among trials with respect to study design and interventions. CONCLUSIONS These results provide new evidence supporting that early reduction in proteinuria can be used as a surrogate end point for studies of chronic kidney disease progression in IgAN.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA.
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Ulysses Diva
- Biometrics, Travere Therapeutics Inc, San Diego, CA
| | - Alex Mercer
- Clinical Drug Development, JAMCO Pharma Consulting AB, Stockholm, Sweden
| | - Gerald B Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY
| | | | - Jürgen Floege
- Division of Nephrology and Immunology, RWTH Aachen University, Aachen, Germany
| | - Philip K T Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Bart D Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | | | - Manuel Praga
- Instituto de Investigación Hospital Universitario 12 de Octubre, i+12, Complutense University, Madrid, Spain
| | - Francesco P Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Tom Greene
- Departments of Population Health Sciences and Internal Medicine, University of Utah, Salt Lake City, UT
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12
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Liu T, Wang Y, Mao H, Yang L, Zhan Y. Efficacy and safety of immunosuppressive therapies in the treatment of high-risk IgA nephropathy: A network meta-analysis. Medicine (Baltimore) 2021; 100:e24541. [PMID: 33663060 PMCID: PMC7909110 DOI: 10.1097/md.0000000000024541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND IgA nephropathy (IgAN) is one of the significant contributing factors of end-stage renal disease (ESRD). It is reported that over half of patients with IgAN accompany multiple high-risk factors, which increase the risk of ESRD progression. Studies have shown that immunosuppressive agents were beneficial in high-risk IgAN, but the efficacy and safety have not been fully demonstrated yet. The present study aims to elucidate the efficacy of commonly used immunosuppressants in high-risk IgAN and their relative safety profiles via a network meta-analysis strategy. METHODS Randomized controlled trials (RCTs) eligible for this network meta-analysis were included to evaluate the efficacy and safety of different immunosuppressants for high-risk IgAN. Main outcomes and measures include incidence of renal composite end point, the rate of total remission, adverse events, and proteinuria. Besides, subgroup analysis and cluster analysis were carried out. RESULTS This network meta-analysis of 37 RCTs involving 3012 participants found that Mycophenolate mofetil (MMF) combined with corticosteroids (CS) was superior to other interventions in end point events and proteinuria. Cyclosporine A (CsA) plus CS was the best option for clinical remission rate, and supportive care (SC) was the safest treatment. Cluster analysis showed that MMF+CS and Leflunomide (LEF)+CS were best protocols in efficacy and safety. Subgroup analysis indicated the best benefits of MMF were presented among the Asian population, and the benefits increased with the increase of follow-up duration. The effect of Cyclophosphamide (CTX) +CS on crescent IgAN was better than that of other risk factors. Moreover, the increasing follow-up duration was negatively associated with the effect. CONCLUSIONS MMF+CS and LEF+CS appear to serve as the best choice for treating high-risk IgAN than other immunosuppressive therapies.
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Han S, Yao T, Lu Y, Chen M, Xu Y, Wang Y. Efficacy and Safety of Immunosuppressive Monotherapy Agents for IgA Nephropathy: A Network Meta-Analysis. Front Pharmacol 2021; 11:539545. [PMID: 33551793 PMCID: PMC7862876 DOI: 10.3389/fphar.2020.539545] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/26/2020] [Indexed: 01/10/2023] Open
Abstract
Background: The efficacy and safety of immunosuppressive monotherapy agents were evaluated for immunoglobulin A nephropathy (IgAN) using a network meta-analysis approach. Methods: Randomized controlled trials (RCTs) published prior to October 1, 2019, using immunosuppressive agents for treating IgAN, were systematically searched in PubMed, Embase, Cochrane Library, and Web of Science databases. Relative risks (RRs) or standard mean differences with 95% confidence intervals (CIs) were estimated using the random-effects model. The primary outcomes were clinical remission, end-stage renal disease (ESRD), and serious adverse events (SAEs). The secondary outcomes were urinary protein excretion and serum creatinine. Results: Twenty-five RCTs with 2,005 participants were deemed eligible. Six medications were evaluated: corticosteroids, mycophenolate mofetil (MMF), tacrolimus (TAC), cyclosporine, leflunomide, and hydroxychloroquine (HCQ). Steroids (RR 1.50, 95% CI 1.17-1.93), MMF (RR 2.05, 95% CI 1.15-3.65), TAC (RR 3.67, 95% CI 1.06-12.63), and HCQ (RR 3.25, 95% CI 1.05-10.09) significantly improved clinical remission rates compared to supportive care alone. Only steroids reduced the risk of ESRD (RR 0.35, 95% CI 0.12-0.98); however, there were significantly more SAEs than in the control group (RR 2.90, 95% CI 1.37-6.13). No significantly different effects in serum creatinine levels were found among the therapies. MMF showed no significant improvement in remission when excluding studies with a follow-up of fewer than 2 years in the sensitivity analysis (RR 1.41, 95% CI 0.40-4.92). The effect of TAC in the decrease of proteinuria was reversed after discontinuing medication for 3 months; the long-term effects of HCQ could not be evaluated due to the short follow-up duration. Conclusion: Corticosteroids might induce remission and increase renal survival in IgAN; however, adverse reactions should be taken into consideration. MMF, TAC, and HCQ might improve the remission of proteinuria when treating IgAN, but showed no superiority compared to steroids, and the long-term effects require further study.
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Affiliation(s)
| | | | | | | | | | - Yi Wang
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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14
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Wu CY, Hua KF, Hsu WH, Suzuki Y, Chu LJ, Lee YC, Takahata A, Lee SL, Wu CC, Nikolic-Paterson DJ, Ka SM, Chen A. IgA Nephropathy Benefits from Compound K Treatment by Inhibiting NF-κB/NLRP3 Inflammasome and Enhancing Autophagy and SIRT1. THE JOURNAL OF IMMUNOLOGY 2020; 205:202-212. [PMID: 32482710 DOI: 10.4049/jimmunol.1900284] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 04/24/2020] [Indexed: 12/15/2022]
Abstract
IgA nephropathy (IgAN), the most common primary glomerular disorder, has a relatively poor prognosis yet lacks a pathogenesis-based treatment. Compound K (CK) is a major absorbable intestinal bacterial metabolite of ginsenosides, which are bioactive components of ginseng. The present study revealed promising therapeutic effects of CK in two complementary IgAN models: a passively induced one developed by repeated injections of IgA immune complexes and a spontaneously occurring model of spontaneous grouped ddY mice. The potential mechanism for CK includes 1) inhibiting the activation of NLRP3 inflammasome in renal tissues, macrophages and bone marrow-derived dendritic cells, 2) enhancing the induction of autophagy through increased SIRT1 expression, and 3) eliciting autophagy-mediated NLRP3 inflammasome inhibition. The results support CK as a drug candidate for IgAN.
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Affiliation(s)
- Chung-Yao Wu
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 114, Taiwan
| | - Kuo-Feng Hua
- Department of Biotechnology and Animal Science, National Ilan University, Ilan 260, Taiwan
| | - Wan-Han Hsu
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 114, Taiwan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo 113-8421, Japan
| | - Lichieh Julie Chu
- Molecular Medicine Research Center, Chang Gung University, Taoyuan 333, Taiwan.,Liver Research Center, Chang Gung Memorial Hospital at Linkou, Gueishan, Taoyuan 333, Taiwan
| | - Yu-Chieh Lee
- Department of Biotechnology and Animal Science, National Ilan University, Ilan 260, Taiwan
| | - Akiko Takahata
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo 113-8421, Japan
| | - Sheau-Long Lee
- Department of Chemistry, R.O.C. Military Academy, Kaohsiung 830, Taiwan
| | - Chia-Chao Wu
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
| | - David J Nikolic-Paterson
- Department of Nephrology and Monash University Centre for Inflammatory Diseases, Monash Medical Centre, Clayton, Victoria 3168, Australia
| | - Shuk-Man Ka
- Graduate Institute of Aerospace and Undersea Medicine, Department of Medicine, National Defense Medical Center, Taipei 114, Taiwan; and
| | - Ann Chen
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei 114, Taiwan; .,Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei 114, Taiwan
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15
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The precise long-term outcomes of adult IgA nephropathy by mail questionnaires: Better renal survival compared to earlier cohort studies. PLoS One 2020; 15:e0233186. [PMID: 32413080 PMCID: PMC7228083 DOI: 10.1371/journal.pone.0233186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022] Open
Abstract
The estimated 20-year renal survival rate of immunoglobulin A (IgA) nephropathy is approx. 60%, but it is difficult to determine the 'big picture' for IgA nephropathy because a biopsy is essential for its diagnosis. Here we attempted to determine the longer and more precise renal prognosis of IgA nephropathy. We examined 310 patients with primary IgA nephropathy. Using the patients' clinical records and histological reports from our hospital and other clinics, we surveyed their renal prognoses and treatments within 1 year post-biopsy, and we sent questionnaires to the patients who had stopped visiting any hospital. We set renal death as the primary endpoint and analyzed factors related to renal death. The total patient cohort was 267: 159 males, 108 females; average age at biopsy, 37.7 years; average estimated glomerular filtration rate (eGFR), 69.7 mL/min/1.73m2; urinary protein, 1.3 g/day. The mean follow-up duration was prolonged to 13.8±8.9 years (vs. 9.2±8.5 years using only medical records). The 10- and 20-year follow-up rates were 61.7% and 27.3%. The 10-, 20-year renal survival rates were 83.6% and 72.5%. Lower eGFR, hypertension, and smoking were revealed as factors independently related to renal death. To study survival of relatively benign diseases such as IgA nephropathy, longer survival rate was affected by many censoring cases. The results regarding the long-term renal prognoses of IgA nephropathy patients (including those with a mild phenotype) obtained by our analysis of a questionnaire sent to the patients provided more precise and longer-term prognoses compared to earlier studies.
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16
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The efficacy and safety of immunosuppressive therapies in the treatment of IgA nephropathy: A network meta-analysis. Sci Rep 2020; 10:6062. [PMID: 32269271 PMCID: PMC7142138 DOI: 10.1038/s41598-020-63170-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 03/19/2020] [Indexed: 02/05/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is a common autoimmune glomerulonephritis that can result in end-stage renal disease (ESRD). Whether immunosuppressants are superior or equivalent to supportive care is still controversial. A network meta-analysis was conducted to compare the efficacy and safety of immunosuppressive treatment for IgAN. Medline, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and EMBASE were searched on December 30, 2018. We used a random-effects model with a Bayesian approach to appraise both renal outcomes and serious adverse effects. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated to present the relative effects. The ranking probabilities were calculated by the surface under the cumulative ranking curve (SUCRA). In total, 24 RCTs comprising 6 interventions were analyzed. Steroids significantly delayed the progression of renal deterioration with acceptable serious adverse effects, compared with supportive care (RR = 0.28, 95% CI = 0.13–0.51, SUCRA = 48.7%). AZA combined with steroids might be an alternative immunosuppressive therapy. Tacrolimus might decrease the proteinuria level (RR = 3.1, 95% CI = 1.2–9.4, SUCRA = 66.5%) but cannot improve renal function, and the side effects of tacrolimus should not be neglected. MMF and CYC showed no superiority in the treatment of IgAN. In summary, steroids might be recommended as the first-line immunosuppressive therapy for IgAN.
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17
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Natale P, Palmer SC, Ruospo M, Saglimbene VM, Craig JC, Vecchio M, Samuels JA, Molony DA, Schena FP, Strippoli GFM. Immunosuppressive agents for treating IgA nephropathy. Cochrane Database Syst Rev 2020; 3:CD003965. [PMID: 32162319 PMCID: PMC7066485 DOI: 10.1002/14651858.cd003965.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND IgA nephropathy is the most common glomerulonephritis world-wide. IgA nephropathy causes end-stage kidney disease (ESKD) in 15% to 20% of affected patients within 10 years and in 30% to 40% of patients within 20 years from the onset of disease. This is an update of a Cochrane review first published in 2003 and updated in 2015. OBJECTIVES To determine the benefits and harms of immunosuppression strategies for the treatment of IgA nephropathy. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 9 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs of treatment for IgA nephropathy in adults and children and that compared immunosuppressive agents with placebo, no treatment, or other immunosuppressive or non-immunosuppressive agents. DATA COLLECTION AND ANALYSIS Two authors independently assessed study risk of bias and extracted data. Estimates of treatment effect were summarised using random effects meta-analysis. Treatment effects were expressed as relative risk (RR) and 95% confidence intervals (95% CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Risks of bias were assessed using the Cochrane tool. Evidence certainty was evaluated using GRADE methodology. MAIN RESULTS Fifty-eight studies involving 3933 randomised participants were included. Six studies involving children were eligible. Disease characteristics (kidney function and level of proteinuria) were heterogeneous across studies. Studies evaluating steroid therapy generally included patients with protein excretion of 1 g/day or more. Risk of bias within the included studies was generally high or unclear for many of the assessed methodological domains. In patients with IgA nephropathy and proteinuria > 1 g/day, steroid therapy given for generally two to four months with a tapering course probably prevents the progression to ESKD compared to placebo or standard care (8 studies; 741 participants: RR 0.39, 95% CI 0.23 to 0.65; moderate certainty evidence). Steroid therapy may induce complete remission (4 studies, 305 participants: RR 1.76, 95% CI 1.03 to 3.01; low certainty evidence), prevent doubling of serum creatinine (SCr) (7 studies, 404 participants: RR 0.43, 95% CI 0.29 to 0.65; low certainty evidence), and may lower urinary protein excretion (10 studies, 705 participants: MD -0.58 g/24 h, 95% CI -0.84 to -0.33;low certainty evidence). Steroid therapy had uncertain effects on glomerular filtration rate (GFR), death, infection and malignancy. The risk of adverse events with steroid therapy was uncertain due to heterogeneity in the type of steroid treatment used and the rarity of events. Cytotoxic agents (azathioprine (AZA) or cyclophosphamide (CPA) alone or with concomitant steroid therapy had uncertain effects on ESKD (7 studies, 463 participants: RR 0.63, 95% CI 0.33 to 1.20; low certainty evidence), complete remission (5 studies; 381 participants: RR 1.47, 95% CI 0.94 to 2.30; very low certainty evidence), GFR (any measure), and protein excretion. Doubling of serum creatinine was not reported. Mycophenolate mofetil (MMF) had uncertain effects on the progression to ESKD, complete remission, doubling of SCr, GFR, protein excretion, infection, and malignancy. Death was not reported. Calcineurin inhibitors compared with placebo or standard care had uncertain effects on complete remission, SCr, GFR, protein excretion, infection, and malignancy. ESKD and death were not reported. Mizoribine administered with renin-angiotensin system inhibitor treatment had uncertain effects on progression to ESKD, complete remission, GFR, protein excretion, infection, and malignancy. Death and SCr were not reported. Leflunomide followed by a tapering course with oral prednisone compared to prednisone had uncertain effects on the progression to ESKD, complete remission, doubling of SCr, GFR, protein excretion, and infection. Death and malignancy were not reported. Effects of other immunosuppressive regimens (including steroid plus non-immunosuppressive agents or mTOR inhibitors) were inconclusive primarily due to insufficient data from the individual studies in low or very low certainty evidence. The effects of treatments on death, malignancy, reduction in GFR at least of 25% and adverse events were very uncertain. Subgroup analyses to determine the impact of specific patient characteristics such as ethnicity or disease severity on treatment effectiveness were not possible. AUTHORS' CONCLUSIONS In moderate certainty evidence, corticosteroid therapy probably prevents decline in GFR or doubling of SCr in adults and children with IgA nephropathy and proteinuria. Evidence for treatment effects of immunosuppressive agents on death, infection, and malignancy is generally sparse or low-quality. Steroid therapy has uncertain adverse effects due to a paucity of studies. Available studies are few, small, have high risk of bias and generally do not systematically identify treatment-related harms. Subgroup analyses to identify specific patient characteristics that might predict better response to therapy were not possible due to a lack of studies. There is no evidence that other immunosuppressive agents including CPA, AZA, or MMF improve clinical outcomes in IgA nephropathy.
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Affiliation(s)
- Patrizia Natale
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Marinella Ruospo
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Valeria M Saglimbene
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Joshua A Samuels
- UT‐Houston Health Science CenterDivision of Pediatric Nephrology and Hypertension6431 Fannin Street, MSB 3‐121HoustonTXUSA77030
| | - Donald A Molony
- UT‐Houston Health Science CenterInternal MedicineDivision of Renal Diseases and Hypertension64312 Fannin StHoustonTXUSA77030
| | | | - Giovanni FM Strippoli
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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18
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Obrișcă B, Sinescu I, Ismail G, Mircescu G. Has The Time Arrived to Refine The Indications of Immunosuppressive Therapy and Prognosis in IgA Nephropathy? J Clin Med 2019; 8:E1584. [PMID: 31581654 PMCID: PMC6833025 DOI: 10.3390/jcm8101584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most frequent glomerular disease worldwide and a leading cause of end-stage renal disease. Particularly challenging to the clinician is the early identification of patients at high risk of progression, an estimation of the decline in renal function, and the selection of only those that would benefit from additional immunosuppressive therapies. Nevertheless, the pathway to a better prognostication and to the development of targeted therapies in IgAN has been paved by recent understanding of the genetic and molecular basis of this disease. Merging the data from the Oxford Classification validation studies and prospective treatment studies has suggested that a disease-stratifying algorithm would be appropriate for disease management, although it awaits validation in a prospective setting. The emergence of potential noninvasive biomarkers may assist traditional markers (proteinuria, hematuria) in monitoring disease activity and treatment response. The recent landmark trials of IgAN treatment (STOP-IgAN and TESTING trials) have suggested that the risks associated with immunosuppressive therapy outweigh the benefits, which may shift the treatment paradigm of this disease. While awaiting the approval of the first therapies for IgAN, more targeted and less toxic immunotherapies are warranted. Accordingly, the targeting of complement activation, the modulation of mucosal immunity, the antagonism of B-cell activating factors, and proteasomal inhibition are currently being evaluated in pilot studies for IgAN treatment.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
| | - Ioanel Sinescu
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
- Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
| | - Gabriel Mircescu
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
- Department of Nephrology, “Dr. Carol Davila” Teaching Hospital of Nephrology, 010731 Bucharest, Romania
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19
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Zhang Z, Yang Y, Jiang SM, Li WG. Efficacy and safety of immunosuppressive treatment in IgA nephropathy: a meta-analysis of randomized controlled trials. BMC Nephrol 2019; 20:333. [PMID: 31455248 PMCID: PMC6710882 DOI: 10.1186/s12882-019-1519-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023] Open
Abstract
Background Immunosuppressive agents have been widely used in the treatment of IgA nephropathy (IgAN), but the efficacy and safety remain controversial. The recent STOP-IgAN and TESTING studies have again focused attention on the application of immunosuppressive agents in IgAN. This study investigated the benefits and risks of immunosuppressive agents in IgAN. Methods MEDLINE, EMBASE, the Cochrane Library, and article reference lists were searched for randomized controlled trials (RCTs) comparing immunosuppressive agents with any other non-immunosuppressive agents for treating IgAN. A meta-analysis was performed on the outcomes of proteinuria, creatinine (Cr), estimated glomerular filtration rate (eGFR), and adverse events in patients with IgAN, and trial sequential analyses were also performed for outcomes. Results Twenty-nine RCTs (1957 patients) that met our inclusion criteria were identified. Steroids (weighted mean difference [WMD] –0.70, 95% confidence interval [CI] –1.2 to − 0.20), non-steroidal immunosuppressive agents (NSI) (WMD –0. 43, 95% CI − 0.55 to − 0.31), and combined steroidal and non-steroidal immunosuppressive agents (S&NSI) (WMD –1.46, 95% CI − 2.13 to − 0.79) therapy significantly reduced proteinuria levels compared with the the control group. Steroid treatment significantly reduced the risk of end-stage renal disease (ESRD) (relative risk [RR] 0.39, CI 0.19 to 0.79) compared with the control group. The immunosuppressive therapy group showed significant increases in gastrointestinal, hematological, dermatological, and genitourinary side effects, as well as impaired glucose tolerance or diabetes. Hyperkalemia was more common in the control group. Conclusion Immunosuppressive therapy can significantly reduce proteinuria and ESRD risk in patients with IgAN, but with a concomitant increase in adverse reactions. Therefore, care is required in the application of immunosuppressive agents in IgAN.
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Affiliation(s)
- Zheng Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Yue Yang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Shi-Min Jiang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China.,Graduate School of Peking Union Medical College, Beijing, China
| | - Wen-Ge Li
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China.
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20
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Inker LA, Heerspink HJL, Tighiouart H, Levey AS, Coresh J, Gansevoort RT, Simon AL, Ying J, Beck GJ, Wanner C, Floege J, Li PKT, Perkovic V, Vonesh EF, Greene T. GFR Slope as a Surrogate End Point for Kidney Disease Progression in Clinical Trials: A Meta-Analysis of Treatment Effects of Randomized Controlled Trials. J Am Soc Nephrol 2019; 30:1735-1745. [PMID: 31292197 DOI: 10.1681/asn.2019010007] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/26/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Surrogate end points are needed to assess whether treatments are effective in the early stages of CKD. GFR decline leads to kidney failure, but regulators have not approved using differences in the change in GFR from the beginning to the end of a randomized, controlled trial as an end point in CKD because it is not clear whether small changes in the GFR slope will translate to clinical benefits. METHODS To assess the use of GFR slope as a surrogate end point for CKD progression, we performed a meta-analysis of 47 RCTs that tested 12 interventions in 60,620 subjects. We estimated treatment effects on GFR slope (mean difference in GFR slope between the randomized groups), for the total slope starting at baseline, chronic slope starting at 3 months after randomization, and on the clinical end point (doubling of serum creatinine, GFR<15 ml/min per 1.73 m2, or ESKD) for each study. We used Bayesian mixed-effects analyses to describe the association of treatment effects on GFR slope with the clinical end point and to test how well the GFR slope predicts a treatment's effect on the clinical end point. RESULTS Across all studies, the treatment effect on 3-year total GFR slope (median R 2=0.97; 95% Bayesian credible interval [BCI], 0.78 to 1.00) and on the chronic slope (R 2 0.96; 95% BCI, 0.63 to 1.00) accurately predicted treatment effects on the clinical end point. With a sufficient sample size, a treatment effect of 0.75 ml/min per 1.73 m2/yr or greater on total slope over 3 years or chronic slope predicts a clinical benefit on CKD progress with at least 96% probability. CONCLUSIONS With large enough sample sizes, GFR slope may be a viable surrogate for clinical end points in CKD RCTs.
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Affiliation(s)
| | | | - Hocine Tighiouart
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | | | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ron T Gansevoort
- Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Jian Ying
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Philip Kam-Tao Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong;
| | - Vlado Perkovic
- George Institute for Global Health, University of New South Wales, Sydney, Australia; and
| | - Edward F Vonesh
- Department of Preventive Medicine, Division of Biostatistics, Northwestern University, Chicago, Illinois
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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21
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Thompson A, Carroll K, A. Inker L, Floege J, Perkovic V, Boyer-Suavet S, W. Major R, I. Schimpf J, Barratt J, Cattran DC, S. Gillespie B, Kausz A, W. Mercer A, Reich HN, H. Rovin B, West M, Nachman PH. Proteinuria Reduction as a Surrogate End Point in Trials of IgA Nephropathy. Clin J Am Soc Nephrol 2019; 14:469-481. [PMID: 30635299 PMCID: PMC6419287 DOI: 10.2215/cjn.08600718] [Citation(s) in RCA: 133] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IgA nephropathy (IgAN) is an important cause of ESKD for which there are no approved therapies. A challenge for evaluating treatments for IgAN is the usual long time course for progression to ESKD. The aim of this Kidney Health Initiative project was to identify surrogate end points that could serve as reliable predictors of a treatment's effect on long-term kidney outcomes in IgAN and be used as a basis for approval. Proteinuria was identified as the most widely recognized and well studied risk factor for progression to ESKD in IgAN. The workgroup performed a critical review of the data on proteinuria reduction as a surrogate end point for a treatment's effect on progression to ESKD in IgAN. Epidemiologic data indicate a strong and consistent relationship between the level and duration of proteinuria and loss of kidney function. Trial-level analyses of data from 13 controlled trials also show an association between treatment effects on percent reduction of proteinuria and treatment effects on a composite of time to doubling of serum creatinine, ESKD, or death. We conclude that data support the use of proteinuria reduction as a reasonably likely surrogate end point for a treatment's effect on progression to ESKD in IgAN. In the United States, reasonably likely surrogate end points can be used as a basis for accelerated approval of therapies intended to treat serious or life-threatening conditions, such as IgAN. The clinical benefit of products approved under this program would need to be verified in a postmarketing confirmatory trial.
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Affiliation(s)
- Aliza Thompson
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Jürgen Floege
- Division of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Sonia Boyer-Suavet
- Service de Néphrologie, Hôpital Pasteur, Centre Hospitalier Universitaire de Nice, Université Nice Sophia-Antipolis, Nice, France; Departments of
| | | | | | - Jonathan Barratt
- Infection, Inflammation and Immunity, University of Leicester, Leicester, UK
| | - Daniel C. Cattran
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Heather N. Reich
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Brad H. Rovin
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Melissa West
- American Society of Nephrology, Washington, DC; and
| | - Patrick H. Nachman
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota
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22
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Qian G, Zhang X, Xu W, Zou H, Li Y. Efficacy and safety of glucocorticoids for patients with IgA nephropathy: a meta-analysis. Int Urol Nephrol 2019; 51:859-868. [PMID: 30843135 DOI: 10.1007/s11255-019-02094-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 01/30/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND The efficacy and safety of glucocorticoids for the treatment of patients with IgA nephropathy (IgAN) remains controversial. The aim of the study is to perform a metaanalysis of randomized controlled trials to evaluate the efficacy and safety of glucocorticoids for patients with IgAN. METHODS We searched PubMed, EMBASE and the Cochrane Library and article reference lists of Controlled Trials, and Clinical Trial Registries for randomized controlled trials comparing glucocorticoids with other non-immunosuppressive agents in patients with IgAN. RESULTS The present meta-analysis, including 10 RCTs and 791 patients from 12 published studies, showed that using glucocorticoids agents relatively preserves kidney function(RR 0.06, 95% CI 0.14-0.61) and plays an effective role on reducing the proteinuria(SMD, - 0.69; 95% CI 0.85 to - 0.53, p < 0.00001; heterogeneity I2 = 0%; p = 0.09) compared with a control group. Moreover, adverse events cannot be neglected, especially gastrointestinal tract (RR 3.10, 95% CI 1.37-6.98, p = 0.006; heterogeneity I2 = 0%, p = 0.86), and corticosteroid regimens in IgAN should be reviewed with regard to safety. CONCLUSIONS Glucocorticoids were wildly used to treat various diseases including IgAN. Meanwhile, adverse events cannot be neglected, such as gastrointestinal adverse events, infection and so on. Corticosteroid should be used with reserve, especially in those patients with hypertension and impaired renal function or older patients.
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Affiliation(s)
- Ge Qian
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China
| | - Xiaoyu Zhang
- Department of Non-communicable Disease Control and Prevention, Xi'an Municipal Center for Disease Control and Prevention, Xi'an, 710054, China
| | - Weicheng Xu
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China
| | - Hequn Zou
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China
| | - Yongqiang Li
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China.
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23
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Zhang YM, Zhang H. Update on treatment of immunoglobulin A nephropathy. Nephrology (Carlton) 2019; 23 Suppl 4:62-67. [PMID: 30298661 DOI: 10.1111/nep.13453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2018] [Indexed: 01/04/2023]
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common form of primary glomerulonephritis worldwide and the most common cause of end-stage renal disease in young adults. However, there are still no specific therapies capable of targeting key pathways involved in disease pathogenesis. Recently, many large randomized controlled trials have been reported, such as Supportive Versus Immunosuppressive Therapy for the Treatment of Progressive IgA Nephropathy, Targeted-release Budesonide Versus Placebo in Patients with IgA Nephropathy and Therapeutic Evaluation of Steroids in IgA Nephropathy Global, which are considered to update the 2012 Kidney Disease: Improving Global Outcomes Guideline. More importantly, with a deeper understanding of the roles of mucosal immunity, B-cell activation and complement activation in IgAN, the studies of targeting pathogenic pathways are ongoing. In this review, by systemically searching the clinical trials in IgAN on ClinicalTrials.gov (https://clinicaltrials.gov/), we update the evidence for corticosteroids/immunosuppressive therapy in IgAN and explore the promising targeting pathogenic pathway therapeutic options. With better understanding of pathogenesis of IgAN, emerging therapies will soon become a reality in future.
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Affiliation(s)
- Yue-Miao Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
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24
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Qin JH, Lin JR, Ding WF, Wu WH. Schisandrin B Improves the Renal Function of IgA Nephropathy Rats Through Inhibition of the NF-κB Signalling Pathway. Inflammation 2018; 42:884-894. [DOI: 10.1007/s10753-018-0943-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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25
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Cedillo-Couvert EA, Hsu JY, Ricardo AC, Fischer MJ, Gerber BS, Horwitz EJ, Kusek JW, Lustigova E, Renteria A, Rosas SE, Saunders M, Sha D, Slaven A, Lash JP. Patient Experience with Primary Care Physician and Risk for Hospitalization in Hispanics with CKD. Clin J Am Soc Nephrol 2018; 13:1659-1667. [PMID: 30337326 PMCID: PMC6237062 DOI: 10.2215/cjn.03170318] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 08/14/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES In the general population, the quality of the patient experience with their primary care physician may influence health outcomes but this has not been evaluated in CKD. This is relevant for the growing Hispanic CKD population, which potentially faces challenges to the quality of the patient experience related to language or cultural factors. We evaluated the association between the patient experience with their primary care physician and outcomes in Hispanics with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS This prospective observational study included 252 English- and Spanish-speaking Hispanics with entry eGFR of 20-70 ml/min per 1.73 m2, enrolled in the Hispanic Chronic Renal Insufficiency Cohort study between 2005 and 2008. Patient experience with their primary care physician was assessed by the Ambulatory Care Experiences Survey subscales: communication quality, whole-person orientation, health promotion, interpersonal treatment, and trust. Poisson and proportional hazards models were used to assess the association between the patient experience and outcomes, which included hospitalization, ESKD, and all-cause death. RESULTS Participants had a mean age of 56 years, 38% were women, 80% were primary Spanish speakers, and had a mean eGFR of 38 ml/min per 1.73 m2. Over 4.8 years (median) follow-up, there were 619 hospitalizations, 103 ESKD events, and 56 deaths. As compared with higher subscale scores, lower scores on four of the five subscales were associated with a higher adjusted rate ratio (RR) for all-cause hospitalization (communication quality: RR, 1.54; 95% confidence interval [95% CI], 1.25 to 1.90; health promotion: RR, 1.31; 95% CI, 1.05 to 1.62; interpersonal treatment: RR, 1.50; 95% CI, 1.22 to 1.85; and trust: RR, 1.57; 95% CI, 1.27 to 1.93). There was no significant association of subscales with incident ESKD or all-cause death. CONCLUSIONS Lower perceived quality of the patient experience with their primary care physician was associated with a higher risk of hospitalization.
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Affiliation(s)
| | - Jesse Y. Hsu
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ana C. Ricardo
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Michael J. Fischer
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
| | - Ben S. Gerber
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | | | - John W. Kusek
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Eva Lustigova
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | - Amada Renteria
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Sylvia E. Rosas
- Joslin Diabetes Center and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
| | - Milda Saunders
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Daohang Sha
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Anne Slaven
- Department of Medicine, MetroHealth, Cleveland, Ohio
| | - James P. Lash
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - on behalf of the CRIC Study Investigators
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown Veterans Affairs Medical Center, Chicago, Illinois
- Department of Medicine, MetroHealth, Cleveland, Ohio
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
- Joslin Diabetes Center and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; and
- Department of Medicine, University of Chicago, Chicago, Illinois
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26
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Comprehensive evaluation of the significance of immunofluorescent findings on clinicopathological features in IgA nephropathy. Clin Exp Nephrol 2018; 23:169-181. [DOI: 10.1007/s10157-018-1619-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 07/16/2018] [Indexed: 11/26/2022]
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27
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Chan TM. Corticosteroids in the treatment of IgA nephropathy: any light beyond the clouds of confusion? Postgrad Med J 2018; 94:371-373. [PMID: 29891644 DOI: 10.1136/postgradmedj-2017-135239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 11/03/2022]
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28
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Lin Y, Jia J, Guo Y, He D, Zhang Y, Wang F, Yan T, Liu Y, Lin S. Corticosteroid for IgA Nephropathy: Are They Really Therapeutic? Am J Nephrol 2018; 47:385-394. [PMID: 29874651 DOI: 10.1159/000489580] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND IgA nephropathy (IgAN) is a common chronic glomerular disease that, in most patients, slowly progresses to end-stage kidney disease. The therapy with corticosteroid in IgAN is still a worldwide problem that is confusing the clinicians. METHODS MEDLINE, EMBASE, the Cochrane Library, and article reference lists were searched for randomized controlled trials (RCTs) that compared corticosteroids with placebo and any other non-immunosuppressive agents in treating IgAN. Twelve RCTs involving 1,057 patients were included. RESULTS Overall, we found that steroids had statistically significant effects in preventing the decline in renal function (relative risk 0.42, 95% CI 0.25-0.71, p < 0.001) and reducing proteinuria (SMD: -0.58 g/day, 95% CI -0.80 to -0.36 g/day) in patients with IgAN. The association between glucocorticoid and risk of kidney outcome was not modified by steroids' type (prednisone or methylprednisone), dose (≤30 or > 30 mg/day), duration (≤8 or > 8 months), or serum creatinine (< 1.10 or ≥1.10 mg/dL). But steroids increased the risk of side effects such as gastrointestinal and endocrinium symptoms. CONCLUSION This study provides the clear beneficial effects of the steroids therapy on the kidney function and proteinuria, although it should be used with caution.
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Affiliation(s)
- Yujia Lin
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Junya Jia
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Yipeng Guo
- Department of Epidemiology, Tianjin Public Health Bureau, Tianjin, China
| | - Dandan He
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Yaru Zhang
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Fuzhen Wang
- Department of Statistics, Fenyang Hospital of Shanxi Province, Fenyang, China
| | - Tiekun Yan
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Youxia Liu
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
| | - Shan Lin
- Department of Nephrology, General Hospital of Tianjin Medical University, Tianjin, China
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29
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Stangou M, Papasotiriou M, Xydakis D, Oikonomaki T, Marinaki S, Zerbala S, Stylianou C, Kalliakmani P, Andrikos A, Papadaki A, Balafa O, Golfinopoulos S, Visvardis G, Moustakas G, Papachristou E, Kouloukourgiotou T, Kapsia E, Panagiotou A, Koulousios C, Kavlakoudis C, Georgopoulou M, Panagoutsos S, Vlahakos DV, Apostolou T, Stefanidis I, Siamopoulos K, Tzanakis I, Papadogiannakis A, Daphnis E, Iatrou C, Boletis JN, Papagianni A, Goumenos DS. IgA nephropathy in Greece: data from the registry of the Hellenic Society of Nephrology. Clin Kidney J 2017; 11:38-45. [PMID: 29423199 PMCID: PMC5798157 DOI: 10.1093/ckj/sfx076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/11/2017] [Indexed: 01/09/2023] Open
Abstract
Background Natural history, predisposing factors to an unfavourable outcome and the effect of various therapeutic regimens were evaluated in a cohort of 457 patients with immunoglobulin A nephropathy (IgAN) and follow-up of at least 12 months. Methods Patients with normal renal function and proteinuria <1 g/24 h as well as those with serum creatinine (SCr) >2.5 mg/dL and/or severe glomerulosclerosis received no treatment. Patients with normal or impaired renal function and proteinuria >1 g/24 h for >6 months received daily oral prednisolone or a 3-day course of intravenous (IV) methylprednisolone followed by oral prednisolone per os every other day or a combination of prednisolone and azathioprine. The clinical outcome was estimated using the primary endpoints of end-stage renal disease and/or doubling of baseline SCr. Results The overall 10-year renal survival was 90.8%, while end-stage renal disease and doubling of baseline SCr developed in 9.2% and 14.7% of patients, respectively. Risk factors related to the primary endpoints were elevated baseline SCr, arterial hypertension, persistent proteinuria >0.5 g/24 h and severity of tubulointerstial fibrosis. There was no difference in the clinical outcome of patients treated by the two regimens of corticosteroids; nevertheless, remission of proteinuria was more frequent in patients who received IV methylprednisolone (P = 0.000). The combination of prednisolone with azathioprine was not superior to IV methylprednisolone followed by oral prednisolone. Side effects related to immunossuppressive drugs were observed in 12.8% of patients. Conclusion The clinical outcome of patients with IgAN was related to the severity of clinical and histological involvement. The addition of azathioprine to a corticosteroid-based regimen for IgAN does not improve renal outcome.
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Affiliation(s)
- Maria Stangou
- Department of Nephrology, Hippokratio General Hospital, Aristotle University, Thessaloniki, Greece
| | - Marios Papasotiriou
- Department of Nephrology, University Hospital of Patras, Patras, Greece
- Correspondence and offprint requests to: Marios Papasotiriou; E-mail:
| | - Dimitrios Xydakis
- Department of Nephrology, Venizelio General Hospital of Heraklion, Heraklion Crete, Greece
| | | | - Smaragdi Marinaki
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | - Synodi Zerbala
- Department of Nephrology, General Hospital of Nikaia, Piraeus, Greece
| | | | | | - Aimilios Andrikos
- Department of Nephrology, Hatzikosta General Hospital of Ioannina, Ioannina, Greece
| | - Antonia Papadaki
- Department of Nephrology, General Hospital of Chania, Chania Crete, Greece
| | - Olga Balafa
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | | | - Georgios Visvardis
- Department of Nephrology, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Georgios Moustakas
- Department of Nephrology, Gennimatas General Hospital of Athens, Athens, Greece
| | | | | | - Eleni Kapsia
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | | | | | - Christos Kavlakoudis
- Department of Nephrology, Papageorgiou General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Maria Georgopoulou
- Department of Nephrology, Gennimatas General Hospital of Athens, Athens, Greece
| | - Stylianos Panagoutsos
- Department of Nephrology, University Hospital of Alexandroupolis, Alexandroupoli, Greece
| | - Demetrios V Vlahakos
- Department of Nephrology, Attikon University Hospital, National and Kapodistrian University, Athens, Greece
| | | | - Ioannis Stefanidis
- Department of Nephrology, University Hospital of Larissa, Larissa, Greece
| | - Kostas Siamopoulos
- Department of Nephrology, University Hospital of Ioannina, Ioannina, Greece
| | - Ioannis Tzanakis
- Department of Nephrology, General Hospital of Chania, Chania Crete, Greece
| | | | - Eugene Daphnis
- Department of Nephrology, University Hospital of Heraklion, Heraklion Crete, Greece
| | - Christos Iatrou
- Department of Nephrology, General Hospital of Nikaia, Piraeus, Greece
| | - John N Boletis
- Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens, Greece
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokratio General Hospital, Aristotle University, Thessaloniki, Greece
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30
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Rasche FM, Keller F, Rasche WG, Schiekofer S, Boldt A, Sack U, Fahnert J. Why, when and how should immunosuppressive therapy considered in patients with immunoglobulin A nephropathy? Clin Exp Immunol 2016; 186:115-133. [PMID: 27283488 PMCID: PMC5054563 DOI: 10.1111/cei.12823] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/20/2016] [Accepted: 05/20/2016] [Indexed: 12/13/2022] Open
Abstract
IgA nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. Lifelong mesangial deposition of IgA1 complexes subsist inflammation and nephron loss, but the complex pathogenesis in detail remains unclear. In regard to the heterogeneous course, classical immunosuppressive and specific therapeutic regimens adapted to the loss of renal function will here be discussed in addition to the essential common renal supportive therapy. Renal supportive therapy alleviates secondary, surrogate effects or sequelae on renal function and proteinuria of high intraglomerular pressure and subsequent nephrosclerosis by inhibition of the renin angiotensin system (RAASB). In patients with physiological (ΔGFR < 1·5 ml/min/year) or mild (ΔGFR 1·5-5 ml/min/year) decrease of renal function and proteinuric forms (> 1 g/day after RAASB), corticosteroids have shown a reduction of proteinuria and might protect further loss of renal function. In patients with progressive loss of renal function (ΔGFR > 3 ml/min within 3 months) or a rapidly progressive course with or without crescents in renal biopsy, cyclophosphamide with high-dose corticosteroids as induction therapy and azathioprine maintenance has proved effective in one randomized controlled study of a homogeneous cohort in loss of renal function (ΔGFR). Mycophenolic acid provided further maintenance in non-randomized trials. Differentiated, precise, larger, randomized, placebo-controlled studies focused on the loss of renal function in the heterogeneous forms of IgAN are still lacking. Prospectively, fewer toxic agents will be necessary in the treatment of IgAN.
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Affiliation(s)
- F M Rasche
- Department of Internal Medicine, Neurology, Dermatology, Clinic for Endocrinology, Nephrology, Section of Nephrology, University Leipzig, Leipzig, Germany
| | - F Keller
- Department of Internal Medicine I, Division of Nephrology, University Hospital of Ulm, Ulm, Germany.
| | - W G Rasche
- Department of Head Medicine and Oral Health, Department of Ophthalmology, University Leipzig, Leipzig, Germany
| | - S Schiekofer
- Center for Geriatric Medicine at Bezirksklinikum Regensburg, Department of Psychiatry and Psychotherapy, University Regensburg, Regensburg, Germany
| | - A Boldt
- Institute of Clinical Immunology, Medical Faculty, Leipzig, Germany
| | - U Sack
- Institute of Clinical Immunology, Medical Faculty, Leipzig, Germany
| | - J Fahnert
- Department of Diagnostic and Interventional Radiology, University Leipzig, Leipzig, Germany
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Peng W, Tang Y, Jiang Z, Li Z, Mi X, Qin W. The effect of calcineurin inhibitors in the treatment of IgA nephropathy: A systematic review and meta-analysis (PRISMA). Medicine (Baltimore) 2016; 95:e4731. [PMID: 27583915 PMCID: PMC5008599 DOI: 10.1097/md.0000000000004731] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Immunoglobin A nephropathy (IgAN), the most prevalent form of primary glomerulonephritis, represents the leading cause of kidney failure among East Asian populations. Immunosuppressive treatment regimen, except for a 6-month trial of corticosteroids, has not been approved by the KDIGO guideline yet. Specific and effective treatment is still lacking. We decided to evaluate the efficacy and safety of the calcineurin inhibitors (CNIs) in the treatment of IgAN. METHODS Database from the Cochrane library, PubMed, Embase, CBM, CNKI, and CENTRAL databases were searched and reviewed up to March 2016. Literature was screened by 2 independent reviewers accordingly. Clinical trials were analyzed using Stata 12.0. RESULTS Five random control trials and 2 nonrandomized concurrent control trials were selected and included in this study according to our inclusion and exclusion criteria. The rates of complete remission in patients with IgAN were significantly increased in the group of CNIs (RR 1.56, P = 0.002). No statistical difference was observed in the rates of partial remission, or response between the CNIs and steroids alone. Additionally, CNIs resulted in a significant reduction in urinary protein (WMD 0.34, P = 0.002) and increase in serum albumin level (WMD 1.89, P = 0.013). No differences were found in the serum creatinine, estimated glomerular filtration rate, and rates of adverse effects including infection, hyperglycemia, and liver dysfunction. CONCLUSION With present evidence, CNIs may be promising immunosuppressive agents for IgAN in future. However, large, long-term, multicenter trials are required to confirm our findings.
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Affiliation(s)
- Wei Peng
- Division of Nephrology, Department of Medicine, West China School of Medicine
| | - Yi Tang
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zheng Jiang
- Division of Nephrology, Department of Medicine, West China School of Medicine
| | - Zi Li
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xuhua Mi
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei Qin
- West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Correspondence: Wei Qin, Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China. 610041 (e-mail: )
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Feehally J, Barratt J. Should Immunosuppressive Therapy Be Used in Slowly Progressive IgA Nephropathy? Am J Kidney Dis 2016; 68:184-186. [DOI: 10.1053/j.ajkd.2016.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 11/11/2022]
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Abstract
IgA nephropathy is the most common form of primary glomerulonephritis worldwide and an important cause of chronic kidney disease and end-stage kidney failure. Its pathophysiology remains in part unsolved but it is recognized as an immune complex disease. Recent years have brought progress in the field through the discovery of several genetic susceptibility loci and the formulation of the multi-hit pathogenesis model. Presentation, clinical course and histology can be extremely variable, making any histological classification still difficult. Indeed, most therapeutic studies until now include patients based only on the severity of clinical criteria but the new classification of Oxford should change that. Only the management of patients with nephropathy with minimal change glomerular lesions and nephrotic syndrome, or extra-capillary glomerulonephritis and rapidly progressive renal failure, is consensual: Corticosteroids alone for the first and associated with immunosuppressive drugs for the latter. The recent Kidney Disease Improving Global Outcomes (KDIGO) consensus treatment guideline is still controversial, especially in light of the last clinical studies. Corticosteroid therapy can be discussed in patients with proteinuria greater than 1 g/day without renal failure. All IgA nephropathy patients should benefit from the global management of chronic glomerular disease, including a renin-angiotensin system blocker in the presence of hypertension or proteinuria.
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Affiliation(s)
- Evangéline Pillebout
- Service de néphrologie, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - Jérôme Vérine
- Service d'anatomie pathologique, hôpital Saint-Louis, 1, avenue Claude-Vellefaux, 75010 Paris, France
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Inker LA, Mondal H, Greene T, Masaschi T, Locatelli F, Schena FP, Katafuchi R, Appel GB, Maes BD, Li PK, Praga M, Del Vecchio L, Andrulli S, Manno C, Gutierrez E, Mercer A, Carroll KJ, Schmid CH, Levey AS. Early Change in Urine Protein as a Surrogate End Point in Studies of IgA Nephropathy: An Individual-Patient Meta-analysis. Am J Kidney Dis 2016; 68:392-401. [PMID: 27032886 DOI: 10.1053/j.ajkd.2016.02.042] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 02/12/2016] [Indexed: 11/11/2022]
Abstract
BACKGROUND The role of change in proteinuria as a surrogate end point for randomized trials in immunoglobulin A nephropathy (IgAN) has previously not been thoroughly evaluated. STUDY DESIGN Individual patient-level meta-analysis. SETTING & POPULATION Individual-patient data for 830 patients from 11 randomized trials evaluating 4 intervention types (renin-angiotensin system [RAS] blockade, fish oil, immunosuppression, and steroids) examining associations between changes in urine protein and clinical end points at the individual and trial levels. SELECTION CRITERIA FOR STUDIES Randomized controlled trials of IgAN with measurements of proteinuria at baseline and a median of 9 (range, 5-12) months follow-up, with at least 1 further year of follow-up for the clinical outcome. PREDICTOR 9-month change in proteinuria. OUTCOME Doubling of serum creatinine level, end-stage renal disease, or death. RESULTS Early decline in proteinuria at 9 months was associated with lower risk for the clinical outcome (HR per 50% reduction in proteinuria, 0.40; 95% CI, 0.32-0.48) and was consistent across studies. Proportions of treatment effect on the clinical outcome explained by early decline in proteinuria were estimated at 11% (95% CI, -19% to 41%) for RAS blockade and 29% (95% CI, 6% to 53%) for steroid therapy. The direction of the pooled treatment effect on early change in proteinuria was in accord with the direction of the treatment effect on the clinical outcome for steroids and RAS blockade. Trial-level analyses estimated that the slope for the regression line for the association of treatment effects on the clinical end points and for the treatment effect on proteinuria was 2.15 (95% Bayesian credible interval, 0.10-4.32). LIMITATIONS Study population restricted to 11 trials, all having fewer than 200 patients each with a limited number of clinical events. CONCLUSIONS Results of this analysis offer novel evidence supporting the use of an early reduction in proteinuria as a surrogate end point for clinical end points in IgAN in selected settings.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA.
| | - Hasi Mondal
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Tom Greene
- Division of Epidemiology, University of Utah, Salt Lake City, UT
| | | | - Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Lecco, Italy
| | | | | | - Gerald B Appel
- The Glomerular Kidney Disease Center, Columbia University College of Physicians and Surgeons, New York, NY
| | - Bart D Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Philip K Li
- Department of Medicine, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Manuel Praga
- Nephrology, Department of Medicine, Hospital Universitario 12 de Octubre, Complutense University, Madrid, Spain
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Lecco, Italy
| | - Simeone Andrulli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Lecco, Italy
| | - Carlo Manno
- Renal, Dialysis & Transplant Unit, University of Bari, Bari, Italy
| | - Eduardo Gutierrez
- Nephrology, Department of Medicine, Hospital Universitario 12 de Octubre, Complutense University, Madrid, Spain
| | | | - Kevin J Carroll
- KJC Statistics Ltd and University of Sheffield, Sheffield, United Kingdom
| | - Christopher H Schmid
- Department of Biostatistics and Center for Evidence Based Medicine, Brown University School of Public Health, Providence, RI
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
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Comparison of steroid-pulse therapy and combined with mizoribine in IgA nephropathy: a randomized controlled trial. Clin Exp Nephrol 2016; 20:896-903. [PMID: 26758039 DOI: 10.1007/s10157-016-1226-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 01/02/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The significance of immunosuppressants as an adjunct treatment with corticosteroids for IgA nephropathy (IgAN) has not been well demonstrated. This study was performed to compare two treatment regimens, steroid-pulse therapy or combined with mizoribine (MZR) in progressive IgAN. METHODS Study design was a prospective randomized controlled trial of 40 patients with moderate to severe glomerular injuries who were randomly administered either pulse methylprednisolone followed by a 25-month course of oral prednisolone (P group, n = 20) or in combination with MZR (150 mg/day for 24 months, M + P group, n = 20). The primary endpoint was a reduction of proteinuria by ≥50 % of the baseline value. Secondary endpoints were increased serum creatinine (Cr) by ≥50 %, or a decrease in estimated glomerular filtration rate by ≤50 %. RESULTS Twenty-five months after the initiation of treatment, urinary protein excretion significantly declined from the median of 0.98 to 0.17 g/gCr in the P group (P < 0.05) and from 1.01 to 0.38 g/gCr in the M + P group (P < 0.05). There was no statistical difference in the serial changes of proteinuria between two groups (P = 0.81). All patients reached the primary endpoint, and the cumulative incidence of the reduction of proteinuria was not significantly different (P = 0.76). No patient reached the secondary endpoint during the 25 months of treatment. CONCLUSIONS Both therapeutic regimens significantly reduced the levels of proteinuria. We could not find the additional effect of MZR in combination with steroid-pulses in this small-scale controlled trial. Steroid-pulse therapy with a 25-month course of oral steroids seems to be effective for progressive IgAN.
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Treatment of IgA nephropathy with renal insufficiency. J Nephrol 2016; 29:551-8. [DOI: 10.1007/s40620-015-0257-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 12/07/2015] [Indexed: 10/22/2022]
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Comparison of immunosuppressive therapies for IgA nephropathy after tonsillectomy: three-course versus one-course steroid pulse combined with mizoribine. Int Urol Nephrol 2015; 47:1823-30. [PMID: 26433884 PMCID: PMC4628097 DOI: 10.1007/s11255-015-1118-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 09/19/2015] [Indexed: 01/08/2023]
Abstract
Purpose
It has been reported that steroid pulse therapy for IgA nephropathy improves renal prognosis. However, because of the side effects, steroid dose must be restricted to some cases. Treatment effects of steroid on cases already presenting with reduced renal function are unknown. In this study, we performed tonsillectomy in patients with IgA nephropathy and conducted a comparative study about subsequent immunosuppressive therapy.
Methods
Subjects were patients younger than 70 years of age diagnosed with IgA nephropathy by renal biopsy. Treatment protocols were a single-course steroid pulse combined with mizoribine during a period from August 2006 to June 2010 (Group A; n = 34) and a three-course steroid pulse during a period from July 2010 to March 2013 (Group B; n = 32). Primary end points were excretory amounts of proteinuria, disappearance of proteinuria and hematuria, and exacerbation of renal function. Results In both the groups, proteinuria decreased significantly 12 months after treatment, and no significant difference in alleviation effects on proteinuria was found between groups. eGFR increased significantly 12 months after treatment in Group A, whereas it tended to decrease in Group B. As for the preservation effect on eGFR, Group A showed significantly higher preservation of eGFR. Similar results were shown in the patients whose eGFR at the start of the treatment was less than 60 mL/min/1.73 m2. Conclusions Single-course steroid pulse therapy combined with mizoribine was considered to have a protective effect on the renal function in IgA nephropathy, especially accompanying renal dysfunction.
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Cheng G, Liu D, Margetts P, Liu L, Zhao Z, Liu Z, Tang L, Fang Y, Li H, Guo Y, Chen F, Liu F. Valsartan combined with clopidogrel and/or leflunomide for the treatment of progressive immunoglobulin A nephropathy. Nephrology (Carlton) 2015; 20:77-84. [PMID: 25358874 DOI: 10.1111/nep.12359] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2014] [Indexed: 12/20/2022]
Abstract
AIM The current standard treatment for IgA nephropathy relies on steroid and/or immunosuppressive therapy and angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARB). This study examines the benefits and safety of combining valsartan with clopidogrel and leflunomide as a treatment for progressive IgA nephropathy. METHODS Patients with primary IgA nephropathy, confirmed by renal biopsy, were recruited for this study. Patients were separated into four groups (n = 42 each) after 2 months of run-in period of valsartan treatment. All patients were treated with valsartan alone (Group 1) or valsartan and either clopidogrel (Group 2) or leflunomide (Group 3) or both clopidogrel and leflunomide (Group 4). Each group was followed up for their next 24 months for 24 h urinary protein excretion, serum creatinine and estimated glomerular filtration rate (eGFR) to assess the effect of the treatment. Adverse effects were recorded concurrently to evaluate the safety of the treatment. RESULTS Of all 168 patients, 107 were males and 61 were females, with an average age of 33.8 ± 8.79 years. Baseline characteristics were comparable among the four groups (P > 0.05) prior to the experimental treatment. There was a significant (P < 0.05) decrease in 24 h urinary protein excretion after 4 months of experimental treatment. At the end of the 24 months, groups 3 and 4 showed a respective 62.35% and 69.47% reduction in proteinuria. The serum creatinine was significantly higher (P < 0.05) in group 1 and 2 at the end of the follow-up, and their respective eGFR was significantly lower. The incidence of cardiovascular complication was 11.9% and 9.5% for group 1 and 3, respectively. CONCLUSIONS The treatment with Valsartan combined with Clopidogrel and Leflunomide can reduce the urinary proteins loss and renal function deterioration for IgA nephropathy patients and cause minimal adverse reactions. Our study suggests a new clinical treatment option for IgA nephropathy.
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Affiliation(s)
- Genyang Cheng
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Xie Y, Bowe B, Xian H, Balasubramanian S, Al-Aly Z. Rate of Kidney Function Decline and Risk of Hospitalizations in Stage 3A CKD. Clin J Am Soc Nephrol 2015; 10:1946-55. [PMID: 26350437 DOI: 10.2215/cjn.04480415] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 08/10/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Risk of hospitalizations is increased in patients with CKD. We sought to examine the association between rate of kidney function decline and risk of hospitalization in a cohort of patients with early CKD. DESIGN, SETTINGS, PARTICIPANTS, & MEASUREMENTS We built a cohort of 247,888 United States veterans who had at least one eGFR measurement between October 1999 and September 2003 and an additional eGFR between October 2003 and September 2004. We selected patients whose initial eGFR was between 45 and 59 ml/min per 1.73 m2. Rate of eGFR change (in milliliters per minute per 1.73 m2 per year) was categorized as no decline (>0), mild (0 to -1, and served as the referent group), moderate (-1 to -5), or severe (>-5) eGFR decline. We built survival models to examine the association between the rate of kidney function decline and the risk of hospitalization and readmission and linear regression to estimate length of hospital stay. RESULTS Over a median observation of 9 years (interquartile range, 5.28-9.00), patients with moderate and severe eGFR decline exhibited a higher risk of hospitalizations (hazard ratio [HR], 1.22; 95% confidence interval [95% CI], 1.19 to 1.26; and HR, 1.33; 95% CI, 1.28 to 1.39, respectively). Among patients with moderate and severe eGFR decline, the association between the rate of decline and the risk of hospitalizations was more pronounced with an increased number of hospitalizations (P<0.01). Patients with moderate and severe eGFR decline had a higher risk of readmission (HR, 1.19; 95% CI, 1.13 to 1.26; and HR, 1.53; 95% CI, 1.43 to 1.63, respectively). Among patients with severe eGFR decline, the association between the rate of kidney function decline and the risk of readmission was stronger with an increased number of readmissions (P<0.01). Patients with moderate and severe eGFR decline experienced an additional length of stay of 1.40 (95% CI, 0.88 to 1.92) and 5.00 days per year (95% CI, 4.34 to 5.66), respectively. CONCLUSIONS The rate of kidney function decline is associated with a higher risk of hospitalizations, readmissions, and prolonged length of hospital stay.
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Affiliation(s)
- Yan Xie
- Clinical Epidemiology Center and
| | | | - Hong Xian
- Clinical Epidemiology Center and Department of Biostatistics, College for Public Health and Social Justice, Saint Louis University, Saint Louis, Missouri; and
| | | | - Ziyad Al-Aly
- Clinical Epidemiology Center and Division of Nephrology, Department of Medicine, Veterans Affairs Saint Louis Health Care System, Saint Louis, Missouri; Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
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Prognostic value of endocapillary hypercellularity in IgA nephropathy patients with no immunosuppression. J Nephrol 2015; 29:367-375. [PMID: 26318019 DOI: 10.1007/s40620-015-0227-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 08/20/2015] [Indexed: 12/15/2022]
Abstract
AIM Interpretation of retrospective clinicopathological studies of IgA nephropathy (IgAN) has been confounded by immunosuppression bias. In published validation studies of the Oxford Classification of IgAN, an average of 33 % of patients received non-randomised steroid and/or cytotoxic therapy. In order to determine the true impact of proliferative lesions on the natural history of IgAN, analysis of patient cohorts that have received no immunosuppression is required. METHODS We performed a retrospective single centre study of patients with IgAN managed without immunosuppressive therapy. Biopsies were scored according to the Oxford Classification. The primary outcomes were renal survival or a rapid loss of renal function defined as a decline in eGFR of >5 ml/min/year. RESULTS 237 patients with IgAN were identified with a mean follow-up of 82 months. 200 had biopsies available for review, of which 156 were adequate for scoring using the Oxford Classification. 9/156 patients (5.8 %) received some immunosuppressive therapy, mostly for unrelated conditions: these were excluded. In multivariate COX regression, including histological and clinical data, the only independent predictors of time to ESRD were baseline eGFR (HR 0.96 per ml/min increase, p = 0.018), baseline proteinuria (HR 1.36 per doubling, p = 0.004) and endocapillary hypercellularity (HR 4.75 for E1 compared to E0, p < 0.001). Independent predictors of a rapid decline in eGFR were proteinuria (OR 1.45 per doubling, p = 0.006), endocapillary hypercellularity (OR 3.41 for E1 compared to E0, p = 0.025) and tubular atrophy/interstitial fibrosis (OR 8.77 for T2 compared to T0, p = 0.006). CONCLUSIONS In a cohort of IgAN patients receiving no immunosuppression, endocapillary proliferation and tubular atrophy/interstitial fibrosis are independent predictors of rate of loss of renal function. The lack of predictive value of E score in other clinicopathological studies is most likely a result of immunosuppression-associated bias. Our findings provide evidence to support immunosuppressive treatment of endocapillary-pattern IgAN.
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Vecchio M, Bonerba B, Palmer SC, Craig JC, Ruospo M, Samuels JA, Molony DA, Schena FP, Strippoli GFM. Immunosuppressive agents for treating IgA nephropathy. Cochrane Database Syst Rev 2015:CD003965. [PMID: 26235292 DOI: 10.1002/14651858.cd003965.pub2] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most common glomerulonephritis world-wide and a cause of end-stage kidney disease (ESKD) in 15% to 20% of patients within 10 years and in 30% to 40% of patients within 20 years from the onset of disease. This is an update of a review first published in 2003. OBJECTIVES To determine the benefits and harms of immunosuppression for the treatment of IgAN. SEARCH METHODS For this review update we searched the Specialised Register to 19 February 2015 through contact with the Trials Search Co-ordinator using search terms relevant to this review. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs of treatment for IgAN in adults and children and that compared immunosuppressive agents with placebo, no treatment, or other immunosuppressive or non-immunosuppressive agents. DATA COLLECTION AND ANALYSIS Two authors independently assessed study risk of bias and extracted data for population characteristics, interventions and outcomes including mortality, infection, hospitalisation, ESKD requiring renal replacement therapy (dialysis or kidney transplantation), doubling of serum creatinine, remission of proteinuria, and end of treatment urinary protein excretion, serum creatinine, and glomerular filtration rate.Estimates of treatment effect and hazards were summarised using random effects meta-analysis. Treatment effects were expressed as relative risk (RR) and 95% confidence intervals (95% CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS We included 32 studies comprising 1781 participants. Risk of bias within the included studies was generally high: 22 studies (69%) did not describe the method used to generate the randomisation sequence; 24 (75%) did not describe the methods used to conceal allocation; performance bias was not reported or high in 30 studies (94%); detection bias was unclear in 31 studies (97%); attrition bias was low in 14 studies (44%), unclear in eight (25%) and high in 12 studies (38%); reporting bias was low in 21 studies (67%) and high in 10 studies (31%); and four studies received industry funding or were terminated early (13%).Steroids lowered risks of progression to ESKD (6 studies, 341 participants: RR 0.44, 95% CI 0.25 to 0.80), and doubling of serum creatinine (6 studies, 341 participants: RR 0.45, 95% CI 0.29 to 0.69), lowered urinary protein excretion (6 studies, 263 participants: MD -0.49 g/24 h, 95% CI -0.72 to -0.25); and preserved glomerular filtration rate (4 studies, 138 participants: MD 17.87 mL/min/1.73 m(2), 95% CI 4.93 to 30.82) compared to no treatment or placebo. Combining steroids plus renin-angiotensin-system (RAS) inhibitors lowered the risk of progression to ESKD (2 studies, 160 participants: RR 0.16, 95% CI 0.04 to 0.59) and reduced urinary protein excretion (1 study, 38 participants: MD -0.20 g/24 h, 95% CI -0.26 to -0.14) compared with RAS inhibitors or steroids alone. Cytotoxic agents (azathioprine) plus steroid regimens plus dipyridamole increased remission of proteinuria (1 study, 78 participants: RR 1.24, 95% CI 1.01 to 1.52) compared to steroids alone but had uncertain effects on other outcomes.Mycophenolate mofetil plus RAS inhibitors lowered the risk of progression to ESKD (1 study, 40 participants: RR 0.22, 95% CI 0.05 to 0.90), improved remission of proteinuria (1 study, 40 participants: RR 2.67, 95% CI 1.32 to 5.39) and reduced urinary protein excretion (1 study, 40 participants: MD -1.26 g/24 h, 95% CI -1.46 to -1.06). Effects of other immunosuppressive regimens (including cyclosporin, leflunomide) were inconclusive primarily due to insufficient data from the individual studies. Subgroup analyses to determine the impact of patient characteristics on treatment effectiveness were not possible. AUTHORS' CONCLUSIONS The optimal management of IgAN remains uncertain although corticosteroid therapy may lower the risks of kidney disease progression and need for dialysis or transplantation. Evidence for treatment effects of immunosuppressive agents on mortality, infection, and cancer is generally sparse or low-quality and insufficient to guide clinical practice. Available RCTs are few, small, have high risk of bias - particularly selective reporting - and generally do not systematically identify treatment-related harms. Subgroup analyses to identify specific patient characteristics that might predict better response to therapy were not possible. Larger placebo-controlled studies of corticosteroid therapy or mycophenolate mofetil which are sufficiently powered to evaluate patient-relevant end points including adverse events and that examine the optimal duration of treatment are now required in populations with IgAN with a range of kidney function.
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Yuan Y, Wang Q, Ni Z, Che X, Cao L, Shao X, Zhang M, Xie Y, Qi C, Zhou W, Tian L, Mou S. Long-term kidney survival analyses in IgA nephropathy patients under steroids therapy: a case control study. J Transl Med 2015; 13:186. [PMID: 26048044 PMCID: PMC4467637 DOI: 10.1186/s12967-015-0549-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 05/26/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Corticosteroids are preferred to treat patients with active IgA nephropathy (IgAN), and beneficial effects from the short-term use of corticosteroids have been confirmed. However, a large number of patients will progress to end-stage renal disease after a long time follow-up. This study aimed to evaluate kidney disease progression and risk factors on kidney survival in IgAN patients receiving steroids treatment. METHODS Two hundred biopsy-proven IgAN patients who received corticosteroid therapy were enrolled and followed for a median period of 63.33 months. Risk factors on kidney survival were retrospectively investigated by the Cox proportional hazards model. RESULTS Of the two hundred patients, twenty patients showed progression of renal impairment at the end of follow-up. The median and interquartile range values for initial serum creatinine were 89.2 and 68.08-121.35 µmol/L, respectively. Multivariate Cox regression analyses revealed that relapse, non-remission, time-averaged eGFR (TA-eGFR), and time-averaged serum albumin (TA-ALB) were independently associated with the kidney progression. Those with TA-ALB levels <35 g/L and TA-eGFR levels <60 mL/min/1.73 m(2) were less likely to recover from kidney progression. Patients were more likely to show kidney function deterioration, when they had non-remission or relapse after corticosteroids treatment. CONCLUSION This study demonstrated that relapse, non-remission, TA-eGFR, and TA-ALB could serve as independent predictors of long term prognosis of IgAN patients receiving corticosteroid therapy.
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Affiliation(s)
- Yanhong Yuan
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Qin Wang
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Zhaohui Ni
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Xiajing Che
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Liou Cao
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Xinghua Shao
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Minfang Zhang
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Yuanyuan Xie
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Chaojun Qi
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Wenyan Zhou
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Lei Tian
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
| | - Shan Mou
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, 160 Pujian Road, Shanghai, 200127, China.
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Tian L, Shao X, Xie Y, Wang L, Wang Q, Che X, Ni Z, Mou S. The long-term efficacy and safety of immunosuppressive therapy on the progression of IgA nephropathy: a meta-analysis of controlled clinical trials with more than 5-year follow-up. Expert Opin Pharmacother 2015; 16:1137-47. [PMID: 25892092 DOI: 10.1517/14656566.2015.1038238] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the long-term efficacy of immunosuppressive therapy on Immunoglobulin A nephropathy (IgAN). METHODS Trials with at least 5-year follow-up investigating immunosuppressive therapy were selected. MAIN OUTCOME MEASURES Primary outcome was end-stage renal disease (ESRD). Secondary outcome was deterioration in renal function defined as doubled serum creatinine or 50% reduction of eGFR. RESULTS Seven studies were enrolled. Immunosuppression lowered the risk for ESRD risk ratio (RR = 0.30, 95% CI 0.19 - 0.48, p < 0.00001) and deterioration in renal function (RR = 0.19, 95% CI 0.07 - 0.54, p = 0.002). As for pooled RRs of ESRD, there were four studies with < 7-year follow-up, three followed for > 7 years, four adopted corticosteroids, two used corticosteroids plus other immunosuppressive agents, four were from Asia, and three from Europe. Pooled RRs were 0.32 (95% CI, 0.18 - 0.58, p = 0.0001), 0.28 (95% CI, 0.13 - 0.59, p = 0.0009), 0.34 (95% CI, 0.17 - 0.67, p = 0.002), 0.29 (95% CI, 0.15 - 0.58, p = 0.0005), 0.37 (95% CI, 0.20 - 0.68, p = 0.001) and 0.23 (95% CI, 0.11 - 0.47, p < 0.0001), respectively. Immunosuppression was associated with an increased risk for adverse events (RR = 2.13, 95% CI 1.17 - 3.86, p = 0.01). CONCLUSIONS Immunosuppressive therapy for IgAN might reduce long-term risk of ESRD and deterioration in renal function but increase risk of adverse events, and the efficacy on patients from Europe and Asia might be similar. Addition of other immunosuppressive agents did not provide additional benefit.
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Affiliation(s)
- Lei Tian
- Shanghai Jiao Tong University, Ren Ji Hospital, School of Medicine, Molecular Cell Lab for Kidney Disease, Department of Nephrology , 1630 Dongfang Road, Shanghai , China +86 21 6838 3188 ; +86 21 6838 3124 ;
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Inker LA, Lambers Heerspink HJ, Mondal H, Schmid CH, Tighiouart H, Noubary F, Coresh J, Greene T, Levey AS. GFR decline as an alternative end point to kidney failure in clinical trials: a meta-analysis of treatment effects from 37 randomized trials. Am J Kidney Dis 2014; 64:848-59. [PMID: 25441438 DOI: 10.1053/j.ajkd.2014.08.017] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 08/19/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND There is increased interest in using alternative end points for trials of kidney disease progression. The currently established end points of end-stage renal disease and doubling of serum creatinine level, equivalent to a 57% decline in estimated glomerular filtration rate (eGFR), are late events in chronic kidney disease (CKD), requiring large clinical trials with long follow-up. As part of a comprehensive evaluation of lesser declines in eGFR as alternative end points, we describe the consistency of treatment effects of intervention on the alternative and established end points in past trials. STUDY DESIGN Diagnostic test study. SETTING & POPULATION 9,488 participants from 37 randomized controlled trials of CKD progression across 5 intervention types. INDEX TEST Alternative end points including percentage change in eGFR from baseline (20%, 30%, 40%, and 57%) throughout study duration and to 12, 18, and 24 months. eGFR change confirmed versus nonconfirmed at the next visit. REFERENCE TEST The historically established end point of time to composite of treated kidney failure (end-stage renal disease), untreated kidney failure (GFR<15mL/min/1.73m(2)), or doubling of serum creatinine level throughout study duration. RESULTS Over a median of 3.62 years' follow-up, there were 3,070 established end points. Compared to the established end point, the number of alternative end points was greater for smaller versus larger declines in eGFR and longer versus shorter follow-up intervals. There was a general trend toward attenuation of the treatment effect with end points defined by a lesser eGFR decline, with greater attenuation with nonconfirmed end points, except for the low-protein-diet intervention, for which a stronger treatment effect was observed. The ratio (95% credible interval) of the HR for the alternative to established end point for the 5 intervention types ranged from 0.91 (0.64-1.43) to 1.12 (0.89-1.40) for 40% decline and from 0.88 (0.63-1.39) to 1.15 (0.88-1.54) for 30% decline for the overall study duration, indicating consistency of treatment effects. LIMITATIONS Limited variety of interventions tested and low statistical power for many CKD clinical trials. CONCLUSIONS These results provide some support for the use of lesser eGFR declines as a surrogate end point, with stronger support for the 40% than 30% decline.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA.
| | - Hiddo J Lambers Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hasi Mondal
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Christopher H Schmid
- Department of Biostatistics, Brown University School of Public Health, Providence, RI
| | - Hocine Tighiouart
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Farzad Noubary
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins, Baltimore, MD
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
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Wang X, Zhou Y, Zhu N, Wang L, Gu LJ, Yuan WJ. The deposition of Notch1 in hepatitis B virus-associated nephropathy and its role in hepatitis B virus X protein-induced epithelial-mesenchymal transdifferentiation and immunity disorder in renal tubular epithelial cells. J Viral Hepat 2014; 21:734-43. [PMID: 24628678 DOI: 10.1111/jvh.12244] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 01/02/2014] [Indexed: 12/18/2022]
Abstract
Notch1 plays an important role in the regulation of immune responses and epithelial-mesenchymal transdifferentiation (EMT). Previous studies have observed inflammatory cell infiltration and tubulointerstitial fibrosis in the renal biopsies from patients with HBV-associated glomerulonephritis (HBV-GN). We hypothesized that Notch1 may be involved in the progression of HBV-GN. In this study, we evaluated the distribution of Notch1 in patients with HBV-GN. Our results showed that Notch1 was mainly distributed in renal tubules and the interstitial area, and the expression levels of Notch1 had a positive correlation with the renal tubular pathology. In this respect, we used human proximal tubular epithelial cells (HK-2) as target cells, which were transiently transfected with the hepatitis B virus X (HBx) gene using a eukaryotic vector. HBx expression resulted in significantly increased detection of Notch1, alpha-smooth muscle actin (α-SMA), major histocompatibility complex-II (MHC-II), CD40 and interleukin-4 (IL-4). At the same time, E-cadherin and interferon-γ (IFN-γ) expression levels were significantly inhibited. These HBx-induced phenotypes were exacerbated by upregulation of Notch1. Knock-down of Notch1 by specific shRNA caused decreases of α-SMA, MHC-II, CD40 and IL-4, and increases of E-cadherin and IFN-γ. These findings suggest that Notch1 is significantly associated with renal tubular and interstitial lesions. Notch1 can mediate HBx-induced EMT of HK-2 cells, promote HBx-induced increases in immune molecule expression and exacerbation of cytokine disorders, which may contribute to the progression of HBV-GN. Inhibitors of Notch1 signalling may be useful as new therapeutics for the treatment of HBV-GN.
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Affiliation(s)
- X Wang
- Department of Nephrology, Shanghai Jiaotong University Affiliated Shanghai First People's Hospital, Shanghai, China
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Dhaun N, Bellamy CO, Cattran DC, Kluth DC. Utility of renal biopsy in the clinical management of renal disease. Kidney Int 2014; 85:1039-48. [PMID: 24402095 DOI: 10.1038/ki.2013.512] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 09/23/2013] [Accepted: 09/26/2013] [Indexed: 12/31/2022]
Abstract
Characterizing chronic kidney disease (CKD) at all stages is an essential part of rational management and the renal biopsy plays a key role in defining the processes involved. There remain no global guidelines available to the renal community on indications for this important diagnostic, prognostic, and relatively safe test. Although most nephrologists recognize several clear indications for a renal biopsy, it is still underutilized. It not only helps the clinician to manage the patient with CKD, but it can also help clarify the epidemiology of CKD, and aid research into the pathobiology of disease with the aim of discovering new therapies. It may be useful for instance in elderly patients with CKD, those with diabetes and presumed 'hypertensive nephropathy', and in some patients with advanced CKD as part of the pretransplant work-up. In some populations (for example, immunoglobulin A nephropathy and ANCA vasculitis), renal biopsy allows disease classification that may predict CKD progression and response to therapy. For the individual, interval renal biopsy may be of use in providing ongoing therapeutic and prognostic information. Molecular advances will change the landscape of renal pathology and add a new dimension to the diagnostic precision of kidney biopsy. Organizing the multiplicity of information available in a renal biopsy to maximize benefits to the patient, as well as to the epidemiologist and researcher, is one of the challenges that face the nephrology community.
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Affiliation(s)
- Neeraj Dhaun
- 1] BHF Centre of Research Excellence, University of Edinburgh, The Queen's Medical Research Institute, Edinburgh, UK [2] Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Daniel C Cattran
- University Health Network, Toronto General Hospital, Toronto, Canada
| | - David C Kluth
- Department of Renal Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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Luo MN, Yao CW, Xu BH, Xu YZ, Liu WJ, Feng YM, Tao JL, Liu HF. Continuation of immunosuppressive treatment may be necessary in IgA nephropathy patients with remission of proteinuria: Evaluation by repeat renal biopsy. Exp Ther Med 2013; 7:553-559. [PMID: 24520244 PMCID: PMC3919854 DOI: 10.3892/etm.2013.1467] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 12/23/2013] [Indexed: 11/21/2022] Open
Abstract
The present study aimed to evaluate the effects of an individualized, low-dose multi-drug immunosuppressive regimen for the treatment of immunoglobulin A nephropathy (IgAN). A preliminary investigation of the course of IgAN following immunosuppressive treatment was conducted based on repeat renal biopsies. Clinical and pathological data of 17 patients with IgAN who received repeat renal biopsies were analyzed retrospectively. In addition to basic treatment, 16 patients regularly received an individualized low-dose immunosuppressive regimen according to their clinical manifestations and pathological patterns following the first biopsy. Clinical parameters, including 24-h urinary protein excretion and levels of serum albumin, uric acid and total cholesterol were collected. Glomerular deposits of IgA and C3, as well as the activity and chronicity indexes of renal lesions were evaluated by semi-quantitative methods. The 24-h urinary protein excretion of the patients decreased significantly from the first biopsy (2.53±2.17 g/day) to the repeated biopsy (0.26±0.55 g/day) (P<0.001). Deposits of IgA and C3 in the glomerulus were persistent, but were reduced in quantity at the second biopsy. Although active renal lesions were observed in the majority of patients, the activity index decreased significantly from 3.18±1.33 prior to therapy to 2.47±0.80 following therapy (P<0.05), while the chronicity index did not change significantly (2.59±2.00 versus 2.76±1.89, respectively). The individualized, low-dose multi-drug immunosuppressive regimen used in the present study significantly minimized proteinuria, stabilized renal function and alleviated histological lesions in patients with IgAN without causing overt adverse effects during the short-term follow-up. In addition to proteinuria, renal pathological changes should be appraised when considering the withdrawal of immunosuppressants from IgAN treatment.
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Affiliation(s)
- Mian-Na Luo
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Cui-Wei Yao
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Bi-Hua Xu
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Yong-Zhi Xu
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Wei Jing Liu
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Yong-Min Feng
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Jing-Li Tao
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
| | - Hua-Feng Liu
- Institute of Nephrology, Guangdong Medical College, Zhanjiang, Guangdong 524001, P.R. China
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Yang SM, Ka SM, Hua KF, Wu TH, Chuang YP, Lin YW, Yang FL, Wu SH, Yang SS, Lin SH, Chang JM, Chen A. Antroquinonol mitigates an accelerated and progressive IgA nephropathy model in mice by activating the Nrf2 pathway and inhibiting T cells and NLRP3 inflammasome. Free Radic Biol Med 2013; 61:285-97. [PMID: 23567192 DOI: 10.1016/j.freeradbiomed.2013.03.024] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Revised: 02/25/2013] [Accepted: 03/28/2013] [Indexed: 12/12/2022]
Abstract
High levels of reactive oxygen species (ROS), systemic T cell activation, and macrophage infiltration in the kidney are implicated in the acceleration and progression of IgA nephropathy (IgAN), the most frequent type of primary glomerulonephritis. However, the pathogenic mechanism of IgAN is still little understood, and it remains a challenge to establish a specific therapeutic strategy for this type of glomerular disorder. Recently, we showed that antroquinonol (Antroq), a pure active compound from Antrodia camphorata mycelium, inhibits renal inflammation and reduces oxidative stress in a mouse model of renal fibrosis. But the anti-inflammatory and immune-regulatory effects of Antroq on the acceleration and progression of primary glomerular disorders have not been determined. In this study, we show that Antroq administration substantially impeded the development of severe renal lesions, such as intense glomerular proliferation, crescents, sclerosis, and periglomerular interstitial inflammation, in mice with induced accelerated and progressive IgAN (AcP-IgAN). Further mechanistic analysis in AcP-IgAN mice showed that, early in the developmental stage of the AcP-IgAN model, Antroq promoted the Nrf2 antioxidant pathway and inhibited the activation of T cells and NLRP3 inflammasome. Significantly improved proteinuria/renal function and histopathology in AcP-IgAN mice of an established stage supported potential therapeutic effects of Antroq on the disease. In addition, Antroq was shown to inhibit activation of NLRP3 inflammasome in vitro by an IgA immune complex (IC) partly involving a reduced ROS production in IgA-IC-primed macrophages, and this finding may be helpful in the understanding of the mode of action of Antroq in the treated AcP-IgAN mice.
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Affiliation(s)
- Shun-Min Yang
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Shuk-Man Ka
- Graduate Institute of Aerospace and Undersea Medicine, National Defense Medical Center, Taipei, Taiwan, ROC.
| | - Kuo-Feng Hua
- Department of Biotechnology and Animal Science, National Ilan University, Ilan, Taiwan, ROC
| | - Tzu-Hua Wu
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Yi-Ping Chuang
- Department of Microbiology and Immunology, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Ya-Wen Lin
- Department of Microbiology and Immunology, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Feng-Ling Yang
- Institute of Biological Chemistry, Academia Sinica, Taipei, Taiwan, ROC
| | - Shih-Hsiung Wu
- Institute of Biological Chemistry, Academia Sinica, Taipei, Taiwan, ROC
| | - Sung-Sen Yang
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Shih-Hua Lin
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Jia-Ming Chang
- Department of Pharmacology, Institute for Drug Evaluation Platform, Development Center for Biotechnology, Taipei, Taiwan, ROC
| | - Ann Chen
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan, ROC; Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC.
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Abstract
Treatment options for primary IgA nephropathy (IgAN) and Henoch-Schönlein nephritis are still largely based on opinion or weak evidence. Consequently, the recent KDIGO Clinical Practice Guidelines for Glomerulonephritis have assigned low levels of evidence for almost all recommendations and suggestions related to these two diseases. In this Review, we describe an algorithm for structuring the treatment of IgAN depending on the clinical scenario. Key to therapeutic decision making is assessment of the individual's prognosis. Clinical parameters (such as proteinuria, hypertension, and impaired glomerular filtration rate [GFR]) are used to estimate risk, but the clinical value of the novel histological Oxford-MEST classification remains to be determined. If these parameters indicate a risk of progressive GFR loss, comprehensive supportive care remains the mainstay of therapy. Two large trials, STOP-IgAN and TESTING, are underway to evaluate the value of adding corticosteroids after initiating such supportive care. At present, little evidence exists to suggest that any other immunosuppressive therapy beyond corticosteroids is effective in either IgAN or Henoch-Schönlein nephritis.
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