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Anderson H, Van Voorthuizen M, O'Donnell J, Beck S. C3 concentrations can be normal in patients with C3 glomerulopathy secondary to C3 nephritic factor. J Clin Pathol 2024; 77:503-506. [PMID: 38538072 DOI: 10.1136/jcp-2023-209319] [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: 11/28/2023] [Accepted: 03/07/2024] [Indexed: 06/21/2024]
Abstract
C3 glomerulopathy (C3G) is a rare kidney disease caused by the glomerular deposition of C3 fragments secondary to alternative pathway complement dysregulation. C3 nephritic factors (C3Nef) are the most common acquired cause, and their detection has treatment and prognostic implications. Although C3 concentration can be normal in the presence of C3Nef, many laboratories will only perform C3Nef testing when C3 is low. We performed a retrospective study of all positive C3Nef results from the authors' laboratory since 2015 and found that two of the four patients with positive C3Nef and biopsy-confirmed C3G had normal C3 concentrations. This may be in part due to limitations in commercial C3 testing methods which use anti-C3c antisera directed against both C3 breakdown products and native C3. A normal C3 concentration should not preclude C3Nef testing in the appropriate clinical context.
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Affiliation(s)
- Hamish Anderson
- Immunology, Te Whatu Ora-Health New Zealand Canterbury Health Laboratories, Christchurch, New Zealand
| | - Mark Van Voorthuizen
- Immunology, Te Whatu Ora-Health New Zealand Canterbury Health Laboratories, Christchurch, New Zealand
| | - John O'Donnell
- Immunology, Te Whatu Ora-Health New Zealand Canterbury Health Laboratories, Christchurch, New Zealand
| | - Sarah Beck
- Immunology, Te Whatu Ora-Health New Zealand Canterbury Health Laboratories, Christchurch, New Zealand
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2
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Vivarelli M, Barratt J, Beck LH, Fakhouri F, Gale DP, Goicoechea de Jorge E, Mosca M, Noris M, Pickering MC, Susztak K, Thurman JM, Cheung M, King JM, Jadoul M, Winkelmayer WC, Smith RJH. The role of complement in kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2024:S0085-2538(24)00389-2. [PMID: 38844295 DOI: 10.1016/j.kint.2024.05.015] [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: 12/22/2023] [Revised: 04/25/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Uncontrolled complement activation can cause or contribute to glomerular injury in multiple kidney diseases. Although complement activation plays a causal role in atypical hemolytic uremic syndrome and C3 glomerulopathy, over the past decade, a rapidly accumulating body of evidence has shown a role for complement activation in multiple other kidney diseases, including diabetic nephropathy and several glomerulonephritides. The number of available complement inhibitor therapies has also increased during the same period. In 2022, Kidney Diseases: Improving Global Outcomes (KDIGO) convened a Controversies Conference, "The Role of Complement in Kidney Disease," to address the expanding role of complement dysregulation in the pathophysiology, diagnosis, and management of various glomerular diseases, diabetic nephropathy, and other forms of hemolytic uremic syndrome. Conference participants reviewed the evidence for complement playing a primary causal or secondary role in progression for several disease states and considered how evidence of complement involvement might inform management. Participating patients with various complement-mediated diseases and caregivers described concerns related to life planning, implications surrounding genetic testing, and the need for inclusive implementation of effective novel therapies into clinical practice. The value of biomarkers in monitoring disease course and the role of the glomerular microenvironment in complement response were examined, and key gaps in knowledge and research priorities were identified.
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Affiliation(s)
- Marina Vivarelli
- Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Laurence H Beck
- Section of Nephrology, Department of Medicine, Boston Medical Center Boston, Massachusetts, USA; Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, Nantes, France; INSERM UMR S1064, Nantes, France
| | - Daniel P Gale
- Department of Renal Medicine, University College London, UK
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and ORL, Complutense University, Madrid, Spain; Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Marta Mosca
- Department of Clinical and Experimental Medicine-Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College, Hammersmith Campus, London, UK
| | - Katalin Susztak
- Department of Medicine and Nephrology, Albert Einstein College Medicine, Bronx, New York, USA
| | - Joshua M Thurman
- Division of Nephrology and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Pediatrics Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
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3
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van Schaik M, de Vries AP, Bemelman FJ, Rabelink TJ, Trouw LA, van Kooten C, Teng YKO. Clinical Remission and Reduction of Circulating Nephritic Factors by Combining Rituximab With Belimumab in a Case of Complement Factor 3 Glomerulopathy. Kidney Int Rep 2024; 9:1919-1922. [PMID: 38899188 PMCID: PMC11184254 DOI: 10.1016/j.ekir.2024.02.1402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 06/21/2024] Open
Affiliation(s)
- Mieke van Schaik
- Center of Expertise for Lupus, Vasculitis and Complement-mediated Systemic disease (LuVaCs), Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Aiko P.J. de Vries
- Department of Nephrology and Leiden Transplant Center, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederike J. Bemelman
- Department of Nephrology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Ton J. Rabelink
- Center of Expertise for Lupus, Vasculitis and Complement-mediated Systemic disease (LuVaCs), Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Leendert A. Trouw
- Department of Immunology, Leiden University Medical Center, Leiden, The Netherlands
| | - Cees van Kooten
- Center of Expertise for Lupus, Vasculitis and Complement-mediated Systemic disease (LuVaCs), Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yoe Kie Onno Teng
- Center of Expertise for Lupus, Vasculitis and Complement-mediated Systemic disease (LuVaCs), Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
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4
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Günay N, Dursun İ, Gökçe İ, Akbalık Kara M, Tekcan D, Çiçek N, Torun Bayram M, Koyun M, Dinçel N, Dursun H, Saygılı S, Yürük Yıldırım ZN, Yüksel S, Dönmez O, Yel S, Demircioğlu Kılıç B, Aydoğ Ö, Atmış B, Çaltık Yılmaz A, Bakkaloğlu SA, Aytaç MB, Taşdemir M, Kasap Demir B, Soylu A, Çomak E, Kantar Özşahin A, Kaçar A, Canpolat N, Yılmaz A, Girişgen İ, Akkoyunlu KB, Alpay H, Poyrazoğlu HM. Complement gene mutations in children with C3 glomerulopathy: do they affect the response to mycophenolate mofetil? Pediatr Nephrol 2024; 39:1435-1446. [PMID: 38041748 DOI: 10.1007/s00467-023-06231-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND C3 glomerulopathy (C3G) is a complement-mediated disease. Although genetic studies are not required for diagnosis, they are valuable for treatment planning and prognosis prediction. The aim of this study is to investigate the clinical phenotypes, kidney survival, and response to mycophenolate mofetil (MMF) treatment in pediatric C3G patients with and without mutations in complement-related genes. METHODS Sixty pediatric C3G patients were included, divided into two groups based on complement-related gene mutations. Demographic and clinical-pathological findings, treatment modalities, and outcome data were compared, and Kaplan-Meier analysis was performed for kidney survival. RESULTS Out of the 60 patients, 17 had mutations. The most common mutation was in the CFH gene (47%). The mean age at diagnosis was higher in the group with mutation (12.9 ± 3.6 vs. 11.2 ± 4.1 years, p = 0.039). While the patients without mutation most frequently presented with nephritic syndrome (44.2%), the mutation group was most likely to have asymptomatic urinary abnormalities (47.1%, p = 0.043). Serum parameters and histopathological characteristics were similar, but hypoalbuminemia was more common in patients without mutation. During 45-month follow-up,10 patients progressed to chronic kidney disease stage 5 (CKD5), with 4 having genetic mutation. The time to develop CKD5 was longer in the mutation group but not significant. MMF treatment had no effect on progression in either group. CONCLUSIONS This study is the largest pediatric C3G study examining the relationship between genotype and phenotype. We showed that the mutation group often presented with asymptomatic urinary abnormalities, was diagnosed relatively late but was not different from the without mutation group in terms of MMF treatment response and kidney survival.
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Affiliation(s)
- Neslihan Günay
- Department of Pediatric Nephrology, Kayseri City Training and Research Hospital, Kayseri, Turkey
| | - İsmail Dursun
- Department of Pediatric Nephrology, Erciyes University Medical Faculty, Kayseri, Turkey.
| | - İbrahim Gökçe
- Department of Pediatric Nephrology, Marmara University Medical Faculty, Istanbul, Turkey
| | - Mehtap Akbalık Kara
- Department of Pediatric Nephrology, Gaziantep University Medical Faculty, Gaziantep, Turkey
| | - Demet Tekcan
- Department of Pediatric Nephrology, Ondokuz Mayıs University Medical Faculty, Samsun, Turkey
| | - Neslihan Çiçek
- Department of Pediatric Nephrology, Marmara University Medical Faculty, Istanbul, Turkey
| | - Meral Torun Bayram
- Dokuz Eylül University Medical Faculty, Department of Pediatric Nephrology, İzmir, Turkey
| | - Mustafa Koyun
- Department of Pediatric Nephrology, Akdeniz University Medical Faculty, Antalya, Turkey
| | - Nida Dinçel
- Behçet Uz Pediatric Diseases Training and Research Hospital, Pediatric Nephrology Clinic, İzmir, Turkey
| | - Hasan Dursun
- Prof. Dr. Cemil, Taşcıoğlu City Hospital Pediatric Nephrology Clinic, Istanbul, Turkey
| | - Seha Saygılı
- Department of Pediatric Nephrology, İstanbul University Cerrahpaşa Medical Faculty, Istanbul, Turkey
| | | | - Selçuk Yüksel
- Department of Pediatric Nephrology, Pamukkale University Medical Faculty, Denizli, Turkey
| | - Osman Dönmez
- Department of Pediatric Nephrology, Uludağ University Medical Faculty, Bursa, Turkey
| | - Sibel Yel
- Department of Pediatric Nephrology, Erciyes University Medical Faculty, Kayseri, Turkey
| | | | - Özlem Aydoğ
- Department of Pediatric Nephrology, Ondokuz Mayıs University Medical Faculty, Samsun, Turkey
| | - Bahriye Atmış
- Department of Pediatric Nephrology, Çukurova University Medical Faculty, Adana, Turkey
| | - Aysun Çaltık Yılmaz
- Department of Pediatric Nephrology, Ankara Baskent University, Ankara, Turkey
| | - Sevcan A Bakkaloğlu
- Department of Pediatric Nephrology, Gazi University Medical Faculty, Ankara, Turkey
| | - Mehmet Baha Aytaç
- Department of Pediatric Nephrology, Kocaeli University Medical Faculty, Kocaeli, Turkey
| | - Mehmet Taşdemir
- Department of Pediatric Nephrology, İstinye University Medical Faculty, Istanbul, Turkey
| | - Belde Kasap Demir
- Medical Faculty Division of Pediatric Nephrology, İzmir Katip Çelebi University, İzmir, Turkey
| | - Alper Soylu
- Dokuz Eylül University Medical Faculty, Department of Pediatric Nephrology, İzmir, Turkey
| | - Elif Çomak
- Department of Pediatric Nephrology, Akdeniz University Medical Faculty, Antalya, Turkey
| | - Aslı Kantar Özşahin
- Behçet Uz Pediatric Diseases Training and Research Hospital, Pediatric Nephrology Clinic, İzmir, Turkey
| | - Alper Kaçar
- Prof. Dr. Cemil, Taşcıoğlu City Hospital Pediatric Nephrology Clinic, Istanbul, Turkey
| | - Nur Canpolat
- Department of Pediatric Nephrology, İstanbul University Cerrahpaşa Medical Faculty, Istanbul, Turkey
| | - Alev Yılmaz
- İstanbul Faculty of Medicine, Department of Pediatric Nephrology, İstanbul University, Istanbul, Turkey
| | - İlknur Girişgen
- Department of Pediatric Nephrology, Pamukkale University Medical Faculty, Denizli, Turkey
| | | | - Harika Alpay
- Department of Pediatric Nephrology, Marmara University Medical Faculty, Istanbul, Turkey
| | - Hakan M Poyrazoğlu
- Department of Pediatric Nephrology, Erciyes University Medical Faculty, Kayseri, Turkey
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5
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Watanabe-Kusunoki K, Anders HJ. Balancing efficacy and safety of complement inhibitors. J Autoimmun 2024; 145:103216. [PMID: 38552408 DOI: 10.1016/j.jaut.2024.103216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 05/15/2024]
Abstract
Complement inhibitors have been approved for several immune-mediated diseases and they are considered the next paradigm-shifting approach in the treatment of glomerulonephritis. The hierarchical organization of the complement system offers numerous molecular targets for therapeutic intervention. However, complement is an integral element of host defense and therefore complement inhibition can be associated with serious infectious complications. Here we give a closer look to the hierarchical complement system and how interfering with proximal versus distal or selective versus unselective molecular targets could determine efficacy and safety. Furthermore, we propose to consider the type of disease, immunological activity, and patient immunocompetence when stratifying patients, e.g., proximal/unselective targets for highly active and potentially fatal diseases while distal and selective targets may suit more chronic disease conditions with low or moderate disease activity requiring persistent complement blockade in patients with concomitant immunodeficiency. Certainly, there exists substantial promise for anti-complement therapeutics. However, balancing efficacy and safety will be key to establish powerful treatment effects with minimal adverse events, especially when complement blockade is continued over longer periods of time in chronic disorders.
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Affiliation(s)
- Kanako Watanabe-Kusunoki
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany; Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hans-Joachim Anders
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany.
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6
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Ueda C, Horinouchi T, Inoki Y, Ichikawa Y, Tanaka Y, Kitakado H, Kondo A, Sakakibara N, Nagano C, Yamamura T, Fujimura J, Kamiyoshi N, Ishimori S, Ninchoji T, Kaito H, Shima Y, Iijima K, Nozu K, Yoshikawa N. Clinical characteristics and outcomes of immune-complex membranoproliferative glomerulonephritis and C3 glomerulopathy in Japanese children. Pediatr Nephrol 2024:10.1007/s00467-024-06377-7. [PMID: 38662234 DOI: 10.1007/s00467-024-06377-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Membranoproliferative glomerulonephritis (MPGN) can be divided into immune-complex MPGN (IC-MPGN) and C3 glomerulopathy (C3G), which includes dense deposit disease (DDD) and C3 glomerulonephritis (C3GN). These conditions result from abnormalities in different complement pathways and may lead to different prognoses. However, there are limited studies describing the respective clinical courses. METHODS In this study, Japanese pediatric patients diagnosed with MPGN based on kidney biopsies conducted between February 2002 and December 2022 were reclassified as having IC-MPGN or C3G (DDD or C3GN). We retrospectively analyzed the clinical characteristics and outcomes of these patients. RESULTS Out of 25 patients with MPGN, three (12.0%) were diagnosed with DDD, 20 (80.0%) with C3GN, and two (8.0%) with IC-MPGN. There were 13 (65.0%) patients and one (33.3%) patient in remission after treatment for C3GN and DDD, respectively, and no patients with IC-MPGN achieved remission. The median follow-up period was 5.3 (2.5-8.9) years, and none of the patients in either group progressed to an estimated glomerular filtration rate < 15 ml/min/1.73 m2. Patients with C3GN presenting mild to moderate proteinuria (n = 8) received a renin-angiotensin system inhibitor (RAS-I) alone, and these patients exhibited a significant decrease in the urinary protein creatinine ratio and a notable increase in serum C3 levels at the last follow-up. CONCLUSIONS Most patients with MPGN were diagnosed with C3GN. The remission rate for C3GN was high, and no patients developed kidney failure during the approximately 5-year follow-up. Additionally, patients with C3GN with mild to moderate proteinuria had good outcomes with RAS-I alone, but continued vigilance is necessary to determine long-term prognosis.
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Affiliation(s)
- Chika Ueda
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan.
| | - Yuta Inoki
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Yuta Ichikawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Yu Tanaka
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Hideaki Kitakado
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Atsushi Kondo
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Nana Sakakibara
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - China Nagano
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Junya Fujimura
- Department of Pediatrics, Kakogawa Central City Hospital, 439 Honmachi, Kakogawa-Cho, Kakogawa, 675-8611, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Japanese Red Cross Society Himeji Hospital, 1-12-1 Shimoteno, Himeji, 670-8540, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe‑cho, Takatsuki, 569-1192, Japan
| | - Takeshi Ninchoji
- Department of Pediatrics, Harima-Himeji General Medical Center, 3-264 Kamiyacho, Himeji, 670-8560, Japan
| | - Hiroshi Kaito
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojima-Minamimachi, Chuo-Ku, Kobe, 650-0047, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Kazumoto Iijima
- Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojima-Minamimachi, Chuo-Ku, Kobe, 650-0047, Japan
- Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Norishige Yoshikawa
- Clinical Research Center, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, 569-1192, Japan
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7
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Andeen NK, Hou J. Diagnostic Challenges and Emerging Pathogeneses of Selected Glomerulopathies. Pediatr Dev Pathol 2024:10935266241237656. [PMID: 38576387 DOI: 10.1177/10935266241237656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Recent progress in glomerular immune complex and complement-mediated diseases have refined diagnostic categories and informed mechanistic understanding of disease development in pediatric patients. Herein, we discuss selected advances in 3 categories. First, membranous nephropathy antigens are increasingly utilized to characterize disease in pediatric patients and include phospholipase A2 receptor (PLA2R), Semaphorin 3B (Sema3B), neural epidermal growth factor-like 1 (NELL1), and protocadherin FAT1, as well as the lupus membranous-associated antigens exostosin 1/2 (EXT1/2), neural cell adhesion molecule 1 (NCAM1), and transforming growth factor beta receptor 3 (TGFBR3). Second, we examine advances in techniques for paraffin and light chain immunofluorescence (IF), including the former's function as a salvage technique and their necessity for diagnosis in adolescent cases of membranous-like glomerulopathy with masked IgG kappa deposits (MGMID) and proliferative glomerulonephritis with monotypic Ig deposits (PGNMID), respectively. Finally, progress in understanding the roles of complement in pediatric glomerular disease is reviewed, with specific attention to overlapping clinical, histologic, and genetic or functional alternative complement pathway (AP) abnormalities among C3 glomerulopathy (C3G), infection-related and post-infectious GN, "atypical" post-infectious GN, immune complex mediated membranoproliferative glomerulonephritis (IC-MPGN), and atypical hemolytic uremic syndrome (aHUS).
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Affiliation(s)
- Nicole K Andeen
- Oregon Health & Science University, Department of Pathology and Laboratory Medicine, Portland, OR, USA
| | - Jean Hou
- Cedars-Sinai Medical Center, Department of Pathology, Los Angeles, CA, USA
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8
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Zanchi C, Locatelli M, Cerullo D, Aumiller V, Corna D, Rottoli D, Schubert S, Noris M, Tomasoni S, Remuzzi G, Zoja C, Benigni A. Efficacy of GalNAc C3 siRNAs in factor H-deficient mice with C3 glomerulopathy. Mol Immunol 2024; 168:10-16. [PMID: 38368725 DOI: 10.1016/j.molimm.2024.02.010] [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: 11/03/2023] [Revised: 01/17/2024] [Accepted: 02/12/2024] [Indexed: 02/20/2024]
Abstract
Complement alternative pathway (AP) dysregulation drives C3 glomerulopathy (C3G), a rare renal disorder characterized by glomerular C3 deposition and glomerular damage, for which no effective treatments are available. Blockade of complement C3 is emerging as a viable therapeutic option. In an earlier study we showed that SLN500, a small interfering RNA targeting liver C3 synthesis, was able to limit AP dysregulation and glomerular C3d deposits in mice with partial factor H (FH) deficiency (Cfh+/- mice). Here, we assessed the pharmacological effects of SLN501 - an optimized SLN500 version - in mice with complete FH deficiency (Cfh-/- mice) that exhibit a more severe C3G phenotype. SLN501 effectively prevented liver C3 synthesis, thus limiting AP dysregulation, glomerular C3d deposits and the development of ultrastructural alterations. These data provide firm evidence of the use of siRNA-mediated liver C3 gene silencing as a potential therapy for treating C3G patients with either partial or complete FH loss of function.
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Affiliation(s)
- Cristina Zanchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Monica Locatelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Domenico Cerullo
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | | | - Daniela Corna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Daniela Rottoli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | | | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Susanna Tomasoni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Carlamaria Zoja
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori, Science and Technology Park Kilometro Rosso, Bergamo, Italy.
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9
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Obata S, Vaz de Castro PAS, Riella LV, Cravedi P. Recurrent C3 glomerulopathy after kidney transplantation. Transplant Rev (Orlando) 2024; 38:100839. [PMID: 38412598 DOI: 10.1016/j.trre.2024.100839] [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: 01/25/2024] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 02/29/2024]
Abstract
The complement system is part of innate immunity and is pivotal in protecting the body against pathogens and maintaining host homeostasis. Activation of the complement system is triggered through multiple pathways, including antibody deposition, a mannan-binding lectin, or activated complement deposition. C3 glomerulopathy (C3G) is a rare glomerular disease driven by complement dysregulation with high post-transplantation recurrence rates. Its treatment is mainly based on immunosuppressive therapies, specifically mycophenolate mofetil and glucocorticoids. Recent years have seen significant progress in understanding complement biology and its role in C3G pathophysiology. New complement-tergeting treatments have been developed and initial trials have shown promising results. However, challenges persist in C3G, with recurrent post-transplantation cases leading to suboptimal outcomes. This review discusses the pathophysiology and management of C3G, with a focus on its recurrence after kidney transplantation.
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Affiliation(s)
- Shota Obata
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Pedro A S Vaz de Castro
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Brazil
| | - Leonardo V Riella
- Division of Nephrology and Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Paolo Cravedi
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
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10
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Honma S, Sato N, Sakaguchi R, Hashiguchi A, Uesugi N, Nakamura Y, Sasano H, Joh K. Morphological and etiological analyses of C3 and non-C3 glomerulonephritis in primary membranoproliferative glomerulonephritis using periodic acid-methenamine silver stain electron microscopy: a retrospective multicentered study. Med Mol Morphol 2024; 57:23-34. [PMID: 37823929 DOI: 10.1007/s00795-023-00370-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/23/2023] [Indexed: 10/13/2023]
Abstract
This study elucidated the etiology of C3 glomerulonephritis (C3GN) and non-C3GN with primary membranoproliferative glomerulonephritis (MPGN) using transmission electron microscopy (TEM) and periodic acid-methenamine silver stain (PAM-EM). Thirty-one primary MPGN cases were analyzed by TEM and PAM-EM to distinguish among MPGN I, MPGN II, MPGN III Burkholder subtype (MPGN IIIB), and Anders and Strife subtype (MPGN IIIA/S). Each case was also classified into C3GN or non-C3GN according to the standard C3GN definition using immunostaining. Four cases of MPGN II met C3 glomerulopathy; whereas, four cases of MPGN IIIB did not meet C3 glomerulopathy. Seven of 11 cases (64%) of MPGN I without GBM disruption and 7 of 12 cases (58%) of MPGN IIIA/S with GBM disruption met the non-C3GN criteria with significant immunoglobulins' deposition. Regardless of the C3GN or non-C3GN diagnosis, the deposits in primary MPGN I and MPGN IIIA/S exhibited ill-defined, amorphous, and foggy characteristics similar to those found in postinfectious GN but were different from immune complex (IC) deposits seen in MPGN IIIB. Not only C3GN but also non-C3GN was due to mechanisms other than IC deposition as found in postinfectious GN. Consequently, GBM disruption of MPGN IIIA/S was not due to IC deposition.
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Affiliation(s)
- Shiko Honma
- Department of Pathology, School of Medicine, The Jikei University, Tokyo, Japan
| | - Naomi Sato
- Department of Pathology, Graduate School of Medicine, Tohoku University, Sendai, Japan
- Department of Pathology, Iwate Prefectural Central Hospital, Iwate, Japan
| | - Ryoko Sakaguchi
- Department of Pathology, School of Medicine, The Jikei University, Tokyo, Japan
| | - Akinori Hashiguchi
- Department of Pathology, School of Medicine, Keio University, Tokyo, Japan
| | - Noriko Uesugi
- Department of Pathology, Fukuoka University of Medicine, Fukuoka, Japan
| | - Yasuhiro Nakamura
- Faculty of Medicine, Division of Pathology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Hironobu Sasano
- Department of Pathology, Graduate School of Medicine, Tohoku University, Sendai, Japan
| | - Kensuke Joh
- Department of Pathology, School of Medicine, The Jikei University, Tokyo, Japan.
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11
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Nell D, Wolf R, Podgorny PM, Kuschnereit T, Kuschnereit R, Dabers T, Stracke S, Schmidt T. Complement Activation in Nephrotic Glomerular Diseases. Biomedicines 2024; 12:455. [PMID: 38398059 PMCID: PMC10886869 DOI: 10.3390/biomedicines12020455] [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: 12/30/2023] [Revised: 01/23/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
The nephrotic syndrome holds significant clinical importance and is characterized by a substantial protein loss in the urine. Damage to the glomerular basement membrane or podocytes frequently underlies renal protein loss. There is an increasing belief in the involvement of the complement system, a part of the innate immune system, in these conditions. Understanding the interactions between the complement system and glomerular structures continually evolves, challenging the traditional view of the blood-urine barrier as a passive filter. Clinical studies suggest that a precise inhibition of the complement system at various points may soon become feasible. However, a thorough understanding of current knowledge is imperative for planning future therapies in nephrotic glomerular diseases such as membranous glomerulopathy, membranoproliferative glomerulonephritis, lupus nephritis, focal segmental glomerulosclerosis, and minimal change disease. This review provides an overview of the complement system, its interactions with glomerular structures, and insights into specific glomerular diseases exhibiting a nephrotic course. Additionally, we explore new diagnostic tools and future therapeutic approaches.
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12
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Sándor N, Schneider AE, Matola AT, Barbai VH, Bencze D, Hammad HH, Papp A, Kövesdi D, Uzonyi B, Józsi M. The human factor H protein family - an update. Front Immunol 2024; 15:1135490. [PMID: 38410512 PMCID: PMC10894998 DOI: 10.3389/fimmu.2024.1135490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 01/08/2024] [Indexed: 02/28/2024] Open
Abstract
Complement is an ancient and complex network of the immune system and, as such, it plays vital physiological roles, but it is also involved in numerous pathological processes. The proper regulation of the complement system is important to allow its sufficient and targeted activity without deleterious side-effects. Factor H is a major complement regulator, and together with its splice variant factor H-like protein 1 and the five human factor H-related (FHR) proteins, they have been linked to various diseases. The role of factor H in inhibiting complement activation is well studied, but the function of the FHRs is less characterized. Current evidence supports the main role of the FHRs as enhancers of complement activation and opsonization, i.e., counter-balancing the inhibitory effect of factor H. FHRs emerge as soluble pattern recognition molecules and positive regulators of the complement system. In addition, factor H and some of the FHR proteins were shown to modulate the activity of immune cells, a non-canonical function outside the complement cascade. Recent efforts have intensified to study factor H and the FHRs and develop new tools for the distinction, quantification and functional characterization of members of this protein family. Here, we provide an update and overview on the versatile roles of factor H family proteins, what we know about their biological functions in healthy conditions and in diseases.
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Affiliation(s)
- Noémi Sándor
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
- HUN-REN-ELTE Complement Research Group, Hungarian Research Network, Budapest, Hungary
| | | | | | - Veronika H. Barbai
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Dániel Bencze
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Hani Hashim Hammad
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Alexandra Papp
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
| | - Dorottya Kövesdi
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
- HUN-REN-ELTE Complement Research Group, Hungarian Research Network, Budapest, Hungary
| | - Barbara Uzonyi
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
- HUN-REN-ELTE Complement Research Group, Hungarian Research Network, Budapest, Hungary
| | - Mihály Józsi
- Department of Immunology, ELTE Eötvös Loránd University, Budapest, Hungary
- HUN-REN-ELTE Complement Research Group, Hungarian Research Network, Budapest, Hungary
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13
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Gao S, Song H. Integrated comparison of the mRNAome in cartilage, synovium, and macrophages in osteoarthritis. Z Rheumatol 2024; 83:62-70. [PMID: 35178608 DOI: 10.1007/s00393-022-01171-y] [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: 01/21/2022] [Indexed: 11/09/2022]
Abstract
The precise molecular mechanisms associated with osteoarthritis (OA), the most common musculoskeletal disorder, are poorly understood. There are currently no effective treatments to prevent the initiation and progression of the disease. In recent years, the development of mRNAome has made it possible to identify new mechanisms and therapeutic targets. However, the differentially expressed genes screened by different microarrays are not completely the same. In order to avoid this shortcoming, we integrate the different genes from different tissues and data sets, and select the commonly expressed genes for further studies.
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Affiliation(s)
- Siming Gao
- Department of Rheumatology, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xicheng District, 100035, Beijing, China
| | - Hui Song
- Department of Rheumatology, Beijing Jishuitan Hospital, No. 31, Xin Jie Kou East Street, Xicheng District, 100035, Beijing, China.
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14
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Nayak PP, Pradhan P, Pradhan D, Mohapatra N, Raman S, Sahoo P. To interpret and analyze the changing patterns of histology and direct immunofluorescence findings in membranoproliferative glomerulonephritis. INDIAN J PATHOL MICR 2024; 67:80-85. [PMID: 38358193 DOI: 10.4103/ijpm.ijpm_1015_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Background Membranoproliferative glomerulonephritis has in the recent past been regrouped into immune complex-mediated (ICM MPGN) disease (driven by the classical complement pathway) and complement-mediated (C3GN) disease (driven by the alternative complement pathway) based on pathogenetic role of alternative complement pathway and immunofluorescence deposits. The proposed regrouping lent therapeutic and prognostic support in managing the disease of MPGN. Aims and Objectives The present study is undertaken to study the patterns of MPGN based on histopathological and DIF examination and sub-categorize the cases into mainly complement dominant and immune complex-mediated diseases for better prognostic and therapeutic utility. Materials and Methods This is a prospective observational study carried out in a tertiary care center over a period of 2 yrs. The clinically suspected cases of MPGN were subjected to histopathologic and direct immunofluorescence examination (DIF), and the findings were interpreted in light of complement-mediated and immune complex-mediated MPGN. Results Out of 620 renal biopsies, diagnosis of MPGN was confirmed both on histopathology and DIF in 36 cases accounting for 5.8% of all biopsies. Based on DIF findings, the various groups comprised 20 cases (55.6%) of immune complex deposits, 11 (30.5%) of C3 dominant picture, and 5 (13.9%) of Nil immune deposits. On analysis of the patterns on DIF, 16 cases (80%) of C3 + Ig group and 6 (54.5%) of C3GN group showed predominantly MPGN pattern. Crescentic glomerulonephritis, global glomerulosclerosis, and interstitial fibrosis were markedly observed in C3GN group. Conclusion DIF is of immense prognostic and therapeutic value in managing cases of MPGN.
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Affiliation(s)
- Pragnya P Nayak
- Department of Patholgy, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India
| | - Pranati Pradhan
- Department of Patholgy, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India
| | - Dilleswari Pradhan
- Department of Patholgy, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India
| | - Nachiketa Mohapatra
- Department of Patholgy, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India
| | - Sarojini Raman
- Department of Patholgy, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India
| | - Pranabandhu Sahoo
- Department of Patholgy, Srirama Chandra Bhanja Medical College, Cuttack, Odisha, India
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15
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Loganathan L, Jeyaraman J, Muthusamy K. HTNpedia: A Knowledge Base for Hypertension Research. Comb Chem High Throughput Screen 2024; 27:745-753. [PMID: 37202885 DOI: 10.2174/1386207326666230518162439] [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: 11/12/2022] [Revised: 03/27/2023] [Accepted: 03/31/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Hypertension is notably a serious public health concern due to its high prevalence and strong association with cardiovascular disease and renal failure. It is reported to be the fourth leading disease that leads to death worldwide. OBJECTIVES Currently, there is no active operational knowledge base or database for hypertension or cardiovascular illness. METHODS The primary data source was retrieved from the research outputs obtained from our laboratory team working on hypertension research. We have presented a preliminary dataset and external links to the public repository for detailed analysis to readers. RESULTS As a result, HTNpedia was created to provide information regarding hypertension-related proteins and genes. CONCLUSION The complete webpage is accessible via www.mkarthikeyan.bioinfoau.org/HTNpedia.
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Affiliation(s)
- Lakshmanan Loganathan
- Department of Bioinformatics, Alagappa University, Karaikudi, 630003, Tamil Nadu, India
| | - Jeyakanthan Jeyaraman
- Department of Bioinformatics, Alagappa University, Karaikudi, 630003, Tamil Nadu, India
| | - Karthikeyan Muthusamy
- Department of Bioinformatics, Alagappa University, Karaikudi, 630003, Tamil Nadu, India
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16
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Vivarelli M, Bomback AS, Meier M, Wang Y, Webb NJ, Veldandi UK, Smith RJ, Kavanagh D. Iptacopan in Idiopathic Immune Complex-Mediated Membranoproliferative Glomerulonephritis: Protocol of the APPARENT Multicenter, Randomized Phase 3 Study. Kidney Int Rep 2024; 9:64-72. [PMID: 38312795 PMCID: PMC10831369 DOI: 10.1016/j.ekir.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Immune complex-mediated membranoproliferative glomerulonephritis (IC-MPGN) is an ultra-rare, fast-progressing kidney disease that may be idiopathic (primary) or secondary to chronic infection, autoimmune disorders, or monoclonal gammopathies. Dysregulation of the alternative complement pathway is implicated in the pathophysiology of IC-MPGN; and currently, there are no approved targeted treatments. Iptacopan is an oral, highly potent proximal complement inhibitor that specifically binds to factor B and inhibits the alternative pathway (AP). Methods This randomized, double-blind, placebo-controlled phase 3 study (APPARENT; NCT05755386) will evaluate the efficacy and safety of iptacopan in patients with idiopathic (primary) IC-MPGN, enrolling up to 68 patients (minimum of 10 adolescents) aged 12 to 60 years with biopsy-confirmed IC-MPGN, proteinuria ≥1 g/g, and estimated glomerular filtration rate (eGFR) ≥30 ml/min per 1.73 m2. All patients will receive maximally tolerated angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and vaccination against encapsulated bacteria. Patients with any organ transplant, progressive crescentic glomerulonephritis, or kidney biopsy with >50% interstitial fibrosis/tubular atrophy, will be excluded. Patients will be randomized 1:1 to receive either iptacopan 200 mg twice daily (bid) or placebo for 6 months, followed by open-label treatment with iptacopan 200 mg bid for all patients for 6 months. The primary objective of the study is to evaluate the efficacy of iptacopan versus placebo in proteinuria reduction measured as urine protein-to-creatinine ratio (UPCR) (24-h urine) at 6 months. Key secondary end points will assess kidney function measured by eGFR, patients who achieve a proteinuria-eGFR composite end point, and patient-reported fatigue. Conclusion This study will provide evidence toward the efficacy and safety of iptacopan in idiopathic (primary) IC-MPGN.
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Affiliation(s)
- Marina Vivarelli
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrew S. Bomback
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Matthias Meier
- Global Drug Development, Novartis Pharma AG, Basel, Switzerland
| | - Yaqin Wang
- Global Drug Development, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | | | - Richard J.H. Smith
- Molecular Otolaryngology and Renal Research Laboratories and the Departments of Internal Medicine and Pediatrics (Divisions of Nephrology), Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals, National Health Service Foundation Trust, Newcastle upon Tyne, UK
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17
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Wong E, Nester C, Cavero T, Karras A, Le Quintrec M, Lightstone L, Eisenberger U, Soler MJ, Kavanagh D, Daina E, Praga M, Medjeral-Thomas NR, Gäckler A, Garcia-Carro C, Biondani A, Chaperon F, Kulmatycki K, Milojevic J, Webb NJ, Nidamarthy PK, Junge G, Remuzzi G. Efficacy and Safety of Iptacopan in Patients With C3 Glomerulopathy. Kidney Int Rep 2023; 8:2754-2764. [PMID: 38106570 PMCID: PMC10719607 DOI: 10.1016/j.ekir.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/21/2023] [Accepted: 09/11/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Complement 3 glomerulopathy (C3G) is a rare inflammatory kidney disease mediated by dysregulation of the alternative complement pathway. No targeted therapy exists for this aggressive glomerulonephritis. Efficacy, safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) (measured by complement biomarkers) of iptacopan were assessed in patients with C3G. Methods In this phase 2, multicenter, open-label, single-arm, nonrandomized study, adults with biopsy-proven, native kidney C3G (native cohort) and kidney transplant recipients with C3G recurrence (recurrent kidney transplant [KT] cohort) received iptacopan twice daily (bid) for 84 days (days 1-21: 10-100 mg; days 22-84: 200 mg). The primary end point was the urine protein-to-creatinine ratio (UPCR; native cohort) and the change in the C3 deposit score of kidney biopsy (recurrent KT cohort). The complement pathway measures included Wieslab assay, soluble C5b9, and serum C3 levels. Results A total of 27 patients (16 native cohort and 11 recurrent KT cohort) were enrolled and all completed the study. In the native cohort, UPCR levels decreased by 45% from baseline to week 12 (P = 0.0003). In the recurrent KT cohort, the median C3 deposit score decreased by 2.50 (scale: 0-12) on day 84 versus baseline (P = 0.03). Serum C3 levels were normalized in most patients; complement hyperactivity observed pretreatment was reduced. Severe adverse events (AEs) included post-biopsy hematuria and hyperkalemia. No deaths occurred during the study. Conclusion Iptacopan resulted in statistically significant and clinically important reductions in UPCR and normalization of serum C3 levels in the native cohort and reduced C3 deposit scores in the recurrent KT cohort with favorable safety and tolerability. (ClinicalTrials.gov identifier: NCT03832114).
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Affiliation(s)
- Edwin Wong
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Carla Nester
- The University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa, USA
| | - Teresa Cavero
- Nephrology Department, University Hospital Doce de Octubre, Madrid, Spain
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges-Pompidou, APHP, Paris, France
| | - Moglie Le Quintrec
- Service de Néphrologie et Transplantation Rénale, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Liz Lightstone
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Ute Eisenberger
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Maria Jose Soler
- Nephrology Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Nicholas R. Medjeral-Thomas
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Anja Gäckler
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Clara Garcia-Carro
- Nephrology Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - Andrea Biondani
- Novartis Institutes for BioMedical Research, Translational Medicine, Novartis AG, Basel, Switzerland
| | - Frederique Chaperon
- Novartis Institutes for BioMedical Research, Translational Medicine, Novartis AG, Basel, Switzerland
| | - Kenneth Kulmatycki
- Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
| | - Julie Milojevic
- Novartis Institutes for BioMedical Research, Translational Medicine, Novartis AG, Basel, Switzerland
| | - Nicholas J.A. Webb
- Novartis Institutes for BioMedical Research, Translational Medicine, Novartis AG, Basel, Switzerland
| | | | - Guido Junge
- Novartis Institutes for BioMedical Research, Translational Medicine, Novartis AG, Basel, Switzerland
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
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Zotta F, Diomedi-Camassei F, Gargiulo A, Cappoli A, Emma F, Vivarelli M. Successful treatment with avacopan (CCX168) in a pediatric patient with C3 glomerulonephritis. Pediatr Nephrol 2023; 38:4197-4201. [PMID: 37306717 DOI: 10.1007/s00467-023-06035-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/14/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND C3 glomerulonephritis (C3GN) is a subtype of C3 glomerulopathy (C3G), characterized by dysregulation of the alternative pathway of complement and by dominant C3 by immunofluorescence on the kidney biopsy. There is no approved treatment for patients with C3G. Immunosuppressive drugs as well as biologics have been used with limited success. In recent decades, substantial advances in the understanding of the complement system have led to the development of new complement inhibitors. Avacopan (CCX168) is an orally administered small-molecule C5aR antagonist that blocks the effects of C5a, one of the most potent pro-inflammatory mediators of the complement system. CASE REPORT We describe a child with biopsy-proven C3GN treated with avacopan. She was enrolled in the ACCOLADE double-blind placebo-controlled Phase 2 study (NCT03301467), where during the first 26 weeks she was randomized to receive an avacopan-matching placebo orally twice daily, while in the following 26 weeks, the study was open-label and she received avacopan. After a wash-out period, she was restarted on avacopan through an expanded access program. CONCLUSIONS In this case, use of avacopan in a pediatric patient with C3GN was safe and well tolerated. On avacopan, the patient was able to discontinue mycophenolate mofetil (MMF) while maintaining remission.
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Affiliation(s)
- Federica Zotta
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | | | - Antonio Gargiulo
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Andrea Cappoli
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Francesco Emma
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marina Vivarelli
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
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19
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Lafayette RA, Charu V. Expert Discussion on Challenges in C3G Diagnosis: A Podcast Article on Best Practices in Kidney Biopsies. Adv Ther 2023; 40:5557-5566. [PMID: 37751024 PMCID: PMC10611840 DOI: 10.1007/s12325-023-02654-3] [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: 02/16/2023] [Accepted: 08/17/2023] [Indexed: 09/27/2023]
Abstract
Complement 3 glomerulopathy (C3G) is an ultra-rare, progressive kidney disease resulting from dysregulation of the alternative complement pathway. Clinical presentation of C3G is heterogeneous and definitive diagnosis relies on kidney biopsy and immunofluorescence staining. The term C3G encompasses two subgroups, dense deposit disease and C3 glomerulonephritis, distinguished via electron microscopy. In this podcast article, the authors discuss the challenges associated with C3G diagnosis and the central role of kidney biopsy. Using an illustrative case study, key histological observations are described, and best practices are discussed from the perspectives of a nephrologist and a nephropathologist. Podcast Audio (MP4 141866 KB).
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Affiliation(s)
| | - Vivek Charu
- Department of Pathology, Stanford University, Stanford, CA, USA
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Abstract
The complement cascade comprises soluble and cell surface proteins and is an important arm of the innate immune system. Once activated, the complement system rapidly generates large quantities of protein fragments that are potent mediators of inflammatory, vasoactive and metabolic responses. Although complement is crucial to host defence and homeostasis, its inappropriate or uncontrolled activation can also drive tissue injury. For example, the complement system has been known for more than 50 years to be activated by glomerular immune complexes and to contribute to autoimmune kidney disease. Notably, the latest research shows that complement is also activated in kidney diseases that are not traditionally thought of as immune-mediated, including haemolytic-uraemic syndrome, diabetic kidney disease and focal segmental glomerulosclerosis. Several complement-targeted drugs have been approved for the treatment of kidney disease, and additional anti-complement agents are being investigated in clinical trials. These drugs are categorically different from other immunosuppressive agents and target pathological processes that are not effectively inhibited by other classes of immunosuppressants. The development of these new drugs might therefore have considerable benefits in the treatment of kidney disease.
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Affiliation(s)
- Vojtech Petr
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joshua M Thurman
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.
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21
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Meuleman MS, Vieira-Martins P, El Sissy C, Audard V, Baudouin V, Bertrand D, Bridoux F, Louillet F, Dossier C, Esnault V, Jourde-Chiche N, Karras A, Morin MP, Provot F, Remy P, Ribes D, Rousset-Rouviere C, Servais A, Thervet E, Tricot L, Zaidan M, Wynckel A, Zuber J, Le Quintrec M, Frémeaux-Bacchi V, Chauvet S. Rare Variants in Complement Gene in C3 Glomerulopathy and Immunoglobulin-Mediated Membranoproliferative GN. Clin J Am Soc Nephrol 2023; 18:1435-1445. [PMID: 37615951 PMCID: PMC10637453 DOI: 10.2215/cjn.0000000000000252] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 08/17/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND C3 glomerulopathy and idiopathic immunoglobulin-mediated membranoproliferative GN (Ig-MPGN) are rare complement-mediated kidney diseases. Inherited forms of C3 glomerulopathy/Ig-MPGN are rarely described. METHODS Three hundred ninety-eight patients with C3 glomerulopathy ( n =296) or Ig-MPGN ( n =102) from a national registry were screened for three complement genes: factor H ( CFH ), factor I ( CFI ), and C3 . Patients with rare variant (minor allele frequency <0.1%) were included. Epidemiologic, clinical, and immunologic data at diagnosis and kidney outcomes of patients were retrospectively collected. RESULTS Fifty-three different rare variants, including 30 (57%), 13 (24%), and ten (19%) in CFH , CFI , and C3 variants, were identified in 66/398 (17%) patients. Thirty-eight (72%) variants were classified as pathogenic, including 20/30 (66%) and 11/13 (84%) variants in CFH and CFI , respectively, impairing synthesis of factor H or factor I regulators. Fifteen of 53 (27%) variants were of unknown significance. At diagnosis, 69% of patients were adult (median age of 31 years). With the exception of biologic stigma of thrombotic microangiopathy, which was more frequent in patients with CFI variants (5/14 [36%] versus 1/37 [3%] and 0% in the CFH group and C3 group, respectively, P < 0.001), the clinical and histologic features were similar among the three variants groups. The kidney outcome was poor regardless of the age at onset and treatment received. Sixty-five percent (43/66) of patients with rare variant reach kidney failure after a median delay of 41 (19-104) months, compared with 28% (55/195) after a median delay of 34 (12-143) months in the nonvariant group. Among 36 patients who received a kidney transplant, 2-year recurrence was frequent, occurring in 39% (12/31), without difference between variant groups, and led to graft failure in three cases. CONCLUSIONS In our cohort, 17% of C3 glomerulopathy/Ig-MPGN cases were associated with rare variants in the CFH , CFI , or C3 genes. In most cases, a quantitative deficiency in factor H or factor I was identified. The presence of a rare variant was associated with poor kidney survival. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_11_08_CJN0000000000000252.mp3.
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Affiliation(s)
- Marie Sophie Meuleman
- Team “Inflammation, Complement and Cancer,” INSERM UMRS1138, Centre de Recherche des Cordeliers, Paris, France
| | - Paula Vieira-Martins
- Department of Immunology Biology, Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Paris, France
| | - Carine El Sissy
- Team “Inflammation, Complement and Cancer,” INSERM UMRS1138, Centre de Recherche des Cordeliers, Paris, France
- Department of Immunology Biology, Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Paris, France
| | - Vincent Audard
- Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Henri-Mondor Hospital, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Véronique Baudouin
- Department of Pediatric Nephrology, Assistance Publique-Hôpitaux de Paris, Robert Debré University Hospital, Paris, France
| | | | - Frank Bridoux
- Department of Nephrology, Poitiers University Hospital, Poitiers, France
| | | | - Claire Dossier
- Department of Pediatric Nephrology, Assistance Publique-Hôpitaux de Paris, Robert Debré University Hospital, Paris, France
| | - Vincent Esnault
- Department of Nephrology, Nice University Hospital, Nice, France
| | - Noémie Jourde-Chiche
- Department of Nephrology, Assistance Publique-Hôpitaux de Marseille, CHU Conception, Marseille, France
- INSERM, INRAE, C2VN, Aix-Marseille University, Marseille, France
| | - Alexandre Karras
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Paris, France
| | | | - François Provot
- Department of Nephrology, Lille University Hospital, Lille, France
| | - Philippe Remy
- Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Paris, Henri-Mondor Hospital, Créteil, France
| | - David Ribes
- Department of Nephrology, Toulouse University Hospital, Toulouse, France
| | - Caroline Rousset-Rouviere
- Department of Pediatric Nephrology, Assistance Publique-Hôpitaux de Marseille, Timone Hospital, Marseille, France
| | - Aude Servais
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris, Necker Hospital, Paris, France
| | - Eric Thervet
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Paris, France
| | - Leila Tricot
- Department of Nephrology, Foch Hospital, Suresnes, France
| | - Mohamad Zaidan
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris, Bicetre Hospital, Le Kremlin-Bicêtre, France
| | - Alain Wynckel
- Department of Nephrology, Reims University Hospital, Reims, France
| | - Julien Zuber
- Department of Nephrology and Renal Transplantation, Assistance Publique-Hôpitaux de Paris, Necker Hospital, Paris, France
| | - Moglie Le Quintrec
- Department of Nephrology, Montpellier University Hospital, Montpellier, France
| | - Véronique Frémeaux-Bacchi
- Team “Inflammation, Complement and Cancer,” INSERM UMRS1138, Centre de Recherche des Cordeliers, Paris, France
- Department of Immunology Biology, Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Paris, France
| | - Sophie Chauvet
- Team “Inflammation, Complement and Cancer,” INSERM UMRS1138, Centre de Recherche des Cordeliers, Paris, France
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Paris, France
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Dixon BP, Greenbaum LA, Huang L, Rajan S, Ke C, Zhang Y, Li L. Clinical Safety and Efficacy of Pegcetacoplan in a Phase 2 Study of Patients with C3 Glomerulopathy and Other Complement-Mediated Glomerular Diseases. Kidney Int Rep 2023; 8:2284-2293. [PMID: 38025230 PMCID: PMC10658235 DOI: 10.1016/j.ekir.2023.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Dysregulated complement activation is likely the primary driver of disease in C3 glomerulopathy (C3G) and contributes to other complement-mediated diseases, including immunoglobulin A nephropathy (IgAN), lupus nephritis (LN), and primary membranous nephropathy (PMN). No complement inhibitors are proven to halt disease progression in these diseases. Pegcetacoplan, a targeted C3 and C3b inhibitor, may mitigate complement-mediated kidney damage in C3G and other glomerular diseases in which complement may have a pathogenic role. Methods This open-label, phase 2, 48-week study evaluated the preliminary efficacy and safety of subcutaneous pegcetacoplan for patients with complement-mediated glomerular diseases. The primary end point was proteinuria reduction, measured as 24-hour urine protein-to-creatinine ratio. Secondary end points included remission status, changes in estimated glomerular filtration rate (eGFR), and pharmacodynamic biomarkers. Treatment-emergent adverse events (TEAEs) were monitored. Results Efficacy results for the C3G cohort are reported herein, along with safety results for the study population. In the C3G cohort, mean proteinuria reduction from baseline to week 48 was 50.9% in the intent-to-treat (ITT) population (n = 7) and 65.4% in the per-protocol (PP) population (n = 4). Mean serum albumin normalized and mean eGFR was stable over 48 weeks. Mean serum C3 levels increased 6-fold and mean soluble C5b-9 levels decreased by 57.3% at week 48. The most common adverse events (AEs) were upper respiratory tract infection, injection site erythema, nausea, and headache. No meningitis or sepsis cases were reported, and no serious treatment-related AEs were observed. Conclusion Pegcetacoplan may provide therapeutic benefit for C3G and has a favorable safety profile across the 4 glomerular diseases studied.
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Affiliation(s)
- Bradley P. Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Larry A. Greenbaum
- Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Liwei Huang
- Tidewater Kidney Specialists, Inc, Chesapeake, Virginia, USA
| | - Sandeep Rajan
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chunlei Ke
- Apellis Pharmaceuticals, Inc., Waltham, Massachusetts, USA
| | - Yiwei Zhang
- Apellis Pharmaceuticals, Inc., Waltham, Massachusetts, USA
| | - Li Li
- Apellis Pharmaceuticals, Inc., Waltham, Massachusetts, USA
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23
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Boi R, Ebefors K, Nyström J. The role of the mesangium in glomerular function. Acta Physiol (Oxf) 2023; 239:e14045. [PMID: 37658606 DOI: 10.1111/apha.14045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/12/2023] [Accepted: 08/01/2023] [Indexed: 09/03/2023]
Abstract
When discussing glomerular function, one cell type is often left out, the mesangial cell (MC), probably since it is not a part of the filtration barrier per se. The MCs are instead found between the glomerular capillaries, embedded in their mesangial matrix. They are in direct contact with the endothelial cells and in close contact with the podocytes and together they form the glomerulus. The MCs can produce and react to a multitude of growth factors, cytokines, and other signaling molecules and are in the perfect position to be a central hub for crosstalk communication between the cells in the glomerulus. In certain glomerular diseases, for example, in diabetic kidney disease or IgA nephropathy, the MCs become activated resulting in mesangial expansion. The expansion is normally due to matrix expansion in combination with either proliferation or hypertrophy. With time, this expansion can lead to fibrosis and decreased glomerular function. In addition, signs of complement activation are often seen in biopsies from patients with glomerular disease affecting the mesangium. This review aims to give a better understanding of the MCs in health and disease and their role in glomerular crosstalk and inflammation.
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Affiliation(s)
- Roberto Boi
- Department of Physiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kerstin Ebefors
- Department of Physiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jenny Nyström
- Department of Physiology, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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24
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Shekarchian F, Hosseini SM, Khazaei S. Hypertensive retinopathy and Purtscher-like retinopathy in a child with complement 3 glomerulopathy. J AAPOS 2023; 27:312-314. [PMID: 37717617 DOI: 10.1016/j.jaapos.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 06/19/2023] [Accepted: 07/03/2023] [Indexed: 09/19/2023]
Abstract
We report the case of a 15-year-old boy with hypertensive retinopathy and Purtscher-like retinopathy eventually diagnosed with complement 3 glomerulopathy (C3G). The patient presented with bilateral severe painless visual loss and posterior pole cotton wool spots, optic disk and macular edema, and macular star-shaped hard exudate depositions, arterial narrowing, and venous tortuosity, indicative of hypertensive retinopathy (with an initial blood pressure of 210/130 mm Hg) and Purtscher-like retinopathy. He was subsequently diagnosed with C3G based on results of a kidney biopsy. There was a mild visual improvement on follow-up examination, and optic disk swelling and subretinal fluid and cotton wool spots resolved.
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Affiliation(s)
- Farid Shekarchian
- Eye Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Sahel Khazaei
- Eye Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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25
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Rydberg V, Aradottir SS, Kristoffersson AC, Svitacheva N, Karpman D. Genetic investigation of Nordic patients with complement-mediated kidney diseases. Front Immunol 2023; 14:1254759. [PMID: 37744338 PMCID: PMC10513385 DOI: 10.3389/fimmu.2023.1254759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023] Open
Abstract
Background Complement activation in atypical hemolytic uremic syndrome (aHUS), C3 glomerulonephropathy (C3G) and immune complex-mediated membranoproliferative glomerulonephritis (IC-MPGN) may be associated with rare genetic variants. Here we describe gene variants in the Swedish and Norwegian populations. Methods Patients with these diagnoses (N=141) were referred for genetic screening. Sanger or next-generation sequencing were performed to identify genetic variants in 16 genes associated with these conditions. Nonsynonymous genetic variants are described when they have a minor allele frequency of <1% or were previously reported as being disease-associated. Results In patients with aHUS (n=94, one also had IC-MPGN) 68 different genetic variants or deletions were identified in 60 patients, of which 18 were novel. Thirty-two patients had more than one genetic variant. In patients with C3G (n=40) 29 genetic variants, deletions or duplications were identified in 15 patients, of which 9 were novel. Eight patients had more than one variant. In patients with IC-MPGN (n=7) five genetic variants were identified in five patients. Factor H variants were the most frequent in aHUS and C3 variants in C3G. Seventeen variants occurred in more than one condition. Conclusion Genetic screening of patients with aHUS, C3G and IC-MPGN is of paramount importance for diagnostics and treatment. In this study, we describe genetic assessment of Nordic patients in which 26 novel variants were found.
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Affiliation(s)
| | | | | | | | - Diana Karpman
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
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26
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Chabannes M, Rabant M, El Sissy C, Dragon-Durey MA, Vieira Martins P, Meuleman MS, Karras A, Buob D, Bridoux F, Daugas E, Audard V, Caillard S, Olagne J, Kandel C, Ferlicot S, Philipponnet C, Crepin T, Thervet E, Ducloux D, Frémeaux-Bacchi V, Chauvet S. C3 Glomerulopathy With Concurrent Thrombotic Microangiopathy: Clinical and Immunological Features. Am J Kidney Dis 2023; 82:279-289. [PMID: 37061020 DOI: 10.1053/j.ajkd.2022.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 12/31/2022] [Indexed: 04/17/2023]
Abstract
RATIONALE & OBJECTIVE C3 glomerulopathy (C3GN) and atypical hemolytic uremic syndrome (aHUS) are 2 distinct rare kidney diseases caused by dysregulation of the alternative complement pathway. Patients with C3GN and concurrent kidney lesions of thrombotic microangiopathy (TMA) have been rarely reported. We characterized the clinical features and underlying immunological abnormalities in these patients. STUDY DESIGN Case series. SETTING & PARTICIPANTS Patients with C3GN and concomitant TMA lesions on biopsy registered from 2009 to 2019 in the French National Registry of C3GN. FINDINGS Among 278 registered patients with C3GN, 16 (6%) had biopsy-proven glomerular and/or vascular TMA lesions. Their median age at diagnosis was 39 years (range, 7-76), and 59% were female. Fourteen of the 16 patients (88%) had an estimated glomerular filtration rate of<30mL/min/1.73m2 and 3 of 16 (19%) required dialysis. Twelve of the 14 evaluated patients (86%) showed evidence of mechanical hemolysis. Fifty percent of the patients had low C3 levels. Six of the 14 evaluated patients had a rare variant in complement genes, and 4 of the 16 patients (25%) had monoclonal gammopathy. Among the 16 patients, 10 (63%) received eculizumab, 5 (31%) received immunosuppressive therapy, and 4 (25%) received clone-targeted chemotherapy. Median kidney survival was 49 months. LIMITATIONS Small retrospective case series with a limited number of biopsies including electron microscopy. CONCLUSIONS Concomitant C3GN and TMA is extremely rare and is associated with poor kidney outcomes. Genetic or acquired abnormalities of the alternative complement pathway are common as is the presence of monoclonal gammopathy, which may inform the selection of treatment approaches.
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Affiliation(s)
- Melchior Chabannes
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital, Besançon
| | - Marion Rabant
- Department of Pathology, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris; Université de Paris Cité, Paris, France
| | - Carine El Sissy
- Department of Biological Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris
| | - Marie-Agnès Dragon-Durey
- Department of Biological Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris; INSERM UMRS 1138, Cordelier Research Center, Paris; Université de Paris Cité, Paris, France
| | - Paula Vieira Martins
- Department of Biological Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris
| | - Marie Sophie Meuleman
- INSERM UMRS 1138, Cordelier Research Center, Paris; Université de Paris Cité, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris
| | - David Buob
- Department of Pathology, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Paris
| | - Frank Bridoux
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital, Poitiers
| | - Eric Daugas
- Department of Nephrology, Hôpital Bichat-Claude Bernard, Assistance Publique-Hôpitaux de Paris, Paris
| | - Vincent Audard
- Department of Nephrology and Transplantation, Henri Mondor University Hospital, Assistance Publique-Hôpitaux de Paris, Créteil; Univ Paris Est Creteil, INSERM, IMRB, Créteil, France
| | - Sophie Caillard
- Department of Nephrology and Transplantation, University Hospital, Strasbourg
| | - Jérôme Olagne
- Department of Pathology, University Hospital, Strasbourg
| | | | - Sophie Ferlicot
- Department of Pathology, Hôpital Kremlin-Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre
| | | | - Thomas Crepin
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital, Besançon
| | - Eric Thervet
- INSERM UMRS 1138, Cordelier Research Center, Paris
| | - Didier Ducloux
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital, Besançon
| | - Véronique Frémeaux-Bacchi
- Department of Biological Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris
| | - Sophie Chauvet
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris; INSERM UMRS 1138, Cordelier Research Center, Paris; Université de Paris Cité, Paris, France.
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27
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Zanchi C, Locatelli M, Corna D, Cerullo D, Fishilevich E, Desai D, Rottoli D, Donadelli R, Noris M, Zoja C, Remuzzi G, Benigni A. Liver factor B silencing to cure C3 glomerulopathy: Evidence from a mouse model of complement dysregulation. Mol Immunol 2023; 161:25-32. [PMID: 37481826 DOI: 10.1016/j.molimm.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/28/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Abstract
Uncontrolled activation of the alternative pathway (AP) of complement, due to genetic and/or acquired defects, plays a primary pathogenetic role in C3 glomerulopathy (C3G), a rare and heterogeneous disease characterised by predominant C3 fragment deposition within the glomerulus, as well as glomerular damage. There are currently no approved disease-specific treatments for C3G, but new drugs that directly counteract AP dysregulation, targeting components of the pathway, have opened promising new perspectives for managing the disease. Complement factor B (FB), which is primarily synthesised by hepatocytes, is a key component of the AP, as it drives the central amplification loop of the complement system. In this study we used a GalNAc (N-Acetylgalactosamine)-conjugated siRNA to selectively target and suppress liver FB expression in two mouse models characterised by the complete (Cfh-/- mice) or partial (Cfh+/-) loss of function of complement factor H (FH). Homozygous deletion of FH induced a severe C3G phenotype, with strong dysregulation of the AP of complement, glomerular C3 deposition and almost complete C3 consumption. Mice with a heterozygous deletion of FH had intermediate C3 levels and exhibited slower disease progression, resembling human C3G more closely. Here we showed that FB siRNA treatment did not improve serum C3 levels, nor limit glomerular C3 deposition in Cfh-/- mice, while it did normalise circulating C3 levels, reduce glomerular C3 deposits, and limit mesangial electron-dense deposits in Cfh+/- mice. The present data provide important insights into the potential benefits and limitations of FB-targeted inhibition strategies and suggest RNA interference-mediated FB silencing in the liver as a possible therapeutic approach for treating C3G patients with FH haploinsufficiency.
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Affiliation(s)
- Cristina Zanchi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Monica Locatelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Daniela Corna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Domenico Cerullo
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | | | - Dhruv Desai
- Alnylam Pharmaceuticals Inc., Boston, MA, United States
| | - Daniela Rottoli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Roberta Donadelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Carlamaria Zoja
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori Science and Technology Park Kilometro Rosso, Bergamo, Italy
| | - Ariela Benigni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Centro Anna Maria Astori Science and Technology Park Kilometro Rosso, Bergamo, Italy.
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28
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Hallam TM, Sharp SJ, Andreadi A, Kavanagh D. Complement factor I: Regulatory nexus, driver of immunopathology, and therapeutic. Immunobiology 2023; 228:152410. [PMID: 37478687 DOI: 10.1016/j.imbio.2023.152410] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/23/2023] [Accepted: 06/01/2023] [Indexed: 07/23/2023]
Abstract
Complement factor I (FI) is the nexus for classical, lectin and alternative pathway complement regulation. FI is an 88 kDa plasma protein that circulates in an inactive configuration until it forms a trimolecular complex with its cofactor and substrate whereupon a structural reorganization allows the catalytic triad to cleave its substrates, C3b and C4b. In keeping with its role as the master complement regulatory enzyme, deficiency has been linked to immunopathology. In the setting of complete FI deficiency, a consumptive C3 deficiency results in recurrent infections with encapsulated microorganisms. Aseptic cerebral inflammation and vasculitic presentations are also less commonly observed. Heterozygous mutations in the factor I gene (CFI) have been demonstrated to be enriched in atypical haemolytic uraemic syndrome, albeit with a very low penetrance. Haploinsufficiency of CFI has also been associated with decreased retinal thickness and is a strong risk factor for the development of age-related macular degeneration. Supplementation of FI using plasma purified or recombinant protein has long been postulated, however, technical difficulties prevented progression into clinical trials. It is only using gene therapy that CFI supplementation has reached the clinic with GT005 in phase I/II clinical trials for geographic atrophy.
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Affiliation(s)
- T M Hallam
- Gyroscope Therapeutics Limited, A Novartis Company, Rolling Stock Yard, London N7 9AS, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, UK
| | - S J Sharp
- Gyroscope Therapeutics Limited, A Novartis Company, Rolling Stock Yard, London N7 9AS, UK
| | - A Andreadi
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, UK
| | - D Kavanagh
- Translational and Clinical Research Institute, Newcastle University, Newcastle-upon-Tyne NE1 7RU, UK; National Renal Complement Therapeutics Centre, Building 26, Royal Victoria Infirmary, UK; NIHR Newcastle Biomedical Research Centre, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne NE4 5PL, UK.
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Wada Y, Kamata M, Miyasaka R, Abe T, Kawamura S, Takeuchi K, Aoyama T, Oda T, Takeuchi Y. Clinico-Pathogenic Similarities and Differences between Infection-Related Glomerulonephritis and C3 Glomerulopathy. Int J Mol Sci 2023; 24:ijms24098432. [PMID: 37176142 PMCID: PMC10179079 DOI: 10.3390/ijms24098432] [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: 04/05/2023] [Revised: 04/26/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023] Open
Abstract
Recently, the comprehensive concept of "infection-related glomerulonephritis (IRGN)" has replaced that of postinfectious glomerulonephritis (PIGN) because of the diverse infection patterns, epidemiology, clinical features, and pathogenesis. In addition to evidence of infection, hypocomplementemia particularly depresses serum complement 3 (C3), with endocapillary proliferative and exudative GN developing into membranoproliferative glomerulonephritis (MPGN); also, C3-dominant or co-dominant glomerular immunofluorescence staining is central for diagnosing IRGN. Moreover, nephritis-associated plasmin receptor (NAPlr), originally isolated from the cytoplasmic fraction of group A Streptococci, is vital as an essential inducer of C3-dominant glomerular injury and is a key diagnostic biomarker for IRGN. Meanwhile, "C3 glomerulopathy (C3G)", also showing a histological pattern of MPGN due to acquired or genetic dysregulation of the complement alternative pathway (AP), mimics C3-dominant IRGN. Initially, C3G was characterized by intensive "isolated C3" deposition on glomeruli. However, updated definitions allow for glomerular deposition of other complement factors or immunoglobulins if C3 positivity is dominant and at least two orders of magnitude greater than any other immunoreactant, which makes it challenging to quickly distinguish pathomorphological findings between IRGN and C3G. As for NAPlr, it was demonstrated to induce complement AP activation directly in vitro, and it aggravates glomerular injury in the development of IRGN. A recent report identified anti-factor B autoantibodies as a contributing factor for complement AP activation in pediatric patients with PIGN. Moreover, C3G with glomerular NAPlr deposition without evidence of infection was reported. Taken together, the clinico-pathogenic features of IRGN overlap considerably with those of C3G. In this review, similarities and differences between the two diseases are highlighted.
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Affiliation(s)
- Yukihiro Wada
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan
| | - Mariko Kamata
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan
| | - Ryoma Miyasaka
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan
| | - Tetsuya Abe
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan
| | - Sayumi Kawamura
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan
| | - Kazuhiro Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan
| | - Togo Aoyama
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji 193-0998, Tokyo, Japan
| | - Yasuo Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara 252-0374, Kanagawa, Japan
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Caravaca-Fontán F, Cavero T, Díaz-Encarnación M, Cabello V, Ariceta G, Quintana LF, Marco H, Barros X, Ramos N, Rodríguez-Mendiola N, Cruz S, Fernández-Juárez G, Rodríguez A, Pérez de José A, Rabasco C, Rodado R, Fernández L, Pérez-Gómez V, Ávila A, Bravo L, Espinosa N, Allende N, Sanchez de la Nieta MD, Rodríguez E, Rivas B, Melgosa M, Huerta A, Miquel R, Mon C, Fraga G, de Lorenzo A, Draibe J, González F, Shabaka A, López-Rubio ME, Fenollosa MÁ, Martín-Penagos L, Da Silva I, Titos JA, Rodríguez de Córdoba S, Goicoechea de Jorge E, Praga M. Clinical Profiles and Patterns of Kidney Disease Progression in C3 Glomerulopathy. KIDNEY360 2023; 4:659-672. [PMID: 36996481 PMCID: PMC10278771 DOI: 10.34067/kid.0000000000000115] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/07/2023] [Indexed: 04/01/2023]
Abstract
Key Points Kidney survival in C3 glomerulopathy is significantly higher in patients with a disease chronicity score <4 and proteinuria <3.5 g/d, regardless of baseline eGFR. A faster eGFR decline in C3 glomerulopathy is associated with higher probability of kidney failure. Patients with glomerulopathy with a progressive reduction in proteinuria over time did not reach kidney failure. Background C3 glomerulopathy is a rare kidney disease, which makes it difficult to collect large cohorts of patients to better understand its variability. The aims of this study were to describe the clinical profiles and patterns of progression of kidney disease. Methods This was a retrospective, observational cohort study. Patients diagnosed with C3 glomerulopathy between 1995 and 2020 were enrolled. Study population was divided into clinical profiles by combining the following predictors: eGFR under/above 30 ml/min per 1.73 m2, proteinuria under/above 3.5 g/d, and histologic chronicity score under/above 4. The change in eGFR and proteinuria over time was evaluated in a subgroup with consecutive measurements of eGFR and proteinuria. Results One hundred and fifteen patients with a median age of 30 years (interquartile range 19–50) were included. Patients were divided into eight clinical profiles. Kidney survival was significantly higher in patients with a chronicity score <4 and proteinuria <3.5 g/d, both in those presenting with an eGFR under/above 30 ml/min per 1.73 m2. The median eGFR slope of patients who reached kidney failure was −6.5 ml/min per 1.73 m2 per year (interquartile range −1.6 to −17). Patients who showed a reduction in proteinuria over time did not reach kidney failure. On the basis of the rate of eGFR decline, patients were classified as faster eGFR decline (≥5 ml/min per 1.73 m2 per year), slower (<5 ml/min per 1.73 m2 per year), and those without decline. A faster eGFR decline was associated with higher probability of kidney failure. Conclusions Kidney survival is significantly higher in patients with a chronicity score <4 and proteinuria <3.5 g/d regardless of baseline eGFR, and a faster rate of decline in eGFR is associated with higher probability of kidney failure.
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Affiliation(s)
- Fernando Caravaca-Fontán
- Department of Nephrology, Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Teresa Cavero
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Virginia Cabello
- Department of Nephrology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Gema Ariceta
- Department of Pediatric Nephrology, Hospital Universitario Vall d’Hebron, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Luis F. Quintana
- Department of Nephrology and Renal Transplantation, Hospital Clinic de Barcelona; Department of Medicine, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Helena Marco
- Department of Nephrology, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
- Current address: Department of Nephrology, Fundación Puigvert, Barcelona, Spain
| | - Xoana Barros
- Department of Nephrology, Hospital Universitario Doctor Josep Trueta, Gerona, Spain
| | - Natalia Ramos
- Department of Nephrology, Hospital Universitario Vall d’Hebron, Barcelona, Spain
| | | | - Sonia Cruz
- Department of Nephrology, Hospital Universitario Juan Ramón Jiménez, Huelva, Spain
| | - Gema Fernández-Juárez
- Department of Nephrology, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
- Current address: Department of Nephrology, Hospital Universitario La Paz, Madrid, Spain
| | - Adela Rodríguez
- Department of Pediatric Nephrology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ana Pérez de José
- Department of Nephrology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Cristina Rabasco
- Department of Nephrology, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Raquel Rodado
- Department of Nephrology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Loreto Fernández
- Department of Nephrology, Complejo Hospitalario de Navarra, Navarra, Spain
| | - Vanessa Pérez-Gómez
- Department of Nephrology, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Ana Ávila
- Department of Nephrology, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Luis Bravo
- Department of Nephrology, Hospital Universitario A Coruña, La Coruña, Spain
| | - Natalia Espinosa
- Pediatric Nephrology Unit, Hospital Universitario Son Espases, Balearic Islands Health Research Institute (IdISBa). Palma de Mallorca, Spain
| | - Natalia Allende
- Department of Nephrology, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | | | - Eva Rodríguez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Begoña Rivas
- Department of Nephrology, Hospital Universitario La Paz, Madrid, Spain
| | - Marta Melgosa
- Department of Pediatric Nephrology, Hospital Universitario La Paz, Madrid, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Rosa Miquel
- Department of Nephrology, Hospital Universitario Canarias, Tenerife, Spain
| | - Carmen Mon
- Department of Nephrology, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - Gloria Fraga
- Department of Pediatric Nephrology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Alberto de Lorenzo
- Department of Nephrology, Hospital Universitario de Getafe, Madrid, Spain
| | - Juliana Draibe
- Department of Nephrology, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Fayna González
- Department of Nephrology, Hospital Doctor Negrín, Gran Canaria, Spain
| | - Amir Shabaka
- Department of Nephrology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | | | | | - Luis Martín-Penagos
- Department of Nephrology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Iara Da Silva
- Department of Nephrology, Fundación Puigvert, Barcelona, Spain
- Current address: Department of Nephrology, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Juana Alonso Titos
- Department of Nephrology, Hospital Regional Universitario Carlos Haya, Málaga, Spain
| | - Santiago Rodríguez de Córdoba
- Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Madrid and Centro de Investigación Biomédica en Red en Enfermedades Raras, Madrid, Spain
| | - Elena Goicoechea de Jorge
- Department of Nephrology, Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
- Department of Immunology, Universidad Complutense de Madrid, Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
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Jandal A, Zhong W, Gopal D, Horner V, Frater-Rubsam L, Djamali A, Bhutani G. What lies in-between: C3 glomerulopathy with non-hemolytic renal microangiopathy and an ultra-rare C3 variant. Am J Med Sci 2023; 365:286-293. [PMID: 36473547 DOI: 10.1016/j.amjms.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 08/31/2022] [Accepted: 10/12/2022] [Indexed: 12/12/2022]
Abstract
We report a 36-year-old female with mixed nephritic-nephrotic syndrome and recurrent pancreatitis. Kidney biopsy showed a crescentic membranoproliferative glomerulonephritis with dominant C3 staining on immunofluorescence (IF) but only scant deposits on electron microscopy (EM) and instead, evidence of severe acute and chronic microangiopathy - endothelial swelling, sub-endothelial fluff, and segmental basement membrane remodeling. Her serum C3 was normal, Factor Ba, and serum Membrane attack complex (sMAC) levels were elevated, and Properdin was low. Genetic testing revealed a heterozygous ultra rare C3 variant of unknown significance (c.4838G>T, p.Gly1613Val) as well as a heterozygous deletion of CFHR3-CFHR1. She showed an initial response to terminal complement blockade with eculizumab, but her renal disease progressed in the next year. Notably, our patient never demonstrated microangiopathic hemolysis, yet pancreatitis of unclear etiology recurred periodically. Our case suggests the existence of a "C3G/aHUS overlap" clinicopathologic syndrome and highlights the challenges of treating complement-mediated kidney disease.
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Affiliation(s)
- Ali Jandal
- Divsion of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Deepak Gopal
- Divsion of Gastroenterology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Vanessa Horner
- Wisconsin State Laboratory of Hygiene, University of Wisconsin, Madison, Wisconsin, United States; Department of Pediatrics, University of Wisconsin, Madison, United States
| | - Leah Frater-Rubsam
- Wisconsin State Laboratory of Hygiene, University of Wisconsin, Madison, Wisconsin, United States; Department of Pediatrics, University of Wisconsin, Madison, United States
| | - Arjang Djamali
- Divsion of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Gauri Bhutani
- Divsion of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States.
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[Electron microscopy in nephropathology]. PATHOLOGIE (HEIDELBERG, GERMANY) 2023; 44:84-94. [PMID: 36480038 DOI: 10.1007/s00292-022-01164-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/03/2022] [Indexed: 12/13/2022]
Abstract
Non-neoplastic kidney diseases represent a broad spectrum of diseases. Although their pathogenesis differs, the histological findings may be similar in terms of conventional morphology. A precise classification of these diseases is a prerequisite for correct therapy and prognostic assessment. In the diagnostic process, the magnification achieved by electron microscopy is essential and cannot be replaced by any other technique. The most frequent diagnostic questions addressed by ultrastructural studies represent (1) alterations of podocytes (e.g., minimal-change disease), (2) changes of the thickness and structure of the glomerular basement membrane (e.g., diabetic glomerulosclerosis or Alport disease), (3) the presence, characteristics and exact localisation of immune complexes (e.g., membranous glomerulonephritis or lupus nephritis), (4) alterations of endothelial cells and capillaries (e.g., thrombotic microangiopathy) and (5) diseases of the tubular cells (e.g., light-chain nephropathy or toxic effects). Therefore, ultrastructural investigations are-together with conventional microscopy and immunohistochemistry (or immunofluorescence)-an integral part of the so-called triple-diagnostics in routine nephropathology.
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Diagnostic and Prognostic Comparison of Immune-Complex-Mediated Membranoproliferative Glomerulonephritis and C3 Glomerulopathy. Cells 2023; 12:cells12050712. [PMID: 36899849 PMCID: PMC10000503 DOI: 10.3390/cells12050712] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023] Open
Abstract
Membranoproliferative glomerulonephritis (MPGN) is subdivided into immune-complex-mediated glomerulonephritis (IC-MPGN) and C3 glomerulopathy (C3G). Classically, MPGN has a membranoproliferative-type pattern, but other morphologies have also been described depending on the time course and phase of the disease. Our aim was to explore whether the two diseases are truly different, or merely represent the same disease process. All 60 eligible adult MPGN patients diagnosed between 2006 and 2017 in the Helsinki University Hospital district, Finland, were reviewed retrospectively and asked for a follow-up outpatient visit for extensive laboratory analyses. Thirty-seven (62%) had IC-MPGN and 23 (38%) C3G (including one patient with dense deposit disease, DDD). EGFR was below normal (≤60 mL/min/1.73 m2) in 67% of the entire study population, 58% had nephrotic range proteinuria, and a significant proportion had paraproteins in their serum or urine. A classical MPGN-type pattern was seen in only 34% of the whole study population and histological features were similarly distributed. Treatments at baseline or during follow-up did not differ between the groups, nor were there significant differences observed in complement activity or component levels at the follow-up visit. The risk of end-stage kidney disease and survival probability were similar in the groups. IC-MPGN and C3G have surprisingly similar characteristics, kidney and overall survival, which suggests that the current subdivision of MPGN does not add substantial clinical value to the assessment of renal prognosis. The high proportion of paraproteins in patient sera or in urine suggests their involvement in disease development.
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Noris M, Daina E, Remuzzi G. Membranoproliferative glomerulonephritis: no longer the same disease and may need very different treatment. Nephrol Dial Transplant 2023; 38:283-290. [PMID: 34596686 DOI: 10.1093/ndt/gfab281] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Indexed: 12/17/2022] Open
Abstract
Membranoproliferative glomerulonephritis (MPGN) is a pattern of glomerular injury that may be primary or secondary to infections, autoimmune diseases and haematological disorders. Primary C3G and IC-MPGN are rare and the prognosis is unfavourable. Based on immunofluorescence findings, MPGN has been classified into complement-mediated C3 glomerulopathy (C3G) and immune complex-mediated MPGN (IC-MPGN). However, this classification leaves a number of issues unresolved. The finding of genetic and acquired complement abnormalities in both C3G and IC-MPGN indicates that they represent a heterogeneous spectrum rather than distinct diseases. An unsupervised hierarchical clustering in a cohort of patients with primary C3G and IC-MPGN identified four distinct pathogenetic patterns, characterized by specific histologic and clinical features, and genetic and acquired complement abnormalities. These results provide the groundwork for a more accurate diagnosis and the development of targeted therapies. The drugs that are currently used, such as corticosteroids and immunosuppressants, are frequently ineffective in primary C3G and IC-MPGN. Eculizumab, an anti-C5 monoclonal antibody, has been used occasionally in single cases or small series. However, only a few patients have achieved remission. This heterogeneous response could be related to the extent of terminal complement activation, which may vary substantially from patient to patient. Several drugs that target the complement system at different levels are under investigation for C3G and IC-MPGN. However, clinical trials to test new therapeutics will be challenging and heavily influenced by the heterogeneity of these diseases. This creates the need to characterize each patient to match the specific complement abnormality with the type of intervention.
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Affiliation(s)
- Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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Caravaca-Fontán F, Polanco N, Villacorta B, Buxeda A, Coca A, Ávila A, Martínez-Gallardo R, Galeano C, Valero R, Ramos N, Allende N, Cruzado-Vega L, Pérez-Sáez MJ, Sevillano Á, González E, Hernández A, Rodrigo E, Fernández-Ruiz M, Aguado JM, Pérez Valdivia MÁ, Pascuall J, Andrés A, Praga M. Recurrence of immune complex and complement-mediated membranoproliferative glomerulonephritis in kidney transplantation. Nephrol Dial Transplant 2023; 38:222-235. [PMID: 35404425 DOI: 10.1093/ndt/gfac148] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Membranoproliferative glomerulonephritis (MPGN) represents a histologic pattern of glomerular injury that may be due to several aetiologies. Few studies have comprehensively analysed the recurrence of MPGN according to the current classification system. METHODS We collected a multicentre, retrospective cohort of 220 kidney graft recipients with biopsy-proven native kidney disease due to MPGN between 1981 and 2021 in 11 hospitals. Demographic, clinical and histologic parameters of prognostic interest were collected. The main outcomes were time to kidney failure, time to recurrence of MPGN and disease remission after recurrence. RESULTS The study group included 34 complement-mediated and 186 immune complex-mediated MPGN. A total of 81 patients (37%) reached kidney failure in a median follow-up of 79 months. The main predictors of this event were the development of rejection episodes and disease recurrence. In all, 54 patients (25%) had a disease recurrence in a median of 16 months after kidney transplantation. The incidence of recurrence was higher in patients with dysproteinaemia (67%) and complement-mediated MPGN (62%). In the multivariable model, complement-mediated MPGN emerged as a predictor of recurrence. A total of 33 patients reached kidney failure after recurrence. The main determinants of no remission were early time to recurrence (<15 months), estimated glomerular filtration rate <30 mL/min/1.73 m2 and serum albumin <3.5 g/dL at the time of recurrence. CONCLUSIONS One-fourth of the patients with native kidney disease due to MPGN developed clinical recurrence in the allograft, especially in cases with complement-mediated disease or in those associated with dysproteinaemia. The kidney outcomes of disease recurrence with currently available therapies are heterogeneous and thus more effective and individualized therapies are needed.
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Affiliation(s)
- Fernando Caravaca-Fontán
- Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Natalia Polanco
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Blanca Villacorta
- Department of Nephrology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Anna Buxeda
- Department of Nephrology, Hospital del Mar, Institut Mar for Medical Research, Barcelona, Spain
| | - Armando Coca
- Department of Nephrology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Ana Ávila
- Department of Nephrology, Hospital Universitario Doctor Peset, Valencia, Spain
| | | | - Cristina Galeano
- Department of Nephrology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Rosalía Valero
- Department of Nephrology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Natalia Ramos
- Department of Nephrology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Natalia Allende
- Department of Nephrology, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | | | - María José Pérez-Sáez
- Department of Nephrology, Hospital del Mar, Institut Mar for Medical Research, Barcelona, Spain
| | - Ángel Sevillano
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Esther González
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Ana Hernández
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Emilio Rodrigo
- Department of Nephrology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Mario Fernández-Ruiz
- Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Unit of Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - José María Aguado
- Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Unit of Infectious Diseases, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Julio Pascuall
- Department of Nephrology, Hospital del Mar, Institut Mar for Medical Research, Barcelona, Spain
| | - Amado Andrés
- Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain.,Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
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Pisarenka S, Meyer NC, Xiao X, Goodfellow R, Nester CM, Zhang Y, Smith RJH. Modeling C3 glomerulopathies: C3 convertase regulation on an extracellular matrix surface. Front Immunol 2023; 13:1073802. [PMID: 36846022 PMCID: PMC9947773 DOI: 10.3389/fimmu.2022.1073802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/28/2022] [Indexed: 01/19/2023] Open
Abstract
Introduction C3 glomerulopathies (C3G) are ultra-rare complement-mediated diseases that lead to end-stage renal disease (ESRD) within 10 years of diagnosis in ~50% of patients. Overactivation of the alternative pathway (AP) of complement in the fluid phase and on the surface of the glomerular endothelial glycomatrix is the underlying cause of C3G. Although there are animal models for C3G that focus on genetic drivers of disease, in vivo studies of the impact of acquired drivers are not yet possible. Methods Here we present an in vitro model of AP activation and regulation on a glycomatrix surface. We use an extracellular matrix substitute (MaxGel) as a base upon which we reconstitute AP C3 convertase. We validated this method using properdin and Factor H (FH) and then assessed the effects of genetic and acquired drivers of C3G on C3 convertase. Results We show that C3 convertase readily forms on MaxGel and that this formation was positively regulated by properdin and negatively regulated by FH. Additionally, Factor B (FB) and FH mutants impaired complement regulation when compared to wild type counterparts. We also show the effects of C3 nephritic factors (C3Nefs) on convertase stability over time and provide evidence for a novel mechanism of C3Nef-mediated C3G pathogenesis. Discussion We conclude that this ECM-based model of C3G offers a replicable method by which to evaluate the variable activity of the complement system in C3G, thereby offering an improved understanding of the different factors driving this disease process.
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Affiliation(s)
- Sofiya Pisarenka
- Molecular Otolaryngology and Renal Research Laboratories, Caver College of Medicine, University of Iowa, Iowa City, IA, United States
- Molecular Medicine Graduate Program, Caver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Nicole C. Meyer
- Molecular Otolaryngology and Renal Research Laboratories, Caver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Xue Xiao
- Molecular Otolaryngology and Renal Research Laboratories, Caver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Renee Goodfellow
- Molecular Otolaryngology and Renal Research Laboratories, Caver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Carla M. Nester
- Molecular Otolaryngology and Renal Research Laboratories, Caver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Yuzhou Zhang
- Molecular Otolaryngology and Renal Research Laboratories, Caver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Richard J. H. Smith
- Molecular Otolaryngology and Renal Research Laboratories, Caver College of Medicine, University of Iowa, Iowa City, IA, United States
- Molecular Medicine Graduate Program, Caver College of Medicine, University of Iowa, Iowa City, IA, United States
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Abstract
Uncontrolled alternative pathway activation is the primary driver of several diseases, and it contributes to the pathogenesis of many others. Consequently, diagnostic tests to monitor this arm of the complement system are increasingly important. Defects in alternative pathway regulation are strong risk factors for disease, and drugs that specifically block the alternative pathway are entering clinical use. A range of diagnostic tests have been developed to evaluate and monitor the alternative pathway, including assays to measure its function, expression of alternative pathway constituents, and activation fragments. Genetic studies have also revealed many disease-associated variants in alternative pathway genes that predict the risk of disease and prognosis. Newer imaging modalities offer the promise of non-invasively detecting and localizing pathologic complement activation. Together, these various tests help in the diagnosis of disease, provide important prognostic information, and can help guide therapy with complement inhibitory drugs.
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Affiliation(s)
- Joshua M. Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Veronique Fremeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Department of Immunology Biology and INSERM UMRS1138, Centre de Recherche des Cordeliers, Team "Inflammation, Complement and Cancer", Paris, France
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Ryu J, Baek E, Son HE, Ryu JY, Jeong JC, Kim S, Na KY, Chae DW, Kim SP, Kim SH, Jhee JH, Chang TI, Choi BS, Chin HJ. Comparison of dominant and nondominant C3 deposition in primary glomerulonephritis. Kidney Res Clin Pract 2023; 42:98-108. [PMID: 36747358 PMCID: PMC9902730 DOI: 10.23876/j.krcp.22.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 10/19/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Alternative complement pathway dysregulation plays a key role in glomerulonephritis (GN) and is associated with C3 deposition. Herein, we examined pathological and clinical differences between cases of primary GN with C3-dominant (C3D-GN) and nondominant (C3ND-GN) deposition. METHODS We extracted primary GN data from the Korean GlomeruloNEphritis sTudy (KoGNET). C3D-GN was defined as C3 staining two grades greater than C1q, C4, and immunoglobulin via immunofluorescence analysis. To overcome a large difference in the number of patients between the C3D-GN and C3ND-GN groups (31 vs. 9,689), permutation testing was used for analysis. RESULTS The C3D-GN group exhibited higher serum creatinine (p ≤ 0.001), a greater prevalence of estimated glomerular filtration rate of <60 mL/min/1.72 m2 (p ≤ 0.001), higher (but not significantly so) C-reactive protein level, and lower serum C3 level (p ≤ 0.001). Serum albumin, urine protein/creatinine ratio, number of patients who progressed to end-stage renal disease, and all-cause mortality were comparable between groups. Interstitial fibrosis and mesangial cellularity were greater in the C3D-GN group (p = 0.04 and p = 0.01, respectively) than in the C3ND-GN group. C3 deposition was dominant in the former group (p < 0.001), in parallel with increased subendothelial deposition (p ≤ 0.001). CONCLUSION Greater progression of renal injury and higher mortality occurred in patients with C3D-GN than with C3ND-GN, along with pathologic differences in interstitial and mesangial changes.
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Affiliation(s)
- Jiwon Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Eunji Baek
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyung-Eun Son
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Young Ryu
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jong Cheol Jeong
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Ki Young Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Dong-Wan Chae
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Seong Pyo Kim
- Interdisciplinary Program of Medical Informatics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Su Hwan Kim
- Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jong Hyun Jhee
- Division of Nephrology, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Republic of Korea
| | - Bum Soon Choi
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea,Correspondence: Ho Jun Chin Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173beon-gil, Bundang-gu, Seongnam 13620, Republic of Korea. E-mail:
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Abstract
Dysregulation and accelerated activation of the alternative pathway (AP) of complement is known to cause or accentuate several pathologic conditions in which kidney injury leads to the appearance of hematuria and proteinuria and ultimately to the development of chronic renal failure. Multiple genetic and acquired defects involving plasma- and membrane-associated proteins are probably necessary to impair the protection of host tissues and to confer a significant predisposition to AP-mediated kidney diseases. This review aims to explore how our current understanding will make it possible to identify the mechanisms that underlie AP-mediated kidney diseases and to discuss the available clinical evidence that supports complement-directed therapies. Although the value of limiting uncontrolled complement activation has long been recognized, incorporating complement-targeted treatments into clinical use has proved challenging. Availability of anti-complement therapy has dramatically transformed the outcome of atypical hemolytic uremic syndrome, one of the most severe kidney diseases. Innovative drugs that directly counteract AP dysregulation have also opened new perspectives for the management of other kidney diseases in which complement activation is involved. However, gained experience indicates that the choice of drug should be tailored to each patient's characteristics, including clinical, histologic, genetic, and biochemical parameters. Successfully treating patients requires further research in the field and close collaboration between clinicians and researchers who have special expertise in the complement system.
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Affiliation(s)
- Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Monica Cortinovis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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Michels MAHM, Volokhina EB, van de Kar NCAJ, van den Heuvel LPJ. Challenges in diagnostic testing of nephritic factors. Front Immunol 2022; 13:1036136. [PMID: 36451820 PMCID: PMC9702996 DOI: 10.3389/fimmu.2022.1036136] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/12/2022] [Indexed: 09/27/2023] Open
Abstract
Nephritic factors (NeFs) are autoantibodies promoting the activity of the central enzymes of the complement cascade, an important first line of defense of our innate immune system. NeFs stabilize the complement convertase complexes and prevent their natural and regulator-mediated decay. They are mostly associated with rare complement-mediated kidney disorders, in particular with C3 glomerulopathy and related diseases. Although these autoantibodies were already described more than 50 years ago, measuring NeFs for diagnostic purposes remains difficult, and this also complicates our understanding of their clinical associations. In this review, we address the multifactorial challenges of NeF diagnostics. We describe the diseases NeFs are associated with, the heterogenic mechanisms of action of different NeF types, the different methods available in laboratories used for their detection, and efforts for standardization. Finally, we discuss the importance of proper NeF diagnostics for understanding the clinical impact of these autoantibodies in disease pathophysiology and for considering future complement-directed therapy.
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Affiliation(s)
- Marloes A. H. M. Michels
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Elena B. Volokhina
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- Innatoss Laboratories, Oss, Netherlands
| | - Nicole C. A. J. van de Kar
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lambertus P.W. J. van den Heuvel
- Department of Pediatric Nephrology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Laboratory Medicine, Radboud University Medical Center, Nijmegen, Netherlands
- Department of Pediatrics/Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, University Hospitals Leuven, Leuven, Belgium
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41
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Chauvet S, Hauer JJ, Petitprez F, Rabant M, Martins PV, Baudouin V, Delmas Y, Jourde-Chiche N, Cez A, Ribes D, Cloarec S, Servais A, Zaidan M, Daugas E, Delahousse M, Wynckel A, Ryckewaert A, Sellier-Leclerc AL, Boyer O, Thervet E, Karras A, Smith RJH, Frémeaux-Bacchi V. Results from a nationwide retrospective cohort measure the impact of C3 and soluble C5b-9 levels on kidney outcomes in C3 glomerulopathy. Kidney Int 2022; 102:904-916. [PMID: 35752323 PMCID: PMC10588728 DOI: 10.1016/j.kint.2022.05.027] [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: 07/15/2021] [Revised: 04/14/2022] [Accepted: 05/26/2022] [Indexed: 10/17/2022]
Abstract
C3 glomerulopathy (C3G) is a rare complement-mediated disease. Specific treatments are not yet available and factors predictive of kidney survival such as age, kidney function and proteinuria are not specific to C3G. The prognostic value of biomarkers of complement activation, which are pathognomonic of the diseases, remains unknown. In a large cohort of 165 patients from the French National registry, we retrospectively assess the prognostic value of C3, soluble C5b-9 (sC5b-9), C3 nephritic factor, and rare disease-predicting variants in complement genes in predicting clinical outcome of patients. By multivariate analysis age (adult onset), reduced kidney function (defined by estimated glomerular filtration rate under 60ml/min) and presence of rare disease-predicting variants in complement genes predicted risk of progression to kidney failure. Moreover, by multivariate analysis, normal C3/high sC5b-9 levels or low C3/normal sC5b-9 levels remained independently associated with a worse kidney prognosis, with the relative risk 3.7- and 8-times higher, respectively. Subgroup analysis indicated that the complement biomarker profiles independently correlated to kidney prognosis in patients with adult but not pediatric onset. In this subgroup, we showed that profiles of biomarkers C3 and/or sC5b-9 correlated with intra glomerular inflammation and may explain kidney outcomes. In children, only the presence of rare disease-predicting variants correlated with kidney survival. Thus, in an adult population, we propose a three-point C3G prognostic score based on biomarker profiles at risk, estimated glomerular filtration rate at presentation and genetic findings, which may help stratify adult patients into subgroups that require close monitoring and more aggressive therapy.
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Affiliation(s)
- Sophie Chauvet
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France; INSERM UMRS1138, Centre de Recherche des Cordeliers, Team "Inflammation, Complement and cancer", Paris, France; Paris Cité University, Paris, France.
| | - Jill J Hauer
- Molecular Otolaryngology and Renal Research Laboratories, University of Iowa, Iowa City, Iowa, USA
| | - Florent Petitprez
- Programme Cartes d'Identités des Tumeurs, Ligue Nationale Contre le Cancer, Paris, France
| | - Marion Rabant
- Department of Renal Pathology, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Paris, France
| | - Paula Vieira Martins
- Department of Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Véronique Baudouin
- Department of Pediatric Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Robert Debré, Paris, France
| | - Yahsou Delmas
- Department of Nephrology, CH Bordeaux, Bordeaux, France
| | | | - Alexandre Cez
- Department of Nephrology, Tenon Hospital, Assistance Publique-hopitaux de Paris, Paris, France
| | - David Ribes
- Department of Nephrology, CHU Toulouse, Toulouse, France
| | - Sylvie Cloarec
- Department of Pediatric Nephrology, CHU Tours, Tours, France
| | - Aude Servais
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Paris, France
| | - Mohamad Zaidan
- Department of Nephrology, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Eric Daugas
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Department of Nephrology, Paris, France
| | | | | | | | | | - Olivia Boyer
- Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Department of Pediatric Nephrology, Paris, France
| | - Eric Thervet
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, University of Iowa, Iowa City, Iowa, USA
| | - Véronique Frémeaux-Bacchi
- INSERM UMRS1138, Centre de Recherche des Cordeliers, Team "Inflammation, Complement and cancer", Paris, France; Department of Immunology, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, Paris, France
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Al Zabali SM, Rubaihan AK, Alnetaifat MF, Algonaid O, El-Segaier M. Cardiac Tamponade-Associated Dense Deposit Disease: A Case Report and Review of the Literature. Cureus 2022; 14:e29280. [PMID: 36277520 PMCID: PMC9578658 DOI: 10.7759/cureus.29280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2022] [Indexed: 11/05/2022] Open
Abstract
Pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. It can be associated with various cardiac and non-cardiac disorders. Dense deposit disease (DDD) is a rare kidney disease caused by uncontrolled activation of the alternative complement pathway. We are reporting a seven-year-old male child who was diagnosed to have DDD approved by renal biopsy and presented with shortness of breath, cough, and fever. Chest X-ray displayed cardiomegaly. Thereafter, echocardiography showed massive pericardial effusion and left ventricle compression with a risk for cardiac tamponade. He subsequently underwent pericardiocentesis with the removal of 450 ml of pericardial fluid. The patient's edema was not correlated with the described amount of drained pericardial fluid. To the best of our knowledge, this is the first reported case of significant pericardial effusion carrying the risk of cardiac tamponade associated with DDD. With this report, we would like to highlight the importance of cardiac assessment in patients with DDD, in particular those with nephrotic range proteinuria who present with cardiac symptoms and cardiomegaly.
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Lin L, Hu K. Annexin A2 and Kidney Diseases. Front Cell Dev Biol 2022; 10:974381. [PMID: 36120574 PMCID: PMC9478026 DOI: 10.3389/fcell.2022.974381] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/08/2022] [Indexed: 11/22/2022] Open
Abstract
Annexin A2 is a Ca2+- and phospholipid-binding protein which is widely expressed in various types of cells and tissues. As a multifunctional molecule, annexin A2 is found to be involved in diverse cell functions and processes, such as cell exocytosis, endocytosis, migration and proliferation. As a receptor of plasminogen and tissue plasminogen activator, annexin A2 promotes plasmin generation and regulates the homeostasis of blood coagulation, fibrinolysis and matrix degradation. As an antigen expressed on cell membranes, annexin A2 initiates local inflammation and damage through binding to auto-antibodies. Annexin A2 also mediates multiple signaling pathways induced by various growth factors and oxidative stress. Aberrant expression of annexin A2 has been found in numerous kidney diseases. Annexin A2 has been shown to act as a co-receptor of integrin CD11b mediating NF-kB-dependent kidney inflammation, which is further amplified through annexin A2/NF-kB-triggered macrophage M2 to M1 phenotypic change. It also modulates podocyte cytoskeleton rearrangement through Cdc42 and Rac1/2/3 Rho pathway causing proteinuria. Thus, annexin A2 is implicated in the pathogenesis and progression of various kidney diseases. In this review, we focus on the current understanding of the role of annexin A2 in kidney diseases.
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Affiliation(s)
- Ling Lin
- *Correspondence: Ling Lin, ; Kebin Hu,
| | - Kebin Hu
- *Correspondence: Ling Lin, ; Kebin Hu,
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44
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Heiderscheit AK, Hauer JJ, Smith RJH. C3 glomerulopathy: Understanding an ultra-rare complement-mediated renal disease. AMERICAN JOURNAL OF MEDICAL GENETICS. PART C, SEMINARS IN MEDICAL GENETICS 2022; 190:344-357. [PMID: 35734939 PMCID: PMC9613507 DOI: 10.1002/ajmg.c.31986] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 04/27/2022] [Accepted: 06/10/2022] [Indexed: 01/29/2023]
Abstract
C3 glomerulopathy (C3G) describes a pathologic pattern of injury diagnosed by renal biopsy. It is characterized by the dominant deposition of the third component of complement (C3) in the renal glomerulus as resolved by immunofluorescence microscopy. The underlying pathophysiology is driven by dysregulation of the alternative pathway of complement in the fluid-phase and in the glomerular microenvironment. Characterization of clinical features and a targeted evaluation for indices and drivers of complement dysregulation are necessary for optimal patient care. Autoantibodies to the C3 and C5 convertases of complement are the most commonly detected drivers of complement dysregulation, although genetic mutations in complement genes can also be found. Approximately half of patients progress to end-stage renal disease within 10 years of diagnosis, and, while transplantation is a viable option, there is high risk for disease recurrence and allograft failure. This poor outcome reflects the lack of disease-specific therapy for C3G, relegating patients to symptomatic treatment to minimize proteinuria and suppress renal inflammation. Fortunately, the future is bright as several anti-complement drugs are currently in clinical trials.
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Affiliation(s)
- Amanda K. Heiderscheit
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of MedicineUniversity of IowaIowa CityIowaUSA,Graduate PhD Program in Immunology, Carver College of MedicineUniversity of IowaIowa CityIowaUSA
| | - Jill J. Hauer
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of MedicineUniversity of IowaIowa CityIowaUSA
| | - Richard J. H. Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of MedicineUniversity of IowaIowa CityIowaUSA,Graduate PhD Program in Immunology, Carver College of MedicineUniversity of IowaIowa CityIowaUSA
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Bomback AS, Kavanagh D, Vivarelli M, Meier M, Wang Y, Webb NJ, Trapani AJ, Smith RJ. Alternative Complement Pathway Inhibition With Iptacopan for the Treatment of C3 Glomerulopathy-Study Design of the APPEAR-C3G Trial. Kidney Int Rep 2022; 7:2150-2159. [PMID: 36217526 PMCID: PMC9546729 DOI: 10.1016/j.ekir.2022.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/15/2022] [Accepted: 07/04/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Complement 3 glomerulopathy (C3G) is a rare kidney disease characterized by dysregulation of the alternative pathway (AP) of the complement system. About 50% of patients with C3G progress to kidney failure within 10 years of diagnosis. Currently, there are no approved therapeutic agents for C3G. Iptacopan is an oral, first-in-class, potent, and selective inhibitor of factor B, a key component of the AP. In a Phase II study, treatment with iptacopan was associated with a reduction in proteinuria and C3 deposit scores in C3G patients with native and transplanted kidneys, respectively. Methods APPEAR-C3G (NCT04817618) is a randomized, double-blind, and placebo-controlled Phase III study to evaluate the efficacy and safety of iptacopan in C3G patients, enrolling 68 adults with biopsy-confirmed C3G, reduced C3 (<77 mg/dl), proteinuria ≥1.0 g/g, and estimated glomerular filtration rate (eGFR) ≥30 ml/min per 1.73 m2. All patients will receive maximally tolerated angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and vaccination against encapsulated bacteria. Patients with any organ transplantation, progressive crescentic glomerulonephritis (GN), monoclonal gammopathy of undetermined significance, or kidney biopsy with >50% interstitial fibrosis/tubular atrophy, will be excluded. Patients will be randomized 1:1 to receive either iptacopan 200 mg twice daily or placebo for 6 months, followed by open-label treatment with iptacopan 200 mg twice daily for all patients for 6 months. The primary objective is to evaluate the efficacy of iptacopan versus placebo on proteinuria reduction urine protein:creatinine ratio (UPCR) (24 h urine). Key secondary endpoints will assess kidney function measured by eGFR, histological disease total activity score, and fatigue. Conclusion This study aims to demonstrate the clinical benefits of AP inhibition with iptacopan in C3G.
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Lomax-Browne HJ, Medjeral-Thomas NR, Barbour SJ, Gisby J, Han H, Bomback AS, Fervenza FC, Cairns TH, Szydlo R, Tan SJ, Marks SD, Waters AM, Appel GB, D'Agati VD, Sethi S, Nast CC, Bajema I, Alpers CE, Fogo AB, Licht C, Fakhouri F, Cattran DC, Peters JE, Cook HT, Pickering MC. Association of Histologic Parameters with Outcome in C3 Glomerulopathy and Idiopathic Immunoglobulin-Associated Membranoproliferative Glomerulonephritis. Clin J Am Soc Nephrol 2022; 17:994-1007. [PMID: 35777834 PMCID: PMC9269630 DOI: 10.2215/cjn.16801221] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 05/16/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES C3 glomerulopathy and idiopathic Ig-associated membranoproliferative GN are kidney diseases characterized by abnormal glomerular complement C3 deposition. These conditions are heterogeneous in outcome, but approximately 50% of patients develop kidney failure within 10 years. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS To improve identification of patients with poor prognosis, we performed a detailed analysis of percutaneous kidney biopsies in a large cohort of patients. Using a validated histologic scoring system, we analyzed 156 native diagnostic kidney biopsies from a retrospective cohort of 123 patients with C3 glomerulopathy and 33 patients with Ig-associated membranoproliferative GN. We used linear regression, survival analysis, and Cox proportional hazards models to assess the relationship between histologic and clinical parameters with outcome. RESULTS Frequent biopsy features were mesangial expansion and hypercellularity, glomerular basement membrane double contours, and endocapillary hypercellularity. Multivariable analysis showed negative associations between eGFR and crescents, interstitial inflammation, and interstitial fibrosis/tubular atrophy. Proteinuria positively associated with endocapillary hypercellularity and glomerular basement membrane double contours. Analysis of second native biopsies did not demonstrate associations between immunosuppression treatment and improvement in histology. Using a composite outcome, risk of progression to kidney failure associated with eGFR and proteinuria at the time of biopsy, cellular/fibrocellular crescents, segmental sclerosis, and interstitial fibrosis/tubular atrophy scores. CONCLUSIONS Our detailed assessment of kidney biopsy data indicated that cellular/fibrocellular crescents and interstitial fibrosis/tubular atrophy scores were significant determinants of deterioration in kidney function.
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Affiliation(s)
- Hannah J Lomax-Browne
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Nicholas R Medjeral-Thomas
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jack Gisby
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Heedeok Han
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York
| | - Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York
| | | | - Thomas H Cairns
- West London Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Richard Szydlo
- Department for Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.,National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Aoife M Waters
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Gerald B Appel
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Cynthia C Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Charles E Alpers
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Daniel C Cattran
- Toronto General Research Institute, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - James E Peters
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - H Terence Cook
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Matthew C Pickering
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
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47
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Caravaca-Fontán F, Praga M. Prognostication for C3 Glomerulopathy and Idiopathic Immunoglobulin-Associated Membranoproliferative Glomerulonephritis. Clin J Am Soc Nephrol 2022; 17:945-948. [PMID: 35777835 PMCID: PMC9269626 DOI: 10.2215/cjn.05490522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
| | - Manuel Praga
- Nephrology, Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain .,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Schmidt T, Afonso S, Perie L, Heidenreich K, Wulf S, Krebs CF, Zipfel PF, Wiech T. An Interdisciplinary Diagnostic Approach to Guide Therapy in C3 Glomerulopathy. Front Immunol 2022; 13:826513. [PMID: 35693785 PMCID: PMC9186056 DOI: 10.3389/fimmu.2022.826513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Since the re-classification of membranoproliferative glomerulonephritis the new disease entity C3 glomerulopathy is diagnosed if C3 deposition is clearly dominant over immunoglobulins in immunohistochemistry or immunofluorescence. Although this new definition is more orientated at the pathophysiology as mediated by activity of the alternative complement pathway C3 glomerulopathy remains a heterogenous group of disorders. Genetic or autoimmune causes are associated in several but not in all patients with this disease. However, prognosis is poorly predictable, and clinicians cannot directly identify patients that might benefit from therapy. Moreover, therapy may range from supportive care alone, unspecific immune suppression, plasma treatment, or plasma exchange to complement inhibition. The current biopsy based diagnostic approaches sometimes combined with complement profiling are not sufficient to guide clinicians neither (i) whether to treat an individual patient, nor (ii) to choose the best therapy. With this perspective, we propose an interdisciplinary diagnostic approach, including detailed analysis of the kidney biopsy for morphological alterations and immunohistochemical staining, for genetic analyses of complement genes, complement activation patterning in plasma, and furthermore for applying novel approaches for convertase typing and complement profiling directly in renal tissue. Such a combined diagnostic approach was used here for a 42-year-old female patient with a novel mutation in the Factor H gene, C3 glomerulopathy and signs of chronic endothelial damage. We present here an approach that might in future help to guide therapy of renal diseases with relevant complement activation, especially since diverse new anti-complement agents are under clinical investigation.
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Affiliation(s)
- Tilman Schmidt
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sara Afonso
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Jena, Germany
| | - Luce Perie
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Jena, Germany
| | | | - Sonia Wulf
- Nephropathology Section, Institute of Pathology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Christian F Krebs
- Division of Translational Immunology, III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter F Zipfel
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Jena, Germany.,Institute of Microbiology, Friedrich Schiller University, Jena, Germany
| | - Thorsten Wiech
- Nephropathology Section, Institute of Pathology, University Hospital Hamburg Eppendorf, Hamburg, Germany
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Sullivan KE. The yin and the yang of early classical pathway complement disorders. Clin Exp Immunol 2022; 209:151-160. [PMID: 35648651 DOI: 10.1093/cei/uxac056] [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: 03/30/2022] [Revised: 05/13/2022] [Accepted: 05/31/2022] [Indexed: 11/12/2022] Open
Abstract
The classical pathway of the complement cascade has been recognized as a key activation arm, partnering with the lectin activation arm and the alternative pathway to cleave C3 and initiate the assembly of the terminal components. While deficiencies of classical pathway components have been recognized since 1966, only recently have gain-of-function variants been described for some of these proteins. Loss-of-function variants in C1, C4, and C2 are most often associated with lupus and systemic infections with encapsulated bacteria. C3 deficiency varies slightly from this phenotypic class with membranoproliferative glomerulonephritis and infection as the dominant phenotypes. The gain-of- function variants recently described for C1r and C1s lead to periodontal Ehlers Danlos syndrome, a surprisingly structural phenotype. Gain-of-function in C3 and C2 are associated with endothelial manifestations including hemolytic uremic syndrome and vasculitis with C2 gain-of-function variants thus far having been reported in patients with a C3 glomerulopathy. This review will discuss the loss-of-function and gain-of-function phenotypes and place them within the larger context of complement deficiencies.
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Affiliation(s)
- Kathleen E Sullivan
- Division of Allergy Immunology, The Children's Hospital of Philadelphia, 3615 Civic Center Blvd, Philadelphia, PA 19104, USA
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Zhang Y, Goodfellow RX, Ghiringhelli Borsa N, Dunlop HC, Presti SA, Meyer NC, Shao D, Roberts SM, Jones MB, Pitcher GR, Taylor AO, Nester CM, Smith RJH. Complement Factor I Variants in Complement-Mediated Renal Diseases. Front Immunol 2022; 13:866330. [PMID: 35619721 PMCID: PMC9127439 DOI: 10.3389/fimmu.2022.866330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/08/2022] [Indexed: 11/26/2022] Open
Abstract
C3 glomerulopathy (C3G) and atypical hemolytic uremic syndrome (aHUS) are two rare diseases caused by dysregulated activity of the alternative pathway of complement secondary to the presence of genetic and/or acquired factors. Complement factor I (FI) is a serine protease that downregulates complement activity in the fluid phase and/or on cell surfaces in conjunction with one of its cofactors, factor H (FH), complement receptor 1 (CR1/CD35), C4 binding protein (C4BP) or membrane cofactor protein (MCP/CD46). Because altered FI activity is causally related to the pathogenesis of C3G and aHUS, we sought to test functional activity of select CFI missense variants in these two patient cohorts. We identified 65 patients (16, C3G; 48, aHUS; 1 with both) with at least one rare variant in CFI (defined as a MAF < 0.1%). Eight C3G and eleven aHUS patients also carried rare variants in either another complement gene, ADAMTS13 or THBD. We performed comprehensive complement analyses including biomarker profiling, pathway activity and autoantibody testing, and developed a novel FI functional assay, which we completed on 40 patients. Seventy-eight percent of rare CFI variants (31/40) were associated with FI protein levels below the 25th percentile; in 22 cases, FI levels were below the lower limit of normal (type 1 variants). Of the remaining nine variants, which associated with normal FI levels, two variants reduced FI activity (type 2 variants). No patients carried currently known autoantibodies (including FH autoantibodies and nephritic factors). We noted that while rare variants in CFI predispose to complement-mediated diseases, phenotypes are strongly contingent on the associated genetic background. As a general rule, in isolation, a rare CFI variant most frequently leads to aHUS, with the co-inheritance of a CD46 loss-of-function variant driving the onset of aHUS to the younger age group. In comparison, co-inheritance of a gain-of-function variant in C3 alters the phenotype to C3G. Defects in CFH (variants or fusion genes) are seen with both C3G and aHUS. This variability underscores the complexity and multifactorial nature of these two complement-mediated renal diseases.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Richard J. H. Smith
- Molecular Otolaryngology and Renal Research Laboratories, University of Iowa, Iowa City, IA, United States
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