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Bartoli G, Dello Strologo A, Grandaliano G, Pesce F. Updates on C3 Glomerulopathy in Kidney Transplantation: Pathogenesis and Treatment Options. Int J Mol Sci 2024; 25:6508. [PMID: 38928213 DOI: 10.3390/ijms25126508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/01/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024] Open
Abstract
C3 glomerulopathy is a rare disease, characterized by an abnormal activation of the complement's alternative pathway that leads to the accumulation of the C3 component in the kidney. The disease recurs in more than half of kidney transplant recipients, with a significant impact on graft survival. Recurrence of the primary disease represents the second cause of graft loss after organ rejection. In C3 glomerulopathy, there are several risk factors which can promote a recurrence during transplantation, such as delayed graft function, infection and monoclonal gammopathy. All these events can trigger the alternative complement pathway. In this review, we summarize the impact of C3 glomerulopathy on kidney grafts and present the latest treatment options. The most widely used treatments for the disease include corticosteroids and mycophenolate mofetil, which are already used chronically by kidney transplant recipients; thus, additional treatments for C3 glomerulopathy are required. Currently, several studies using anti-complement drugs (i.e., eculizumab, Ravalizumab, avacopan) for C3 glomerulopathy in kidney transplant patients are ongoing with encouraging results.
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Affiliation(s)
- Giulia Bartoli
- Department of Translational Medicine and Surgery, Università Cattolica dl Sacro Cuore, 00168 Rome, Italy
| | - Andrea Dello Strologo
- Department of Translational Medicine and Surgery, Università Cattolica dl Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Grandaliano
- Department of Translational Medicine and Surgery, Università Cattolica dl Sacro Cuore, 00168 Rome, Italy
- Nephrology, Dialysis and Transplantation Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Francesco Pesce
- Department of Translational Medicine and Surgery, Università Cattolica dl Sacro Cuore, 00168 Rome, Italy
- Division of Renal Medicine, "Ospedale Isola Tiberina-Gemelli Isola", 00186 Rome, Italy
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Jiang H, Shen Z, Zhuang J, Lu C, Qu Y, Xu C, Yang S, Tian X. Understanding the podocyte immune responses in proteinuric kidney diseases: from pathogenesis to therapy. Front Immunol 2024; 14:1335936. [PMID: 38288116 PMCID: PMC10822972 DOI: 10.3389/fimmu.2023.1335936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 12/29/2023] [Indexed: 01/31/2024] Open
Abstract
The glomerular filtration barrier, comprising the inner layer of capillary fenestrated endothelial cells, outermost podocytes, and the glomerular basement membrane between them, plays a pivotal role in kidney function. Podocytes, terminally differentiated epithelial cells, are challenging to regenerate once injured. They are essential for maintaining the integrity of the glomerular filtration barrier. Damage to podocytes, resulting from intrinsic or extrinsic factors, leads to proteinuria in the early stages and eventually progresses to chronic kidney disease (CKD). Immune-mediated podocyte injury is a primary pathogenic mechanism in proteinuric glomerular diseases, including minimal change disease, focal segmental glomerulosclerosis, membranous nephropathy, and lupus nephritis with podocyte involvement. An extensive body of evidence indicates that podocytes not only contribute significantly to the maintenance of the glomerular filtration barrier and serve as targets of immune responses but also exhibit immune cell-like characteristics, participating in both innate and adaptive immunity. They play a pivotal role in mediating glomerular injury and represent potential therapeutic targets for CKD. This review aims to systematically elucidate the mechanisms of podocyte immune injury in various podocyte lesions and provide an overview of recent advances in podocyte immunotherapy. It offers valuable insights for a deeper understanding of the role of podocytes in proteinuric glomerular diseases, and the identification of new therapeutic targets, and has significant implications for the future clinical diagnosis and treatment of podocyte-related disorders.
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Affiliation(s)
- Hong Jiang
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Zhirang Shen
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Jing Zhuang
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Chen Lu
- Division of Nephrology, Department of Internal Medicine, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yue Qu
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Chengren Xu
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Shufen Yang
- Division of Nephrology, Department of Internal Medicine, People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, China
| | - Xuefei Tian
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
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Chen B, Guan X, Gunning WT, Ge Y, Gohara AF, Dworkin LD, Gong R. Negative Modulation of B Cell Activation by Melanocortin 1 Receptor Signaling Protects against Membranous Nephropathy. J Am Soc Nephrol 2023; 34:467-481. [PMID: 36446431 PMCID: PMC10103281 DOI: 10.1681/asn.2022050605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 10/09/2022] [Accepted: 11/06/2022] [Indexed: 12/05/2022] Open
Abstract
SIGNIFICANCE STATEMENT Emerging evidence suggests that melanocortin neuropeptides-specifically adrenocorticotropic hormone-offer a novel, steroidogenic-independent therapeutic modality for membranous nephropathy (MN). The molecular mechanism underlying this beneficial effect, however, remains largely elusive. To investigate whether melanocortins modulate humoral immunity, the authors induced passive Heymann nephritis, a model of human MN, in wild-type and melanocortin 1 receptor (MC1R) knockout rats and treated them with melanocortin agents. Additional rats received adoptive transfer of bone marrow-derived cells beforehand from wild-type or MC1R knockout rats. The findings indicate that MC1R signaling plays a key role in negative modulation of B-cell activation and thereby suppresses humoral immune responses in passive Heymann nephritis, and suggest that MC1R signaling might offer a novel B cell-targeted therapeutic strategy for MN. BACKGROUND Emerging evidence suggests that the pituitary neuropeptide melanocortins-specifically, adrenocorticotropic hormone-offer a novel nonsteroidogenic therapeutic modality for membranous nephropathy (MN). However, the mechanism(s) of action remains elusive. METHODS To investigate whether melanocortins modulate humoral immunity, we induced passive Heymann nephritis (PHN), a model of MN, in wild-type (WT) and melanocortin 1 receptor (MC1R) knockout (KO) rats. We treated the animals with melanocortin agents-repository corticotropin injection, the nonsteroidogenic pan-melanocortin receptor agonist [Nle 4 , DPhe 7 ]-α-melanocyte stimulating hormone, the selective MC1R agonist MS05, vehicle gel, or phosphate-buffered saline-and evaluated kidney function, histology, and molecular changes. Additional rats received adoptive transfer of syngeneic bone marrow-derived cells beforehand from WT or MC1R KO rats. RESULTS KO of MC1R worsened PHN and this was associated with increased deposition of autologous immunoglobulin G (IgG) and complement C5b-9 in glomeruli and higher circulating levels of autologous IgG-evidence of a sensitized humoral immune response. Melanocortin therapy ameliorated PHN in WT rats, coinciding with reduced glomerular deposition of autologous IgG and C5b -9. The beneficial efficacy of melanocortins was blunted in KO rats but restored by adoptive transfer of syngeneic bone marrow-derived cells derived from WT rats. Mechanistically, MC1R was expressed in B lymphocytes and was negatively associated with B cell activation. MC1R agonism triggered the expression of microphthalmia-associated transcription factor in activated B cells in a cAMP-dependent mode and also repressed the expression of interferon regulatory factor 4 (a lymphoid transcription factor essential for B-cell development and maturation), resulting in suppressed plasma cell differentiation and IgG production. CONCLUSIONS MC1R signaling negatively modulates B cell activation and suppresses humoral immune responses in PHN, suggesting that MC1R signaling might offer a novel therapeutic target for MN.
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Affiliation(s)
- Bohan Chen
- Division of Nephrology, University of Toledo College of Medicine, Toledo, Ohio
- Current address: Blood Purification Center, Institute of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xuejing Guan
- Division of Nephrology, University of Toledo College of Medicine, Toledo, Ohio
| | - William T. Gunning
- Department of Pathology, University of Toledo Medical Center, Toledo, Ohio
| | - Yan Ge
- Division of Nephrology, University of Toledo College of Medicine, Toledo, Ohio
| | - Amira F. Gohara
- Department of Pathology, University of Toledo Medical Center, Toledo, Ohio
| | - Lance D. Dworkin
- Division of Nephrology, University of Toledo College of Medicine, Toledo, Ohio
- Division of Kidney Disease and Hypertension, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Rujun Gong
- Division of Nephrology, University of Toledo College of Medicine, Toledo, Ohio
- Division of Kidney Disease and Hypertension, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Physiology and Pharmacology, University of Toledo College of Medicine, Toledo, Ohio
- Center for Diabetes and Endocrine Research, University of Toledo Medical Center, Toledo, Ohio
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Guan X, Chen B, Malhotra DK, Gohara AF, Dworkin LD, Gong R. Hematopoietic-specific melanocortin 1 receptor signaling protects against nephrotoxic serum nephritis and mediates the beneficial effect of melanocortin therapy. Kidney Int 2023; 103:331-342. [PMID: 36374665 PMCID: PMC10431720 DOI: 10.1016/j.kint.2022.09.025] [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: 08/05/2021] [Revised: 08/25/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
The melanocortin hormone system has emerged as a novel therapeutic target for treating refractory glomerular diseases. However, the role of hematopoietic melanocortin 1 receptor (MC1R) signaling remains unknown. Upon insult by rabbit nephrotoxic serum, MC1R null-mutant mice developed more severe crescentic glomerulonephritis than wild-type mice, marked by aggravated proteinuria, kidney dysfunction and histologic lesions. Melanocortin therapy, using Repository Corticotropin Injection (Acthar Gel), the pan-melanocortin receptor agonist NDP-MSH, or the MC1R agonist MS05, ameliorated experimental nephritis in wild-type mice but this effect was blunted in null mice. Exacerbated experimental nephritis in null mice was associated with increased glomerular deposition of autologous IgG and C5b-9, in parallel with higher circulating levels of autologous IgG2c and IgG3. Additionally, the Th1 immune response was potentiated in null mice with experimental nephritis, accompanied by diminished kidney FoxP3+ regulatory T cells. Kidney infiltration of macrophages was also augmented by MC1R deficiency with an enhanced M1 polarization. Moreover, adoptive transfer of syngeneic bone marrow-derived cells from wild-type mice mitigated experimental nephritis in null mice and restored the beneficial efficacy of melanocortins. Mechanistically, MC1R was expressed by diverse subsets of kidney leukocytes, including macrophages, T and B lymphocytes, and was inversely associated with the NFκB pathway, a key player in immune responses. MS05 attenuated the production of rabbit IgG-specific IgG2c and IgG3 in cultured wild-type splenocytes, and promoted M2 polarization in M1-primed wild-type macrophages, associated with NFκB inhibition. In contrast, in null splenocytes or macrophages, this effect of MS05 was barely detectable, but was mimicked by an NFκB inhibitor. Thus, hematopoietic MC1R signaling attenuates experimental nephritis and mediates the beneficial effect of melanocortin therapy via, in part, regulating the immune response.
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Affiliation(s)
- Xuejing Guan
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA; The Center for Diabetes and Endocrine Research, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Bohan Chen
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA; The Center for Diabetes and Endocrine Research, University of Toledo Medical Center, Toledo, Ohio, USA; Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Deepak K Malhotra
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Amira F Gohara
- Department of Pathology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Lance D Dworkin
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Rujun Gong
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA; The Center for Diabetes and Endocrine Research, University of Toledo Medical Center, Toledo, Ohio, USA; Department of Physiology and Pharmacology, University of Toledo College of Medicine, Toledo, Ohio, USA.
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Wang Y, Dang X, Wu X, Li Y, He Q, Li X. Real-word adrenocorticotropic hormone treatment for childhood-onset nephrotic syndrome. Front Pediatr 2023; 11:1044075. [PMID: 36969288 PMCID: PMC10036038 DOI: 10.3389/fped.2023.1044075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/14/2023] [Indexed: 03/29/2023] Open
Abstract
Background Current first-line anti-proteinuric treatments do not produce a satisfactory therapeutic effect in a considerable number of patients with nephrotic syndrome (NS). Interest in adrenocorticotropic hormone (ACTH) for the treatment of NS has recently been revived. The present study investigated the efficacy and safety of ACTH treatment in children with frequent relapsing NS (FRNS), steroid-dependent NS (SDNS), and steroid-resistant NS (SRNS). Method The ACTH treatment group was comprised of NS patients receiving ACTH treatment. Patients with serum cortisol concentrations <85.3 nmol/L and who had not received ACTH treatment previously were enrolled in the control group from January 2018 to January 2021. The maintenance dose of prednisone, the number of disease recurrences, the time of first disease relapse, immunosuppressant use, serum cortisol levels, and adverse events were recorded in both groups. Results Fifty-one patients were included in the ACTH group, and twenty-one patients were enrolled in the control group. Concurrent treatment with one or more immunosuppressive and/or cytotoxic treatments occurred in 92.2% and 85.7% of patients in the ACTH and control groups, respectively, throughout the study period. A greater reduction in the prednisone maintenance dose was observed in the ACTH group compared with the control group after 1 year of follow up (0.603 ± 0.445 mg/kg vs. 0.267 ± 0.500 mg/kg, p = 0.006). During the one-year study period, fewer participants experienced one or more disease relapses in the ACTH group (45.1%) compared to the control group (76.2%, odds ratio = 3.896, p = 0.016). The number of disease recurrences per patient in the ACTH group was less than that in the control group (median difference = -1, p = 0.006). The mean length of remission was 8.902 m and 7.905 m in the ACTH group and control group, respectively. A log-rank test showed a longer relapse free survival for patients in the ACTH group (p = 0.046), but the Breslow test showed no significant difference between groups (p = 0.104). Ten patients in the ACTH group successfully discontinued all drug therapies. No patients in the control group were able to discontinue drug therapy as of February 2022. Conclusion ACTH, combined with multiple drugs, is effective at reducing the prednisone maintenance dose and may effectively prevent disease relapses in childhood NS.
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Affiliation(s)
- Ying Wang
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics Nephrology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiqiang Dang
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics Nephrology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiaochuan Wu
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics Nephrology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Yongzhen Li
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics Nephrology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qingnan He
- Department of Pediatrics, The Third Xiangya Hospital, Central South University, Changsha, China
- Correspondence: Qingnan He Xiaoyan Li
| | - Xiaoyan Li
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
- Department of Pediatrics Nephrology, Children's Medical Center, The Second Xiangya Hospital, Central South University, Changsha, China
- Correspondence: Qingnan He Xiaoyan Li
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Yuan XC, Tao YX. Ligands for Melanocortin Receptors: Beyond Melanocyte-Stimulating Hormones and Adrenocorticotropin. Biomolecules 2022; 12:biom12101407. [PMID: 36291616 PMCID: PMC9599618 DOI: 10.3390/biom12101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
The discovery of melanocortins in 1916 has resulted in more than 100 years of research focused on these peptides. Extensive studies have elucidated well-established functions of melanocortins mediated by cell surface receptors, including MSHR (melanocyte-stimulating hormone receptor) and ACTHR (adrenocorticotropin receptor). Subsequently, three additional melanocortin receptors (MCRs) were identified. Among these five MCRs, MC3R and MC4R are expressed primarily in the central nervous system, and are therefore referred to as the neural MCRs. Since the central melanocortin system plays important roles in regulating energy homeostasis, targeting neural MCRs is emerging as a therapeutic approach for treating metabolic conditions such as obesity and cachexia. Early efforts modifying endogenous ligands resulted in the development of many potent and selective ligands. This review focuses on the ligands for neural MCRs, including classical ligands (MSH and agouti-related peptide), nonclassical ligands (lipocalin 2, β-defensin, small molecules, and pharmacoperones), and clinically approved ligands (ACTH, setmelanotide, bremelanotide, and several repurposed drugs).
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Affiliation(s)
- Xiao-Chen Yuan
- College of Animal Science and Technology, Anhui Agricultural University, Hefei 230061, China
| | - Ya-Xiong Tao
- Department of Anatomy, Physiology and Pharmacology, College of Veterinary Medicine, Auburn University, Auburn, AL 36849, USA
- Correspondence:
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How immunosuppressive drugs may directly target podocytes in glomerular diseases. Pediatr Nephrol 2022; 37:1431-1441. [PMID: 34244853 DOI: 10.1007/s00467-021-05196-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 06/07/2021] [Accepted: 06/16/2021] [Indexed: 12/11/2022]
Abstract
Podocytes are the direct target of immunologic injury in many immune-mediated glomerular diseases, leading to proteinuria and subsequent kidney failure. Immunosuppressive agents such as steroids, calcineurin inhibitors, and rituximab are the commonly used treatment strategies in this context for their immunotherapeutic or anti-inflammatory properties. However, in recent years, studies have demonstrated that immunosuppressive agents can have a direct effect on podocytes, introducing the concept of the non-immunologic mechanism of kidney protection by immunomodulators. In this review, we focus on the mechanisms by which these agents may directly target the podocyte independent of their systemic effects and examine their clinical significance.
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8
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Chen B, Alam Z, Ge Y, Dworkin L, Gong R. Pharmacological Melanocortin 5 Receptor Activation Attenuates Glomerular Injury and Proteinuria in Rats With Puromycin Aminonucleoside Nephrosis. Front Physiol 2022; 13:887641. [PMID: 35721571 PMCID: PMC9198460 DOI: 10.3389/fphys.2022.887641] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/10/2022] [Indexed: 11/13/2022] Open
Abstract
Clinical evidence indicates that the melanocortin peptide ACTH is effective in inducing remission of nephrotic glomerulopathies like minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS), including those resistant to steroids. This suggests that a steroid-independent melancortinergic mechanism may contribute. However, the type of melanocortin receptor (MCR) that conveys this beneficial effect as well as the underlying mechanisms remain controversial. Burgeoning evidence suggests that MC5R is expressed in glomeruli and may be involved in glomerular pathobiology. This study aims to test the effectiveness of a novel highly selective MC5R agonist (MC5R-A) in puromycin aminonucleoside (PAN) nephrosis. Upon PAN injury, rats developed evident proteinuria on day 5, denoting an established nephrotic glomerulopathy. Following vehicle treatment, proteinuria continued to persist on day 14 with prominent histologic signs of podocytopathy, marked by ultrastructural glomerular lesions, including extensive podocyte foot process effacement. Concomitantly, there was loss of podocyte homeostatic markers, such as synaptopodin and podocin, and de novo expression of the podocyte injury marker desmin. Treatment with MC5R-A attenuated urine protein excretion and mitigated the loss of podocyte marker proteins, resulting in improved podocyte ultrastructural changes. In vitro in cultured podocytes, MC5R-A prevented the PAN-induced disruption of actin cytoskeleton integrity and apoptosis. MC5R-A treatment in PAN-injured podocytes also reinstated inhibitory phosphorylation and thus averted hyperactivity of GSK3β, a convergent point of multiple podocytopathic pathways. Collectively, pharmacologic activation of MC5R by using the highly selective small-molecule agonist is likely a promising therapeutic strategy to improve proteinuria and glomerular injury in protenuric nephropathies.
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Affiliation(s)
- Bohan Chen
- Division of Nephrology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, United States
- The Center for Diabetes and Endocrine Research, University of Toledo, Toledo, OH, United States
- Center for Hypertension and Precision Medicine, University of Toledo Medical Center, Toledo, OH, United States
- Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
| | - Zubia Alam
- Division of Nephrology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, United States
| | - Yan Ge
- Division of Nephrology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, United States
| | - Lance Dworkin
- Division of Nephrology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, United States
| | - Rujun Gong
- Division of Nephrology, Department of Medicine, University of Toledo Medical Center, Toledo, OH, United States
- The Center for Diabetes and Endocrine Research, University of Toledo, Toledo, OH, United States
- Center for Hypertension and Precision Medicine, University of Toledo Medical Center, Toledo, OH, United States
- Department of Physiology and Pharmacology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, United States
- *Correspondence: Rujun Gong,
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Chen L, Wu J, Ying D, Jiang M, Xu Y, Mo Y, Rong L, Jiang X. Application of adrenocorticotropic hormone in recurrent focal segmental glomerulosclerosis post-transplantation: A case report and literature review. Pediatr Transplant 2022; 26:e14184. [PMID: 34724313 DOI: 10.1111/petr.14184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/29/2021] [Accepted: 10/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The recurrence rate of focal segmental glomerulosclerosis (FSGS) post-renal transplantation is as high as 30%-50%. However, the pathogenesis is unclear. At present, there is no unified standard for the treatment of recurrent FSGS post-transplantation. Its treatment is full of risks and challenges. METHODS We report a child with recurrent FSGS with massive proteinuria 6~9 g/m2 /day and resistance to plasma exchange (PE) and rituximab (RTX). On the basis of receiving anti-rejection therapy of prednisone, tacrolimus, and mycophenolate mofetil (MMF), we treated the child with adrenocorticotropic hormone (ACTH), and reviewed the literature on the application of ACTH in the recurrence of FSGS post-transplantation. RESULTS After 1 year of treatment with ACTH, the patient's urinary protein decreased and fluctuated between 0.6 and 1.1 g/m2 /day. The albumin (ALB) and cholesterol (CHOL) returned to the normal range. The patient achieved complete remission after 19 months of ACTH treatment and maintained until now. There was no obvious adverse reaction. Literature review showed that up to February 2021, a total of 8 studies showed the use of ACTH in kidney transplant patients, and all the patients in the study achieved remission. CONCLUSIONS ACTH is a potential option for treating recurrent FSGS post-transplantation with fewer side effects and relatively safe for patients. However, further evaluation is needed to better adapt to different populations.
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Affiliation(s)
- Lizhi Chen
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jingyi Wu
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Daojing Ying
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Mengjie Jiang
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yuanyuan Xu
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Ying Mo
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Liping Rong
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xiaoyun Jiang
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Jauhal A, Prasad B, Rousseau-Gagnon M, Ouellet G, A Hladunewich M. Synthetic ACTH for Treatment of Glomerular Diseases: A Case Series. Can J Kidney Health Dis 2022; 9:20543581211066979. [PMID: 35024153 PMCID: PMC8744192 DOI: 10.1177/20543581211066979] [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] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 11/10/2021] [Indexed: 11/30/2022] Open
Abstract
Rationale: Synthetic adrenocorticotropic hormone (Tetracosactide) has been used in the
treatment of refractory glomerular diseases. Literature surrounding the use
of this medication is limited to small case series and there is conflicting
data on the rate of adverse events associated with this medication. Presenting concerns of the patient: Glomerulonephritis not in remission after at least 6 months of treatment with
conservative care. Stable doses of concurrent immunosuppression were
permitted. Diagnoses: Membranous nephropathy, IgA nephropathy, minimal change disease, and focal
and segmental glomerulosclerosis. Intervention: Intramuscular synthetic adrenocorticotropic hormone (Tetracosactide,
Synacthen Depot) with doses of either 1 mg weekly or 1 mg twice weekly. Outcomes: Five of 12 patients had at least a partial remission with Tetracosactide.
Median time to response was 6 months for responders. Five of the 12 patients
had adverse events documented, 2 of which led to treatment discontinuation.
No patients with focal and segmental glomerulosclerosis responded to
treatment. Lessons Learned: Higher rate of adverse events than previously reported with synthetic
adrenocorticotropic hormone and uncertain treatment efficacy.
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Affiliation(s)
- Arenn Jauhal
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina General Hospital, Regina, SK, Canada
| | | | - Gabriel Ouellet
- Division of Nephrology, CHU de Québec-Université Laval, Québec City, QC, Canada
| | - Michelle A Hladunewich
- Division of Nephrology, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Hu D, Li J, Zhuang Y, Mao X. Adrenocorticotropic hormone: An expansion of our current understanding of the treatment for nephrotic syndrome. Steroids 2021; 176:108930. [PMID: 34648797 DOI: 10.1016/j.steroids.2021.108930] [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: 12/20/2020] [Revised: 09/14/2021] [Accepted: 09/30/2021] [Indexed: 11/26/2022]
Abstract
In clinical practice, we may encounter a treatment dilemma where in some patients with nephrotic syndrome are resistant to glucocorticoids or immunosuppressive agents. Thus, we currently lack viable treatment options and eagerly await the availability of new drugs. Adrenocorticotropic hormone (ACTH) had earlier been used to treat nephrotic syndrome in children, but has now become less popular owing to the advent of oral glucocorticoids. However, in recent studies, ACTH was reportedly used again for treating nephrotic syndrome, reducing proteinuria and protecting renal function, indicating a possibility for its use in the treatment of refractory nephrotic syndrome. This review analysed the validity of ACTH in these studies, focusing on the mechanism of action, application in both paediatric and adult patients with nephrotic syndrome, particularly in children, and possible side effects. We anticipate that our findings will help clinicians in treatment decision-making.
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Affiliation(s)
- Dongxu Hu
- Southwest Medical University, No. 1, Section 1, Xianglin Road, Longmatan District, Luzhou City, Sichuan Province, China
| | - Jiaqin Li
- Southwest Medical University, No. 1, Section 1, Xianglin Road, Longmatan District, Luzhou City, Sichuan Province, China
| | - Yuan Zhuang
- Department of Paediatrics, The Affiliated Hospital of Southwest Medical University, Sichuan Clinical Research Center for Birth Defects, No. 25, Taiping Street, Luzhou City, Sichuan Province, China
| | - Xiaoyan Mao
- Department of Paediatrics, The Affiliated Hospital of Southwest Medical University, Sichuan Clinical Research Center for Birth Defects, No. 25, Taiping Street, Luzhou City, Sichuan Province, China.
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Naseer MS, Singh A, Singh N. Repository Corticotropin in Treating de novo C3 Glomerulonephritis after Transplantation. GLOMERULAR DISEASES 2021; 2:100-105. [PMID: 36751532 PMCID: PMC9670034 DOI: 10.1159/000520387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/17/2021] [Indexed: 11/19/2022]
Abstract
Introduction De novo C3 glomerulonephritis (C3GN) after transplant is uncommon. Although eculizumab has been used successfully in several cases, the response is heterogeneous, and treatment strategies remain undefined. The use of repository corticotropin in C3GN has not been described in the literature. Case Report A 48-year-old African American male with kidney transplantation secondary to presumed diabetic nephropathy presented 6 years after transplant with lower extremity edema and nephrotic range proteinuria. His urine protein to creatinine ratio (UPCR) was 8.2 g/g. Renal allograft biopsy confirmed the diagnosis of C3GN. He was treated with eculizumab (Solaris®) 900 mg IV once weekly for 4 weeks and repository corticotropin (H.P. Acthar® gel) 80 units SQ twice weekly for 6 months with a near-complete resolution of proteinuria within 3 months of the treatment. The patient presented again 6 months after completing the therapy with a recurrence of proteinuria, which peaked at 11.6 g/g of UPCR. Repeat kidney allograft biopsy was consistent with C3GN. He was started on repository corticotropin 80 units SQ twice weekly, which resulted in a reduction of proteinuria to >50% within 2 months of therapy. When eculizumab 900 mg IV weekly for 4 weeks was added with repository corticotropin, the proteinuria resolved within 10 weeks of treatment. The patient was maintained on monotherapy of repository corticotropin and has been in complete remission of proteinuria for more than a year until his last follow-up. Conclusion This is the first case report describing the role of repository corticotropin as an effective therapy in reducing proteinuria and maintaining patients with C3GN in proteinuria remission.
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Sun K, Xie Q, Hao CM. Mechanisms of Scarring in Focal Segmental Glomerulosclerosis. KIDNEY DISEASES (BASEL, SWITZERLAND) 2021; 7:350-358. [PMID: 34604342 PMCID: PMC8443927 DOI: 10.1159/000517108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/27/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Focal segmental glomerulosclerosis (FSGS) is a histologic pattern characterized by focal glomerular scarring, which often progresses to systemic and diffuse glomerulosclerosis. Previous studies have emphasized that the initiation of classic FSGS occurs in podocytes. The dysfunction and loss of podocytes have been associated with the development of proteinuria and the progression of various diseases. In addition, primary, secondary, and genetic FSGS are caused by different mechanisms of podocyte injury. SUMMARY The potential sources and mechanism of podocyte supplementation are the focus of our current research. Increasing attention has been paid to the role played by parietal epithelial cells (PECs) during the progression of FSGS. PECs are not only the primary influencing factors in glomerulosclerosis lesions but also have repair abilities, which remain a focus of debate. Notably, other resident glomerular cells also play significant roles in the progression of this disease. KEY MESSAGE In this review, we focus on the mechanism of scarring in FSGS and discuss current and potential therapeutic strategies.
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Affiliation(s)
- Ke Sun
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Qionghong Xie
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chuan-Ming Hao
- Division of Nephrology, Huashan Hospital, Fudan University, Shanghai, China
- Nephrology Division, Vanderbilt University Medical Center School of Medicine, Nashville, Tennessee, USA
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Hubert JN, Suybeng V, Vallée M, Delhomme TM, Maubec E, Boland A, Bacq D, Deleuze JF, Jouenne F, Brennan P, McKay JD, Avril MF, Bressac-de Paillerets B, Chanudet E. The PI3K/mTOR Pathway Is Targeted by Rare Germline Variants in Patients with Both Melanoma and Renal Cell Carcinoma. Cancers (Basel) 2021; 13:2243. [PMID: 34067022 PMCID: PMC8125037 DOI: 10.3390/cancers13092243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Malignant melanoma and RCC have different embryonic origins, no common lifestyle risk factors but intriguingly share biological properties such as immune regulation and radioresistance. An excess risk of malignant melanoma is observed in RCC patients and vice versa. This bidirectional association is poorly understood, and hypothetic genetic co-susceptibility remains largely unexplored. Results: We hereby provide a clinical and genetic description of a series of 125 cases affected by both malignant melanoma and RCC. Clinical germline mutation testing identified a pathogenic variant in a melanoma and/or RCC predisposing gene in 17/125 cases (13.6%). This included mutually exclusive variants in MITF (p.E318K locus, N = 9 cases), BAP1 (N = 3), CDKN2A (N = 2), FLCN (N = 2), and PTEN (N = 1). A subset of 46 early-onset cases, without underlying germline variation, was whole-exome sequenced. In this series, thirteen genes were significantly enriched in mostly exclusive rare variants predicted to be deleterious, compared to 19,751 controls of similar ancestry. The observed variation mainly consisted of novel or low-frequency variants (<0.01%) within genes displaying strong evolutionary mutational constraints along the PI3K/mTOR pathway, including PIK3CD, NFRKB, EP300, MTOR, and related epigenetic modifier SETD2. The screening of independently processed germline exomes from The Cancer Genome Atlas confirmed an association with melanoma and RCC but not with cancers of established differing etiology such as lung cancers. Conclusions: Our study highlights that an exome-wide case-control enrichment approach may better characterize the rare variant-based missing heritability of multiple primary cancers. In our series, the co-occurrence of malignant melanoma and RCC was associated with germline variation in the PI3K/mTOR signaling cascade, with potential relevance for early diagnostic and clinical management.
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Affiliation(s)
- Jean-Noël Hubert
- Section of Genetics, International Agency for Research on Cancer (IARC-WHO), 69372 Lyon, France; (J.-N.H.); (M.V.); (T.M.D.); (P.B.); (J.D.M.)
| | - Voreak Suybeng
- Gustave Roussy, Département de Biopathologie, 94805 Villejuif, France; (V.S.); (F.J.)
| | - Maxime Vallée
- Section of Genetics, International Agency for Research on Cancer (IARC-WHO), 69372 Lyon, France; (J.-N.H.); (M.V.); (T.M.D.); (P.B.); (J.D.M.)
| | - Tiffany M. Delhomme
- Section of Genetics, International Agency for Research on Cancer (IARC-WHO), 69372 Lyon, France; (J.-N.H.); (M.V.); (T.M.D.); (P.B.); (J.D.M.)
| | - Eve Maubec
- Department of Dermatology, AP-HP, Hôpital Avicenne, University Paris 13, 93000 Bobigny, France;
- UMRS-1124, Campus Paris Saint-Germain-des-Prés, University of Paris, 75006 Paris, France
| | - Anne Boland
- Centre National de Recherche en Génomique Humaine, Université Paris-Saclay, CEA, 91057 Evry, France; (A.B.); (D.B.); (J.-F.D.)
| | - Delphine Bacq
- Centre National de Recherche en Génomique Humaine, Université Paris-Saclay, CEA, 91057 Evry, France; (A.B.); (D.B.); (J.-F.D.)
| | - Jean-François Deleuze
- Centre National de Recherche en Génomique Humaine, Université Paris-Saclay, CEA, 91057 Evry, France; (A.B.); (D.B.); (J.-F.D.)
| | - Fanélie Jouenne
- Gustave Roussy, Département de Biopathologie, 94805 Villejuif, France; (V.S.); (F.J.)
| | - Paul Brennan
- Section of Genetics, International Agency for Research on Cancer (IARC-WHO), 69372 Lyon, France; (J.-N.H.); (M.V.); (T.M.D.); (P.B.); (J.D.M.)
| | - James D. McKay
- Section of Genetics, International Agency for Research on Cancer (IARC-WHO), 69372 Lyon, France; (J.-N.H.); (M.V.); (T.M.D.); (P.B.); (J.D.M.)
| | | | - Brigitte Bressac-de Paillerets
- Gustave Roussy, Département de Biopathologie, 94805 Villejuif, France; (V.S.); (F.J.)
- INSERM U1279, Tumor Cell Dynamics, 94805 Villejuif, France
| | - Estelle Chanudet
- Section of Genetics, International Agency for Research on Cancer (IARC-WHO), 69372 Lyon, France; (J.-N.H.); (M.V.); (T.M.D.); (P.B.); (J.D.M.)
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Heksch R, Bowden S, Hoffman R. Novel function of adrenocorticotropic hormone in the stimulation of vascular endothelial growth factor release in healthy children and adolescents: a proof-of-concept study. Ann Pediatr Endocrinol Metab 2021; 26:46-52. [PMID: 33541031 PMCID: PMC8026337 DOI: 10.6065/apem.2040110.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 09/28/2020] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To assess the effect of adrenocorticotropic hormone (ACTH) on plasma vascular endothelial growth factor (VEGF) levels in healthy children and adolescents and to inform future work on the effects of ACTH on VEGF in bone. METHODS An Institutional Review Board-approved prospective study of 10 healthy subjects, ages 9-17, was conducted to assess the effect of ACTH on plasma VEGF levels. VEGF levels were collected at baseline and every 30 minutes for 3 hours. Cosyntropin (a synthetic ACTH analogue) was administered at a low-dose (1 μg) given at t=0 minutes and a high-dose (250 μg) given at t=60 minutes. A Friedman test was performed comparing baseline to peak VEGF levels after stimulation with low-dose and high-dose cosyntropin. RESULTS Peak plasma VEGF levels significantly increased after high-dose cosyntropin compared with baseline (P=0.042). Peak plasma VEGF levels did not significantly increase after low-dose cosyntropin compared to baseline. CONCLUSION To our knowledge, this is the first study to demonstrate that ACTH administration causes a significant increase in plasma VEGF levels in humans. This finding may have important implications in the protective effects of ACTH on bone. Decreased bone mineral density and adrenal suppression are common side effects of glucocorticoid use in pediatrics. VEGF increases vascularity and may play a role in reducing glucocorticoid-induced bone disease. Animal studies have shown that ACTH stimulates release of VEGF in osteoblasts, though this effect has yet to be evaluated in humans.
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Affiliation(s)
- Ryan Heksch
- Nationwide Children's Hospital, Columbus, OH, USA,Akron Children's Hospital, Akron, OH, USA,Address for correspondence: Ryan Heksch Department of Pediatric Endocrinology and Diabetes, Akron Children’s Hospital, 215 W. Bowery St., Akron, OH, 44308, USA
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Chang M, Chen B, Shaffner J, Dworkin LD, Gong R. Melanocortin System in Kidney Homeostasis and Disease: Novel Therapeutic Opportunities. Front Physiol 2021; 12:651236. [PMID: 33716796 PMCID: PMC7943476 DOI: 10.3389/fphys.2021.651236] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/03/2021] [Indexed: 12/30/2022] Open
Abstract
Melanocortin peptides, melanocortin receptors, melanocortin receptor accessory proteins, and endogenous antagonists of melanocortin receptors are the key components constituting the melanocortin hormone system, one of the most complex and important hormonal systems in our body. A plethora of evidence suggests that melanocortins possess a protective activity in a variety of kidney diseases in both rodent models and human patients. In particular, the steroidogenic melanocortin peptide adrenocorticotropic hormone (ACTH), has been shown to exert a beneficial effect in a number of kidney diseases, possibly via a mechanism independent of its steroidogenic activity. In patients with steroid-resistant nephrotic glomerulopathy, ACTH monotherapy is still effective in inducing proteinuria remission. This has inspired research on potential implications of the melanocortin system in glomerular diseases. However, our understanding of the role of the melanocortinergic pathway in kidney disease is very limited, and there are still huge unknowns to be explored. The most controversial among these is the identification of effector cells in the kidney as well as the melanocortin receptors responsible for conveying the renoprotective action. This review article introduces the melanocortin hormone system, summarizes the existing evidence for the expression of melanocortin receptors in the kidney, and evaluates the potential strategy of melanocortin therapy for kidney disease.
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Affiliation(s)
- Mingyang Chang
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, OH, United States
| | - Bohan Chen
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, OH, United States
| | - James Shaffner
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, OH, United States
| | - Lance D Dworkin
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, OH, United States
| | - Rujun Gong
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, OH, United States
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17
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Podestà MA, Ponticelli C. Autoimmunity in Focal Segmental Glomerulosclerosis: A Long-Standing Yet Elusive Association. Front Med (Lausanne) 2020; 7:604961. [PMID: 33330569 PMCID: PMC7715033 DOI: 10.3389/fmed.2020.604961] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/26/2020] [Indexed: 01/17/2023] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a histological term that describes a pathologic renal entity affecting both adults and children, with a wide array of possible underlying etiologies. Podocyte damage with scarring, the hallmark of this condition, leads to altered permeability of the glomerular barrier, which may result in massive proteinuria and relentless renal function deterioration. A definite cause of focal segmental glomerulosclerosis can be confirmed in a minority of cases, while most forms have been traditionally labeled as primary or idiopathic. Despite this definition, increasing evidence indicates that primary forms are a heterogenous group rather than a single disease entity: several circulating factors that may affect glomerular permeability have been proposed as potential culprits, and both humoral and cellular immunity have been implicated in the pathogenesis of the disease. Consistently, immunosuppressive drugs are considered as the cornerstone of treatment for primary focal segmental glomerulosclerosis, but response to these agents and long-term outcomes are highly variable. In this review we provide a summary of historical and recent advances on the pathogenesis of primary focal segmental glomerulosclerosis, focusing on implications for its differential diagnosis and treatment.
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Hayes K, Warner E, Bollinger C, Wright D, Fitch RM. Repository corticotropin injection versus corticosteroids for protection against renal damage in a focal segmental glomerulosclerosis rodent model. BMC Nephrol 2020; 21:226. [PMID: 32539845 PMCID: PMC7296742 DOI: 10.1186/s12882-020-01879-6] [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: 11/22/2019] [Accepted: 06/02/2020] [Indexed: 12/30/2022] Open
Abstract
Background Focal segmental glomerulosclerosis (FSGS) causes renal fibrosis and may lead to kidney failure. FSGS and its common complication, proteinuria, are challenging to treat. Corticosteroids are ineffective in many patients with FSGS, and alternative treatments often yield suboptimal responses. Repository corticotropin injection (RCI; Acthar® Gel), a naturally sourced complex mixture of purified adrenocorticotropic hormone analogs and other pituitary peptides, may have beneficial effects on idiopathic FSGS via melanocortin receptor activation. Methods Two studies in a preclinical (female Sprague-Dawley rats) puromycin aminonucleoside FSGS model assessed the effect of RCI on renal function and morphology: an 8-week comparison of a single RCI dose with methylprednisolone (N = 27), and a 12-week chronic RCI dose range study (N = 34). Primary outcomes were proteinuria and renal pathology improvements for measures of renal fibrosis, tubular damage, glomerular injury, and total kidney injury score. Impact of RCI treatment was also determined by assessing urinary biomarkers for renal injury, podocyte expression of podoplanin (a biomarker for injury), podocyte effacement by electron microscopy, and histological staining for fibrosis biomarkers. Results Compared with saline treatment, RCI 30 IU/kg significantly reduced proteinuria, with a 38% reduction in peak mean urine protein levels on day 28 in the 8-week model, and RCI 10 IU/kg, 30 IU/kg, and 60 IU/kg reduced peak mean urine protein in the 12-week model by 18, 47, and 44%, respectively. RCI also showed significant dose-dependent improvements in fibrosis, interstitial inflammation, tubular injury, and glomerular changes. Total kidney injury score (calculated from histopathological evaluations) demonstrated statistically significant improvements with RCI 30 IU/kg in the 8-week study and RCI 60 IU/kg in the 12-week study. RCI treatment improved levels of urinary biomarkers of kidney injury (KIM-1 and OPN), expression of podoplanin, and podocyte morphology. RCI also reduced levels of desmin and fibrosis-associated collagen deposition staining. Methylprednisolone did not improve renal function or pathology in this model. Conclusions These results provide evidence supporting the improvement of FSGS with RCI, which was superior to corticosteroid treatment in this experimental model. To the authors’ knowledge, this is the first evidence that a drug for the treatment of FSGS supports podocyte recovery after repeated injury.
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Affiliation(s)
- Kyle Hayes
- Mallinckrodt Pharmaceuticals, 675 James S. McDonnell Blvd, 20-1-W, Hazelwood, MO, USA.
| | - Elizabeth Warner
- Mallinckrodt Pharmaceuticals, 675 James S. McDonnell Blvd, 20-1-W, Hazelwood, MO, USA
| | - Chris Bollinger
- Mallinckrodt Pharmaceuticals, 675 James S. McDonnell Blvd, 20-1-W, Hazelwood, MO, USA
| | - Dale Wright
- Mallinckrodt Pharmaceuticals, 675 James S. McDonnell Blvd, 20-1-W, Hazelwood, MO, USA
| | - Richard M Fitch
- Mallinckrodt Pharmaceuticals, 675 James S. McDonnell Blvd, 20-1-W, Hazelwood, MO, USA
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ACTH Treatment for Management of Nephrotic Syndrome: A Systematic Review and Reappraisal. Int J Nephrol 2020; 2020:2597079. [PMID: 32566293 PMCID: PMC7292987 DOI: 10.1155/2020/2597079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/07/2020] [Accepted: 04/29/2020] [Indexed: 01/15/2023] Open
Abstract
Background In recent years, the use of adrenocorticotropic hormone (ACTH) therapy for treatment of proteinuria due to nephrotic syndrome (NS) has been heavily explored. ACTH therapy, which comes in the natural (H. P. Acthar Gel) or synthetic (tetracosactide) form, has resulted in remission in patients with immunosuppressive and steroid-resistant NS. However, the exact efficacy of ACTH therapy in the NS etiologies, such as membranous nephropathy (MN), focal segmental glomerulosclerosis (FSGS), minimal change disease (MCD), lupus nephritis (LN), IgA nephropathy (IgAN), and membranoproliferative glomerulonephritis (MPGN), has not been determined. Objective This systematic review analyzed the published literature on ACTH therapy in various NS etiologies to determine its efficacy. Methods A comprehensive search of MEDLINE, EMBASE, and Cochrane databases was conducted for articles through June 2019. An additional search was performed on clinicaltrials.gov to search for additional trials and cross reference the results of our database search. The literature which studied synthetic or natural ACTH treatment in patients with known etiologies of NS was included. Studies were excluded when they consisted of a single case report or did not analyze the lone effect of ACTH in NS. Results The initial search yielded a total of 411 papers, and 22 papers were included. In 214 MN patients, there was an overall remission of 40% (85/214) and an overall remission of 43% (42/98) in FSGS patients. In other etiologies, there were overall remissions of 78% (11/14), 31% (5/16), 40% (16/40), and 62% (8/13) in MCD, LN, IgAN, and MPGN patients, respectively. Conclusion ACTH showed benefits in proteinuria reduction across all etiologies of NS. However, more randomized controlled studies with larger population sets and longer follow-ups are imperative to establish causal benefits. New studies into its efficacy in children are also necessary.
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Ostróżka-Cieślik A, Dolińska B. The Role of Hormones and Trophic Factors as Components of Preservation Solutions in Protection of Renal Function before Transplantation: A Review of the Literature. Molecules 2020; 25:E2185. [PMID: 32392782 PMCID: PMC7248710 DOI: 10.3390/molecules25092185] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/29/2020] [Accepted: 05/05/2020] [Indexed: 12/12/2022] Open
Abstract
Transplantation is currently a routine method for treating end-stage organ failure. In recent years, there has been some progress in the development of an optimal composition of organ preservation solutions, improving the vital functions of the organ and allowing to extend its storage period until implantation into the recipient. Optimizations are mostly based on commercial solutions, routinely used to store grafts intended for transplantation. The paper reviews hormones with a potential nephroprotective effect, which were used to modify the composition of renal perfusion and preservation solutions. Their effectiveness as ingredients of preservation solutions was analysed based on a literature review. Hormones and trophic factors are innovative preservation solution supplements. They have a pleiotropic effect and affect normal renal function. The expression of receptors for melatonin, prolactin, thyrotropin, corticotropin, prostaglandin E1 and trophic factors was confirmed in the kidneys, which suggests that they are a promising therapeutic target for renal IR (ischemia-reperfusion) injury. They can have anti-inflammatory, antioxidant and anti-apoptotic effects, limiting IR injury.
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Affiliation(s)
- Aneta Ostróżka-Cieślik
- Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, Kasztanowa 3, 41-200 Sosnowiec, Poland;
| | - Barbara Dolińska
- Department of Pharmaceutical Technology, Faculty of Pharmaceutical Sciences in Sosnowiec, Medical University of Silesia, Kasztanowa 3, 41-200 Sosnowiec, Poland;
- “Biochefa” Pharmaceutical Research and Production Plant, Kasztanowa 3, 41-200 Sosnowiec, Poland
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Melanocortin therapy ameliorates podocytopathy and proteinuria in experimental focal segmental glomerulosclerosis involving a podocyte specific non-MC1R-mediated melanocortinergic signaling. Clin Sci (Lond) 2020; 134:695-710. [PMID: 32167144 PMCID: PMC9870294 DOI: 10.1042/cs20200016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/02/2020] [Accepted: 03/13/2020] [Indexed: 01/26/2023]
Abstract
The clinical effectiveness of adrenocorticotropin in inducing remission of steroid-resistant nephrotic syndrome points to a steroidogenic-independent anti-proteinuric activity of melanocortins. However, which melanocortin receptors (MCR) convey this beneficial effect and if systemic or podocyte-specific mechanisms are involved remain uncertain. In vivo, wild-type (WT) mice developed heavy proteinuria and kidney dysfunction following Adriamycin insult, concomitant with focal segmental glomerulosclerosis (FSGS) and podocytopathy, marked by loss of podocin and synaptopodin, podocytopenia and extensive foot process effacement on electron microscopy. All these pathologic findings were prominently attenuated by NDP-MSH, a potent non-steroidogenic pan-MCR agonist. Surprisingly, MC1R deficiency in MC1R-null mice barely affected the severity of Adriamycin-elicited injury. Moreover, the beneficial effect of NDP-MSH was completely preserved in MC1R-null mice, suggesting that MC1R is likely non-essential for the protective action. A direct podocyte effect seems to contribute to the beneficial effect of NDP-MSH, because Adriamycin-inflicted cytopathic signs in primary podocytes prepared from WT mice were all mitigated by NDP-MSH, including apoptosis, loss of podocyte markers, de novo expression of the podocyte injury marker desmin, actin cytoskeleton derangement and podocyte hypermotility. Consistent with in vivo findings, the podoprotective activity of NDP-MSH was fully preserved in MC1R-null podocytes. Mechanistically, MC1R expression was predominantly distributed to glomerular endothelial cells in glomeruli but negligibly noted in podocytes in vivo and in vitro, suggesting that MC1R signaling is unlikely involved in direct podocyte protection. Ergo, melanocortin therapy protects against podocyte injury and ameliorates proteinuria and glomerulopathy in experimental FSGS, at least in part, via a podocyte-specific non-MC1R-mediated melanocortinergic signaling.
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Xu Y, Guan X, Zhou R, Gong R. Melanocortin 5 receptor signaling pathway in health and disease. Cell Mol Life Sci 2020; 77:3831-3840. [PMID: 32248247 DOI: 10.1007/s00018-020-03511-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/17/2020] [Accepted: 03/24/2020] [Indexed: 12/20/2022]
Abstract
Melanocortin hormone system plays a key role in maintaining the homeostasis of our body via their neuro-immune-endocrine activities and regulates a diverse array of physiological functions, including melanogenesis, inflammation, immunomodulation, adrenocortical steroidogenesis, hemodynamics, natriuresis, energy homeostasis, sexual function, and exocrine secretion. The pathobiologic actions of all melanocortins are conveyed by melanocortin receptors. As the last melanocortin receptor to be cloned and characterized, melanocortin receptor 5 (MC5R) is widely expressed in both central nervous system and a number of peripheral organ systems in man. However, the exact effect of the MC5R mediated melanocortinergic signaling remains largely uncertain. Owing to the recent advances in developing highly selective peptidomimetic agonists and antagonists of MC5R and also to studies in MC5R knockout animals, our understanding of MC5R pathobiology has been greatly expanded and strengthened. Evidence suggests that MC5R plays a key role in governing immune reaction and inflammatory response, and is pivotal for the regulation of sexual behavior, thermoregulation, and exocrine secretion, like sebogenesis, lacrimal secretion and release of sex pheromones. As such, recent translational efforts have focused on developing novel sebum-suppressive therapies for seborrhoea and acne vulgaris based on antagonizing MC5R. Conversely, selective MC5R agonists have demonstrated promising beneficial effects in immune-mediated diseases, metabolic endocrinopathies and other disease conditions, such as glomerular diseases and dry eyes, skin and mouth. Thus, MC5R-mediated signaling is essential for health. Therapeutic targeting of MC5R represents a promising and pragmatic therapeutic strategy for diverse diseases. This review article delineates the biophysiology of MC5R-mediated biophysiology of the melanocortin hormone system, discusses the existing data on MC5R-targeted therapy in experimental disease models, and envisages the translational potential for treating human diseases.
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Affiliation(s)
- Yahong Xu
- Division of Kidney Disease and Hypertension, Department of Medicine, Brown University School of Medicine, Providence, RI, USA.,Department of Nephrology, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xuejing Guan
- Division of Nephrology, Department of Medicine, The University of Toledo College of Medicine, Toledo, OH, USA
| | - Rong Zhou
- Department of Nephrology, Yangpu Hospital, Tongji University School of Medicine, Shanghai, China
| | - Rujun Gong
- Division of Kidney Disease and Hypertension, Department of Medicine, Brown University School of Medicine, Providence, RI, USA. .,Division of Nephrology, Department of Medicine, The University of Toledo College of Medicine, Toledo, OH, USA.
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Shrivastava S, Chen B, Dworkin LD, Malhotra DK, Gong R. Relapse of Nephrotic Syndrome after Adrenocorticotropic Hormone-Induced Remission: Implications of Adrenocorticotropic Hormone Antibodies. Am J Nephrol 2020; 51:390-394. [PMID: 32187600 DOI: 10.1159/000506854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 02/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Prolonged use of corticosteroids continues to be the mainstay in the management of most proteinuric glomerulopathies, but is limited by extensive side effects. Alternative medications such as adrenocorticotropic hormone (ACTH) have been recently used to treat refractory glomerulopathies and have shown superior outcomes when compared with steroids. However, the clinical responsiveness to ACTH therapy varies considerably with a number of patients exhibiting de novo or acquired resistance. The underlying mechanism remains unknown. METHODS A patient with steroid-dependent focal segmental glomerulosclerosis (FSGS) developed severe steroid side effects impacting quality of life and was converted to repository porcine ACTH therapy. Immediate response in the form of remission of nephrotic syndrome was noted followed by relapse in 10 weeks. Suspecting the role of some ACTH-antagonizing factors, the patient's serum was examined. RESULTS Immunoblot-based antibody assay revealed high titers of de novo IgG antibodies in the patient's serum that were reactive to the porcine corticotropin with negligible cross-reactivity to human corticotropin. In vitro, in cultured B16 melanoma cells that express abundant melanocortin receptors, addition of the patient's serum substantially abrogated the porcine corticotropin triggered signaling activity of the melanocortinergic pathway, marked by phosphorylation of glycogen synthase kinase 3β, thus suggesting a mitigating effect on the biological functionality of porcine corticotropin. CONCLUSION ACTH is a useful alternative therapeutic modality for refractory proteinuric glomerulopathies like FSGS. However, as quintessential therapeutic biologics, natural ACTH, regardless of purity and origin, is inevitably antigenic and may cause the formation of neutralizing antibodies in some sensitive patients, followed by resistance to ACTH therapy. It is imperative to develop ACTH analogues with less immunogenicity for improving its responsiveness in patients with glomerular diseases.
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Affiliation(s)
- Snehal Shrivastava
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Bohan Chen
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Lance D Dworkin
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Deepak K Malhotra
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA
| | - Rujun Gong
- Division of Nephrology, Department of Medicine, University of Toledo College of Medicine, Toledo, Ohio, USA,
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Zand L, Canetta P, Lafayette R, Aslam N, Jan N, Sethi S, Fervenza FC. An Open-Label Pilot Study of Adrenocorticotrophic Hormone in the Treatment of IgA Nephropathy at High Risk of Progression. Kidney Int Rep 2019; 5:58-65. [PMID: 31922061 PMCID: PMC6943772 DOI: 10.1016/j.ekir.2019.10.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/19/2019] [Accepted: 10/21/2019] [Indexed: 12/27/2022] Open
Abstract
Introduction IgA nephropathy (IgAN) is the most common glomerulonephritis with high risk of progression to end-stage renal disease in patients with proteinuria >1 g/24 hours. There are no known effective treatments in patients with IgAN. Methods We conducted a prospective open-label pilot study in patients with IgAN using adrenocorticotrophic hormone (ACTH) (Acthar Gel, Mallinckrodt Pharmaceuticals, Bedminster, NJ) at a dosage of 80 units subcutaneously twice weekly for a total of 6 months and followed patients for a total of 12 months. Patients had to have urinary protein >1 g/24 hours despite adequate renin-angiotensin-aldosterone system (RAAS) blockade and estimated glomerular filtration rate (eGFR) >30 ml/min at enrollment. Results A total of 19 patients were recruited and followed for 1 year. At baseline, the mean age was 34.9 ± 10.5 years with 11 men and 8 women, and 14 Caucasian and 5 Asian individuals. At 12 months, there was a statistically significant decline in 24-hour urinary protein from 2.6 to 1.3 g (P = 0.007) and significant increase in serum albumin (3.79 to 3.93, P = 0.02). There was no significant change in eGFR (65.5 to 61.1 ml/min, P = 0.1). There were 0 complete remissions and 8 partial remissions (42%). There were a total of 6 infections: 2 were viral and 4 required antibiotic therapy (2 sinusitis, 1 pneumonia, 1 otitis media). The most common adverse events included acne, hot flashes, soreness, and anxiety. Conclusion In summary, patients with IgAN with >1 g/24-hour urinary protein and eGFR >30 ml/min had a significant reduction in 24-hour urinary protein with stable eGFR at 12-month follow-up after being treated with 6 months of ACTH.
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Affiliation(s)
- Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Pietro Canetta
- Division of Nephrology and Hypertension, University of Columbia Medical Center, New York, New York, USA
| | - Richard Lafayette
- Division of Nephrology and Hypertension, Stanford University, Stanford, California, USA
| | - Nabeel Aslam
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida, USA
| | - Novak Jan
- Department of Microbiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
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Central Precocious Puberty as a Complication of Therapy with Adrenocorticotropin (ACTH) and an Aromatase Inhibitor for Refractory Nephrotic Syndrome. Case Rep Pediatr 2019; 2019:1624274. [PMID: 31093404 PMCID: PMC6476110 DOI: 10.1155/2019/1624274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/03/2019] [Indexed: 11/19/2022] Open
Abstract
Glucocorticoids are typically prescribed for the treatment of idiopathic nephrotic syndrome of childhood. In selected patients with refractory focal segmental glomuerulosclerosis (FSGS), adrenocorticotropin (ACTH) can be used to induce remission and decrease the progression of the disease. We report a 6 8/12-year-old girl with recurrent proteinuria, resistant to standard immunotherapy. She underwent related renal transplant but again developed proteinuria and was started on ACTH. She subsequently developed peripheral precocious puberty (PPP), presumably from peripheral aromatization of adrenal androgens. She was started on an aromatase inhibitor, and her ACTH dose was slowly decreased. She then developed central precocious puberty (CPP). We hypothesize that treatment of her peripheral precocious puberty with an aromatase inhibitor may have triggered central precocious puberty.
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Hartung DM, Johnston K, Deodhar A, Bourdette DN, Cohen DM. Repository Corticotropin Versus Glucocorticoid for Nephrotic Syndrome: When Will We See the Evidence? Am J Kidney Dis 2019; 74:256-262. [PMID: 30765104 DOI: 10.1053/j.ajkd.2018.12.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 12/04/2018] [Indexed: 01/13/2023]
Abstract
Despite little evidence supporting its superiority to glucocorticoid therapy, use and expenditures for repository corticotropin (rACTH) injection (H.P. Acthar Gel; Mallinckrodt) have increased dramatically in the last 5 years, particularly among a small number of nephrologists, rheumatologists, and neurologists. Recently, the manufacturer justified the extremely high and rapidly increasing cost of rACTH by citing the ongoing need to generate clinical data to support its use. We test this assertion by investigating the quality and provenance of the evidence likely to emerge in the foreseeable future. We identified all completed, in-progress, and proposed studies of rACTH registered at ClinicalTrials.gov. 75 studies representing 2,953 participants met inclusion criteria. Studies addressed primarily nephrologic (n = 23), rheumatologic (n = 28), and neurologic (n =22) indications. Of the 23 studies proposed for renal indications (enrollment, 33 ± 49 [mean ± SD]), 11 were not randomized, 8 compared only different rACTH treatment regimens, and 4 compared rACTH to placebo. No studies of rACTH proposed for renal indications included an rACTH-free arm receiving active treatment (ie, another form of immunosuppression). We conclude that evidence emerging in the foreseeable future is unlikely to broadly support rACTH use over lower-cost glucocorticoid-based alternatives for renal indications.
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Affiliation(s)
- Daniel M Hartung
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR
| | - Kirbee Johnston
- College of Pharmacy, Oregon State University/Oregon Health & Science University, Portland, OR
| | - Atul Deodhar
- Division of Rheumatology, Department of Medicine, Oregon Health & Science University, Portland, OR
| | - Dennis N Bourdette
- Department of Neurology, Oregon Health & Science University, Portland, OR; VA Portland Health Care System, Research Service, Portland, OR; MS Center of Excellence-West, VA Portland Health Care System, Portland, OR
| | - David M Cohen
- VA Portland Health Care System, Research Service, Portland, OR; Division of Nephrology and Hypertension, Department of Medicine, Oregon Health & Science University, Portland, OR.
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Keri KC, Blumenthal S, Kulkarni V, Beck L, Chongkrairatanakul T. Primary membranous nephropathy: comprehensive review and historical perspective. Postgrad Med J 2019; 95:23-31. [DOI: 10.1136/postgradmedj-2018-135729] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 12/01/2018] [Indexed: 11/04/2022]
Abstract
Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in non-diabetic Caucasian adults over 40 years of age. It has an estimated incidence of 8–10 cases per 1 million. Fifty per cent of patients diagnosed with primary MN continue to have nephrotic syndrome and 30% of patients may progress to end-stage renal disease over 10 years. Although it was recognised as a distinct clinic-pathological entity in 1940s by immunofluorescence and electron microscopy, the pathogenesis and treatment have become more apparent only in the last decade. Discovery of M-type phospholipase A2 receptor (PLA2R) antibodies and thrombospondin type 1 domain-containing 7A antibodies has given new perspectives in understanding the pathogenesis of the disease process. Anti-PLA2R antibody is the first serologic marker that has promising evidence to be used as a tool to prognosticate the course of the disease. More importantly, therapeutic agents such as rituximab and adrenocorticotropic hormone analogues are the newer therapeutic options that should be considered in the therapy of primary MN.
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Markell M, Brar A, Bhela S, Patel A, Salifu M. Use of Repository Corticotropin Gel (Acthar) in Progressive Nephrotic Syndrome Secondary to Transplant Glomerulopathy: A Report of Three Cases. Kidney Med 2019; 1:31-35. [PMID: 32734181 PMCID: PMC7380415 DOI: 10.1016/j.xkme.2018.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Transplant glomerulopathy is a feared complication of kidney transplantation, often resulting in rapid loss of kidney function and ultimate graft failure. The underlying cause is unclear, with both antibody and cell-mediated immune mechanisms postulated, as well as intrinsic glomerular factors. At the present time, there is no known therapy. We report here 3 cases in which corticotropin gel (Acthar) was used with varying response of proteinuria and stabilization of graft function with continued graft survival as long as 10 years following the diagnosis. Future randomized controlled trials are warranted to examine the efficacy and safety of ACTH gel therapy in nephrotic patients with transplant glomerulopathy.
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Affiliation(s)
| | | | | | | | - Moro Salifu
- SUNY-Downstate School of Medicine, Brooklyn, NY
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29
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Wang CS, Travers C, McCracken C, Leong T, Gbadegesin R, Quiroga A, Benfield MR, Hidalgo G, Srivastava T, Lo M, Yadin O, Mathias R, Araya CE, Khalid M, Orjuela A, Zaritsky J, Al-Akash S, Kamel M, Greenbaum LA. Adrenocorticotropic Hormone for Childhood Nephrotic Syndrome: The ATLANTIS Randomized Trial. Clin J Am Soc Nephrol 2018; 13:1859-1865. [PMID: 30442868 PMCID: PMC6302334 DOI: 10.2215/cjn.06890618] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/28/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES There is renewed interest in adrenocorticotropic hormone (ACTH) for the treatment of nephrotic syndrome. We evaluated the efficacy and safety of ACTH in children with frequently relapsing or steroid-dependent nephrotic syndrome in a randomized trial. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Participants aged 2-20 years old with frequently relapsing or steroid-dependent nephrotic syndrome were enrolled from 16 sites in the United States and randomized 1:1 to ACTH (repository corticotropin injection) or no relapse-preventing treatment. ACTH treatment regimen was 80 U/1.73 m2 administered twice weekly for 6 months, followed by 40 U/1.73 m2 administered twice weekly for 6 months. The primary outcome was disease relapse during the first 6 months. Participants in the control group were offered crossover to ACTH treatment if they relapsed within 6 months. Secondary outcomes were relapse after ACTH dose reduction and treatment side effects. RESULTS The trial was stopped at a preplanned interim analysis after enrollment of 31 participants because of a lack of discernible treatment efficacy. Fourteen out of 15 (93%) participants in the ACTH arm experienced disease relapse in the first 6 months, with a median time to first relapse of 23 days (interquartile range, 9-32), compared with 15 out of 16 (94%) participants and at a median of 21 days (interquartile range, 14-51) in the control group. There was no difference in the proportion of relapsed patients (odds ratio, 0.93; 95% confidence interval, 0.05 to 16.40; P>0.99) or time to first relapse (hazard ratio, 1.03; 95% confidence interval, 0.50 to 2.15; P=0.93). Thirteen out of 16 participants in the control group crossed over to ACTH treatment. Three out of 28 participants completed 12 months of ACTH treatment; the others exited the trial because of frequent relapses or side effects. There were no disease relapses after ACTH dose reduction among the three participants. Most side effects were mild and similar to side effects of corticosteroids. CONCLUSIONS ACTH at 80 U/1.73 m2 administered twice weekly was ineffective at preventing disease relapses in pediatric nephrotic syndrome.
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Affiliation(s)
- Chia-shi Wang
- Department of Pediatrics, Emory and Children’s Pediatric Institute, Atlanta, Georgia
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Courtney McCracken
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Traci Leong
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Rasheed Gbadegesin
- Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina
| | - Alejandro Quiroga
- Department of Pediatrics and Human Development, Helen DeVos Children’s Hospital, Grand Rapids, Michigan
| | | | - Guillermo Hidalgo
- Department of Pediatrics, East Carolina University, Greenville, North Carolina
| | - Tarak Srivastava
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Megan Lo
- Department of Pediatrics, Medical College of Virginia School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Ora Yadin
- Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles Mattel Children’s Hospital, Los Angeles, California
| | - Robert Mathias
- Department of Pediatrics, Nemours Children’s Hospital, Orlando, Florida
| | - Carlos E. Araya
- Department of Pediatrics, Nemours Children’s Hospital, Orlando, Florida
| | - Myda Khalid
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Alvaro Orjuela
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joshua Zaritsky
- Department of Pediatrics, A.I. DuPont Hospital for Children/ Nemours, Wilmington, Delaware; and
| | | | - Margret Kamel
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Larry A. Greenbaum
- Department of Pediatrics, Emory and Children’s Pediatric Institute, Atlanta, Georgia
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Siligato R, Cernaro V, Nardi C, De Gregorio F, Gembillo G, Costantino G, Conti G, Buemi M, Santoro D. Emerging therapeutic strategies for minimal change disease and focal and segmental glomerulosclerosis. Expert Opin Investig Drugs 2018; 27:839-879. [PMID: 30360670 DOI: 10.1080/13543784.2018.1540587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Minimal change disease (MCD) and Focal and segmental glomerulosclerosis (FSGS) are two of the major causes of nephrotic syndrome (NS) in children and adults. According to KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, the treatment of adult primary MCD and FSGS should be based on immunosuppressants and antiproteinuric drugs. Recently, Rituximab, a humanized monoclonal antibody (mAb) has emerged as a potential treatment for steroid or calcineurin inhibitor-dependent patients; it has however demonstrated lower efficacy in those with nephrotic syndrome that is resistant to the above indicated drugs. AREAS COVERED Analysis of ongoing and already completed clinical trials, retrieved from clinicaltrials.gov, clinicaltrialsregister.eu and PubMed involving new therapies for nephrotic syndrome secondary to MCD and FSGS. EXPERT OPINION The most promising drugs under investigation for MCD and FSGS are mAbs. We are hopeful that new therapeutic options to treat multi-drug resistant MCD and FSGS will emerge from currently ongoing studies. What appears certain is the difficulty in enrolling patients affected by orphan renal diseases and the selection of valid endpoints in clinical trials, such as kidney failure.
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Affiliation(s)
- Rossella Siligato
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Valeria Cernaro
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Chiara Nardi
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Francesca De Gregorio
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Guido Gembillo
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Giuseppe Costantino
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Giovanni Conti
- b Unit of Pediatric Nephrology and Rheumatology , University of Messina , Messina , Italy
| | - Michele Buemi
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Domenico Santoro
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
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Kutz CF, Dix AL. Repository corticotropin injection in multiple sclerosis: an update. Neurodegener Dis Manag 2018; 8:217-225. [PMID: 29869572 DOI: 10.2217/nmt-2018-0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Relapse management is a crucial component of multiple sclerosis care. Acute relapses are defined as new neurological symptoms or worsening of existing symptoms persisting for >24 h that are not attributable to heat, overexertion, or infection. The most commonly used treatment for multiple sclerosis relapse is a 3-5-day course of corticosteroids, primarily intravenous methylprednisolone with or without oral steroid taper. Repository corticotropin injection is also the US FDA-approved option for managing acute relapse, particularly in the patients with inadequate response, intolerability or allergy to corticosteroid treatment; poor venous access; or limited ability to receive home or clinic infusions.
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Affiliation(s)
- Christen F Kutz
- Colorado Springs Neurological Associates, 2312 N. Nevada Avenue, Colorado Springs, CO 80907, USA
| | - Amy L Dix
- Kansas City Multiple Sclerosis Center College Park Neurology, 10600 Mastin, Overland Park, KS 66208, USA
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Prasad B, Giebel S, McCarron MCE, Leung N. Use of synthetic adrenocorticotropic hormone in patients with IgA nephropathy. BMC Nephrol 2018; 19:118. [PMID: 29792169 PMCID: PMC5966849 DOI: 10.1186/s12882-018-0915-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 05/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Synthetic adrenocorticotropic hormone (ACTH) has been demonstrated to be effective in patients with membranous nephropathy, minimal change disease and some histological subtypes of focal segmental glomerulosclerosis. Its clinical impact in patients with IgA nephropathy is currently unclear. Case presentation In this report, we describe the clinical use of ACTH in patients with IgA nephropathy. Three female patients (24–44 years) with overt proteinuria received intramuscular (IM) ACTH for varying time periods (8–14 months). Pre-treatment urine protein varied from 2.9 g/d to 4.3 g/d. Conclusions There was complete remission in one patient on ACTH monotherapy and in the other two when prescribed as a steroid-sparing agent in combination with cyclophosphamide. All three had resolution in proteinuria to less than 1 g/d and maintained their GFR to baseline values. There were no reported side effects at a once a week dose. This study illustrates that ACTH is an effective agent that is well tolerated with minimal side effects and can be used as an alternative to prednisone in patients with IgA nephropathy.
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Affiliation(s)
- Bhanu Prasad
- Section of Nephrology, Department of Medicine, Regina General Hospital, 1440, 14th Avenue, Regina, SK, S4P 0W5, Canada.
| | - Shelley Giebel
- Faculty of Nursing, Research and Innovation Centre, University of Regina, Room 508, 3737, Wascana Parkway, Regina, SK, S4S 0A2, Canada
| | - Michelle C E McCarron
- Research and Performance Support, Regina Qu'Appelle Health Region, 2180-23rd Avenue, Regina, SK, S4S 0A5, Canada
| | - Nelson Leung
- Nephrology and Hypertension, Mayo Clinic, 200 First Street, Minnesota, Rochester, MN, 55905, USA
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Aggarwal R, Marder G, Koontz DC, Nandkumar P, Qi Z, Oddis CV. Efficacy and safety of adrenocorticotropic hormone gel in refractory dermatomyositis and polymyositis. Ann Rheum Dis 2017; 77:720-727. [DOI: 10.1136/annrheumdis-2017-212047] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 01/08/2023]
Abstract
AimTo evaluate the efficacy, safety, tolerability and steroid-sparing effect of repository corticotropin injection (RCI), in an open-label clinical trial, in refractory adult polymyositis (PM) and dermatomyositis (DM).MethodsAdults with refractory PM and DM were enrolled by two centres. Inclusion criteria included refractory disease defined as failing glucocorticoid and/or ≥1 immunosuppressive agent, as well as active disease defined as significant muscle weakness and >2 additional abnormal core set measures (CSMs) or a cutaneous 10 cm Visual Analogue Scale score of ≥3 cm and at least three other abnormal CSMs. All patients received RCI of 80 units subcutaneously twice weekly for 24 weeks. The primary end point for the trial was the International Myositis Assessment and Clinical Studies definition of improvement. Secondary end points included safety, tolerability, steroid-sparing as well as the 2016 American College of Rheumatology (ACR)/European League Against Rheumatism myositis response criteria (EULAR)ResultsTen of the 11 enrolled subjects (6 DM, 4 PM) completed the study. Seven of 10 met the primary end point of efficacy at a median of 8 weeks. There was a significant decrease in prednisone dose from baseline to conclusion (18.5 (15.7) vs 2.3 (3.2); P<0.01). Most individual CSMs improved at week 24 compared with the baseline, with the muscle strength improving by >10% and the physician global by >40%. RCI was considered safe and tolerable. No patient developed significant weight gain or an increase of haemoglobin A1c or cushingoid features.ConclusionTreatment with RCI was effective in 70% of patients, safe and tolerable, and led to a steroid dose reduction in patients with adult myositis refractory to glucocorticoid and traditional immunosuppressive drugs.Trial registration numberNCT01906372; Results.
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Irwin RS, Manaker S, Metersky ML, Baughman RP, Otulana T, Weinberger SE, Sussman AJ, McGrath NA. Higher Priced Older Pharmaceuticals: How Should We Respond? Chest 2017; 153:23-33. [PMID: 29017958 DOI: 10.1016/j.chest.2017.09.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 09/13/2017] [Accepted: 09/22/2017] [Indexed: 02/08/2023] Open
Abstract
We and our patients have been aware of the high cost of medications in the United States for decades; however, we are now witnessing a relatively new phenomenon: exponential price increases for some older pharmaceuticals that have been available for years. To assist practitioners in how to respond to the issue of higher priced pharmaceuticals, an interprofessional session was developed and held at CHEST 2016 in Los Angeles. The session proceedings and a few updates are presented here to summarize what pulmonologists; a sarcoidosis expert; a retired executive of a medical society, an executive of a pharmaceutical company and of a pharmacy; and an ethicist advise that we do about the problem. Because the comments presented at the session and in this manuscript represent the opinions of each author, this commentary in essence is a compilation of nine editorials. It does not represent a comprehensive discussion of the field of pricing of drugs. In reflecting upon the answers to the questions posed, and regardless of their sector of health care, all participants stated that they focused on the patient. However, actually providing patient-focused care (ie, the care defined from the patient's perspective) is another matter. To significantly improve patient satisfaction and health-care outcomes, patient-focused care needs to embody the 3 Cs of (1) communication, (2) continuity of care, and (3) concordance of expectations (ie, finding the common ground). Therefore, we discuss how the 3 Cs apply to responses to higher priced pharmaceuticals.
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Affiliation(s)
| | - Scott Manaker
- The Perelman School of Medicine and University of Pennsylvania, Philadelphia, PA
| | - Mark L Metersky
- University of Connecticut School of Medicine, Farmington, CT
| | - Robert P Baughman
- Department of Internal Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | | | - Steven E Weinberger
- The Perelman School of Medicine and University of Pennsylvania, Philadelphia, PA; Medical Education and Publishing Division, American College of Physicians, Philadelphia, PA
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Angioi A, Lepori N, López AC, Sethi S, Fervenza FC, Pani A. Treatment of primary membranous nephropathy: where are we now? J Nephrol 2017; 31:489-502. [PMID: 28875476 DOI: 10.1007/s40620-017-0427-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Accepted: 07/26/2017] [Indexed: 02/02/2023]
Abstract
In the last 10 years, basic science and clinical research have made important contributions to the understanding and management of primary membranous nephropathy (MN). The identification of antibodies directed against the M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing 7A protein have added a new perspective on diagnosis, monitoring the immunological activity, predicting prognosis and guiding therapy in patients with primary MN. Mounting evidence suggests that quantification and follow-up of antiPLA2R Abs levels can help in assessing prognosis and evaluate the response to treatment. The kidney disease improving global outcomes guidelines published in 2012 have not been updated. New data on the use of rituximab suggest it should be considered as a potential initial therapy in the treatment of patients with primary MN.
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Affiliation(s)
- Andrea Angioi
- Division of Nephrology and Dialysis, Azienda Ospedaliera G. Brotzu, Piazzale Ricchi n 1, 09100, Cagliari, Italy
| | - Nicola Lepori
- Division of Nephrology and Dialysis, Azienda Ospedaliera G. Brotzu, Piazzale Ricchi n 1, 09100, Cagliari, Italy
| | - Ana Coloma López
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, USA
| | - Sanjeev Sethi
- Department of Anatomic Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Antonello Pani
- Division of Nephrology and Dialysis, Azienda Ospedaliera G. Brotzu, Piazzale Ricchi n 1, 09100, Cagliari, Italy.
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Wang P, Zhang Y, Wang Y, Brem AS, Liu Z, Gong R. Acquired Resistance to Corticotropin Therapy in Nephrotic Syndrome: Role of De Novo Neutralizing Antibody. Pediatrics 2017. [PMID: 28642375 PMCID: PMC5495526 DOI: 10.1542/peds.2016-2169] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
There is increasing evidence supporting the use of corticotropin as an alternative treatment of refractory proteinuric glomerulopathies. The efficacy of short-acting corticotropin, however, remains unknown and was tested here in an adolescent with steroid-dependent nephrotic syndrome caused by minimal change disease. After developing Cushing syndrome and recently being afflicted with severe cellulitis, the patient was weaned off all immunosuppressants, including corticosteroids. This resulted in a relapse of generalized anasarca, associated with massive proteinuria and hypoalbuminemia. Subsequently, mono-therapy with short-acting animal-derived natural corticotropin was initiated and resulted in a rapid response, marked by substantial diuresis, reduction in body weight, and partial remission of proteinuria. Ten days later, the patient developed mild skin rash and subcutaneous nodules at injection sites. A relapse followed despite doubling the dose of corticotropin, consistent with delayed-onset resistance to treatment. Immunoblot-based antibody assay revealed de novo formation of antibodies in the patient's serum that were reactive to the natural corticotropin. In cultured melanoma cells known to express abundant melanocortin receptors, addition of the patient's serum strikingly mitigated dendritogenesis and cell signaling triggered by natural corticotropin, denoting neutralizing properties of the newly formed antibodies. Collectively, short-acting natural corticotropin seems effective in steroid-dependent nephrotic syndrome. De novo formation of neutralizing antibodies is likely responsible for acquired resistance to corticotropin therapy. The proof of concept protocols established in this study to examine the anticorticotropin neutralizing antibodies may aid in determining the cause of resistance to corticotropin therapy in future studies.
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Affiliation(s)
- Pei Wang
- Blood Purification Center, Institute of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China;,Divisions of Kidney Disease and Hypertension, Rhode Island Hospital, and
| | - Yan Zhang
- Blood Purification Center, Institute of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yu Wang
- Tongbai County Hospital, Henan, China
| | - Andrew S. Brem
- Divisions of Kidney Disease and Hypertension, Rhode Island Hospital, and,Pediatric Nephrology, Hasbro Children’s Hospital, Brown Medical School, Providence, Rhode Island; and
| | - Zhangsuo Liu
- Blood Purification Center, Institute of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Rujun Gong
- Blood Purification Center, Institute of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China; .,Divisions of Kidney Disease and Hypertension, Rhode Island Hospital, and.,Pediatric Nephrology, Hasbro Children's Hospital, Brown Medical School, Providence, Rhode Island; and
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Safety and Efficacy of Combination ACTHar Gel and Tacrolimus in Treatment-Resistant Focal Segmental Glomerulosclerosis and Membranous Glomerulopathy. Kidney Int Rep 2017; 2:924-932. [PMID: 29270498 PMCID: PMC5733765 DOI: 10.1016/j.ekir.2017.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 05/27/2017] [Accepted: 05/31/2017] [Indexed: 01/13/2023] Open
Abstract
Introduction H.P. ACTHar gel is a preparation of melanocortin peptides that has been used to treat resistant forms of nephrotic syndrome. To determine whether combination therapy with ACTHar gel and tacrolimus reduces proteinuria and stabilizes renal function, we conducted a prospective, open-label trial in patients with treatment-resistant membranous glomerulopathy (MGN) and focal segmental glomerulosclerosis (FSGS). Methods Nine patients with treatment-resistant MGN and 13 with treatment-resistant FSGS received subcutaneous ACTHar gel for 6 months. Patients with no response or a partial response to ACTHar gel alone received an additional 6 months of therapy with combination ACTHar gel and oral tacrolimus. The study endpoint was the percentage of patients achieving a complete or partial remission after 6 months of combination therapy. Results Among patients with MGN, treatment with ACTHar gel alone achieved a partial remission in 44% and no response in 56% of patients. No patient achieved a complete response with ACTHar gel therapy alone. An additional 6 months of combination therapy with ACTHar gel and tacrolimus resulted in partial and complete response rates of 25% and 75%, respectively. Among patients with FSGS, ACTHar gel therapy alone resulted in complete and partial response rate of 7.7% and 62.0%. Combination therapy increased complete response rates to 17% and partial responses to 66%. Proteinuria (urinary protein-to-creatinine ratio) was significantly reduced in both patients with MGN and those with FSGS after 6 months of ACTHar gel alone and was further reduced among the patients with MGN with the addition of tacrolimus. There were no significant changes in estimated glomerular filtration rate during the treatment phase or long-term follow-up. Discussion Combination therapy with ACTHar gel and tacrolimus was well tolerated by patients with treatment-resistant MGN and FSGS and significantly reduced proteinuria and improved clinical response rates compared with ACTHar gel alone.
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Huang Y, Pei Y, Guan H, Wei S, Wu H, Zhou Y, Pei J, Chen L, Wang Y, Chen Y, Han Q, Wang D, Wang D. Stability and Pharmacological Effects of Gene-Recombinant Wild Type and Mutant Human Adrenocorticotropic Hormone. Pharm Res 2017; 34:793-799. [PMID: 28127707 DOI: 10.1007/s11095-017-2107-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 01/13/2017] [Indexed: 11/30/2022]
Abstract
PURPOSE Adrenocorticotropic hormone (ACTH) is the only medicine for treating infantile spasms, however, it is catabolized rapidly. In order to make an ACTH derivative with prolonged effects, we prepared genetically engineered wild type (WT) and mutant ACTH candidates based on protease database analysis, and compared their stability and pharmacological effects. METHODS For analysis of stability, serum concentration of WT and mutant ACTH candidates were tested at different time after intravenous injection, and elimination curves were calculated to compare pharmacokinetic properties of WT and E5D-mutant ACTH. For comparison of their pharmacological effects, levels of glucocorticoids (GC) in the blood serum and secreted from cultured Y1 mouse adrenal cells were tested, and their effects on the signaling pathway mediating the expression of genes critical for GC synthesis were analyzed. The effects of ACTHs on transcription levels of the genes involved in GC synthesis were tested by qPCR. RESULTS The blood concentration of E5D ACTH is higher than the WT after injection, and E5D mutation increased the t1/2 and AUC of ACTH. Pharmacological experiments showed that the effects of E5D and Y2S mutant ACTH on the production of GC and the critical signal transduction were equivalent to those of WT. WT, E5D and Y2S ACTH also have similar effects on the transcriptional levels of the genes for GC synthesis, including STAR, P450-scc, 3β-HSD, and SF-1. CONCLUSION The stability of E5D mutant ACTH is higher than WT ACTH. The pharmacological effects of E5D ACTH is equivalent to those of WT ACTH.
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Affiliation(s)
- Yonglin Huang
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China
| | - Yechun Pei
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China
| | - Huai Guan
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China
| | - Shuangshuang Wei
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China
| | - Hao Wu
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China
| | - Yuan Zhou
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China.,School of Molecular and Cellular Biology, University of Illinois at Urbana-Champaign, Illinois, 61801, USA
| | - Jinli Pei
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China
| | - Lintao Chen
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China
| | - Yuerong Wang
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China
| | - Yibo Chen
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China
| | - Qian Han
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China
| | - Daming Wang
- Qiqihar Teachers College, Heilongjiang, 161005, China.
| | - Dayong Wang
- Laboratory of Biotechnology and Molecular Pharmacology, Hainan Province Key Laboratory for Sustainable Utilization of Tropical Bioresources, Hainan University, Hainan, 570208, China.
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Berkovich R, Bakshi R, Amezcua L, Axtell RC, Cen SY, Tauhid S, Neema M, Steinman L. Adrenocorticotropic hormone versus methylprednisolone added to interferon β in patients with multiple sclerosis experiencing breakthrough disease: a randomized, rater-blinded trial. Ther Adv Neurol Disord 2017; 10:3-17. [PMID: 28450891 PMCID: PMC5400152 DOI: 10.1177/1756285616670060] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The objective of this study was to evaluate monthly intramuscular adrenocorticotropic hormone (ACTH) gel versus intravenous methylprednisolone (IVMP) add-on therapy to interferon β for breakthrough disease in patients with relapsing forms of multiple sclerosis. METHODS This was a prospective, open-label, examiner-blinded, 15-month pilot study evaluating patients with Expanded Disability Status Scale (EDSS) score 3.0-6.5 and at least one clinical relapse or new T2 or gadolinium-enhanced lesion in the previous year. Twenty-three patients were randomized to ACTH (n = 12) or IVMP (n = 11) and completed the study. The primary outcome measure was the cumulative number of relapses. Secondary outcomes included EDSS, Mental Health Inventory (MHI), plasma cytokines, MS Functional Composite (MSFC), Quality-of-Life (MS-QOL) score, bone mineral density (BMD), and new or worsened psychiatric symptoms per month. Brain magnetic resonance imaging was analyzed post hoc. This was a preliminary and small-scale study. RESULTS Relapse rates differed significantly [ACTH 0.08, 95% confidence interval (CI) 0.01-0.54 versus IVMP 0.80, 95% CI 0.36-1.75; rate ratio, IVMP versus ACTH: 9.56, 95% CI 1.23-74.6; p = 0.03]. ACTH improved (p = 0.03) MHI (slope 0.95 ± 0.38 points/month; p = 0.02 versus slope -0.38 ± 0.43 points/month; p = 0.39). On-study decreases (all p < 0.05) in eight cytokine levels occurred only in the ACTH group. However, on-study EDSS, MSFC, MS-QOL, BMD, and MRI lesion changes were not significant between groups. Psychiatric symptoms per patient were greater with IVMP than ACTH (0.55, 95% CI 0.12-2.6 versus 0; p < 0.0001). Other common adverse events were insomnia and urinary tract infections (IVMP, seven events each) and fatigue or flu symptoms (ACTH, five events each). CONCLUSIONS This study provided class II evidence that ACTH produced better examiner-assessed cumulative rates of relapses per patient than IVMP in the adjunctive treatment of breakthrough disease in multiple sclerosis.
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Affiliation(s)
- Regina Berkovich
- USC MS Comprehensive Care Center and Research Group, 1520 San Pablo Street, Suite 3000, Los Angeles, CA 90033, USA
| | - Rohit Bakshi
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Lilyana Amezcua
- University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | | | - Steven Y. Cen
- University of Southern California, Keck School of Medicine, Los Angeles, CA, USA
| | - Shahamat Tauhid
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Mohit Neema
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Montero-Melendez T, Forfar RAE, Cook JM, Jerman JC, Taylor DL, Perretti M. Old drugs with new skills: fenoprofen as an allosteric enhancer at melanocortin receptor 3. Cell Mol Life Sci 2016; 74:1335-1345. [PMID: 27853832 PMCID: PMC5346439 DOI: 10.1007/s00018-016-2419-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 11/08/2016] [Accepted: 11/10/2016] [Indexed: 01/08/2023]
Abstract
The efficiency of drug research and development has paradoxically declined over the last decades despite major scientific and technological advances, promoting new cost-effective strategies such as drug repositioning by systematic screening for new actions of known drugs. Here, we performed a screening for positive allosteric modulators (PAMs) at melanocortin (MC) receptors. The non-steroidal anti-inflammatory drug fenoprofen, but not the similar compound ibuprofen, presented PAM activity at MC3, MC4, and MC5 receptors. In a model of inflammatory arthritis, fenoprofen afforded potent inhibition while ibuprofen was nearly inactive. Fenoprofen presented anti-arthritic actions on cartilage integrity and synovitis, effects markedly attenuated in Mc3r−/− mice. Fenoprofen displayed pro-resolving properties promoting macrophage phagocytosis and efferocytosis, independently of cyclooxygenase inhibition. In conclusion, combining repositioning with advances in G-protein coupled receptor biology (allosterism) may lead to potential new therapeutics. In addition, MC3 PAMs emerged as a viable approach to the development of innovative therapeutics for joint diseases.
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Affiliation(s)
- Trinidad Montero-Melendez
- The William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK.
| | - Rachel A E Forfar
- Medical Research Council Technology, Centre for Therapeutics Discovery, 1-3 Burtonhole Lane, Mill Hill, London, NW7 1AD, UK
| | - Jennifer M Cook
- Medical Research Council Technology, Centre for Therapeutics Discovery, 1-3 Burtonhole Lane, Mill Hill, London, NW7 1AD, UK
| | - Jeffrey C Jerman
- Medical Research Council Technology, Centre for Therapeutics Discovery, 1-3 Burtonhole Lane, Mill Hill, London, NW7 1AD, UK
| | - Debra L Taylor
- Medical Research Council Technology, Centre for Therapeutics Discovery, 1-3 Burtonhole Lane, Mill Hill, London, NW7 1AD, UK
| | - Mauro Perretti
- The William Harvey Research Institute, Barts and The London School of Medicine, Queen Mary University of London, Charterhouse Square, London, EC1M 6BQ, UK
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Filippone EJ, Dopson SJ, Rivers DM, Monk RD, Udani SM, Jafari G, Huang SC, Melhem A, Assioun B, Schmitz PG. Adrenocorticotropic hormone analog use for podocytopathies. Int Med Case Rep J 2016; 9:125-33. [PMID: 27418857 PMCID: PMC4935005 DOI: 10.2147/imcrj.s104899] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Adrenocorticotropic hormone is being increasingly studied for treatment of various glomerulopathies, most notably membranous nephropathy. Less data are available regarding its use in idiopathic nephrotic syndrome (INS) secondary to minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS). We report here our experience with H.P. Acthar(®) Gel (repository corticotropin injection) as first-line or subsequent therapy in patients with INS. METHODS Data were taken from three patients with MCD and ten patients with FSGS from around the US, who were treated with Acthar Gel as initial or subsequent therapy. Treatment was solely at the discretion of the primary nephrologist without a specific protocol. A complete response (CR) was defined as final urine protein-to-creatinine ratio <500 mg/g and a partial response (PR) as 50% decrease without rise of serum creatinine. Side effects and tolerability were noted. RESULTS All three patients with MCD received Acthar Gel as second-line or later immunosuppressive (IS) therapy and all responded (one CR and two PRs). Two of the ten patients with FSGS received Acthar Gel as first-line IS therapy, while the other eight had failed multiple agents. Four of the ten patients with FSGS had responses, including two CRs and two PRs. The three patients with MCD tolerated therapy well without side effects. Five patients with FSGS tolerated therapy well, while five had various steroid-like side effects, resulting in therapy discontinuation in two patients. CONCLUSION Acthar Gel is a viable alternative IS agent for treatment of INS in patients intolerant or resistant to conventional therapy. More data are needed to better define its appropriate place.
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Affiliation(s)
- Edward J Filippone
- Division of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia
| | - Shirley J Dopson
- Division of Medicine, Washington Health System, Southwestern Nephrology, Inc, Washington, PA
| | - Denise M Rivers
- Department of Medicine, University Nephrology, University of Tennessee, Knoxville, TN
| | - Rebeca D Monk
- Department of Medicine, Division of Nephrology, University of Rochester Medical Center, Rochester, NY
| | - Suneel M Udani
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL
| | - Golriz Jafari
- Division of Nephrology and Hypertension, Olive View–University of California, Los Angeles Medical Center, Sylmar, CA
| | - Solomon C Huang
- Division of Nephrology and Hypertension, Olive View–University of California, Los Angeles Medical Center, Sylmar, CA
| | - Arafat Melhem
- Department of Internal Medicine, Division of Nephrology, Saint Louis University, St Louis, MO, USA
| | - Bassim Assioun
- Department of Internal Medicine, Division of Nephrology, Saint Louis University, St Louis, MO, USA
| | - Paul G Schmitz
- Department of Internal Medicine, Division of Nephrology, Saint Louis University, St Louis, MO, USA
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Qiao Y, Berg AL, Wang P, Ge Y, Quan S, Zhou S, Wang H, Liu Z, Gong R. MC1R is dispensable for the proteinuria reducing and glomerular protective effect of melanocortin therapy. Sci Rep 2016; 6:27589. [PMID: 27270328 PMCID: PMC4897792 DOI: 10.1038/srep27589] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/17/2016] [Indexed: 12/21/2022] Open
Abstract
Melanocortin therapy by using adrenocorticotropic hormone (ACTH) or non-steroidogenic melanocortin peptides attenuates proteinuria and glomerular injury in experimental glomerular diseases and induces remission of nephrotic syndrome in patients with diverse glomerulopathies, even those resistant to steroids. The underlying mechanism remains elusive, but the role of melanocortin 1 receptor (MC1R) has been implicated and was examined here. Four patients with congenital red hair color and nephrotic syndrome caused by idiopathic membranous nephropathy or focal segmental glomerulosclerosis were confirmed by gene sequencing to bear dominant-negative MC1R mutations. Despite prior corticosteroid resistance, all patients responded to ACTH monotherapy and ultimately achieved clinical remission, inferring a steroidogenic-independent and MC1R-dispensable anti-proteinuric effect of melanocortin signaling. In confirmatory animal studies, the protective effect of [Nle4, D-Phe7]-α-melanocyte stimulating hormone (NDP-MSH), a potent non-steroidogenic pan-melanocortin receptor agonist, on the lipopolysaccharide elicited podocytopathy was completely preserved in MC1R-null mice, marked by reduced albuminuria and diminished histologic signs of podocyte injury. Moreover, in complementary in vitro studies, NDP-MSH attenuated the lipopolysaccharide elicited apoptosis, hypermotility and impairment of filtration barrier function equally in primary podocytes derived from MC1R-null and wild-type mice. Collectively, our findings suggest that melanocortin therapy confers a proteinuria reducing and podoprotective effect in proteinuric glomerulopathies via MC1R-independent mechanisms.
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Affiliation(s)
- Yingjin Qiao
- Institute of Nephrology, Blood Purification Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Anna-Lena Berg
- Department of Nephrology, Lund University Hospital, Lund, Sweden
| | - Pei Wang
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Yan Ge
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Songxia Quan
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Sijie Zhou
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Hai Wang
- Department of Pathology, Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island, USA
| | - Zhangsuo Liu
- Institute of Nephrology, Blood Purification Center, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Rujun Gong
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Brown University School of Medicine, Providence, Rhode Island, USA
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Kittanamongkolchai W, Cheungpasitporn W, Zand L. Efficacy and safety of adrenocorticotropic hormone treatment in glomerular diseases: a systematic review and meta-analysis. Clin Kidney J 2016; 9:387-96. [PMID: 27274822 PMCID: PMC4886926 DOI: 10.1093/ckj/sfw045] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/23/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND There is growing evidence that adrenocorticotropic hormone (ACTH) may be effective in treating various forms of glomerular diseases. However, the efficacy of treatment and frequency of adverse effects associated with the use of ACTH in glomerular diseases are unknown. A systematic review and meta-analysis of the literature was performed. METHODS A literature search was performed using Medline, Embase, Google Scholar and the Cochrane Database of Systematic Reviews from inception through 18 July 2015. Studies assessing the efficacy and safety of ACTH treatment in adults with glomerular diseases were included. RESULTS Of the 343 identified citations, 18 evaluated the drug efficacy and 12 evaluated the adverse effects. The most common glomerular diseases were membranous nephropathy (MN), primary focal segmental glomerulosclerosis (FSGS) and minimal change disease (MCD). The overall rate of complete remission in MN was 80% at 0-6 months, 69% at >6-12 months, 90% at >12-24 months and 95% beyond 24 months of follow-up. Fifty percent of primary FSGS and MCD patients treated with ACTH were in remission at 6 months, but the relapse rate was high after ACTH discontinuation (17%). Evidence of ACTH efficacy for other glomerular diseases was scarce. Edema was the most commonly reported adverse effect {incidence rate [IR] 0.10 [95% confidence interval (CI) 0.04-0.18]} followed by insomnia [IR 0.08 (95% CI 0.03-0.15)]. The dropout rate due to adverse events was 7%, mostly due to edema and weight gain. CONCLUSIONS ACTH is a well-tolerated therapy and is most promising when treating patients with MN. There may be a potential role for ACTH in patients with MCD and FSGS, but data are lacking.
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Affiliation(s)
- Wonngarm Kittanamongkolchai
- Department of Medicine, Division of Nephrology and Hypertension , Mayo Clinic , 200 First Street SW, Rochester, MN 55905 , USA
| | - Wisit Cheungpasitporn
- Department of Medicine, Division of Nephrology and Hypertension , Mayo Clinic , 200 First Street SW, Rochester, MN 55905 , USA
| | - Ladan Zand
- Department of Medicine, Division of Nephrology and Hypertension , Mayo Clinic , 200 First Street SW, Rochester, MN 55905 , USA
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Groves AP, Reich P, Sigdel B, Davis TK. Pneumococcal hemolytic uremic syndrome and steroid resistant nephrotic syndrome. Clin Kidney J 2016; 9:572-5. [PMID: 27478599 PMCID: PMC4957713 DOI: 10.1093/ckj/sfw025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 03/14/2016] [Indexed: 12/31/2022] Open
Abstract
Pneumococcal-associated hemolytic uremic syndrome (pHUS) is a rare but severe complication of invasive Streptococcus pneumoniae infection. We report the case of a 12-year-old female with steroid-resistant nephrotic syndrome treated with adrenocorticotrophic hormone (H.P. Acthar(®) Gel), who developed pneumococcal pneumonia and subsequent pHUS. While nephrotic syndrome is a well-known risk factor for invasive pneumococcal disease, this is the first reported case of pHUS in an adolescent patient with nephrotic syndrome, and reveals novel challenges in the diagnosis, treatment and potential prevention of this complication.
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Affiliation(s)
- Andrew P Groves
- Washington University School of Medicine , St Louis, MO , USA
| | - Patrick Reich
- Division of Infectious Disease, Department of Pediatrics , Washington University School of Medicine , St Louis, MO , USA
| | - Binayak Sigdel
- Division of Critical Care Medicine, Department of Pediatrics , Washington University School of Medicine , St Louis, MO , USA
| | - T Keefe Davis
- Division of Nephrology, Department of Pediatrics , Washington University School of Medicine , St Louis, MO , USA
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Mallipattu SK, He JC. The podocyte as a direct target for treatment of glomerular disease? Am J Physiol Renal Physiol 2016; 311:F46-51. [PMID: 27097894 DOI: 10.1152/ajprenal.00184.2016] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 04/18/2016] [Indexed: 11/22/2022] Open
Abstract
The Centers for Disease Control and Prevention estimates more than 10% of adults in the United States, over 20 million Americans, have chronic kidney disease (CKD). A failure to maintain the glomerular filtration barrier directly contributes to the onset of CKD. The visceral epithelial cells, podocytes, are integral to the maintenance of this renal filtration barrier. Direct podocyte injury contributes to the onset and progression of glomerular diseases such as minimal change disease (MCD), focal segmental glomerular sclerosis (FSGS), diabetic nephropathy, and HIV-associated nephropathy (HIVAN). Since podocytes are terminally differentiated with minimal capacity to self-replicate, they are extremely sensitive to cellular injury. In the past two decades, our understanding of the mechanism(s) by which podocyte injury occurs has greatly expanded. With this newfound knowledge, therapeutic strategies have shifted to identifying targets directed specifically at the podocyte. Although the systemic effects of these agents are important, their direct effect on the podocyte proves to be essential in ameliorating glomerular disease. In this review, we highlight the mechanisms by which these agents directly target the podocyte independent of its systemic effects.
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Affiliation(s)
- Sandeep K Mallipattu
- Division of Nephrology, Department of Medicine, Stony Brook University, Stony Brook, New York
| | - John C He
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; and Renal Section, James J. Peters VA Medical Center, New York, New York
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Adrenocorticotropic hormone therapy for the treatment of idiopathic nephrotic syndrome in children and young adults: a systematic review of early clinical studies with contemporary relevance. J Nephrol 2016; 30:35-44. [PMID: 27084801 PMCID: PMC5316399 DOI: 10.1007/s40620-016-0308-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 04/03/2016] [Indexed: 11/02/2022]
Abstract
Adrenocorticotropic hormone (ACTH) as a treatment for proteinuria due to nephrotic syndrome (NS) has re-emerged over the last decade. Current clinical data are primarily limited to adults with treatment-resistant NS. Largely unknown to today's clinicians is the existence of early clinical studies, following ACTH's introduction in the late 1940s, showing sustained proteinuria response in idiopathic NS in predominantly pediatric, treatment-naïve patients. Before ACTH, patients suffered severe edema and high mortality rates with no reliable or safe treatment. ACTH dramatically altered NS management, initially through recognition of diuresis effects and then through sustained proteinuria remission. This review synthesizes early clinical literature to inform current NS patient management. We undertook a MEDLINE search using MeSH terms "adrenocorticotropic hormone" and "nephrotic syndrome," with limits 1945-1965 and English. Sixty papers totaling 1137 patients were found; 14 studies (9 short-term, five long-term, N = 419 patients) met inclusion criteria. Studies were divided into two groups: short-term (≤28 days) and long-term (>5 weeks; short-term initial daily treatment followed by long-term intermittent)ACTH therapy and results were aggregated. An initial response, defined as a diuresis, occurred in 74 % of patients/treatment courses across nine short-term ACTH studies. Analyzed in eight of these studies, proteinuria response occurred in 56 % of patients/treatment courses. Across five long-term ACTH studies, proteinuria response was shown in 71 % of patients and was sustained up to 4.7 years following treatment. The inventory and re-evaluation of early clinical data broadens the evidence base of clinical experiences with ACTH for implementation of current treatment strategies and aiding the design of future studies.
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Madan A, Mijovic-Das S, Stankovic A, Teehan G, Milward AS, Khastgir A. Acthar gel in the treatment of nephrotic syndrome: a multicenter retrospective case series. BMC Nephrol 2016; 17:37. [PMID: 27036111 PMCID: PMC4815175 DOI: 10.1186/s12882-016-0241-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 03/15/2016] [Indexed: 12/29/2022] Open
Abstract
Background Current first-line anti-proteinuric treatments for nephrotic syndrome (NS) do not produce an effective response in all patients and are not tolerated by some patients. Additional effective and tolerable treatment options in NS are strongly needed. This retrospective case series is the largest to date to examine Acthar gel (adrenocorticotropic hormone, ACTH) in patients with varied-etiology NS. Methods This multicenter retrospective case series included adult patients with NS (N = 44) treated with Acthar gel at 6 clinical practices. NS etiologies included idiopathic focal segmental glomerulosclerosis (FSGS, 15), idiopathic membranous nephropathy (iMN, 11), IgA nephropathy (IgAN, 5), diabetic nephropathy (DN, 4), systemic lupus erythematosus class V membranous lupus nephritis (MLN, 2), minimal change disease (MCD, 2), membranoproliferative glomerulonephritis (MPGN, 1), fibrillary glomerulonephritis (FGN, 1), and unbiopsied NS (3). Proteinuria response was assessed as percent reduction from baseline and percent of patients meeting complete remission (final proteinuria <500 mg/d), partial remission (≥50 % reduction in proteinuria from baseline and final proteinuria 500–3500 mg/d), clinical response (≥30 % reduction in proteinuria from baseline that did not meet criteria for complete or partial remission), and no response (failed to meet remission or clinical response criteria) following Acthar gel therapy. Safety and tolerability were examined using adverse event (AE) frequency reported by patients or treating nephrologists and frequency of early discontinuation of treatment due to AEs. Results 68.2 % (30/44) of patients had received prior NS treatment with immunosuppressive or cytotoxic therapies. Thirty-seven patients completed Acthar gel treatment. Seven patients (15.9 %) had early termination due to AEs, including weight gain (2), hypertension (2), edema (1), fatigue (1), seizures (1) and for reasons not stated (2). Proteinuria reduction ≥30 % was shown in 81.1 % (30/37) of patients and 62.2 % (23/37) showed ≥50 % proteinuria reduction. Proteinuria responses were greatest in MCD (n = 2/2 complete remission), MLN (n = 2/2 partial remission), MPGN (n = 1/1 partial remission), FSGS (n = 12/15 [80.0 %] partial remission or clinical response), and iMN (n = 8/11 [72.7 %] complete remission, partial remission, or clinical response). Conclusions Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease.
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Affiliation(s)
- Arvind Madan
- Nephrology Associates of Central Florida, 3885 Oakwater Circle, Orlando, FL, 32806, USA
| | | | | | | | - Amber S Milward
- Nephrology Associates of Central Florida, 3885 Oakwater Circle, Orlando, FL, 32806, USA
| | - Anupa Khastgir
- Nephrology Practice, 3366 NW Expressway, Bldg D, Suite 280, Oklahoma City, OK, 73112, USA.
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Zhou Y, Lower EE, Li H, Baughman RP. Clinical management of pulmonary sarcoidosis. Expert Rev Respir Med 2016; 10:577-91. [DOI: 10.1586/17476348.2016.1164602] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Maroz N, Field H. Necrotizing crescentic glomerulonephritis related to sarcoidosis: a case report. J Med Case Rep 2015; 9:282. [PMID: 26651490 PMCID: PMC4677431 DOI: 10.1186/s13256-015-0764-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 11/08/2015] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Renal injury due to sarcoidosis develops in less than a quarter of patients with this systemic disease. In most cases, granulomatous tissue alters the production of vitamin D, which leads to hypercalciuria, nephrocalcinosis, and nephrolithiasis. Granulomatous interstitial nephritis is another well-recognized pathological process associated with sarcoidosis. However, a glomerular pathology is very rarely noted, and only a few cases are reported to have cellular crescentic glomerulonephritis. CASE PRESENTATION We describe the case of a 26-year-old African American woman with systemic sarcoidosis, with a unique constellation of renal lesions, including noncaseating epithelioid granulomatous necrotizing interstitial nephritis, cellular crescent formation, and necrotizing vasculitis. Immunosuppressive therapy was helpful for alleviating her nephrotic syndrome and maintaining the stability of her renal function over a 30-month period. CONCLUSION Glomerular involvement of sarcoidosis needs to be considered in the differential diagnosis in cases of rapidly progressive glomerular nephritis.
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Affiliation(s)
- Natallia Maroz
- Renal Physicians Inc., One Elizabeth Place, Suite 190, Dayton, OH, 45418, USA. .,Department of Medicine, Wright State University, Boonshoft School of Medicine, 128 E. Apple St., 2nd Floor, Dayton, OH, 45409, USA. .,Department of Medicine, Kettering Medical Center, 3535 Southern Blvd Kettering, Dayton, OH, 45429, USA.
| | - Halle Field
- Department of Medicine, Kettering Medical Center, 3535 Southern Blvd Kettering, Dayton, OH, 45429, USA.
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Loram LC, Culp ME, Connolly-Strong EC, Sturgill-Koszycki S. Melanocortin peptides: potential targets in systemic lupus erythematosus. Inflammation 2015; 38:260-71. [PMID: 25323206 PMCID: PMC4312383 DOI: 10.1007/s10753-014-0029-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Systemic lupus erythematosus (SLE) is a systemic autoimmune disease resulting in loss of self-tolerance with multiple organs, such as the kidney, skin, joints, and the central nervous system (CNS), being targeted. Numerous immunosuppressant therapies are currently being used for the treatment of SLE, but their clinical utility is somewhat variable because of the clinical heterogeneity. Melanocortins are a family of peptides derived from the common precursor protein pro-opiomelanocortin. These multifunctional peptides activate five subtypes of melanocortin receptors expressed on immune, skin, muscle, bone, and kidney cells and cells within the CNS. Melanocortin peptides have demonstrated a variety of biologic actions including immunomodulation, melanogenesis, and renoprotection. This review aims to introduce the melanocortin system and explore the mechanisms by which they may be beneficial in diseases such as SLE.
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Affiliation(s)
- Lisa Carole Loram
- Mallinckrodt Pharmaceuticals (formerly Questcor), 26118 Research Road, Hayward, CA, 94545, USA
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