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Freedman BI, Kistler AL, Skewes-Cox P, Ganem D, Spainhour M, Turner J, Divers J, Langefeld CD, Murea M, Hicks PJ, Hemal AK, Snipes JA, Zhao L, Abend JR, Lyles DS, Ma L, Skorecki KL. JC polyoma viruria associates with protection from chronic kidney disease independently from apolipoprotein L1 genotype in African Americans. Nephrol Dial Transplant 2019; 33:1960-1967. [PMID: 29420808 DOI: 10.1093/ndt/gfx368] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 12/14/2017] [Indexed: 12/18/2022] Open
Abstract
Background Viral infections can trigger chronic kidney disease (CKD) and the urine virome may inform risk. The Natural History of APOL1-Associated Nephropathy Study (NHAANS) reported that urine JC polyomavirus (JCPyV) associated with a lower risk of APOL1-associated nephropathy in African Americans. Herein, association was assessed between urine JCPyV with CKD in African Americans independent from the APOL1 genotype. Methods Quantitative polymerase chain reaction was performed for urinary detection of JCPyV and BK polyoma virus (BKPyV) in 200 newly recruited nondiabetic African Americans. A combined analysis was performed in these individuals plus 300 NHAANS participants. Results In the 200 new participants, urine JCPyV was present in 8.8% of CKD cases and 45.8% of nonnephropathy controls (P = 3.0 × 10-8). In those with APOL1 renal-risk genotypes, JCPyV was detected in 5.1% of cases and 40.0% of controls (P = 0.0002). In those lacking APOL1 renal-risk genotypes, JCPyV was detected in 12.2% of cases and 48.8% of controls (P = 8.5 × 10-5). BKPyV was detected in 1.3% of cases and 0.8% of controls (P = 0.77). In a combined analysis with 300 NHAANS participants (n = 500), individuals with urine JCPyV had a 63% lower risk of CKD compared with those without urine JCPyV (odds ratio 0.37; P = 4.6 × 10-6). RNA fluorescence in situ hybridization confirmed the presence of JCPyV genomic DNA and JCPyV messenger RNA (mRNA) in nondiseased kidney. Conclusions Inverse relationships exist between JCPyV viruria and non-diabetic CKD. Future studies should determine whether renal inflammation associated with CKD is less permissive for JCPyV reactivation/replication or whether JCPyV is a marker of reduced host immune responsiveness that diminishes immune pathologic contributions to CKD.
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Affiliation(s)
- Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Amy L Kistler
- Infectious Diseases Area, Novartis Institutes for Biomedical Research, Emeryville, CA, USA
| | - Peter Skewes-Cox
- Infectious Diseases Area, Novartis Institutes for Biomedical Research, Emeryville, CA, USA
| | - Don Ganem
- Infectious Diseases Area, Novartis Institutes for Biomedical Research, Emeryville, CA, USA
| | - Mitzie Spainhour
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Jolyn Turner
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Jasmin Divers
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Carl D Langefeld
- Department of Biostatistical Sciences, Division of Public Health Sciences, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Mariana Murea
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Pamela J Hicks
- Department of Biochemistry, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - James A Snipes
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Lihong Zhao
- Infectious Diseases Area, Novartis Institutes for Biomedical Research, Emeryville, CA, USA
| | - Johanna R Abend
- Infectious Diseases Area, Novartis Institutes for Biomedical Research, Emeryville, CA, USA
| | - Douglas S Lyles
- Department of Biochemistry, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Karl L Skorecki
- Department of Genetics and Developmental Biology, Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology and Department of Nephrology, Rambam Health Care Campus, Haifa, Israel
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Kruzel-Davila E, Divers J, Russell GB, Kra-Oz Z, Cohen MS, Langefeld CD, Ma L, Lyles DS, Hicks PJ, Skorecki KL, Freedman BI. JC Viruria Is Associated With Reduced Risk of Diabetic Kidney Disease. J Clin Endocrinol Metab 2019; 104:2286-2294. [PMID: 30715336 PMCID: PMC6489692 DOI: 10.1210/jc.2018-02482] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 01/25/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE African Americans who shed JC polyomavirus (JCV) in their urine have reduced rates of nondiabetic chronic kidney disease (CKD). We assessed the associations between urinary JCV and urine BK polyomavirus (BKV) with CKD in African Americans with diabetes mellitus. METHODS African Americans with diabetic kidney disease (DKD) and controls lacking nephropathy from the Family Investigation of Nephropathy and Diabetes Consortium (FIND) and African American-Diabetes Heart Study (AA-DHS) had urine tested for JCV and BKV using quantitative PCR. Of the 335 individuals tested, 148 had DKD and 187 were controls. RESULTS JCV viruria was detected more often in the controls than in the patients with DKD (FIND: 46.6% vs 32.2%; OR, 0.52; 95% CI, 0.29 to 0.93; P = 0.03; AA-DHS: 30.4% vs 26.2%; OR, 0.63; 95% CI, 0.27 to 1.48; P = 0.29). A joint analysis adjusted for age, sex, and study revealed that JC viruria was inversely associated with DKD (OR, 0.56; 95% CI, 0.35 to 0.91; P = 0.02). Statistically significant relationships between BKV and DKD were not observed. MAIN CONCLUSIONS The results from the present study extend the inverse association between urine JCV and nondiabetic nephropathy in African Americans to DKD. These results imply that common pathways likely involving the innate immune system mediate coincident chronic kidney injury and restriction of JCV replication. Future studies are needed to explore causative pathways and characterize whether the absence of JC viruria can serve as a biomarker for DKD in the African American population.
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Affiliation(s)
- Etty Kruzel-Davila
- Department of Nephrology, Rambam Health Care Campus and Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology, Haifa, Israel
| | - Jasmin Divers
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Gregory B Russell
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Zipi Kra-Oz
- Virology Laboratory, Rambam Health Care Campus, Haifa, Israel
| | | | - Carl D Langefeld
- Division of Public Health Sciences, Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Douglas S Lyles
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Pamela J Hicks
- Department of Biochemistry, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Karl L Skorecki
- Department of Nephrology, Rambam Health Care Campus and Rappaport Faculty of Medicine and Research Institute, Technion-Israel Institute of Technology, Haifa, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Tzefat, Israel
- Correspondence and Reprint Requests: Karl. L. Skorecki, MD, Azrieli Faculty of Medicine, Bar-Ilan University, Henrietta Szold, 8, PO Box 1589, Galilee 1311502, Israel. E-mail: ; or Barry I. Freedman, MD, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1053. E-mail:
| | - Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Correspondence and Reprint Requests: Karl. L. Skorecki, MD, Azrieli Faculty of Medicine, Bar-Ilan University, Henrietta Szold, 8, PO Box 1589, Galilee 1311502, Israel. E-mail: ; or Barry I. Freedman, MD, Section on Nephrology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1053. E-mail:
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Besse W, Mansour S, Jatwani K, Nast CC, Brewster UC. Collapsing glomerulopathy in a young woman with APOL1 risk alleles following acute parvovirus B19 infection: a case report investigation. BMC Nephrol 2016; 17:125. [PMID: 27600725 PMCID: PMC5013576 DOI: 10.1186/s12882-016-0330-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 08/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Collapsing Glomerulopathy (CG), also known as the collapsing variant of Focal Segmental Glomerulosclerosis (FSGS), is distinct in both its clinical severity and its pathophysiologic characteristics from other forms of FSGS. This lesion occurs disproportionally in patients carrying two APOL1 risk alleles, and is the classic histologic lesion resulting from Human Immunodeficiency Virus (HIV) infection of podocytes. Other viral infections, including parvovirus B19, and drugs such as interferon that perturb the immune system, have also been associated with CG. Despite significant advances, explaining such genetic and immune/infectious associations with causative mechanisms and supporting evidence has proven challenging. CASE PRESENTATION We report the case of a healthy (HIV-negative) pregnant 36 year-old Caribbean-American woman who presented with nephrotic syndrome and fetal demise in the setting of acute parvovirus B19 infection. A series of three renal biopsies and rapid clinical course showed progression from significant podocyte injury with mild light microscopy findings to classic viral-associated CG to ESRD in less than 3 months. Genetic analysis revealed two APOL1 G1 risk alleles. CONCLUSIONS This is the first published case report of CG in the setting of acute parvovirus infection in a patient with two APOL1 risk allelles, and parvoviral proteins identified in renal epithelium on kidney biopsy. These findings support the causative role of parvovirus B19 infection in the development of CG on the background of APOL1 genetic risk.
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Affiliation(s)
- Whitney Besse
- Section of Nephrology, Yale University, 330 Cedar Street, BB 121, New Haven, CT 06520-8029, USA
| | - Sherry Mansour
- Section of Nephrology, Yale University, 330 Cedar Street, BB 121, New Haven, CT 06520-8029, USA
| | - Karan Jatwani
- Government Medical College & Hospital Chandigarh Sector, Chandigarh, India
| | - Cynthia C Nast
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Ursula C Brewster
- Section of Nephrology, Yale University, 330 Cedar Street, BB 121, New Haven, CT 06520-8029, USA.
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Freedman BI, Julian BA, Pastan SO, Israni AK, Schladt D, Gautreaux MD, Hauptfeld V, Bray RA, Gebel HM, Kirk AD, Gaston RS, Rogers J, Farney AC, Orlando G, Stratta RJ, Mohan S, Ma L, Langefeld CD, Hicks PJ, Palmer ND, Adams PL, Palanisamy A, Reeves-Daniel AM, Divers J. Apolipoprotein L1 gene variants in deceased organ donors are associated with renal allograft failure. Am J Transplant 2015; 15:1615-22. [PMID: 25809272 PMCID: PMC4784684 DOI: 10.1111/ajt.13223] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 11/05/2014] [Accepted: 11/22/2014] [Indexed: 01/25/2023]
Abstract
Apolipoprotein L1 gene (APOL1) nephropathy variants in African American deceased kidney donors were associated with shorter renal allograft survival in a prior single-center report. APOL1 G1 and G2 variants were genotyped in newly accrued DNA samples from African American deceased donors of kidneys recovered and/or transplanted in Alabama and North Carolina. APOL1 genotypes and allograft outcomes in subsequent transplants from 55 U.S. centers were linked, adjusting for age, sex and race/ethnicity of recipients, HLA match, cold ischemia time, panel reactive antibody levels, and donor type. For 221 transplantations from kidneys recovered in Alabama, there was a statistical trend toward shorter allograft survival in recipients of two-APOL1-nephropathy-variant kidneys (hazard ratio [HR] 2.71; p = 0.06). For all 675 kidneys transplanted from donors at both centers, APOL1 genotype (HR 2.26; p = 0.001) and African American recipient race/ethnicity (HR 1.60; p = 0.03) were associated with allograft failure. Kidneys from African American deceased donors with two APOL1 nephropathy variants reproducibly associate with higher risk for allograft failure after transplantation. These findings warrant consideration of rapidly genotyping deceased African American kidney donors for APOL1 risk variants at organ recovery and incorporation of results into allocation and informed-consent processes.
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Affiliation(s)
- Barry I. Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC,Center for Human Genomics & Personalized Medicine Research, Wake Forest School of Medicine; Winston-Salem, NC
| | - Bruce A. Julian
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham School of Medicine; Birmingham, AL
| | - Stephen O. Pastan
- Department of Medicine, Renal Division, Emory University School of Medicine; Atlanta, GA
| | - Ajay K. Israni
- Department of Medicine, Division of Nephrology, Hennepin County Medical Center, University of Minnesota; Minneapolis, MN,Minneapolis Medical Research Foundation; Minneapolis, MN
| | - David Schladt
- Minneapolis Medical Research Foundation; Minneapolis, MN
| | - Michael D. Gautreaux
- General Surgery & HLA Immunogenetics Lab, Wake Forest School of Medicine; Winston-Salem, NC
| | - Vera Hauptfeld
- Alabama Regional Histocompatibility Laboratory at UAB, University of Alabama at Birmingham School of Medicine; Birmingham, AL
| | - Robert A. Bray
- Department of Pathology & Lab Medicine; Emory School of Medicine; Atlanta, GA
| | - Howard M. Gebel
- Department of Pathology & Lab Medicine; Emory School of Medicine; Atlanta, GA
| | - Allan D. Kirk
- Department of General Surgery, Duke University School of Medicine; Durham, NC
| | - Robert S. Gaston
- Department of Medicine, Division of Nephrology, University of Alabama at Birmingham School of Medicine; Birmingham, AL
| | - Jeffrey Rogers
- Department of General Surgery, Wake Forest School of Medicine; Winston-Salem, NC
| | - Alan C. Farney
- Department of General Surgery, Wake Forest School of Medicine; Winston-Salem, NC
| | - Giuseppe Orlando
- Department of General Surgery, Wake Forest School of Medicine; Winston-Salem, NC
| | - Robert J. Stratta
- Department of General Surgery, Wake Forest School of Medicine; Winston-Salem, NC
| | - Sumit Mohan
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
| | - Lijun Ma
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Carl D. Langefeld
- Division of Public Health Sciences, Wake Forest School of Medicine; Winston-Salem, NC
| | - Pamela J. Hicks
- Center for Human Genomics & Personalized Medicine Research, Wake Forest School of Medicine; Winston-Salem, NC
| | - Nicholette D. Palmer
- Center for Human Genomics & Personalized Medicine Research, Wake Forest School of Medicine; Winston-Salem, NC
| | - Patricia L. Adams
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Amudha Palanisamy
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Amber M. Reeves-Daniel
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine; Winston-Salem, NC
| | - Jasmin Divers
- Division of Public Health Sciences, Wake Forest School of Medicine; Winston-Salem, NC
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5
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Affiliation(s)
- Ana P Rossi
- Section of Transplant Nephrology, Washington University School of Medicine in St Louis, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - Kelsey L Anderson
- Section of Transplant Nephrology, Washington University School of Medicine in St Louis, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - Daniel C Brennan
- Section of Transplant Nephrology, Washington University School of Medicine in St Louis, Barnes-Jewish Hospital, St Louis, Missouri, USA
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6
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Palmer ND, Ng MCY, Langefeld CD, Divers J, Lea JP, Okusa MD, Kimberly RP, Bowden DW, Freedman BI. Lack of Association of the APOL1 G3 Haplotype in African Americans with ESRD. J Am Soc Nephrol 2014; 26:1021-5. [PMID: 25249559 DOI: 10.1681/asn.2014050444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 08/05/2014] [Indexed: 01/13/2023] Open
Abstract
Apolipoprotein L1 gene (APOL1) G1 and G2 variants are strongly associated with progressive nondiabetic nephropathy in populations with recent African ancestry. Selection for these variants occurred as a result of protection from human African trypanosomiasis (HAT). Resequencing of this region in 10 genetically and geographically distinct African populations residing in HAT endemic regions identified eight single nucleotide polymorphisms (SNPs) in strong linkage disequilibrium and comprising a novel G3 haplotype. To determine whether the APOL1 G3 haplotype was associated with nephropathy, G1, G2, and G3 SNPs and 70 ancestry informative markers spanning the genome were genotyped in 937 African Americans with nondiabetic ESRD, 965 African Americans with type 2 diabetes-associated ESRD, and 1029 non-nephropathy controls. In analyses adjusting for age, sex, APOL1 G1/G2 risk (recessive), and global African ancestry, the G3 haplotype was not significantly associated with ESRD (P=0.05 for nondiabetic ESRD, P=0.57 for diabetes-associated ESRD, and P=0.27 for all-cause ESRD). We conclude that variation in APOL1 G3 makes a nominal, if any, contribution to ESRD in African Americans; G1 and G2 variants explain the vast majority of nondiabetic nephropathy susceptibility.
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Affiliation(s)
- Nicholette D Palmer
- Departments of Biochemistry, Centers for Genomics and Personalized Medicine Research and Public Health Genomics, and
| | - Maggie C Y Ng
- Centers for Genomics and Personalized Medicine Research and Public Health Genomics, and
| | | | - Jasmin Divers
- Public Health Genomics, and Biostatistical Sciences, and
| | - Janice P Lea
- Division of Renal Medicine, Department of Medicine, Emory School of Medicine, Atlanta, Georgia
| | - Mark D Okusa
- Division of Nephrology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia; and
| | - Robert P Kimberly
- Division of Clinical Immunology and Rheumatology, University of Alabama, Birmingham, Alabama
| | - Donald W Bowden
- Departments of Biochemistry, Centers for Genomics and Personalized Medicine Research and
| | - Barry I Freedman
- Centers for Genomics and Personalized Medicine Research and Public Health Genomics, and Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina; Internal Medicine,
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Halimi JM. [Hypertension, chronic kidney disease and genetics in patients with African ancestry]. Ann Cardiol Angeiol (Paris) 2014; 63:189-91. [PMID: 24952678 DOI: 10.1016/j.ancard.2014.05.010] [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: 05/03/2014] [Accepted: 05/16/2014] [Indexed: 10/25/2022]
Abstract
The incidence and prevalence of hypertension is markedly elevated in Afro-American populations vs Caucasians. The development of end-stage renal disease is also more frequent in Afro-American subjects, independently of blood pressure control. As compared to Caucasians, Afro-American subjects have a higher risk of end-stage renal disease when they are infected with HIV or have lupus. For decades, these data remained mysterious. Within the last 3 years, results from studies in the field of genetics and infectious diseases have transformed our view on this problem. The aim of this paper is to explain how these results have changed our understanding of hypertension and its consequences in Afro-American subjects.
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Affiliation(s)
- J-M Halimi
- Service de néphrologie-immunologie clinique, hôpital Bretonneau, EA 4245, université François-Rabelais, 2, boulevard Tonnellé, 37000 Tours, France.
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Freedman BI, Skorecki K. Gene-gene and gene-environment interactions in apolipoprotein L1 gene-associated nephropathy. Clin J Am Soc Nephrol 2014; 9:2006-13. [PMID: 24903390 DOI: 10.2215/cjn.01330214] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Molecular genetics have revolutionized the understanding of susceptibility to the broad spectrum of kidney diseases with light microscopic appearance of FSGS, particularly in populations with recent African ancestry. These disorders include idiopathic FSGS, HIV-associated nephropathy, severe lupus nephritis, sickle cell nephropathy, and the primary kidney disorder focal global glomerulosclerosis, which had historically been ascribed to systemic hypertension. FSGS was once thought to include a multitude of unrelated disorders with similar histologic appearance. However, variation in the apolipoprotein L1 gene locus is now known to account for the vast majority of such cases in African Americans as well as nearly all the excess risk for FSGS and related forms of progressive nondiabetic nephropathy in populations with recent African ancestry, relative to European ancestry. Inheriting two coding apolipoprotein L1 gene nephropathy risk variants is necessary for susceptibility to CKD; however, these variants alone are insufficient to produce disease. This work reviews the evidence supporting second hits or modifying factors that affect risk for apolipoprotein L1 gene-associated nephropathy and produce the protean manifestations of this common and complex syndrome. Targeting modifiable second factors will lead to preventive therapies for slowing progression of nondiabetic nephropathy in many patients possessing two apolipoprotein L1 gene risk variants. This model of genetic risk coupled with modifiable second hits will serve as a paradigm applicable to patients with CKD of various etiologies as well as a host of other complex disorders.
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Affiliation(s)
- Barry I Freedman
- Department of Internal Medicine, Section on Nephrology, Wake Forest School of Medicine, Winston-Salem, North Carolina; and
| | - Karl Skorecki
- Molecular Medicine Laboratory, Rambam Healthcare Campus, Haifa, Israel
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