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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; 106:369-391. [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] [MESH Headings] [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 University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, Nantes, France; INSERM UMR S1064, Nantes, France
| | - Daniel P Gale
- Centre for Kidney and Bladder Health, University College London, UK
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and ORL, Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, 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
- Clinical Research Center for Rare Diseases Aldo e Cele Daccò, 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
- Division of Nephrology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, 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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2
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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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3
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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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Wooden B, Nester CM, Bomback AS. Update on C3 Glomerulopathy. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:223-233. [PMID: 39004462 DOI: 10.1053/j.akdh.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 07/16/2024]
Abstract
C3 glomerulopathy (C3G) is a rare disorder marked by deposition of C3 in the glomerulus, resulting in damage to the glomerular filtration unit and presenting with features of the nephritic and nephrotic syndromes. Fundamentally, C3G is caused by dysregulation of the alternative pathway of the complement cascade, either due to genetic variants or acquired humoral factors. Despite significant advances in recent years in the understanding of the underlying mechanisms and culprit lesions that result in the development of C3G, treatment options remain severely limited, and the prognosis is often poor. Fortunately, a number of anticomplement therapies are emerging from the drug development pipeline, with several in late-stage testing in patients with C3G, and there is hope that we will soon have more targeted options for managing patients with this devastating disease. In this review, we provide an overview of C3G, as well as summarizing the evidence for current treatments and detailing the clinical trials that are currently underway.
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Affiliation(s)
- Benjamin Wooden
- Division of Nephrology, Department of Medicine, Columbia University, New York, NY.
| | - Carla M Nester
- Division of Nephrology, Department of Medicine, University of Iowa, Iowa City, IA
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University, New York, NY
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5
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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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6
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Noris M, Remuzzi G. C3G and Ig-MPGN-treatment standard. Nephrol Dial Transplant 2024; 39:202-214. [PMID: 37604793 PMCID: PMC10828209 DOI: 10.1093/ndt/gfad182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 08/23/2023] Open
Abstract
Among the broad spectrum of membranoproliferative glomerulonephritis (MPGN), immunofluorescence distinguishes C3 glomerulopathy (C3G), with predominant C3 deposits, and immunoglobulin-associated MPGN (Ig-MPGN), with combined C3 and Ig. However, there are several intersections between C3G and Ig-MPGN. Primary C3G and Ig-MPGN share the same prevalence of low serum C3 levels and of abnormalities of the alternative pathway of complement, and patients who present a bioptic pattern of Ig-MPGN at onset may show a C3G pattern in a subsequent biopsy. There is no specific therapy for primary C3G and Ig-MPGN and prognosis is unfavourable. The only recommended indications are inhibitors of the renin-angiotensin system, lipid-lowering agents and other renoprotective agents. The other drugs used currently, such as corticosteroids and mycophenolate mofetil, are often ineffective. The anti-C5 monoclonal antibody eculizumab has been tested in several patients, with mixed results. One reason for the uncertainty is the extremely variable clinical course, most likely reflecting a heterogeneous pathogenesis. An unsupervised clustering analysis that included histologic, biochemical, genetic and clinical data available at onset in patients with primary C3G and Ig-MPGN identified four clusters characterized by specific pathogenic mechanisms. This approach may facilitate accurate diagnosis and development of targeted therapies. Several trials are ongoing with drugs targeting different molecules of the complement cascade, however it is important to consider which component of the cascade may be the most appropriate for each patient. We review the current standards of treatment and discuss novel developments in the pathophysiology, diagnosis, outcome prediction and management of C3G and Ig-MPGN.
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Affiliation(s)
- Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò Ranica, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Clinical Research Center for Rare Diseases Aldo e Cele Daccò Ranica, Bergamo, Italy
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7
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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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B N, Cj NA, Mk AM, I MI. A typical clinical manifestation of atypical underlying diagnosis: Answers. Pediatr Nephrol 2023; 38:3615-3617. [PMID: 37160459 DOI: 10.1007/s00467-023-05967-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 05/11/2023]
Affiliation(s)
- Nuzaimah B
- Department of Pediatrics, School of Medical Sciences, Universiti Sains Malaysia, Kampus Kesihatan, 16150, Kota Bharu, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia (HUSM), Health Campus, Kubang Kerian, 16150, Kota Bharu, Kelantan, Malaysia
| | - Nur Asyilla Cj
- Hospital Universiti Sains Malaysia (HUSM), Health Campus, Kubang Kerian, 16150, Kota Bharu, Kelantan, Malaysia
- Department of Pathology, School of Medical Sciences, Universiti Sains Malaysia, 16150, Kota Bharu, Kelantan, Malaysia
| | - Anis Munirah Mk
- Department of Pediatrics, School of Medical Sciences, Universiti Sains Malaysia, Kampus Kesihatan, 16150, Kota Bharu, Kelantan, Malaysia
- Hospital Universiti Sains Malaysia (HUSM), Health Campus, Kubang Kerian, 16150, Kota Bharu, Kelantan, Malaysia
| | - Mohamad Ikram I
- Department of Pediatrics, School of Medical Sciences, Universiti Sains Malaysia, Kampus Kesihatan, 16150, Kota Bharu, Kelantan, Malaysia.
- Hospital Universiti Sains Malaysia (HUSM), Health Campus, Kubang Kerian, 16150, Kota Bharu, Kelantan, Malaysia.
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9
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Golshayan D, Schwotzer N, Fakhouri F, Zuber J. Targeting the Complement Pathway in Kidney Transplantation. J Am Soc Nephrol 2023; 34:1776-1792. [PMID: 37439664 PMCID: PMC10631604 DOI: 10.1681/asn.0000000000000192] [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: 02/14/2023] [Accepted: 07/02/2023] [Indexed: 07/14/2023] Open
Abstract
The complement system is paramount in the clearance of pathogens and cell debris, yet is increasingly recognized as a key component in several pathways leading to allograft injury. There is thus a growing interest in new biomarkers to assess complement activation and guide tailored therapies after kidney transplantation (KTx). C5 blockade has revolutionized post-transplant management of atypical hemolytic uremic syndrome, a paradigm of complement-driven disease. Similarly, new drugs targeting the complement amplification loop hold much promise in the treatment and prevention of recurrence of C3 glomerulopathy. Although unduly activation of the complement pathway has been described after brain death and ischemia reperfusion, any clinical attempts to mitigate the ensuing renal insults have so far provided mixed results. However, the intervention timing, strategy, and type of complement blocker need to be optimized in these settings. Furthermore, the fast-moving field of ex vivo organ perfusion technology opens new avenues to deliver complement-targeted drugs to kidney allografts with limited iatrogenic risks. Complement plays also a key role in the pathogenesis of donor-specific ABO- and HLA-targeted alloantibodies. However, C5 blockade failed overall to improve outcomes in highly sensitized patients and prevent the progression to chronic antibody-mediated rejection (ABMR). Similarly, well-conducted studies with C1 inhibitors in sensitized recipients yielded disappointing results so far, in part, because of subtherapeutic dosage used in clinical studies. The emergence of new complement blockers raises hope to significantly reduce the negative effect of ischemia reperfusion, ABMR, and nephropathy recurrence on outcomes after KTx.
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Affiliation(s)
- Dela Golshayan
- Transplantation Center, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nora Schwotzer
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Julien Zuber
- Service de Transplantation rénale adulte, Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
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Rudnicki M, Windpessl M, Eller K, Odler B, Gauckler P, Neumann I, Zitt E, Regele H, Kronbichler A, Lhotta K, Säemann MD. [Diagnosis and treatment of glomerular diseases with a membranoproliferative glomerulonephritis (MPGN) pattern of injury]. Wien Klin Wochenschr 2023; 135:688-695. [PMID: 37728653 PMCID: PMC10511362 DOI: 10.1007/s00508-023-02264-7] [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] [Accepted: 07/24/2023] [Indexed: 09/21/2023]
Abstract
Membranoproliferative glomerulonephritis (MPGN) represents a heterogeneous group of diseases. The common feature of a membranoproliferative lesion pattern in the kidney biopsy can either be idiopathic/primary or-much more frequently-have a secondary cause. The historical classification into MPGN types I to III has largely been abandoned and replaced in recent years by a pathogenesis-oriented classification. A MPGN with C1q, C3 and/or C4 deposits on light microscopy is referred to as immune complex GN (IC-GN), while a MPGN with dominant C3 deposits is referred to as C3 glomerulopathy (C3G). C3G is further divided into C3 glomerulonephritis (C3GN) and dense deposit disease (DDD). These diagnoses can only be made by a kidney biopsy. Possible causes of MPGN are chronic infections (especially hepatitis B and C, bacterial infections, infections with protozoa), autoimmune diseases (especially lupus, rheumatoid arthritis) or malignancies (especially hematological malignancies). Particularly in the case of C3G a comprehensive analysis of the complement system components is strongly recommended. Due to the low incidence and the heterogeneous clinical appearance of MPGN therapeutic decisions must be made individually; an optimal general therapy is unknown, except that supportive treatment as with other glomerular diseases should be optimized. In the case of a secondary MPGN it is generally recommended to treat the potential cause of the MPGN. If significant proteinuria persists and eGFR remains > 30 ml/min/1.73 m2, treatment with systemic steroids and mycophenolate mofetil is recommended. Other treatment options on an individual level after evaluation and discussion of the risk-benefit ratio with the patient are rituximab and eculizumab. Rapidly progressive MPGN should be treated like ANCA-associated vasculitis. The recurrence rates after kidney transplantation are very high and treatment is challenging.
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Affiliation(s)
- Michael Rudnicki
- Department Innere Medizin 4 (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| | - Martin Windpessl
- Abteilung für Innere Medizin IV, Klinikum Wels-Grieskirchen, Wels, Österreich
- Medizinische Fakultät, JKU, Linz, Österreich
| | - Kathrin Eller
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Balazs Odler
- Klinische Abteilung für Nephrologie, Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Medizinische Universität Graz, Graz, Österreich
| | - Philipp Gauckler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Irmgard Neumann
- Vasculitis.at, Wien, Österreich
- Immunologiezentrum Zürich (IZZ), Zürich, Schweiz
| | - Emanuel Zitt
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Heinz Regele
- Klinisches Institut für Pathologie, Medizinische Universität Wien, Wien, Österreich
| | - Andreas Kronbichler
- Department Innere Medizin IV (Nephrologie und Hypertensiologie), Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Karl Lhotta
- Abteilung für Innere Medizin III (Nephrologie, Dialyse und Hypertensiologie), Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Marcus D Säemann
- 6. Medizinische Abteilung mit Nephrologie & Dialyse, Klinik Ottakring, Wien, Österreich
- Medizinische Fakultät, SFU, Wien, Österreich
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11
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Windpessl M, Odler B, Bajema IM, Geetha D, Säemann M, Lee JM, Vaglio A, Kronbichler A. Glomerular Diseases Across Lifespan: Key Differences in Diagnostic and Therapeutic Approaches. Semin Nephrol 2023; 43:151435. [PMID: 37945450 DOI: 10.1016/j.semnephrol.2023.151435] [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: 11/12/2023]
Abstract
Glomerular diseases are common causes of chronic kidney disease in childhood, adolescence, and adulthood. The epidemiology of glomerular diseases differs between different age groups, with minimal change disease being the leading cause of nephrotic syndrome in childhood, while membranous nephropathy and focal segmental glomerulosclerosis are more common in adulthood. IgA vasculitis is also more common in childhood. Moreover, there is a difference in disease severity with more children presenting with a relapsing form of nephrotic syndrome and a more acute presentation of antineutrophil cytoplasmic antibody-associated vasculitis and concomitant glomerulonephritis, as highlighted by the higher percentage of cellular crescents on kidney biopsy specimens in comparison with older patients. There is also a female preponderance in antineutrophil cytoplasmic antibody-associated vasculitis and more children present with tracheobroncholaryngeal disease. This article aims to summarize differences in the presentation of different glomerular diseases that are encountered commonly by pediatric and adult nephrologists and potential differences in the management.
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Affiliation(s)
- Martin Windpessl
- Section of Nephrology, Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria; Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Balazs Odler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ingeborg M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands; Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria; Sigmund Freud University, Medical School, Vienna, Austria
| | - Jiwon M Lee
- Division of Rare Disease Management, Korea Disease Control and Prevention Agency, Cheongju-si, Republic of Korea
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Firenze, Nephrology Unit, Meyer Children's Hospital, Firenze, Italy
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria.
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12
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Niepolski L, Czekała A, Seget-Dubaniewicz M, Frydrychowicz M, Talarska-Markiewicz P, Kowalska A, Szmelter J, Salwa-Żurawska W, Sirek T, Sobański D, Grabarek BO, Żurawski J. Diagnostic Problems in C3 Glomerulopathy. Biomedicines 2023; 11:biomedicines11041101. [PMID: 37189718 DOI: 10.3390/biomedicines11041101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 04/08/2023] Open
Abstract
Background: C3 glomerulopathies (C3GN) are a group of rare kidney diseases associated with impaired complement regulation. The effects of this disease include the accumulation of complement C3 in the kidneys. Based on the clinical data, as well as light, fluorescence, and electron microscopy results, the diagnoses were verified. The study group consisted of biopsy specimens, which were obtained from 332 patients who were diagnosed with C3 glomerulopathy. In all cases, histopathological examinations were performed; deposits of complement C3 and C1q components, as well as the immunoglobulins IgA, IgG, and IgM, were identified using immunofluorescence. Furthermore, electron microscopy was also performed. Results: The histopathological examination results presented cases of C3GN (n = 111) and dense deposit disease (DDD; n = 17). The non-classified (NC) group was the most numerous (n = 204). The lack of classification was due to the poor severity of the lesions, even on the electron microscopic examination or in the presence of intense sclerotic lesions. Conclusions: In cases of suspected C3 glomerulopathies, we believe an electron microscopy examination is necessary. This examination is beneficial in mild-to-extremely-severe cases of this glomerulopathy, where the lesions are barely discernible when using immunofluorescence microscopy.
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Affiliation(s)
- Leszek Niepolski
- Department of Physiology, Poznan University of Medical Sciences, 60-567 Poznan, Poland
| | - Anna Czekała
- Department of Clinical Pathology, Poznan University of Medical Sciences, 60-567 Poznan, Poland
| | | | | | | | - Angelika Kowalska
- Department of Immunobiology, Poznan University of Medical Sciences, 60-567 Poznan, Poland
| | - Jagoda Szmelter
- Department of Immunobiology, Poznan University of Medical Sciences, 60-567 Poznan, Poland
| | - Wiesława Salwa-Żurawska
- Department of Clinical Pathology, Poznan University of Medical Sciences, 60-567 Poznan, Poland
| | - Tomasz Sirek
- Department of Plastic Surgery, Faculty of Medicine, Academy of Silesia, 40-055 Katowice, Poland
- Department of Histology, Cytophysiology and Embryology, Faculty of Medicine, Academy of Silesia, 40-055 Katowice, Poland
| | - Dawid Sobański
- Department of Histology, Cytophysiology and Embryology, Faculty of Medicine, Academy of Silesia, 40-055 Katowice, Poland
- Department of Neurosurgery, Szpital sw. Rafala w Krakowie, 30-091 Krakow, Poland
| | - Beniamin Oskar Grabarek
- Department of Histology, Cytophysiology and Embryology, Faculty of Medicine, Academy of Silesia, 40-055 Katowice, Poland
- Department of Neurosurgery, Szpital sw. Rafala w Krakowie, 30-091 Krakow, Poland
| | - Jakub Żurawski
- Department of Immunobiology, Poznan University of Medical Sciences, 60-567 Poznan, Poland
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13
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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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14
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Welte T, Arnold F, Westermann L, Rottmann FA, Hug MJ, Neumann-Haefelin E, Ganner A. Eculizumab as a treatment for C3 glomerulopathy: a single-center retrospective study. BMC Nephrol 2023; 24:8. [PMID: 36631797 PMCID: PMC9832765 DOI: 10.1186/s12882-023-03058-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND C3 Glomerulopathy (C3G) is a rare glomerular disease caused by dysregulation of the complement pathway. Based on its pathophysiology, treatment with the monoclonal antibody eculizumab targeting complement C5 may be a therapeutic option. Due to the rarity of the disease, observational data on the clinical response to eculizumab treatment is scarce. METHODS Fourteen patients (8 female, 57%) treated for C3 glomerulopathy at the medical center of the University of Freiburg between 2013 and 2022 were included. Subjects underwent biopsy before enrollment. Histopathology, clinical data, and response to eculizumab treatment were analyzed. Key parameters to determine the primary outcome were changes of estimated glomerular filtration rate (eGFR) over time. Positive outcome was defined as > 30% increase, stable outcome as ±30%, negative outcome as decrease > 30% of eGFR. RESULTS Eleven patients (78.8%) were treated with eculizumab, three received standard of care (SoC, 27.2%). Median follow-up time was 68 months (IQR: 45-98 months). Median eculizumab treatment duration was 10 months (IQR 5-46 months). After eculizumab treatment, five patients showed a stable outcome, six patients showed a negative outcome. Among patients receiving SoC, one patient showed a stable outcome, two patients showed a negative outcome. CONCLUSIONS The benefit of eculizumab in chronic progressive C3 glomerulopathy is limited.
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Affiliation(s)
- Thomas Welte
- Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Frederic Arnold
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany ,grid.5963.9Institute for Microbiology and Hygiene, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lukas Westermann
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Felix A. Rottmann
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin J. Hug
- grid.5963.9Pharmacy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Elke Neumann-Haefelin
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Athina Ganner
- Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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15
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Almeida M, Mugford A, Defauw P. Successful Use of Mycophenolate Mofetil as Adjunct to Prednisolone for Treatment of Acute Kidney Injury Secondary to Human Serum Albumin Administration in a Dog. J Am Anim Hosp Assoc 2023; 59:45-50. [PMID: 36584313 DOI: 10.5326/jaaha-ms-7287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 01/01/2023]
Abstract
The use of human serum albumin (HSA) is described in dogs receiving critical care. However, despite the high degree of homology, anaphylactic and delayed hypersensitivity reactions are reported. Delayed type III hypersensitivity reactions can lead to glomerulonephritis and acute kidney injury (AKI). Undiluted 20% HSA was administered to a 4.8 yr old intact male Labrador Retriever with severe hypoalbuminemia, following surgical management of septic peritonitis of gastrointestinal origin. Nineteen days after HSA administration, the dog developed peracute high magnitude renal proteinuria and AKI. Rapid immunosuppression, using a combination of prednisolone and mycophenolate mofetil, resulted in full resolution of AKI, hypoalbuminemia, and proteinuria. Addition of mycophenolate mofetil may have resulted in the first documented case of full renal recovery from hypersensitivity-induced AKI caused by HSA administration.
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Affiliation(s)
- Mariana Almeida
- From Lumbry Park Veterinary Specialists, Alton, United Kingdom (M.A., P.D.)
| | - Adam Mugford
- Anderson Moores Veterinary Specialists, Linnaeus, Mars Veterinary Health, Winchester, United Kingdom (A.M.)
| | - Pieter Defauw
- From Lumbry Park Veterinary Specialists, Alton, United Kingdom (M.A., P.D.)
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16
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Gurung J, Regmi A, Poudel B, Poudel R, Sharma R, Pradhan SR. Atypical hemolytic uremic syndrome (aHUS) responsive to mycophenolate mofetil: A case report from Nepal. Ann Med Surg (Lond) 2022; 84:104932. [PMID: 36582885 PMCID: PMC9793206 DOI: 10.1016/j.amsu.2022.104932] [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: 09/05/2022] [Revised: 10/28/2022] [Accepted: 11/13/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction An atypical hemolytic uremic syndrome is an extremely rare and life-threatening thrombotic microangiopathy. This disorder is caused by dysregulation of the alternative pathway of the complement system in association with genetic abnormalities or the development of autoantibodies. However, 30-50% of patients do not have genetic or acquired mutations in the complement system. Case report Patient presented with fever and periorbital swelling. She had anemia, thrombocytopenia, and deranged liver function tests. Urinalysis revealed hematuria and proteinuria. Antibody tests and genetic analysis were negative. Renal biopsy revealed findings suggestive of thrombotic microangiopathy with predominantly glomerular involvement. Thus, the diagnosis of Atypical Hemolytic Uremic Syndrome, immunofluorescence negative, genetic negative, and anti-complement negative was made. Discussion This article reports a case of atypical hemolytic uremic syndrome in a child with negative genetic analysis and anti-complement factor H antibody, which was treated successfully on steroid and mycophenolate mofetil. Early diagnosis along with prompt treatment and close monitoring will lead to recovery from atypical Hemolytic Uremic Syndrome. Conclusion Although HUS is generally associated with genetic abnormalities or a positive antibody test, some patients with HUS may present atypically with negative genetic analysis and antibody tests.
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Affiliation(s)
- Jyoti Gurung
- Civil Service Hospital, New Baneshwor, Kathmandu, Nepal
| | - Anil Regmi
- Nepal Medical College Teaching Hospital, Kathmandu, Nepal,Corresponding author. Department of Internal Medicine, Nepal Medical College Teaching Hospital, Kathmandu, 44600, Nepal.
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17
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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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18
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Gross hematuria, edema, and hypocomplementemia in a 9-year-old boy: Answers. Pediatr Nephrol 2022; 37:2349-2353. [PMID: 35352193 DOI: 10.1007/s00467-022-05539-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 10/18/2022]
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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: 16] [Impact Index Per Article: 8.0] [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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Karunnaya AV, Dobronravov VA. Remissions and progression of C3 glomerulopathy. TERAPEVT ARKH 2022; 94:718-724. [DOI: 10.26442/00403660.2022.06.201564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/04/2022] [Indexed: 11/22/2022]
Abstract
Aim. To analyze the outcomes of C3-glomerulopathy (C3-GP) and determine the associated factors.
Materials and methods. A retrospective single-center study included 60 patients with newly diagnosed C3-GP (with primary C3-GP pC3-GP 82%). Of these, 48 (80%) patients had clinical data to assess the following disease outcomes: development of remission and disease progression (by a composite endpoint that included initiation of chronic dialysis or a decrease in estimated glomerular filtration rate eGFR 15 mL/min/1.73 m2 or a decrease in eGFR30% of baseline at the time of renal biopsy). The median follow-up period was 25 (7; 52) months.
Results. At early follow-up (median 4 [3; 9] months) remission was registered in 35% of patients; at the end of follow-up, in 48% (for pC3-GP, 32 and 41%). Disease progression occurred in 17 patients. In the overall group the likelihood of achieving early remission was higher with treatment (Exp=6.4, 95% confidence interval CI 1.429.3; p=0.017). Early remission was associated with the presence of remission at the end of follow-up (Exp=6.3, 95% CI 2.218.4; p=0.001). Specific treatment (Exp=0.308, 95% CI 0.1080.881; p=0.028) and late remission (Exp=0.079, 95% CI 0.0170.368; p=0.001) were associated with reduced risk of disease progression in multivariable models (adjusted for eGFR, mean blood pressure). The same results were obtained for the group of patients with pC3-GP.
Conclusion. C3-GP is a variant of severe complement-mediated glomerular damage with unfavorable renal prognosis, which requires timely personalized expert-level diagnostics with clarification of etiopathogenesis of the disease followed by therapy aimed at achieving remission to improve outcomes.
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21
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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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22
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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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23
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Sethi S, De Vriese AS, Fervenza FC. Acute glomerulonephritis. Lancet 2022; 399:1646-1663. [PMID: 35461559 DOI: 10.1016/s0140-6736(22)00461-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 02/10/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
Glomerulonephritis is a heterogeneous group of disorders that present with a combination of haematuria, proteinuria, hypertension, and reduction in kidney function to a variable degree. Acute presentation with full blown nephritic syndrome or rapidly progressive glomerulonephritis is uncommon and is mainly restricted to patients with post-infectious glomerulonephritis, anti-neutrophil cytoplasmic antibodies-associated vasculitis, and anti-glomerular basement membrane disease. Most frequently, patients present with asymptomatic haematuria and proteinuria with or without reduced kidney function. All glomerulonephritis disorders can show periods of exacerbation, but disease flairs characteristically occur in patients with IgA nephropathy or C3 glomerulopathy. The gold standard for the diagnosis of a glomerulonephritis is a kidney biopsy, with a hallmark glomerular inflammation that translates into various histopathological patterns depending on the location and severity of the glomerular injury. Traditionally, glomerulonephritis was classified on the basis of the different histopathological patterns of injury. In the last few years, substantial progress has been made in unravelling the underlying causes and pathogenetic mechanisms of glomerulonephritis and a causal approach to the classification of glomerulonephritis is now favoured over a pattern-based approach. As such, glomerulonephritis can be broadly classified as immune-complex glomerulonephritis (including infection-related glomerulonephritis, IgA nephropathy, lupus nephritis, and cryoglobulinaemic glomerulonephritis), anti-neutrophil cytoplasmic antibodies-associated (pauci-immune) glomerulonephritis, anti-glomerular basement membrane glomerulonephritis, C3 glomerulopathy, and monoclonal immunoglobulin-associated glomerulonephritis. We provide an overview of the clinical presentation, pathology, and the current therapeutic approach of the main representative disorders in the spectrum of glomerulonephritis.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
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24
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Vivarelli M, van de Kar N, Labbadia R, Diomedi-Camassei F, Thurman JM. A clinical approach to children with C3 glomerulopathy. Pediatr Nephrol 2022; 37:521-535. [PMID: 34002292 DOI: 10.1007/s00467-021-05088-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/28/2021] [Accepted: 04/20/2021] [Indexed: 11/28/2022]
Abstract
C3 glomerulopathy is a relatively new clinical entity that represents a challenge both to diagnose and to treat. As new therapeutic agents that act as complement inhibitors become available, many with an oral formulation, a better understanding of this disease and of the underlying complement dysregulation driving it has become increasingly useful to optimize patient care. Moreover, recent advances in research have clarified the role of complement in other glomerular diseases in which its role was less established, namely in immune-complex membranoproliferative glomerulonephritis (IC-MPGN), ANCA-vasculitis, IgA nephropathy, and idiopathic membranous nephropathy. Complement inhibitors are being studied in adult and adolescent clinical trials for these indications. This review summarizes current knowledge and future perspectives on every aspect of the diagnosis and management of C3 glomerulopathy and elucidates current understanding of the role of complement in this condition and in other glomerular diseases in children. An overview of ongoing trials involving therapeutic agents targeting complement in glomerular diseases is also provided.
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Affiliation(s)
- Marina Vivarelli
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy.
| | - Nicole van de Kar
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Raffaella Labbadia
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy
| | | | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
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25
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Chan M, Hanna MG, Willard N, Treece A, Dixon BP. Hypocomplementemic Atypical IgA Vasculitis: A Case Report. Front Pediatr 2022; 10:886371. [PMID: 35757129 PMCID: PMC9218267 DOI: 10.3389/fped.2022.886371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/13/2022] [Indexed: 12/02/2022] Open
Abstract
IgA vasculitis (IgAV, also known as Henoch-Schönlein purpura or HSP) is a vasculitis of small vessels involving multiple organs, particularly of the joints, gastrointestinal tract, skin, and kidneys. Growing laboratory evidence has shown that complement plays a key role in the pathogenesis of IgAV, although direct evidence of this association in patients is lacking. We report a child with IgAV associated with clinical features of hypertension, nephrotic range proteinuria, acute kidney injury, and low serum C3, with histopathologic findings on renal biopsy of membranoproliferative glomerulonephritis with C3 and IgA co-dominance, and extensive complement derangements. This case report suggests that complement modifies the pathogenesis of IgAV, and further investigation into complement-targeted therapy in cases of refractory IgAV may be beneficial.
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Affiliation(s)
- Melvin Chan
- Department of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, United States
| | - Melisha Gayle Hanna
- Department of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, United States
| | - Nicholas Willard
- Department of Pathology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Amy Treece
- Department of Pathology, School of Medicine, University of Colorado, Aurora, CO, United States
| | - Bradley Patton Dixon
- Department of Pediatric Nephrology, Children's Hospital Colorado, Aurora, CO, United States
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26
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Long-term follow-up including extensive complement analysis of a pediatric C3 glomerulopathy cohort. Pediatr Nephrol 2022; 37:601-612. [PMID: 34476601 PMCID: PMC8921070 DOI: 10.1007/s00467-021-05221-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND C3 glomerulopathy (C3G) is a rare kidney disorder characterized by predominant glomerular depositions of complement C3. C3G can be subdivided into dense deposit disease (DDD) and C3 glomerulonephritis (C3GN). This study describes the long-term follow-up with extensive complement analysis of 29 Dutch children with C3G. METHODS Twenty-nine C3G patients (19 DDD, 10 C3GN) diagnosed between 1992 and 2014 were included. Clinical and laboratory findings were collected at presentation and during follow-up. Specialized assays were used to detect rare variants in complement genes and measure complement-directed autoantibodies and biomarkers in blood. RESULTS DDD patients presented with lower estimated glomerular filtration rate (eGFR). C3 nephritic factors (C3NeFs) were detected in 20 patients and remained detectable over time despite immunosuppressive treatment. At presentation, low serum C3 levels were detected in 84% of all patients. During follow-up, in about 50% of patients, all of them C3NeF-positive, C3 levels remained low. Linear mixed model analysis showed that C3GN patients had higher soluble C5b-9 (sC5b-9) and lower properdin levels compared to DDD patients. With a median follow-up of 52 months, an overall benign outcome was observed with only six patients with eGFR below 90 ml/min/1.73 m2 at last follow-up. CONCLUSIONS We extensively described clinical and laboratory findings including complement features of an exclusively pediatric C3G cohort. Outcome was relatively benign, persistent low C3 correlated with C3NeF presence, and C3GN was associated with higher sC5b-9 and lower properdin levels. Prospective studies are needed to further elucidate the pathogenic mechanisms underlying C3G and guide personalized medicine with complement therapeutics.
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27
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Freiwald T, Afzali B. Renal diseases and the role of complement: Linking complement to immune effector pathways and therapeutics. Adv Immunol 2021; 152:1-81. [PMID: 34844708 PMCID: PMC8905641 DOI: 10.1016/bs.ai.2021.09.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The complement system is an ancient and phylogenetically conserved key danger sensing system that is critical for host defense against pathogens. Activation of the complement system is a vital component of innate immunity required for the detection and removal of pathogens. It is also a central orchestrator of adaptive immune responses and a constituent of normal tissue homeostasis. Once complement activation occurs, this system deposits indiscriminately on any cell surface in the vicinity and has the potential to cause unwanted and excessive tissue injury. Deposition of complement components is recognized as a hallmark of a variety of kidney diseases, where it is indeed associated with damage to the self. The provenance and the pathophysiological role(s) played by complement in each kidney disease is not fully understood. However, in recent years there has been a renaissance in the study of complement, with greater appreciation of its intracellular roles as a cell-intrinsic system and its interplay with immune effector pathways. This has been paired with a profusion of novel therapeutic agents antagonizing complement components, including approved inhibitors against complement components (C)1, C3, C5 and C5aR1. A number of clinical trials have investigated the use of these more targeted approaches for the management of kidney diseases. In this review we present and summarize the evidence for the roles of complement in kidney diseases and discuss the available clinical evidence for complement inhibition.
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Affiliation(s)
- Tilo Freiwald
- Immunoregulation Section, Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), Bethesda, MD, United States; Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Behdad Afzali
- Department of Nephrology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany.
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28
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Wong EK, Marchbank KJ, Lomax-Browne H, Pappworth IY, Denton H, Cooke K, Ward S, McLoughlin AC, Richardson G, Wilson V, Harris CL, Morgan BP, Hakobyan S, McAlinden P, Gale DP, Maxwell H, Christian M, Malcomson R, Goodship TH, Marks SD, Pickering MC, Kavanagh D, Cook HT, Johnson SA. C3 Glomerulopathy and Related Disorders in Children: Etiology-Phenotype Correlation and Outcomes. Clin J Am Soc Nephrol 2021; 16:1639-1651. [PMID: 34551983 PMCID: PMC8729419 DOI: 10.2215/cjn.00320121] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 09/17/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Membranoproliferative GN and C3 glomerulopathy are rare and overlapping disorders associated with dysregulation of the alternative complement pathway. Specific etiologic data for pediatric membranoproliferative GN/C3 glomerulopathy are lacking, and outcome data are based on retrospective studies without etiologic data. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS A total of 80 prevalent pediatric patients with membranoproliferative GN/C3 glomerulopathy underwent detailed phenotyping and long-term follow-up within the National Registry of Rare Kidney Diseases (RaDaR). Risk factors for kidney survival were determined using a Cox proportional hazards model. Kidney and transplant graft survival was determined using the Kaplan-Meier method. RESULTS Central histology review determined 39 patients with C3 glomerulopathy, 31 with immune-complex membranoproliferative GN, and ten with immune-complex GN. Patients were aged 2-15 (median, 9; interquartile range, 7-11) years. Median complement C3 and C4 levels were 0.31 g/L and 0.14 g/L, respectively; acquired (anticomplement autoantibodies) or genetic alternative pathway abnormalities were detected in 46% and 9% of patients, respectively, across all groups, including those with immune-complex GN. Median follow-up was 5.18 (interquartile range, 2.13-8.08) years. Eleven patients (14%) progressed to kidney failure, with nine transplants performed in eight patients, two of which failed due to recurrent disease. Presence of >50% crescents on the initial biopsy specimen was the sole variable associated with kidney failure in multivariable analysis (hazard ratio, 6.2; 95% confidence interval, 1.05 to 36.6; P<0.05). Three distinct C3 glomerulopathy prognostic groups were identified according to presenting eGFR and >50% crescents on the initial biopsy specimen. CONCLUSIONS Crescentic disease was a key risk factor associated with kidney failure in a national cohort of pediatric patients with membranoproliferative GN/C3 glomerulopathy and immune-complex GN. Presenting eGFR and crescentic disease help define prognostic groups in pediatric C3 glomerulopathy. Acquired abnormalities of the alternative pathway were commonly identified but not a risk factor for kidney failure.
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Affiliation(s)
- Edwin K.S. Wong
- National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Kevin J. Marchbank
- National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Hannah Lomax-Browne
- Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - Isabel Y. Pappworth
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Harriet Denton
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Katie Cooke
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sophie Ward
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Amy-Claire McLoughlin
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Grant Richardson
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Valerie Wilson
- National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Claire L. Harris
- National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - B. Paul Morgan
- Systems Immunity Research Institute, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Svetlana Hakobyan
- Systems Immunity Research Institute, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Paul McAlinden
- Research and Development Department, Newcastle upon Tyne Hospitals National Health Service (NHS) Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Daniel P. Gale
- Department of Renal Medicine, University College London, London, United Kingdom
| | | | - Martin Christian
- Nottingham Children’s Hospital, Queens Medical Centre, Nottingham, United Kingdom
| | - Roger Malcomson
- Histopathology Department, Leicester Royal Infirmary, Leicester, United Kingdom
| | - Timothy H.J. Goodship
- National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - 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
| | - Matthew C. Pickering
- Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - H. Terence Cook
- Department of Immunology and Inflammation, Imperial College, London, United Kingdom
| | - Sally A. Johnson
- National Renal Complement Therapeutics Centre, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
- Complement Therapeutics Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
- Department of Paediatric Nephrology, Great North Children’s Hospital, Newcastle upon Tyne, United Kingdom
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29
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Abdul-Aziz R, Deng R, Liu L, Tarsi S, Waz WR, Wu X. Complete Renal Recovery in Pediatric Patient with C3 Glomerulonephritis: A Case Report. Case Rep Nephrol Dial 2021; 11:261-269. [PMID: 34703825 PMCID: PMC8460949 DOI: 10.1159/000518714] [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: 04/14/2021] [Accepted: 07/26/2021] [Indexed: 12/03/2022] Open
Abstract
C3 glomerulonephritis (C3GN) is a rare kidney disease resulting from dysregulation of the alternative complement cascade. Without treatment, approximately 70% of affected children and 30–50% of affected adults will develop worsening of proteinuria and progress to end-stage renal disease within 10 years of diagnosis. Here, we describe a 9-year-old Sudanese girl with no significant past medical history who presented to the Emergency Department with a 2-month history of fatigue, poor oral intake, and worsening facial and lower extremity edema, and subsequently found to have anemia, hypoalbuminemia, microscopic hematuria, and proteinuria. Additional laboratory testing revealed that the patient had low C3, high C3 nephritic factor (C3NeF), and high factor H. Renal function was normal. The diagnosis of C3GN was confirmed by renal biopsy. The patient was treated with ACE inhibitor, mycophenolate mofetil (600 mg per m<sup>2</sup> per dose, every 12 h), in combination with “pulse” methylprednisolone at 30 mg/kg/day IV bolus (maximum 1 g) for 3 consecutive days, followed by 2 months of daily oral prednisolone (2 mg/kg/day) and alternate-day prednisolone weaning from 1 mg/kg to 0.1 mg/kg for additional 12 months. Mycophenolate was continued throughout her treatment course and for maintenance therapy. In response to treatment, anemia, microscopic hematuria, hypoalbuminemia, and proteinuria resolved. Complete complement profile before and at 6 months therapy showed normalization of C3NeF, complement regulatory factor H and C3. This present case provides evidence of the full responsiveness of a rare form of complement dysregulation C3GN to a combination of mycophenolate and corticosteroids. The disease has NOT recurred in >2 years after initial presentation.
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Affiliation(s)
- Rabheh Abdul-Aziz
- Oishei Children's Hospital of Buffalo, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Rong Deng
- Oishei Children's Hospital of Buffalo, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Lin Liu
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Shauna Tarsi
- Oishei Children's Hospital of Buffalo, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Wayne R Waz
- Oishei Children's Hospital of Buffalo, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Xiaoyan Wu
- Oishei Children's Hospital of Buffalo, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York, USA
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Caravaca-Fontán F, Lucientes L, Serra N, Cavero T, Rodado R, Ramos N, Gonzalez F, Shabaka A, Cabello V, Huerta A, Pampa-Saico S, Gutiérrez E, Quintana LF, López-Rubio ME, Draibe J, Titos JA, Fernández-Juárez G, de Jorge EG, Praga M. C3 glomerulopathy associated with monoclonal gammopathy: impact of chronic histologic lesions and beneficial effects of clone-targeted therapies. Nephrol Dial Transplant 2021; 37:2128-2137. [PMID: 34677610 DOI: 10.1093/ndt/gfab302] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION C3 glomerulopathy associated with monoclonal gammopathy (C3G-MIg) is a rare entity. Herein, we analyzed the clinical and histologic features of a cohort of C3G-MIg patients. METHODS Retrospective, multicenter, observational study. Patients diagnosed with C3G-MIg between 1995-2021 were enrolled. All had genetic studies of the alternative complement pathway. The degree of disease activity and chronicity was analyzed using the C3G histologic index. Descriptive statistics and propensity-score matching (PSM) analysis were used to evaluate the main outcome of the study (kidney failure [KF]). RESULTS The study group included 23 patients: median age 63 years (IQR 48-70), 57% males. IgG kappa was the most frequent MIg (65%). The diagnosis of C3G-MIg was made in transplanted kidneys in 7 patients (30%). Five (22%) had C3 nephritic factor and 5 (22%) anti-factor H antibodies. One patient carried a pathogenic variant in CFH gene.During a follow-up of 40 months (IQR 14-69), 9 patients (39%) reached KF, and these patients had a significant higher total chronicity score in kidney biopsy. Patients who received clone-targeted therapy had a significant higher survival compared to other management. Those who achieved hematological response had a significant higher kidney survival. Outcome was remarkably poor in kidney transplant recipients, 5 of them (71%) reaching KF.By PSM (adjusting for age, kidney function, proteinuria and chronicity score), no significant differences were observed in kidney survival between C3G patients with/without MIg. CONCLUSIONS The C3G histologic index can be used in patients with C3G-MIg to predict kidney prognosis, with higher chronicity scores being associated with worse outcomes. Clone-targeted therapies and the development of hematological response, are associated with better kidney prognosis.
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Affiliation(s)
- Fernando Caravaca-Fontán
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Laura Lucientes
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.,Department of Immunology, Universidad Complutense de Madrid, Madrid, Spain
| | - Núria Serra
- Department of Nephrology, Fundación Puigvert, Barcelona, Spain
| | - Teresa Cavero
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Raquel Rodado
- Department of Nephrology, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Natalia Ramos
- Department of Nephrology, Hospital Universitario Vall d'Hebron, Barcelona, Spain
| | - Fayna Gonzalez
- Department of Nephrology, Hospital Doctor Negrín, Gran Canaria, Spain
| | - Amir Shabaka
- Department of Nephrology, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Virginia Cabello
- Department of Nephrology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta de Hierro, Madrid, Spain
| | - Saúl Pampa-Saico
- Department of Nephrology, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - Eduardo Gutiérrez
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Luis F Quintana
- Complex Glomerular Disease Unit (CSUR), Department of Nephrology, Hospital Clinic de Barcelona, University of Barcelona, IDIBAPS, Spain
| | | | - Juliana Draibe
- Department of Nephrology, Hospital Universitario de Bellvitge, Barcelona, Spain
| | - Juana Alonso Titos
- Department of Nephrology, Hospital Regional Universitario Carlos Haya, Málaga, Spain
| | - Gema Fernández-Juárez
- Department of Nephrology, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Elena Goicoechea de Jorge
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.,Department of Immunology, Universidad Complutense de Madrid, Madrid, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 748] [Impact Index Per Article: 249.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Kant S, Kronbichler A, Sharma P, Geetha D. Advances in Understanding of Pathogenesis and Treatment of Immune-Mediated Kidney Disease: A Review. Am J Kidney Dis 2021; 79:582-600. [PMID: 34508831 DOI: 10.1053/j.ajkd.2021.07.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/25/2021] [Indexed: 12/21/2022]
Abstract
There continues to be rapid advancement in our understanding of the pathogenesis of immune-mediated kidney disease. This progress has culminated in the development of multiple therapeutic agents that have consistently improved renal and patient outcomes. The focus of this review is to discuss these recent advancements in immune-mediated kidney disease via the lens of direct and indirect immune-mediated mechanisms. In the direct immune-mediated disease, recently described antigens in anti-glomerular basement membrane (GBM) disease and membranous nephropathy are discussed, along with new therapeutic regimens in membranous nephropathy and focal segmental glomerulosclerosis. From an indirect immune-mediated disease standpoint, recent pivotal trials in antineutrophil cytoplasmic antibody vasculitis, lupus nephritis, and IgA nephropathy are examined from a real-world practice perspective. New molecular pathways in various disorders of alternate complement pathway are described, which in turn have led to development of various experimental therapies. In addition, pivotal and ongoing therapeutic trials in the aforementioned diseases are presented.
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Affiliation(s)
- Sam Kant
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Purva Sharma
- Division of Kidney Diseases and Hypertension, Zucker School of Medicine, Hofstra University/Northwell Health, Hempstead, New York
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
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Fernandez-Ruiz R, Blank RB, Wu M, Belmont HM. C3 glomerulonephritis and systemic lupus erythematosus: A report of a patient treated with eculizumab and review of the literature. Lupus 2021; 30:1671-1678. [PMID: 34192954 DOI: 10.1177/09612033211027938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Activation of the complement pathway by immune complexes is a key feature of systemic lupus erythematosus (SLE) and SLE glomerulonephritis, which translates into low levels of C3 and C4 during active disease. C3 glomerulonephritis (C3GN) is part of a broader group of rare renal diseases, the C3 glomerulopathies, characterized by prominent C3 accumulation in the glomeruli with minimal to no immunoglobulin (Ig) deposition secondary to dysregulation of the alternative pathway of the complement system. Distinguishing lupus nephritis from other complement-mediated kidney disorders, including C3GN, represents a diagnostic challenge with potential therapeutic implications. METHODS We report an unusual case of a 55-year-old woman with SLE and previous biopsy-proven class IV lupus nephritis, subsequently diagnosed with C3GN. Furthermore, we review the available literature published from January 2010-March 2021 on the clinical features and management of C3GN in the setting of SLE. RESULTS In addition to our case, very few reports exist in the literature regarding C3GN in association with SLE. The underlying pathogenic mechanism of C3GN consists of dysregulation of the alternative pathway of the complement system, either due to genetic variation in complement-related genes or to acquired autoantibodies targeting C3 or C5 convertases; the latter mechanism could explain the occurrence of C3GN in the setting of autoimmune diseases, although it was not definitively identified in our patient or others with SLE. Similar to some of the previous reports, after suboptimal renal response on mycophenolate mofetil and rituximab, our patient has been successfully treated with eculizumab, thus far with >50% improvement in proteinuria. CONCLUSIONS C3GN represents an additional mechanism of renal injury in SLE mediated by alternative complement pathway dysregulation. Although rare, patients with SLE and persistent proteinuria with very low C3 would benefit from expedited renal biopsy to evaluate for C3GN as well as genetic testing, since this entity could require a different therapeutic approach.
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Affiliation(s)
- Ruth Fernandez-Ruiz
- Division of Rheumatology, New York University Grossman School of Medicine, New York, USA
| | - Rebecca B Blank
- Division of Rheumatology, New York University Grossman School of Medicine, New York, USA
| | - Ming Wu
- Department of Pathology, New York University Grossman School of Medicine, New York, USA
| | - H Michael Belmont
- Division of Rheumatology, New York University Grossman School of Medicine, New York, USA
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Pınarbaşı AS, Dursun I, Gokce I, Çomak E, Saygılı S, Bayram MT, Donmez O, Melek E, Tekcan D, Çiçek N, Yılmaz D, Tabel Y, Yıldırım ZY, Bahat E, Koyun M, Soylu A, Canpolat N, Aksu B, Çelakıl ME, Taşdemir M, Benzer M, Özçelik G, Bakkaloğlu SA, Düşünsel R. Predictors of poor kidney outcome in children with C3 glomerulopathy. Pediatr Nephrol 2021; 36:1195-1205. [PMID: 33130981 DOI: 10.1007/s00467-020-04799-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/13/2020] [Accepted: 09/24/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND C3 glomerulopathy (C3G) is characterized by heterogeneous clinical presentation, outcome, and predominant C3 accumulation in glomeruli without significant IgG. There is scarce outcome data regarding childhood C3G. We describe clinical and pathological features, treatment and outcomes, and risk factors for progression to chronic kidney disease stage 5 (CKD5) in the largest pediatric series with biopsy-proven C3G. METHODS Sixty pediatric patients with C3G from 21 referral centers in Turkey were included in this retrospective study. Patients were categorized according to CKD stage at last visit as CKD5 or non-CKD5. Demographic data, clinicopathologic findings, treatment, and outcome data were compared and possible risk factors for CKD5 progression determined using Cox proportional hazards model. RESULTS Mean age at diagnosis was 10.6 ± 3.0 years and follow-up time 48.3 ± 36.3 months. Almost half the patients had gross hematuria and hypertension at diagnosis. Nephritic-nephrotic syndrome was the commonest presenting feature (41.6%) and 1/5 of patients presented with nephrotic syndrome. Membranoproliferative glomerulonephritis was the leading injury pattern, while 40 patients had only C3 staining. Patients with DDD had significantly lower baseline serum albumin compared with C3GN. Eighteen patients received eculizumab. Clinical remission was achieved in 68.3%. At last follow-up, 10 patients (16.6%) developed CKD5: they had lower baseline eGFR and albumin and higher frequency of nephrotic syndrome and dialysis requirement than non-CKD5 patients. Lower serum albumin and eGFR at diagnosis were independent predictors for CKD5 development. CONCLUSIONS Children with C3G who have impaired kidney function and hypoalbuminemia at diagnosis should be carefully monitored for risk of progression to CKD5. Graphical abstract.
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Affiliation(s)
- Ayşe Seda Pınarbaşı
- Department of Pediatric Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Ismail Dursun
- Department of Pediatric Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey.
| | - Ibrahim Gokce
- Department of Pediatric Nephrology, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Elif Çomak
- Department of Pediatric Nephrology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Seha Saygılı
- Department of Pediatric Nephrology, Cerrahpasa Faculty of Medicine, Istanbul University, İstanbul, Turkey
| | - Meral Torun Bayram
- Department of Pediatric Nephrology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Osman Donmez
- Department of Pediatric Nephrology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Engin Melek
- Department of Pediatric Nephrology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Demet Tekcan
- Department of Pediatric Nephrology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Neslihan Çiçek
- Department of Pediatric Nephrology, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Dilek Yılmaz
- Department of Pediatric Nephrology, Faculty of Medicine, Adnan Menderes University, Aydın, Turkey
| | - Yılmaz Tabel
- Department of Pediatric Nephrology, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - Zeynep Y Yıldırım
- Department of Pediatric Nephrology, Istanbul Faculty of Medicine, Istanbul University, İstanbul, Turkey
| | - Elif Bahat
- Department of Pediatric Nephrology, Faculty of Medicine, Karadeniz Teknik University, Trabzon, Turkey
| | - Mustafa Koyun
- Department of Pediatric Nephrology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Alper Soylu
- Department of Pediatric Nephrology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Nur Canpolat
- Department of Pediatric Nephrology, Cerrahpasa Faculty of Medicine, Istanbul University, İstanbul, Turkey
| | - Bağdagül Aksu
- Department of Pediatric Nephrology, University of Health Sciences, Haseki Education and Research Hospital, İstanbul, Turkey
| | - Mehtap Ezel Çelakıl
- Department of Pediatric Nephrology, Faculty of Medicine, Kocaeli University, İzmit, Kocaeli, Turkey
| | - Mehmet Taşdemir
- Department of Pediatric Nephrology, Faculty of Medicine, Koç University, İstanbul, Turkey
| | - Meryem Benzer
- Department of Pediatric Nephrology, Bakırköy Dr Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Gül Özçelik
- Department of Pediatric Nephrology, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Sevcan A Bakkaloğlu
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ruhan Düşünsel
- Department of Pediatric Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
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Li L, Liu LQ, Yang YY, Hu ZX. C3 glomerulonephritis associated with ANCA positivity: a case report. BMC Nephrol 2021; 22:143. [PMID: 33882866 PMCID: PMC8061169 DOI: 10.1186/s12882-021-02354-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 04/13/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND C3 glomerulopathy (C3G) is a recent disease classification that is characterized by the presence of glomerular deposits (composed of C3) in the absence of significant amounts of immunoglobulin and comprises dense deposit disease and C3 glomerulonephritis (C3GN). Most C3GN manifests as membranoproliferative, mesangial proliferative glomerulonephritis patterns via light microscopy. Pure membranous nephropathy (MN)-like glomerular lesions are rare manifestations of C3GN. Anti-neutrophil cytoplasmic antibodies (ANCAs) are also seldomly reported to be positive in C3GN. Herein, we report the case of a C3GN patient presenting with an MN-like glomerular pattern with ANCA positivity. CASE PRESENTATION A 68-year-old woman was admitted to a local hospital with elevated serum creatinine for two weeks. Laboratory tests showed a hemoglobin level of 85 g/L. Urinalysis was positive for 2 + protein and 360 RBCs/HPF. Blood biochemistry analysis revealed the following concentrations: albumin, 30.3 g/L; globulin, 46.2 g/L; blood urea nitrogen, 19.9 mmol/L; and serum creatinine, 234 µmol/L. The serum C3 level was 0.4950 g/L, and the serum C4 level was 0.1050 g/L. The direct Coombs test was positive. Serologic testing for ANCA revealed the presence of p-ANCA (1:10) by indirect immunofluorescence microscopy assay, as well as the presence of PR3 1.2 (normal range < 1) and MPO 3.5 (normal range < 1) by enzyme immunoassay. Renal biopsy sample pathology showed 2/6 cellular crescents and thickened glomerular basement membranes. Immunofluorescence testing revealed only diffuse, finely granular depositions of C3 along the glomerular capillary walls in frozen and paraffin-embedded tissue sections. Electron microscopy demonstrated the presence of subepithelial electron-dense deposits, similar to those that are observed in membranous nephropathy. Corticosteroid and cyclophosphamide were administered, with a subsequent improvement in renal function. CONCLUSIONS We present the rare case of a patient with MN-like C3GN with ANCA positivity. C3GN with ANCA positivity may be represented by more crescents, severe renal dysfunction and more extrarenal manifestations. More cases are needed to elucidate the clinicopathologic features and optimal treatments of these patients.
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Affiliation(s)
- Ling Li
- Renal Division, Department of Medicine, West China Hospital of Sichuan University, 610041, Chengdu, China
| | - Li-Qin Liu
- West China School of Medicine, Sichuan University, 610041, Chengdu, China
| | - Ying-Ying Yang
- Renal Division, Department of Medicine, West China Hospital of Sichuan University, 610041, Chengdu, China
| | - Zhang-Xue Hu
- Renal Division, Department of Medicine, West China Hospital of Sichuan University, 610041, Chengdu, China.
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Caravaca-Fontán F, 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, de José AP, Rabasco C, Rodado R, Fernández L, Gómez VP, Ávila A, Bravo L, Espinosa N, Allende N, Sanchez de la Nieta MD, Rodríguez E, Olea T, Melgosa M, Huerta A, Miquel R, Mon C, Fraga G, de Lorenzo A, Draibe J, Cano-Megías M, González F, Shabaka A, López-Rubio ME, Fenollosa MÁ, Martín-Penagos L, Da Silva I, Titos JA, de Córdoba SR, de Jorge EG, Praga M. Longitudinal change in proteinuria and kidney outcomes in C3 glomerulopathy. Nephrol Dial Transplant 2021; 37:1270-1280. [PMID: 33779754 DOI: 10.1093/ndt/gfab075] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The association between a change in proteinuria over time and its impact in kidney prognosis has not been analyzed in C3 glomerulopathy. This study aims to investigate the association between the longitudinal change in proteinuria and the risk of kidney failure. METHODS Retrospective, multicenter observational cohort study in 35 nephrology departments belonging to the Spanish Group for the Study of Glomerular Diseases (GLOSEN). Patients diagnosed with C3 glomerulopathy between 1995 and 2020 were enrolled. A joint modeling of linear mixed-effects models was applied to assess the underlying trajectory of a repeatedly measured proteinuria, and a Cox model to evaluate the association of this trajectory with the risk of kidney failure. RESULTS The study group consisted of 85 patients, 70 C3 glomerulonephritis and 15 dense deposit disease, with a median age of 26 years (range 13-41). During a median follow-up of 42 months, 25 patients reached kidney failure. The longitudinal change in proteinuria showed a strong association with the risk of this outcome, with a doubling of proteinuria levels resulting in a 2.5-fold increase of the risk. A second model showed that a ≥ 50% proteinuria reduction over time was significantly associated with a lower risk of kidney failure (HR: 0.79; 95% CI : 0.56-0.97; p < 0.001). This association was also found when the ≥50% proteinuria reduction was observed within the first 6 and 12 months of follow-up. CONCLUSION The longitudinal change in proteinuria is strongly associated with the risk of kidney failure. The change in proteinuria over time can provide clinicians a dynamic prediction of kidney outcomes.
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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
| | | | - 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
| | - 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
| | - 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
| | - Teresa Olea
- 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
| | - Marta Cano-Megías
- Department of Nephrology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, 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
| | - 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
- Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Immunology, Universidad Complutense de Madrid, Madrid, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Therapy and outcomes of C3 glomerulopathy and immune-complex membranoproliferative glomerulonephritis. Pediatr Nephrol 2021; 36:591-600. [PMID: 32886193 DOI: 10.1007/s00467-020-04736-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/13/2020] [Accepted: 07/31/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Data on therapy and outcome of dense deposit disease (DDD), C3 glomerulonephritis (C3GN), and immune-complex MPGN (IC-MPGN) in children are limited. METHODS In this retrospective single-center study from 2007 to 2019, kidney biopsies were reviewed to include patients aged <18-years with C3 glomerulopathy and IC-MPGN. Initial immunosuppression comprised prednisolone, mycophenolate mofetil (n = 51), tacrolimus (n = 11), and/or IV cyclophosphamide (n = 20). Clinicopathological features, response to therapy, and adverse outcome (eGFRcr < 15 mL/min/1.73 m2 or death) were evaluated. RESULTS A total of 92 patients were classified as DDD (n = 48, 52.2%), C3GN (n = 26, 28.3%), and IC-MPGN (n = 18, 19.6%) by immunohistochemistry and electron microscopy; 8 patients with DDD were misclassified as IC-MPGN on immunofluorescence. At last follow-up (median 4.3 years), complete or partial remission occurred in 28.5, 36.1, and 16.7% patients with DDD, C3GN, and IC-MPGN, respectively. Serum albumin at onset < 2.5 g/dL (HR = 0.29, P = 0.005) and persistently low serum C3 (HR = 0.34, P = 0.02) were associated with lack of remission. The 5-year kidney survival was 62.6, 85.5, and 88.5% in patients with DDD, C3GN, and IC-MPGN, respectively (log-rank, P = 0.006). Presentation as rapidly progressive GN (HR = 11.2, P < 0.001), age > 10 years at onset (HR = 4.0, P = 0.004), and DDD (HR = 4.2, P = 0.02) were independently associated with adverse outcome; achieving remission was protective (HR = 0.04; P < 0.001). CONCLUSION Outcome in patients with C3 glomerulopathy and IC-MPGN was unsatisfactory, and only a small proportion of patients achieved complete or partial remission. Patients with DDD were more likely to present with rapidly progressive GN and were at higher risk of adverse outcomes, including kidney failure.
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Pinarbasi AS, Dursun I, Poyrazoglu MH, Akgun H, Bozpolat A, Dusunsel R. Evaluation of the children with C3 glomerulopathy. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2021; 31:79-89. [PMID: 32129200 DOI: 10.4103/1319-2442.279964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
C3 glomerulopathy (C3G) is a clinical spectrum that presents with a variety of symptoms, ranging from a mild disease with asymptomatic microhematuria and/or proteinuria to severe disease with nephritic or nephrotic syndrome and renal impairment. Herein, we aim to document the clinical and laboratory findings, response to immunosuppressive and supportive treatment and prognosis of the children with C3G. We retrospectively reviewed the medical records of patients diagnosed with membranoproliferative glomerulonephritis (MPGN). Kidney biopsy materials were reexamined for the diagnosis of C3G. The inclusion criteria for C3G are the dominant C3 staining with or without scanty immunoglobulins (Ig) deposition on immuno- fluorescence (IF) and MPGN patterns on light microscope. Twelve of 69 patients with MPGN were included in the study based on the definition criteria of C3G. Ten of them had only C3 staining and the rest of the patients had both C3 staining and a small amount of IgG/M staining on IF microscopy. One patient was on remission with only ACEI. The rest of the patients used immunosuppressive treatment and two of them needed eculizumab therapy. One of them did not respond to the treatment of eculizumab and progressed to end-stage renal failure. C3G is a disease characterized by a heterogeneous clinical presentation and outcome. Because of this broad spectrum of disease, treatment may vary widely. We think that complement-targeting therapy with eculizumab should be an alternative option for refractory cases, especially in the early stage of disease, if they did not respond to immunosuppressive treatment.
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Affiliation(s)
- Ayse Seda Pinarbasi
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ismail Dursun
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Muammer Hakan Poyrazoglu
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Hulya Akgun
- Department of Pathology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Adil Bozpolat
- Department of Pediatrics, Nevsehir State Hospital, Nevsehir, Turkey
| | - Ruhan Dusunsel
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
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Turkmen K, Baloglu I, Ozer H. C3 glomerulopathy and atypical hemolytic uremic syndrome: an updated review of the literature on alternative complement pathway disorders. Int Urol Nephrol 2021; 53:2067-2080. [PMID: 33389509 DOI: 10.1007/s11255-020-02729-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022]
Abstract
The complement system plays a significant role within the pathological process of C3 glomerulopathy (C3GP) and atypical hemolytic uremic syndrome (aHUS). In daily practice, clinicians should differentiate the subgroups of C3GP because of they should apply different treatment modalities. In the past, C3GP was considered as a part of membranoproliferative glomerulonephritis (MPGN). MPGN is defined as glomerular capillary thickening secondary to the synthesis of the new glomerular basement membrane and mesangial cellular hyperplasia with mesangial matrix expansion. Atypical hemolytic uremic syndrome is an ultra-rare disease that can be outlined by the triad of Coombs negative microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Recent advances demonstrated that these diseases share common abnormalities of the control of the alternative complement system. Therefore, nowadays, most researchers advocate that there may be overlap in the pathogenesis of C3GP and aHUS. This review will provide recent novel mechanisms and treatment options in these diseases. For the purposes that we mentioned above and to help clinicians, we aimed to describe the etiology, pathophysiology, and treatment of C3GP and aHUS in this comprehensive review.
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Affiliation(s)
- Kultigin Turkmen
- Department of Nephrology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey.
| | - Ismail Baloglu
- Department of Nephrology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey
| | - Hakan Ozer
- Department of Nephrology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey
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Cavanaugh C, Okusa MD. The Evolving Role of Novel Biomarkers in Glomerular Disease: A Review. Am J Kidney Dis 2021; 77:122-131. [DOI: 10.1053/j.ajkd.2020.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/06/2020] [Indexed: 02/06/2023]
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Caravaca-Fontán F, Trujillo H, Alonso M, Díaz-Encarnación M, Cabello V, Ariceta G, Quintana LF, Marco H, Barros X, Ramos N, Rodríguez-Mendiola N, Cruz S, Fernández-Juárez G, Rodríguez E, de la Cerda F, Pérez de José A, López I, Fernández L, Pérez Gómez V, Ávila A, Bravo L, Lumbreras J, Allende N, Sanchez de la Nieta MD, Olea T, Melgosa M, Huerta A, Miquel R, Mon C, Fraga G, de Lorenzo A, Draibe J, González F, Shabaka A, Illescas ML, Calvo C, Oviedo V, Da Silva I, Goicoechea de Jorge E, Caravaca F, Praga M. Validation of a Histologic Scoring Index for C3 Glomerulopathy. Am J Kidney Dis 2020; 77:684-695.e1. [PMID: 33359150 DOI: 10.1053/j.ajkd.2020.11.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 11/06/2020] [Indexed: 12/22/2022]
Abstract
RATIONALE & OBJECTIVE A previous study that evaluated associations of kidney biopsy findings with disease progression in patients with C3 glomerulopathy (C3G) proposed a prognostic histologic index (C3G-HI) that has not yet been validated. Our objective was to validate the performance of the C3G-HI in a new patient population. STUDY DESIGN Multicenter, retrospective cohort study. SETTING & PARTICIPANTS 111 patients fulfilling diagnostic criteria of C3G between January 1995 and December 2019, from 33 nephrology departments belonging to the Spanish Group for the Study of Glomerular Diseases (GLOSEN). PREDICTORS Demographic, clinical parameters, C3G-HI total activity score, and the C3G-HI total chronicity score. OUTCOME Time to kidney failure. ANALYTICAL APPROACH Intraclass correlation coefficients and κ statistic were used to summarize inter-rater reproducibility for assessment of histopathology in kidney biopsies. The nonlinear relationships of risk of kidney failure with the total activity score and total chronicity score were modeled using Cox proportional hazards analysis that incorporated cubic splines. RESULTS The study group included 93 patients with C3 glomerulonephritis and 18 with dense-deposit disease. Participants had an overall meanage of 35±22 (SD) years. Forty-eight patients (43%) developed kidney failure after a mean follow-up of 65±27 months. The overall inter-rater reproducibility was very good for the total activity score (intraclass correlation coefficient [ICC]=0.63) and excellent for total chronicity score (ICC=0.89). Baseline estimated glomerular filtration rate (eGFR), 24-hour proteinuria, and treatment with immunosuppression were the main determinants of kidney failure in a model with only clinical variables. Only tubular atrophy and interstitial fibrosis were identified as predictors in a model with histological variables. When the total activity score and total chronicity score were added to the model, only the latter was identified as an independent predictor of kidney failure. LIMITATIONS Only a subset of the kidney biopsies was centrally reviewed. Residual confounding. CONCLUSIONS We validated the performance of C3G-HI as a predictor of kidney failure in patients with C3G. The total chronicity score was the principal histologic correlate of kidney failure.
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Affiliation(s)
- Fernando Caravaca-Fontán
- Instituto de Investigación Hospital 12 de octubre (i+12), Madrid, Spain; Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Hernando Trujillo
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Marina Alonso
- Department of Pathology, 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, Hospital Clinic de Barcelona Department of Medicine, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Helena Marco
- Department of Nephrology, Hospital Universitario Germans Trias i Pujol, Badalona, 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
| | - Eva Rodríguez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Francisco de la Cerda
- Department of Pediatric Nephrology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Ana Pérez de José
- Department of Nephrology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Inmaculada López
- 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
| | - Javier Lumbreras
- 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
| | | | - Teresa Olea
- 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
| | - Maria Luisa Illescas
- Department of Nephrology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Consuelo Calvo
- Department of Nephrology, Hospital General Universitario de Castellón, Castellón, Spain
| | - Victoria Oviedo
- Department of Nephrology, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Iara Da Silva
- Department of Nephrology, Fundación Puigvert, Barcelona, Spain
| | - Elena Goicoechea de Jorge
- Department of Immunlogy, Universidad Complutense de Madrid, Madrid, Spain; Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Madrid and Centro de Investigación Biomédica en Red en Enfermedades Raras, Madrid, Spain
| | - Francisco Caravaca
- Department of Nephrology, Hospital Universitario de Badajoz, Badajoz, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de octubre (i+12), 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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Treatment of C3 Glomerulopathy in Adult Kidney Transplant Recipients: A Systematic Review. Med Sci (Basel) 2020; 8:medsci8040044. [PMID: 33096866 PMCID: PMC7712822 DOI: 10.3390/medsci8040044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/09/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND C3 glomerulopathy (C3G), a rare glomerular disease mediated by alternative complement pathway dysregulation, is associated with a high rate of recurrence and graft loss after kidney transplantation (KTx). We aimed to assess the efficacy of different treatments for C3G recurrence after KTx. METHODS Databases (MEDLINE, EMBASE, and Cochrane Database) were searched from inception through 3 May, 2019. Studies were included that reported outcomes of adult KTx recipients with C3G. Effect estimates from individual studies were combined using the random-effects, generic inverse variance method of DerSimonian and Laird., The protocol for this meta-analysis is registered with PROSPERO (no. CRD42019125718). RESULTS Twelve studies (7 cohort studies and 5 case series) consisting of 122 KTx patients with C3G (73 C3 glomerulonephritis (C3GN) and 49 dense deposit disease (DDD)) were included. The pooled estimated rates of allograft loss among KTx patients with C3G were 33% (95% CI: 12-57%) after eculizumab, 42% (95% CI: 2-89%) after therapeutic plasma exchange (TPE), and 81% (95% CI: 50-100%) after rituximab. Subgroup analysis based on type of C3G was performed. Pooled estimated rates of allograft loss in C3GN KTx patients were 22% (95% CI: 5-46%) after eculizumab, 56% (95% CI: 6-100%) after TPE, and 70% (95% CI: 24-100%) after rituximab. Pooled estimated rates of allograft loss in DDD KTx patients were 53% (95% CI: 0-100%) after eculizumab. Data on allograft loss in DDD after TPE (1 case series, 0/2 (0%) allograft loss at 6 months) and rituximab (1 cohort, 3/3 (100%) allograft loss) were limited. Among 66 patients (38 C3GN, 28 DDD) who received no treatment (due to stable allograft function at presentation and/or clinical judgment of physicians), pooled estimated rates of allograft loss were 32% (95% CI: 7-64%) and 53% (95% CI: 28-77%) for C3GN and DDD, respectively. Among treated C3G patients, data on soluble membrane attack complex of complement (sMAC) were limited to patients treated with eculizumab (N = 7). 80% of patients with elevated sMAC before eculizumab responded to treatment. In addition, all patients who responded to eculizumab had normal sMAC levels after post-eculizumab. CONCLUSIONS Our study suggests that the lowest incidence of allograft loss (33%) among KTX patients with C3G are those treated with eculizumab. Among those who received no treatment for C3G due to stable allograft function, there is a high incidence of allograft loss of 32% in C3GN and 53% in DDD. sMAC level may help to select good responders to eculizumab.
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Sutherland LJ, Talreja H. C3-glomerulonephritis in New Zealand - a case series. BMC Nephrol 2020; 21:399. [PMID: 32943008 PMCID: PMC7495885 DOI: 10.1186/s12882-020-02056-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 09/06/2020] [Indexed: 12/01/2022] Open
Abstract
Background C3-glomerulonephritis can lead to progressive renal impairment from complement-mediated glomerular injury. Incidence and outcomes of C3-glomerulonephritis are not known in the New Zealand population. Methods We reviewed all cases of C3-glomerulonephritis from the past 10 years at a tertiary referral centre in New Zealand. Descriptive information on baseline characteristics and clinical outcomes was collected. Results Twenty-six patients were included (16 men; mean ± SD age 44 ± 25 years) with a median follow-up of 30 months. Disease incidence was 1.3 cases per million individuals, of which 42% were Pacific Islanders. Most patients presented with renal impairment, with a median (IQR) creatinine at diagnosis of 210 (146–300) μmol/L, and 11 (42%) patients presented with nephrotic syndrome. Seven (27%) patients progressed to end stage renal disease and 2 (8%) had died. End stage renal disease occurred in 20% of patients treated with immunosuppression and in 50% of those not treated. Complete remission was seen in 25% of patients treated with some form of immunosuppression and in 17% of those not treated. Conclusions Our results are consistent with previous descriptions of C3-glomerulonephritis. There was a suggestion of better clinical outcomes in patients treated with immunosuppression. There was a higher disease incidence in Pacific Islanders, which may indicate an underlying susceptibility to complement dysfunction in this population.
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Affiliation(s)
| | - Hari Talreja
- Department of Renal Medicine, Middlemore Hospital, 100 Hospital Rd, Otahuhu, Auckland, 2025, New Zealand.
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Affiliation(s)
- Yonatan Peleg
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Gerald B Appel
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, New York
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Caravaca-Fontán F, Díaz-Encarnación MM, Lucientes L, Cavero T, 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 AI, Bravo L, Lumbreras J, Allende N, Sanchez de la Nieta MD, Rodríguez E, Olea T, Melgosa M, Huerta A, Miquel R, Mon C, Fraga G, de Lorenzo A, Draibe J, Cano-Megías M, González F, Shabaka A, López-Rubio ME, Fenollosa MÁ, Martín-Penagos L, Da Silva I, Alonso Titos J, Rodríguez de Córdoba S, Goicoechea de Jorge E, Praga M. Mycophenolate Mofetil in C3 Glomerulopathy and Pathogenic Drivers of the Disease. Clin J Am Soc Nephrol 2020; 15:1287-1298. [PMID: 32816888 PMCID: PMC7480558 DOI: 10.2215/cjn.15241219] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 05/26/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND OBJECTIVES C3 glomerulopathy is a complement-mediated disease arising from abnormalities in complement genes and/or antibodies against complement components. Previous studies showed that treatment with corticosteroids plus mycophenolate mofetil (MMF) was associated with improved outcomes, although the genetic profile of these patients was not systematically analyzed. This study aims to analyze the main determinants of disease progression and response to this therapeutic regimen. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective, multicenter, observational cohort study in 35 nephrology departments belonging to the Spanish Group for the Study of Glomerular Diseases. Patients diagnosed with C3 glomerulopathy (n=81) or dense deposit disease (n=16) between January 1995 and March 2018 were enrolled. Multivariable and propensity score matching analyses were used to evaluate the association of clinical and genetic factors with response to treatment with corticosteroids and MMF as measured by proportion of patients with disease remission and kidney survival (status free of kidney failure). RESULTS The study group comprised 97 patients (84% C3 glomerulopathy, 16% dense deposit disease). Forty-two patients were treated with corticosteroids plus MMF, and this treatment was associated with a higher rate of remission and lower probability of kidney failure (79% and 14%, respectively) compared with patients treated with other immunosuppressives (24% and 59%, respectively), or ecluzimab (33% and 67%, respectively), or conservative management (18% and 65%, respectively). The therapeutic superiority of corticosteroids plus MMF was observed both in patients with complement abnormalities and with autoantibodies. However, patients with pathogenic variants in complement genes only achieved partial remission, whereas complete remissions were common among patients with autoantibody-mediated forms. The main determinant of no remission was baseline proteinuria. Relapses occurred after treatment discontinuation in 33% of the patients who had achieved remission with corticosteroids plus MMF, and a longer treatment length of MMF was associated with a lower risk of relapse. CONCLUSIONS The beneficial response to corticosteroids plus MMF treatment in C3 glomerulopathy appears independent of the pathogenic drivers analyzed in this study.
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Affiliation(s)
- Fernando Caravaca-Fontán
- Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Laura Lucientes
- Department of Immunology, 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 Clínic de Barcelona, Universitat de Barcelona,Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR); Institut d'Investigacions Biomediques August Pi I Sunyer, Barcelona, Spain
| | - Helena Marco
- Department of Nephrology, Hospital Universitari Germans Trias i Pujol, Badalona, 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
| | - 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 I Ávila
- Department of Nephrology, Hospital Universitario Doctor Peset, Valencia, Spain
| | - Luis Bravo
- Department of Nephrology, Hospital Universitario A Coruña, La Coruña, Spain
| | - Javier Lumbreras
- Pediatric Nephrology Unit, Hospital Universitario Son Espases, Balearic Islands Health Research Institute, 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
| | - Teresa Olea
- 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
| | - Marta Cano-Megías
- Department of Nephrology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, 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
| | - 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, Fundación Puigvert, Barcelona, Spain.,Centro de Investigaciones Biológicas, Consejo Superior de Investigaciones Científicas, Madrid and Centro de Investigación Biomédica en Red en Enfermedades Raras, Madrid, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain .,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Fakhouri F, Le Quintrec M, Frémeaux-Bacchi V. Practical management of C3 glomerulopathy and Ig-mediated MPGN: facts and uncertainties. Kidney Int 2020; 98:1135-1148. [PMID: 32622830 DOI: 10.1016/j.kint.2020.05.053] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 05/06/2020] [Accepted: 05/27/2020] [Indexed: 01/11/2023]
Abstract
In recent years, a substantial body of experimental and clinical work has been devoted to C3 glomerulopathy and Ig-mediated membranoproliferative glomerulonephritis. Despite the rapid accumulation of data, several uncertainties about these 2 rare forms of nephropathies persist. They concern their pathophysiology, classification, clinical course, relevance of biomarkers and of pathology findings, and assessment of the efficacy of the available therapies. The present review discusses the impact of these uncertainties on the clinical management of patients.
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Affiliation(s)
- Fadi Fakhouri
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Moglie Le Quintrec
- Department of nephrology, Université de Montpellier, CHU de Montpellier, Montpellier, France
| | - Véronique Frémeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Service d'Immunologie and Paris University, Paris, France
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Mastrangelo A, Serafinelli J, Giani M, Montini G. Clinical and Pathophysiological Insights Into Immunological Mediated Glomerular Diseases in Childhood. Front Pediatr 2020; 8:205. [PMID: 32478016 PMCID: PMC7235338 DOI: 10.3389/fped.2020.00205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/03/2020] [Indexed: 11/13/2022] Open
Abstract
The kidney is often the target of immune system dysregulation in the context of primary or systemic disease. In particular, the glomerulus represents the anatomical entity most frequently involved, generally as the expression of inflammatory cell invasion or circulant or in situ immune-complex deposition. Glomerulonephritis is the most common clinical and pathological manifestation of this involvement. There are no universally accepted classifications for glomerulonephritis. However, recent advances in our understanding of the pathophysiological mechanisms suggest the assessment of immunological features, biomarkers, and genetic analysis. At the same time, more accurate and targeted therapies have been developed. Data on pediatric glomerulonephritis are scarce and often derived from adult studies. In this review, we update the current understanding of the etiologic events and genetic factors involved in the pathogenesis of pediatric immunologically mediated primitive forms of glomerulonephritis, together with the clinical spectrum and prognosis. Possible new therapeutic targets are also briefly discussed.
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Affiliation(s)
- Antonio Mastrangelo
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Jessica Serafinelli
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Marisa Giani
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Montini
- Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Caravaca-Fontán F, Lucientes L, Cavero T, Praga M. Update on C3 Glomerulopathy: A Complement-Mediated Disease. Nephron Clin Pract 2020; 144:272-280. [PMID: 32369815 DOI: 10.1159/000507254] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 03/14/2020] [Indexed: 11/19/2022] Open
Abstract
C3 glomerulopathy (C3G) is a clinicopathologic entity secondary to dysregulation of the alternative complement pathway in plasma and the glomerular microenvironment. The current consensus definition of C3G relies on immunofluorescence staining criteria. However, due to its high clinical variability, these criteria may not be accurate enough in some clinical scenarios. Thus, a new pathogenic classification based on a cluster analysis of clinical, histologic, and genetic data has recently been proposed, which could also help identify patients at higher risk of progression. Several pathogenic abnormalities in complement genes have been described, and the role of autoantibodies in the disease is increasingly recognized, but still the genotype-phenotype correlations in C3G are poorly understood. C3G may be diagnosed in both children and adults. The spectrum of clinical manifestations is wide, although one of the most common clinical presentations is proteinuria with relatively preserved kidney function. In order to standardize the evaluation of kidney biopsies from these patients, a histopathologic index was recently proposed, including both parameters of activity and chronicity. However, this index has not yet been validated in independent cohorts. Currently, no targeted therapies are available in clinical settings for the treatment of C3G, although several new molecules are under investigation. Treatment with corticosteroids plus mycophenolate mofetil has been shown to be associated with improved renal outcomes, as compared to other immunosuppressive regimens. Yet, the main determinants of treatment response with this regimen and the influence of the underlying pathogenic drivers have not been extensively studied. The therapeutic response to eculizumab, an anti-C5 monoclonal antibody, has been shown to be highly heterogeneous. Thus, its current clinical indication in C3G is restricted to rapidly progressive forms of the disease. To summarize, in recent years, several important advances have taken place in the understanding of C3G, but still further studies are warranted to elucidate the best therapeutic strategies that could improve prognosis of this entity.
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Affiliation(s)
- Fernando Caravaca-Fontán
- Instituto de Investigación Hospital 12 de octubre (i+12), Madrid, Spain, .,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain,
| | - Laura Lucientes
- Instituto de Investigación Hospital 12 de octubre (i+12), Madrid, Spain.,Department of Immunology, Universidad Complutense de Madrid, Madrid, Spain
| | - Teresa Cavero
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de octubre (i+12), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Ahmad SB, Bomback AS. C3 Glomerulopathy: Pathogenesis and Treatment. Adv Chronic Kidney Dis 2020; 27:104-110. [PMID: 32553242 DOI: 10.1053/j.ackd.2019.12.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 12/13/2019] [Accepted: 12/13/2019] [Indexed: 12/18/2022]
Abstract
C3 glomerulopathy (C3G) is a rare set of kidney diseases with 2 patterns: C3 glomerulonephritis (C3GN) and dense deposit disease. Pathogenesis of both diseases is due to complement dysregulation in the alternative pathway. Acquired or genetic alterations of the regulatory proteins of the complement pathway result in C3G. Although the disease is characterized by low C3 levels in serum and C3-dominant staining by immunofluorescence on biopsy, other disease entities such as infection-related glomerulonephritis and masked monoclonal deposits can present similarly. Both the C3GN and dense deposit disease variants of C3G are progressive and recur in transplanted kidneys. Although no direct treatment is available, complement blockers are either available or in the clinical trial phase. This review will survey the pathogenesis of C3GN and current treatment options.
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Prakash R, Ali US, Ohri A, Parekhji SN, Deokar A, Khubchandani S. Clinico-pathological Profile and Outcome of C-3 Glomerulopathy in Indian Children. Indian J Nephrol 2020; 30:370-376. [PMID: 33840955 PMCID: PMC8023037 DOI: 10.4103/ijn.ijn_226_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 03/20/2019] [Accepted: 05/24/2019] [Indexed: 12/02/2022] Open
Abstract
Introduction: There is paucity of data of C3 glomerulopathy in Indian children. Methods: First Indian pediatric case series where consecutive renal biopsies done over a period of ten years were reviewed to identify those patients who had isolated or predominant C3 deposits on immunofluorescent microscopy, fulfilling the criteria for C-3 glomerulopathy. The clinical, biochemical, serological, histopathological profile, eGFR and the need for renal replacement therapy was analyzed. Results: Eighteen patients, comprising 5.3% (18/298) of all renal biopsies, had C3 glomerulopathy, four with Dense Deposit Disease (DDD) and fourteen with C3 Glomerulonephritis (C3GN) with a median follow-up of 38.2 months. Median age of presentation was 7.45±3.03 years (2.5yrs- 13.5yrs) with nine boys and nine girls. Presentation was nephrotic syndrome in seven (39%), acute nephritic syndrome in three (16.7%), hematuria in five (27.7%) and acute kidney injury in three (16.7%). Median eGFR was 69 ml/min/1.73m2 (8.2-107 ml/min/1.73m2). Hematuria was seen in 16 (88%), proteinuria in 18 (100%) and low C3 in 16 (88%) at the time of presentation. Mesangioproliferative glomerulonephritis was the predominant pattern in DDD while C3GN showed a mix of mesangioproliferative, membranoproliferative, endocapillary and crescentic GN (p = 0.43).Complete or partial remission was seen in seven patients who received long term alternate day steroids alone or with added mycophenolate mofetil. The cumulative patient survival was 70.8%. Kaplan Meir analyses for renal survival without progression to ESRD was 60.2% at one year and 48.1% at five and ten years. Conclusion: Interstitial fibrosis and tubular atrophy on renal biopsy was an independent predictor of adverse renal outcome in the cohort (p = 0.013, HR8.1;95% CI -1.6-42).
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Affiliation(s)
- Richa Prakash
- Division of Pediatric Nephrology, Department of Pediatrics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Uma S Ali
- Division of Pediatric Nephrology, Department of Pediatrics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Alpana Ohri
- Division of Pediatric Nephrology, Department of Pediatrics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Shashank Nitin Parekhji
- Division of Pediatric Nephrology, Department of Pediatrics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Atul Deokar
- Division of Pediatric Nephrology, Department of Pediatrics, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India
| | - Shaila Khubchandani
- Department of Pathology, Jaslok Hospital and Medical Research Institute, Mumbai, Maharashtra, India
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