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Bi X, Yu Y, Zhou S, Zhou Y, Zhao J, Xiong J. Immunosuppressant Agents as Add-On Therapy Failed to Improve the Outcome of Immunoglobulin A Nephropathy with Crescent Score C1. Nephron Clin Pract 2024:1-14. [PMID: 38723614 DOI: 10.1159/000534788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 10/11/2023] [Indexed: 06/19/2024] Open
Abstract
INTRODUCTION The renoprotective benefits of adding immunosuppressant therapy to corticosteroid (CS) treatment for immunoglobulin A nephropathy (IgAN) patients with less than 25% crescent formation (C1) remain uncertain, warranting further research. METHODS A retrospective study was conducted on IgAN patients with crescent C1 lesions confirmed by renal biopsy at Xinqiao Hospital between May 1, 2017, and May 1, 2020. Patients were stratified into either the CS treatment group or the CS combined with an additional immunosuppressant therapy group. Follow-up assessments were conducted within 24 months. Propensity score analysis was used to match patients receiving CS and CS + immunosuppressant drug treatment in a 1:1 ratio. Primary outcomes included changes in estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (UACR). Subgroup analyses were performed to evaluate the benefits of different populations. Composite endpoint outcomes comprised a 30% eGFR decrease, end-stage kidney disease (ESKD) necessitating dialysis or transplant, or kidney disease-related mortality. Adverse events were also compared between the two groups. RESULTS 296 IgAN patients with C1 lesions were included in the analysis. Baseline characteristics indicated that IgAN patients in the CS + immunosuppressant group exhibited poorer renal function and higher UACR levels. Propensity score analysis effectively minimized the influence of baseline clinical characteristics, including age, serum creatinine, initial eGFR, UACR, and 24-h proteinuria. Both treatment groups demonstrated continuous eGFR improvement and significant UACR reduction during follow-up, especially at 6 months. However, no significant differences in eGFR and UACR reduction rates were observed between the two groups throughout the entire follow-up period, both before and after matching. Subgroup analysis revealed improved eGFR in both treatment groups, notably among patients with an initial eGFR below 90 mL/min/1.73 m2. Conversely, IgAN patients with C1 lesions and a cellular crescent ratio exceeding 50% treated with CS and immunosuppressant therapy experienced a significant improvement in renal function and a decline in urinary protein creatinine ratio. Composite endpoint outcomes did not significantly differ between the two groups, while the incidence of adverse events was comparable. CONCLUSION Our findings suggest that the addition of immunosuppressant therapy to corticosteroid monotherapy did not confer significant therapeutic advantages in patients with C1 lesions compared to CS monotherapy, although some specific patient populations appeared to derive modest benefits from this combined approach.
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Affiliation(s)
- Xianjin Bi
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Department of Cardiovasology, People's Liberation Army Joint Logistic Support Force 945th Hospital, Yaan, China
| | - Yanlin Yu
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Siyan Zhou
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yue Zhou
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jinghong Zhao
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiachuan Xiong
- Department of Nephrology, The Key Laboratory for the Prevention and Treatment of Chronic Kidney Disease of Chongqing, Kidney Center of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Ma J, Xing J, Zhang Y, Liu G. Efficacy and safety of biologic agents for IgA nephropathy: A protocol for systematic review and meta-analysis. PLoS One 2024; 19:e0298732. [PMID: 38547115 PMCID: PMC10977724 DOI: 10.1371/journal.pone.0298732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 01/29/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND IgA nephropathy (IgAN) is the most prevalent primary glomerulonephritis worldwide and a leading cause of chronic kidney failure. There are currently no definitive therapeutic regimens to treat or prevent the progression of IgAN. However, biologic agents offer novel therapeutic approaches that target immunological mechanisms to slow or halt disease progression. The objective of this study is to evaluate the efficacy and safety of biologic agents in patients with IgA nephropathy. METHODS We will systematically search PubMed, EMbase, Web of Science, Cochrane Library, and www.clinicaltrials.gov for randomized controlled trials of biologic agents for the treatment of IgA nephropathy. The search period will span from the establishment of each database until October 2023. The quality assessment of included studies will be performed individually using the revised Cochrane risk-of-bias tool for randomized trials (RoB 2), and meta-analysis will be conducted using Revman 5.4.1 software. CONCLUSIONS The results of this study will provide evidence-based medical evidence for the clinical application of biologic agents in patients with IgA nephropathy. PROSPERO REGISTRATION NUMBER CRD42023400450.
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Affiliation(s)
- Jia Ma
- Shanxi Traditional Chinese Medical Hospital, Taiyuan, China
- Shanxi University of Chinese Medicine, Taiyuan, China
| | - Jianyue Xing
- Shanxi Traditional Chinese Medical Hospital, Taiyuan, China
| | - Yupeng Zhang
- Shanxi Traditional Chinese Medical Hospital, Taiyuan, China
| | - Guangzhen Liu
- Shanxi Traditional Chinese Medical Hospital, Taiyuan, China
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Stamellou E, Seikrit C, Tang SCW, Boor P, Tesař V, Floege J, Barratt J, Kramann R. IgA nephropathy. Nat Rev Dis Primers 2023; 9:67. [PMID: 38036542 DOI: 10.1038/s41572-023-00476-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/02/2023]
Abstract
IgA nephropathy (IgAN), the most prevalent primary glomerulonephritis worldwide, carries a considerable lifetime risk of kidney failure. Clinical manifestations of IgAN vary from asymptomatic with microscopic or intermittent macroscopic haematuria and stable kidney function to rapidly progressive glomerulonephritis. IgAN has been proposed to develop through a 'four-hit' process, commencing with overproduction and increased systemic presence of poorly O-glycosylated galactose-deficient IgA1 (Gd-IgA1), followed by recognition of Gd-IgA1 by antiglycan autoantibodies, aggregation of Gd-IgA1 and formation of polymeric IgA1 immune complexes and, lastly, deposition of these immune complexes in the glomerular mesangium, leading to kidney inflammation and scarring. IgAN can only be diagnosed by kidney biopsy. Extensive, optimized supportive care is the mainstay of therapy for patients with IgAN. For those at high risk of disease progression, the 2021 KDIGO Clinical Practice Guideline suggests considering a 6-month course of systemic corticosteroid therapy; however, the efficacy of systemic steroid treatment is under debate and serious adverse effects are common. Advances in understanding the pathophysiology of IgAN have led to clinical trials of novel targeted therapies with acceptable safety profiles, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, as well as blockade of complement components.
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Affiliation(s)
- Eleni Stamellou
- Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Claudia Seikrit
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Sydney C W Tang
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Peter Boor
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
- Department of Pathology, RWTH Aachen University, Aachen, Germany
| | - Vladimir Tesař
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rafael Kramann
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany.
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, Netherlands.
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Zhang Y, Li Q, Shi S, Liu L, Lv J, Zhu L, Zhang H. Clinical and pathological characteristics in elderly patients with IgA nephropathy. Clin Kidney J 2023; 16:1974-1979. [PMID: 37915928 PMCID: PMC10616429 DOI: 10.1093/ckj/sfad203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Indexed: 11/03/2023] Open
Abstract
Background Immunoglobulin A nephropathy (IgAN) is the most common cause of primary glomerulonephritis, with highly variable manifestations. Although the peak incidence of IgAN is in young adults, the diagnosis among elderly people is increasing. Here we explored the effect of aging on IgAN features, as well as cellular senescence in the kidney of IgAN. Methods A total of 910 patients with IgAN were enrolled, which contained 182 individuals in each age stage (aged ≥60, 50-59, 40-49, 30-39 and 20-29 years). Clinical and pathological manifestations at the time of renal biopsy were compared. Additionally, 38 patients with IgAN (19 aged over or equal to 60 years and 19 aged below 60 years) were randomly selected for p16INK4a staining by immunohistochemistry. The percentage of p16INK4a-positive cells in glomeruli, renal tubule and interstitium were separately quantified. Results Compared with young IgAN patients, elderly patients presented with higher levels of circulating IgA, uric acid and proteinuria, but lower estimated glomerular filtration rates (eGFR), as well as lower red blood cell counts, platelet counts and lymphocyte counts. Moreover, elderly IgAN patients showed higher incidence of hypertension, and lower incidence of prodromic infection. Regarding histological lesions in the kidney, young IgAN patients had higher degree of IgA and C3 deposits, while elderly IgAN patients had more severe Oxford-E lesions, but less severe Oxford-S lesions. The percentage of glomerular and tubular p16INK4a-positive cells in elderly patients showed an increasing trend, but statistical significance was not reached. The percentage of p16INK4a-positive nuclei in renal interstitium was positively associated with T score, while increased percentage of p16INK4a-positive nuclei in renal tubule was associated with eGFR and 24-h urinary protein level. Conclusion In our IgAN cohort, elderly IgAN patients presented with some aging-related features, and both aging- and IgAN-induced pathological injury contributed to the kidney lesions in patients with IgAN.
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Affiliation(s)
- Yongji Zhang
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Science, Beijing, China
| | - Qianqian Li
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Science, Beijing, China
| | - Sufang Shi
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Science, Beijing, China
| | - Lijun Liu
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Science, Beijing, China
| | - Jicheng Lv
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Science, Beijing, China
| | - Li Zhu
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Science, Beijing, China
| | - Hong Zhang
- Renal Division, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
- Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Science, Beijing, China
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Tziastoudi M, Chronopoulou I, Pissas G, Cholevas C, Eleftheriadis T, Stefanidis I. Tumor Necrosis Factor-α G-308A Polymorphism and Sporadic IgA Nephropathy: A Meta-Analysis Using a Genetic Model-Free Approach. Genes (Basel) 2023; 14:1488. [PMID: 37510392 PMCID: PMC10378840 DOI: 10.3390/genes14071488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/11/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Tumor necrosis factor-α (TNF-α) is a potent pro-inflammatory cytokine, involved in the pathogenesis and progression of immunoglobulin A nephropathy (IgAN). A bi-allelic polymorphism in the promoter region, at position -308 (G/A) of the TNF-α gene (rs1800629) is associated with an increased TNF-a production. However, several previous association studies of TNF-α G-308A polymorphism and IgAN rendered contradictory findings. The objective of the present study is to shed light on these inconclusive results and clarify the role of TNF-α and any possible contribution of this factor in the development and progression of sporadic IgAN. Therefore, a meta-analysis of all available genetic association studies relating the TNF-α G-308A polymorphism to the risk for development and/or progression of IgAN was conducted. Seven studies were included in the meta-analysis. Three of them included populations of European descent (Caucasians) and four involved Asians. The generalized odds ratio (ORG) was used to estimate the risk for the development and/or progression of the disease. Overall, the meta-analysis did not detect any significant association between the G-308A variant and both the risk of developing IgAN and the risk for progression of IgAN. In conclusion, these results suggest that TNF-α does not constitute a key component in the genetic architecture of sporadic IgAN. However, further evidence deciphering the influence of TNF-α on IgAN is still needed.
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Affiliation(s)
- Maria Tziastoudi
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece
| | - Ioanna Chronopoulou
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece
| | - Georgios Pissas
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece
| | - Christos Cholevas
- First Department of Ophthalmology, Faculty of Health Sciences, Aristotle University of Thessaloniki School of Medicine, AHEPA Hospital, 54636 Thessaloniki, Greece
| | - Theodoros Eleftheriadis
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece
| | - Ioannis Stefanidis
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece
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Du Y, Cheng T, Liu C, Zhu T, Guo C, Li S, Rao X, Li J. IgA Nephropathy: Current Understanding and Perspectives on Pathogenesis and Targeted Treatment. Diagnostics (Basel) 2023; 13:diagnostics13020303. [PMID: 36673113 PMCID: PMC9857562 DOI: 10.3390/diagnostics13020303] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 01/19/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide, with varied clinical and histopathological features between individuals, particularly across races. As an autoimmune disease, IgAN arises from consequences of increased circulating levels of galactose-deficient IgA1 and mesangial deposition of IgA-containing immune complexes, which are recognized as key events in the widely accepted "multi-hit" pathogenesis of IgAN. The emerging evidence further provides insights into the role of genes, environment, mucosal immunity and complement system. These developments are paralleled by the increasing availability of diagnostic tools, potential biomarkers and therapeutic agents. In this review, we summarize current evidence and outline novel findings in the prognosis, clinical trials and translational research from the updated perspectives of IgAN pathogenesis.
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Ruocco A, Sirico A, Novelli R, Iannelli S, Van Breda SV, Kyburz D, Hasler P, Aramini A, Amendola PG. The role of C5a-C5aR1 axis in bone pathophysiology: A mini-review. Front Cell Dev Biol 2022; 10:957800. [PMID: 36003145 PMCID: PMC9393612 DOI: 10.3389/fcell.2022.957800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Bone remodeling is a physiological, dynamic process that mainly depends on the functions of 2 cell types: osteoblasts and osteoclasts. Emerging evidence suggests that complement system is crucially involved in the regulation of functions of these cells, especially during inflammatory states. In this context, complement component 5a (C5a), a powerful pro-inflammatory anaphylatoxin that binds the receptor C5aR1, is known to regulate osteoclast formation and osteoblast inflammatory responses, and has thus been proposed as potential therapeutic target for the treatment of inflammatory bone diseases. In this review, we will analyze the role of C5a-C5aR1 axis in bone physiology and pathophysiology, describing its involvement in the pathogenesis of some of the most frequent inflammatory bone diseases such as rheumatoid arthritis, and also in osteoporosis and bone cancer and metastasis. Moreover, we will examine C5aR1-based pharmacological approaches that are available and have been tested so far for the treatment of these conditions. Given the growing interest of the scientific community on osteoimmunology, and the scarcity of data regarding the role of C5a-C5aR1 axis in bone pathophysiology, we will highlight the importance of this axis in mediating the interactions between skeletal and immune systems and its potential use as a therapeutic target.
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Affiliation(s)
| | | | | | | | | | - Diego Kyburz
- Departement Biomedizin, University of Basel, Basel, Switzerland
| | - Paul Hasler
- Division of Rheumatology, Kantonsspital Aarau AG, Aarau, Switzerland
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Jäger C, Stampf S, Molyneux K, Barratt J, Golshayan D, Hadaya K, Huynh-Do U, Binet FI, Mueller TF, Koller M, Kim MJ. Recurrence of IgA nephropathy after kidney transplantation: experience from the Swiss transplant cohort study. BMC Nephrol 2022; 23:178. [PMID: 35538438 PMCID: PMC9088042 DOI: 10.1186/s12882-022-02802-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 04/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background Recurrence of IgA nephropathy (IgAN) after kidney transplantation occurs in about 30% of patients. The relevance of recurrence for the long-term graft survival is expected to increase, since graft survival continues to improve. Methods In a nested study within the Swiss Transplant Cohort Study the incidence of IgAN recurrence, predictive factors, graft function and graft and patient survival were evaluated. Serum concentration of total IgA, total IgG, Gd-IgA1 and IgA-IgG immune complex were measured using ELISA-based immunologic assays. Results Between May 2008 and December 2016, 28 women and 133 men received their kidney allograft for end-stage kidney disease due to IgAN in Switzerland. Over a median follow-up time of 7 years after transplantation, 43 out of 161 patients (26.7%) developed an IgAN recurrence, of which six (13.9%) had an allograft failure afterwards and further four patients (9.3%) died. During the same follow-up period, 6 out of 118 patients (5%) each experienced allograft failure or died without prior IgAN recurrence. After 11 years the risk for IgAN recurrence was 27.7% (95%-CI: 20.6–35.3%). Renal function was similar in patients with and without recurrence up to 7 years after transplantation, but worsened thereafter in patients with recurrence (eGFR median (interquartile range) at 8 years: 49 ml/min/1.73m2 (29–68) vs. 60 ml/min/1.73m2 (38–78)). Serum concentration of total IgA, total IgG, Gd-IgA1 and IgA-IgG immune complex within the first year posttransplant showed no significant effect on the recurrence of IgAN. Younger recipients and women had a higher risk of recurrence, but the latter only in the short term. Conclusions Our study showed a recurrence risk of 28% at 11 years after transplantation, which is consistent with previous literature. However, the predictive value of known biomarkers, such as serum Gd-IgA1 and IgA-IgG IC, for IgAN recurrence could not be confirmed. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02802-x.
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Affiliation(s)
- Cédric Jäger
- Clinic for Nephrology and Dialysis, Cantonal Hospital Basel-Land, Liestal, Switzerland
| | - Susanne Stampf
- Clinic for Transplantation immunology and nephrology, University Hospital Basel, Basel & Swiss Transplant Cohort Study (STCS), Basel, Switzerland
| | - Karen Molyneux
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Déla Golshayan
- Transplantation Center, CHUV University Hospital, Lausanne, Switzerland
| | - Karine Hadaya
- Division of Nephrology, Geneva University Hospital, Geneva, Switzerland
| | - Uyen Huynh-Do
- Department of Nephrology and Hypertension, University of Bern, Bern, Switzerland
| | - Francoise-Isabelle Binet
- Division of Nephrology/Transplantation Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Thomas F Mueller
- Division of Nephrology, University Hospital Zürich, Zürich, Switzerland
| | - Michael Koller
- Clinic for Transplantation immunology and nephrology, University Hospital Basel, Basel & Swiss Transplant Cohort Study (STCS), Basel, Switzerland
| | - Min Jeong Kim
- Division of Nephrology, Cantonal Hospital Aarau, Aarau, Switzerland.
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Basu B, Angeletti A, Islam B, Ghiggeri GM. New and Old Anti-CD20 Monoclonal Antibodies for Nephrotic Syndrome. Where We Are? Front Immunol 2022; 13:805697. [PMID: 35222385 PMCID: PMC8873567 DOI: 10.3389/fimmu.2022.805697] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/25/2022] [Indexed: 12/16/2022] Open
Abstract
Nephrotic proteinuria is the hallmark of several glomerulonephritis determined by different pathogenetic mechanisms, including autoimmune, degenerative and inflammatory. Some conditions such as Minimal Change Nephropathy (MCN) and Focal Segmental Glomerulosclerosis (FSGS) are of uncertain pathogenesis. Chimeric anti-CD20 monoclonal antibodies have been used with success in a part of proteinuric conditions while some are resistant. New human and humanized monoclonal anti-CD 20 antibodies offer some advantages based on stronger effects on CD20 cell subtypes and have been already administered in hematology and oncology areas as substitutes of chimeric molecules. Here, we revised the literature on the use of human and humanized anti-CD 20 monoclonal antibodies in different proteinuric conditions, resulting effective in those conditions resistant to rituximab. Literature on the use of human anti-CD 20 monoclonal antibodies in different proteinuric diseases is mainly limited to ofatumumab, with several protocols and doses. Studies already performed with ofatumumab given in standard doses of 1,500 mg 1.73m2 suggest no superiority compared to rituximab in children and young adults with steroid dependent nephrotic syndrome. Ofatumumab given in very high doses (300 mg/1.73m2 followed by five infusion 2,000 mg/1.73 m2) seems more effective in patients who are not responsive to common therapies. The question of dose remains unresolved and the literature is not concordant on positive effects of high dose ofatumumab in patients with FSGS prior and after renal transplantation. Obinutuzumab may offer some advantages. In the unique study performed in patients with multidrug dependent nephrotic syndrome reporting positive effects, obinutuzumab was associated with the anti-CD38 monoclonal antibody daratumumab proposing the unexplored frontier of combined therapies. Obinutuzumab represent an evolution also in the treatment of autoimmune glomerulonephritis, such as membranous nephrotahy and lupus nephritis. Results of randomized trials, now in progress, are awaited to add new possibilities in those cases that are resistant to other drugs. The aim of the present review is to open a discussion among nephrologists, with the hope to achieve shared approaches in terms of type of antibodies and doses in the different proteinuric renal conditions.
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Affiliation(s)
- Biswanath Basu
- Division of Pediatric Nephrology, Department of Pediatrics, Nilratan Sircar (NRS) Medical College and Hospital, Kolkata, India
| | - Andrea Angeletti
- Division of Nephrology, Dialysis, Transplantation, IstitutoGianninaGaslini Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
- Laboratory on Molecular Nephrology, IstitutoGianninaGaslini Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
| | - Bilkish Islam
- Department of Pediatrics, Nil Ratan Sircar Medical College and Hospital, Kolkata, India
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, Transplantation, IstitutoGianninaGaslini Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
- Laboratory on Molecular Nephrology, IstitutoGianninaGaslini Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Genoa, Italy
- *Correspondence: Gian Marco Ghiggeri,
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Yang X, Ma F, Bai M, Wang Y, Jia Q, Dong R, Liu C, Sun S. The prognostic effect of immunosuppressive therapy in IgA nephropathy with stage 3 or 4 chronic kidney disease. Ren Fail 2021; 43:1180-1187. [PMID: 34376108 PMCID: PMC8366668 DOI: 10.1080/0886022x.2021.1956536] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background It is debated whether patients with IgAN with heavy proteinuria and decreased eGFR benefit from aggressive treatment consisting of corticosteroids alone or combined with immunosuppressive agents. Methods A retrospective study was performed between January 2008 and December 2016 on patients with IgAN who had urinary protein excretion > 1.0 g/d and an eGFR between 15 and 59 mL/min/1.73 m2. These patients were assigned to receive supportive care alone or supportive care plus immunosuppressive therapy. The primary outcome was defined as the first occurrence of a 50% decrease in eGFR or the development of ESKD. Results All 208 included patients were followed for a median of 43 months, and 92 (44%) patients experienced the primary outcome. Cumulative kidney survival was better in the immunosuppression group than in the supportive care group (p < .001). The median annual rate of eGFR decline in the immunosuppression group was −2.0 (−7.3 to 4.2), compared with −8.4 (–18.9 to −4.1) mL/min/1.73 m2 in the supportive care group (p < .001). In multivariate Cox regression analyses, immunosuppressive therapy was associated with a lower risk of progression to ESKD, independent of age, sex, eGFR, proteinuria, MAP, kidney histologic findings and the use of RASi agents (HR = 0.335; 95% CI 0.209–0.601). Among the adverse events, infection requiring hospitalization occurred at similar rates in both groups (p = .471). Conclusion Immunosuppressive therapy attenuated the rate of eGFR decline and was associated with a favorable kidney outcome in IgAN patients with heavy proteinuria and decreased eGFR, and the side effects were tolerable.
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Affiliation(s)
- Xiaoxia Yang
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Feng Ma
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Yan Wang
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Qing Jia
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Ruijuan Dong
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Chunmei Liu
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, the Fourth Military Medical University, Xi'an, China
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11
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Seikrit C, Rauen T, Stamellou E, Floege J. Precision medicine in immunoglobulin A nephropathy: still a journey ahead. Nephrol Dial Transplant 2021; 36:24-30. [PMID: 34153983 DOI: 10.1093/ndt/gfab032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Indexed: 11/12/2022] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerular disease worldwide and since its first description extensive research has identified a number of key central pathogenetic contributors, including genetic, immunological and environmental factors. Along with its multifaceted pathophysiology, the clinical presentation of IgAN varies, ranging from mild forms with only minor urinary findings and preserved renal function to cases that rapidly progress to end-stage renal disease. Because of this, early identification of patients at risk for a progressive course is urgently needed. The search for valid and easily accessible biomarkers showed urinary Dickkopf-3 as a promising candidate to predict the course of kidney function. In addition, a recently established IgAN risk prediction tool derived from an international cohort of IgAN patients allows estimation of the risk of a 50% loss of kidney function over several years upon diagnosis. This might serve as a significant tool to individually predict the course of renal function by combining biometric, clinical, histological and treatment information at the time of diagnosis. Today there is no doubt that a comprehensive supportive treatment regimen is the main pillar for all IgAN patients. The value of an additional immunosuppressive treatment in IgAN patients at risk for disease progression is less clear. Early risk stratification and individualized therapies would be desirable for IgAN patients to facilitate the choice of treatment strategies, which is still a matter of ongoing discussion.
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Affiliation(s)
- Claudia Seikrit
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Thomas Rauen
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Eleni Stamellou
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
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12
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CORREIA CP, MARTINS A, FREITAS JG, GUIOMAR V, OLIVEIRA J, MENG C. Immunoglobulin A vasculitis: challenging renal implications of adult onset. GAZZETTA MEDICA ITALIANA ARCHIVIO PER LE SCIENZE MEDICHE 2021. [DOI: 10.23736/s0393-3660.19.04211-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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13
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Shah S, Hata J. A Rare and Severe Presentation of Henoch-Schönlein Purpura in an Adolescent With Crescentic Glomerulonephritis, Arrhythmia, Acute Gastrointestinal Bleed, and Neurological Complications. Cureus 2021; 13:e14169. [PMID: 33796429 PMCID: PMC8006498 DOI: 10.7759/cureus.14169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Henoch-Schönlein purpura (HSP) is a childhood vasculitis disorder that involves the skin, joints, gastrointestinal (GI) tract, and kidneys. It is related to immunoglobulin A (IgA) antibody deposition in small blood vessels. HSP is a self-limiting disorder, but its morbidity is primarily associated with renal involvement. GI pathologies like intussusception, gastritis, duodenitis, ileitis, or ulcer have been reported to be associated with this disease. However, cardiac and neurological complications are rarely reported. We present the case of a 16-year-old, previously healthy male who was diagnosed with HSP after presenting with a non-blanching purpuric rash in the lower extremities. The patient also had joint and abdominal pain, and swelling in the extremities. There was renal dysfunction at presentation with blood urea nitrogen (BUN) of 67 mg/dL and serum creatinine of 1.9 mg/dL. The serum albumin was low at 2 g/dL, and the patient had nephrotic range proteinuria. Urine microscopy showed red blood cell casts. A renal biopsy was performed, which showed IgA deposition in glomeruli. He was started on intravenous (IV) pulse methylprednisolone and was later prescribed oral steroids. Four weeks after the treatment initiation, he presented with syncope and acute anemia (hemoglobin of 3.5 g/dL). The fecal occult blood was positive. Esophagogastroduodenoscopy (EGD) was not suggestive of gastritis, duodenitis, or ulcer. The pill-cam capsule endoscopy revealed GI bleeding from the terminal ileum near Meckel’s diverticulum. He subsequently required blood transfusions, and the bleeding eventually improved with symptomatic management. Six weeks after treatment initiation, he presented with dizziness and palpitations. The EKG showed the presence of atrial fibrillation, and he had an episode of non-sustained ventricular tachycardia on telemetry. Arrhythmia was diagnosed secondary to HSP cardiac vasculitis, and we initiated treatment with metoprolol and amiodarone. Seven weeks after the initial treatment, he had neurological clinical findings of proximal muscle weakness, tremors, and upper and lower extremity clonus. A second renal biopsy was then performed due to the presence of persistently elevated serum creatinine, which showed 75% of glomeruli with cellular crescents. He was treated with IV cyclophosphamide. Subsequently, the renal function improved. There were no other GI, cardiac, or neurological complications after six months of follow-up. The presentation of HSP can be more severe in adolescents, and they need to be closely monitored for GI, cardiac, renal, and neurological complications after the disease occurrence. Bleeding from Meckel’s diverticulum or an episode of non-sustained ventricular tachycardia with HSP has not been previously reported to our knowledge. Arrhythmia is an exceptionally unusual occurrence in HSP, and it is usually treated with anti-arrhythmic drugs and intensification of the immunosuppressive regimen.
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Affiliation(s)
- Siddharth Shah
- Pediatric Nephrology, Norton Children's Hospital, Louisville, USA
| | - Jessica Hata
- Pathology, Norton Children's Hospital, Louisville, USA
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14
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Scurt FG, Bose K, Canbay A, Mertens PR, Chatzikyrkou C. [Chronic kidney injury in patients with liver diseases - Reappraising pathophysiology and treatment options]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:560-579. [PMID: 33728618 DOI: 10.1055/a-1402-1502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Acute and chronic kidney disease concurs commonly with liver disease and is associated with a wide array of complications including dialysis dependency and increased mortality. Patients with liver disease or liver cirrhosis show a higher prevalence of chronic kidney disease. This is attributed to concomitant comorbidities, such as metabolic syndrome, chronic inflammation, hypercoagulability, hyperfibrinolysis, diabetes mellitus and dyslipidaemias. But chronic progressive kidney disease is not always due to hepatorenal syndrome. Beyond that, other diseases or disease entities should be considered. Among them are diabetic nephropathy, secondary IgA nephropathy, hepatitis C -associated membranoproliferative Glomerulonephritis (MPGN) and hepatitis B-associated membranous nephropathy.Coexisting diseases, similar underlying pathophysiologic mechanisms, or simultaneously concurring pathophysiological processes and overlapping clinical manifestations, impede the etiologic diagnosis and corresponding treatment of chronic kidney disease in the setting of chronic liver disease. In this review, we focus on common and rare pathologies, which can lead to chronic kidney disease in this particular patient group and try to summarize the most recent therapeutic modalities.
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Affiliation(s)
- Florian Gunnar Scurt
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto von Guericke University, Magdeburg, Germany
| | - Katrin Bose
- Health Campus Immunology, Infectiology and Inflammation, Otto von Guericke University, Magdeburg, Germany.,Universitätsklinik für Gastroenterologie, Hepatologie und Infektiologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland
| | - Ali Canbay
- Ruhr-Universität Bochum, Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Bochum, Deutschland
| | - Peter R Mertens
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto von Guericke University, Magdeburg, Germany
| | - Christos Chatzikyrkou
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto von Guericke University, Magdeburg, Germany
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15
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Jia S, Peng X, Liang L, Zhang Y, Li M, Zhou Q, Shen X, Wang Y, Wang C, Feng S, Chen J, Ren P, Jiang H. The Study of Angptl4-Modulated Podocyte Injury in IgA Nephropathy. Front Physiol 2021; 11:575722. [PMID: 33643055 PMCID: PMC7905042 DOI: 10.3389/fphys.2020.575722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/20/2020] [Indexed: 11/16/2022] Open
Abstract
Background Increasing evidence shows that Angptl4 affects proteinuria in podocytes injured kidney disease, however, whether there is a relationship between Angptl4 and IgA nephropathy (IgAN) has not been studied yet. Methods Plasma and urine samples were obtained from 71 patients with IgAN and 61 healthy controls. Glomeruli from six renal biopsy specimens (three IgAN patients and three healthy controls) were separated by RNA-Seq. Differentially expressed genes (DEGs) related to podocytes and Angptl4 between IgAN patients and healthy controls were performed using the Limma package. Gene set enrichment analysis was used to determine whether there was a statistically significant difference between the two groups. STRING was used to create a protein-protein interaction network of DEGs. Association analysis between Angptl4 levels and clinical features of IgAN was performed. Results Thirty-three podocyte-related and twenty-three Angpt4-related DEGs were found between IgAN patients and healthy controls. By overlapping the genes, FOS and G6PC were found to be upregulated in IgAN patients, while MMP9 was downregulated in IgAN patients. Plasma and urine Angptl4 levels were closely related to the degree of podocyte injury and urine protein, but not to the protein-creatine ratio. Conclusion Our findings show that Angptl4 levels in plasma and urine are related to podocyte damage and, therefore, may be a promising tool for assessing the severity of IgAN patients to identify and reverse the progression to ESRD.
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Affiliation(s)
- Sha Jia
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China.,Dongyang Women & Children Hospital, Dongyang, China
| | - Xiaofeng Peng
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Ludan Liang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Ying Zhang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Meng Li
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Qin Zhou
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Xiujin Shen
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Yucheng Wang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Cuili Wang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Shi Feng
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Pingping Ren
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
| | - Hong Jiang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China.,Key Laboratory of Nephropathy, Hangzhou, China.,Kidney Disease Immunology Laboratory, The Third-Grade Laboratory, State Administration of Traditional Chinese Medicine of China, Hangzhou, China.,Key Laboratory of Multiple Organ Transplantation, Ministry of Health of China, Beijing, China.,Institute of Nephropathy, Zhejiang University, Hangzhou, China
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16
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Kurt-Şükür ED, Sekar T, Tullus K. Biopsy-proven Henoch-Schönlein purpura nephritis: a single center experience. Pediatr Nephrol 2021; 36:1207-1215. [PMID: 33089378 PMCID: PMC8009786 DOI: 10.1007/s00467-020-04809-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/23/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Knowledge on normal progress and treatment of Henoch-Schönlein purpura nephritis (HSPN) is limited. This study reviews outcome, clinical, pathological, and therapeutic factors affecting the prognosis of HSPN patients. METHODS Forty-nine children with biopsy-confirmed HSPN diagnosed between September 2008 and 2018 were included. Demographics, clinical and laboratory data, treatment, and outcome were recorded at the time of biopsy, 3, 6, 12, and 24 months and at last visit. Clinical outcome was graded according to Meadow's criteria. RESULTS The median age at time of biopsy was 10.1 years (IQR:5.7) and female/male ratio 24/25. At presentation, 40.8% of patients had nonnephrotic proteinuria, 18.4% nephrotic syndrome (NS), 4.1% nephritic syndrome (NephrS), and 36.7% NephrS+NS. There were 11 patients with an estimated glomerular filtration rate below 90 ml/min/1.73 m2. Biopsy specimens were classified according to International Study of Kidney Diseases in Children (ISKDC) and Oxford Classification MEST-C scoring systems. Forty-one patients received angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, 37 patients steroids, and 35 patients other immunosuppressive medications. At last visit, 24 patients had stage 1 chronic kidney disease (CKD), three stage 2 CKD, and two had stage 5 CKD. Neither clinical parameters nor ISKDC biopsy grade or treatment modalities effected the final outcome. The Oxford classification showed significantly increased segmental glomerulosclerosis in patients with unfavorable outcome. Favorable outcome was associated with shorter time from kidney involvement to biopsy and start of treatment. CONCLUSION A large proportion of patients continued to show signs of CKD at last follow-up while only a small proportion developed stage 5 CKD.
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Affiliation(s)
- Eda Didem Kurt-Şükür
- Department of Pediatric Nephrology, Dr. Sami Ulus Children’s Hospital, Ankara, Turkey
| | - Thivya Sekar
- Department of Pediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kjell Tullus
- Department of Pediatric Pathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.
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17
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He JW, Zhou XJ, Lv JC, Zhang H. Perspectives on how mucosal immune responses, infections and gut microbiome shape IgA nephropathy and future therapies. Am J Cancer Res 2020; 10:11462-11478. [PMID: 33052226 PMCID: PMC7545987 DOI: 10.7150/thno.49778] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 08/30/2020] [Indexed: 02/06/2023] Open
Abstract
Infections have been considered to play a critical role in the pathogenesis of IgA nephropathy (IgAN) because synpharyngitic hematuria is a common feature in IgAN. However, how infections participate in this process is still debated. More recent studies have also revealed that the alteration of the gut microbiome exerts a profound effect on host immune responses, contributing to the etiology or progression of autoimmunity. Considering IgA as the first line of defense against bacterial and viral antigens, this review evaluates the relationships among intestinal infections, gut microbiome, and IgA for a better understanding of the pathogenesis of IgAN. Moreover, as a prototype of IgA immunity, we provide detailed clarification of IgAN pathogenesis to shed light on other diseases in which IgA plays a role. Finally, we discuss potential therapies focusing on microbes and mucosal immune responses in IgAN.
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18
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Predicative value of urinary protein biomarkers on delayed renal involvement in children with Henoch-Schönlein purpura. SCIENCE CHINA-LIFE SCIENCES 2019; 62:1594-1596. [PMID: 31748952 DOI: 10.1007/s11427-018-9544-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 04/16/2019] [Indexed: 10/25/2022]
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19
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Yaxing L, Xia S, Shu L, Zhihong L, Qiaoju Y, Yanwei W, Tianxue G, Jun Z. Parents’ Resilience Affects Condition of Children With Henoch-Schönlein Purpura Nephritis. J Nurse Pract 2019. [DOI: 10.1016/j.nurpra.2019.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Obrișcă B, Sinescu I, Ismail G, Mircescu G. Has The Time Arrived to Refine The Indications of Immunosuppressive Therapy and Prognosis in IgA Nephropathy? J Clin Med 2019; 8:E1584. [PMID: 31581654 PMCID: PMC6833025 DOI: 10.3390/jcm8101584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most frequent glomerular disease worldwide and a leading cause of end-stage renal disease. Particularly challenging to the clinician is the early identification of patients at high risk of progression, an estimation of the decline in renal function, and the selection of only those that would benefit from additional immunosuppressive therapies. Nevertheless, the pathway to a better prognostication and to the development of targeted therapies in IgAN has been paved by recent understanding of the genetic and molecular basis of this disease. Merging the data from the Oxford Classification validation studies and prospective treatment studies has suggested that a disease-stratifying algorithm would be appropriate for disease management, although it awaits validation in a prospective setting. The emergence of potential noninvasive biomarkers may assist traditional markers (proteinuria, hematuria) in monitoring disease activity and treatment response. The recent landmark trials of IgAN treatment (STOP-IgAN and TESTING trials) have suggested that the risks associated with immunosuppressive therapy outweigh the benefits, which may shift the treatment paradigm of this disease. While awaiting the approval of the first therapies for IgAN, more targeted and less toxic immunotherapies are warranted. Accordingly, the targeting of complement activation, the modulation of mucosal immunity, the antagonism of B-cell activating factors, and proteasomal inhibition are currently being evaluated in pilot studies for IgAN treatment.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
| | - Ioanel Sinescu
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
- Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
| | - Gabriel Mircescu
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
- Department of Nephrology, “Dr. Carol Davila” Teaching Hospital of Nephrology, 010731 Bucharest, Romania
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Sevillano AM, Diaz M, Caravaca-Fontán F, Barrios C, Bernis C, Cabrera J, Calviño J, Castillo L, Cobelo C, Delgado-Mallén P, Espinosa M, Fernandez-Juarez G, Fernandez-Reyes MJ, Garcia-Osuna R, Garcia P, Goicoechea M, Gonzalez-Cabrera F, Guzmán DA, Heras M, Martín-Reyes G, Martinez A, Olea T, Peña JK, Quintana LF, Rabasco C, López Revuelta K, Rodas L, Rodriguez-Mendiola N, Rodriguez E, San Miguel L, Sanchez de la Nieta MD, Shabaka A, Sierra M, Valera A, Velo M, Verde E, Ballarin J, Noboa O, Moreno JA, Gutiérrez E, Praga M. IgA Nephropathy in Elderly Patients. Clin J Am Soc Nephrol 2019; 14:1183-1192. [PMID: 31311818 PMCID: PMC6682823 DOI: 10.2215/cjn.13251118] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 05/01/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVES Some studies suggest that the incidence of IgA nephropathy is increasing in older adults, but there is a lack of information about the epidemiology and behavior of the disease in that age group. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In this retrospective multicentric study, we analyzed the incidence, forms of presentation, clinical and histologic characteristics, treatments received, and outcomes in a cohort of 151 patients ≥65 years old with biopsy-proven IgA nephropathy diagnosed between 1990 and 2015. The main outcome was a composite end point of kidney replacement therapy or death before kidney replacement therapy. RESULTS We found a significant increase in the diagnosis of IgA nephropathy over time from six patients in 1990-1995 to 62 in 2011-2015 (P value for trend =0.03). After asymptomatic urinary abnormalities (84 patients; 55%), AKI was the most common form of presentation (61 patients; 40%). Within the latter, 53 (86%) patients presented with hematuria-related AKI (gross hematuria and tubular necrosis associated with erythrocyte casts as the most important lesions in kidney biopsy), and eight patients presented with crescentic IgA nephropathy. Six (4%) patients presented with nephrotic syndrome. Among hematuria-related AKI, 18 (34%) patients were receiving oral anticoagulants, and this proportion rose to 42% among the 34 patients older than 72 years old who presented with hematuria-related AKI. For the whole cohort, survival rates without the composite end point were 74%, 48%, and 26% at 1, 2, and 5 years, respectively. Age, serum creatinine at presentation, and the degree of interstitial fibrosis in kidney biopsy were risk factors significantly associated with the outcome, whereas treatment with renin-angiotensin-aldosterone blockers was associated with a lower risk. Immunosuppressive treatments were not significantly associated with the outcome. CONCLUSIONS The diagnosis of IgA nephropathy among older adults in Spain has progressively increased in recent years, and anticoagulant therapy may be partially responsible for this trend. Prognosis was poor. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_07_16_CJASNPodcast_19_08_.mp3.
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Affiliation(s)
- Angel M Sevillano
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Department of Medicine, Complutense University, Madrid, Spain
| | - Monserrat Diaz
- Department of Nephrology, Fundación Puigvert, Barcelona, Spain
| | - Fernando Caravaca-Fontán
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Department of Medicine, Complutense University, Madrid, Spain
| | - Clara Barrios
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Carmen Bernis
- Department of Nephrology, Hospital Universitario de La Princesa, Madrid, Spain
| | - Jimena Cabrera
- Programa de prevención y tratamiento de las glomerulopatias (PPTG) de Uruguay, Sociedad Uruguaya de Nefrologia Centro de Nefrología, Hospital de Clinicas Montevideo, Montevideo, Uruguay
| | - Jesus Calviño
- Department of Nephrology, Hospital de Lucus Augusti, Lugo, Spain
| | - Lorena Castillo
- Department of Nephrology, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - Carmen Cobelo
- Department of Nephrology, Hospital de Lucus Augusti, Lugo, Spain
| | | | - Mario Espinosa
- Department of Nephrology, Hospital Universitario Reina Sofia, Cordoba, Spain
| | - Gema Fernandez-Juarez
- Department of Nephrology, Hospital Universitario Fundación Alcorcón, Alcorcon, Spain
| | | | | | - Patricia Garcia
- Department of Nephrology, Hospital Virgen de la Victoria, Malaga, Spain
| | - Marian Goicoechea
- Department of Nephrology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Fayna Gonzalez-Cabrera
- Department of Nephrology, Hospital Universitario de Gran Canaria Dr. Negrin, Gran Canaria, Spain
| | - Diomaris A Guzmán
- Department of Nephrology, Hospital Regional Universitario de Málaga, Malaga, Spain
| | - Manuel Heras
- Department of Nephrology, Hospital General de Segovia, Segovia, Spain
| | | | - Alberto Martinez
- Department of Nephrology, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - Teresa Olea
- Department of Nephrology, Hospital Universitario La Paz, Madrid, Spain
| | - Jessy Korina Peña
- Department of Nephrology, Hospital Principe de Asturias, Alcala de Henares, Spain
| | - Luis F Quintana
- Department of Nephrology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Cristina Rabasco
- Department of Nephrology, Hospital Universitario Reina Sofia, Cordoba, Spain
| | - Katia López Revuelta
- Department of Nephrology, Hospital Universitario Fundación Alcorcón, Alcorcon, Spain
| | - Lida Rodas
- Department of Nephrology, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Eva Rodriguez
- Department of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Luz San Miguel
- Department of Nephrology, Fundación Puigvert, Barcelona, Spain
| | | | - Amir Shabaka
- Department of Nephrology, Hospital Clínico de Madrid, Madrid, Spain
| | - Milagros Sierra
- Department of Nephrology, Hospital San Pedro, Logrono, Spain
| | - Alfonso Valera
- Department of Nephrology, Hospital Virgen de la Victoria, Malaga, Spain
| | - Mercedes Velo
- Department of Nephrology, Hospital Clínico de Madrid, Madrid, Spain
| | - Eduardo Verde
- Department of Nephrology, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Jose Ballarin
- Department of Nephrology, Fundación Puigvert, Barcelona, Spain
| | - Oscar Noboa
- Nephrology Center, Hospital de Clínicas, Department of Medicine, Republic University, Montevideo, Uruguay; and
| | - Juan Antonio Moreno
- Department of Cell Biology, Physiology, and Immunology, Maimonides Biomedical Research Institute of Cordoba, University of Cordoba, Cordoba, Spain
| | - Eduardo Gutiérrez
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain; .,Department of Medicine, Complutense University, Madrid, Spain
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Qian G, Zhang X, Xu W, Zou H, Li Y. Efficacy and safety of glucocorticoids for patients with IgA nephropathy: a meta-analysis. Int Urol Nephrol 2019; 51:859-868. [PMID: 30843135 DOI: 10.1007/s11255-019-02094-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 01/30/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND The efficacy and safety of glucocorticoids for the treatment of patients with IgA nephropathy (IgAN) remains controversial. The aim of the study is to perform a metaanalysis of randomized controlled trials to evaluate the efficacy and safety of glucocorticoids for patients with IgAN. METHODS We searched PubMed, EMBASE and the Cochrane Library and article reference lists of Controlled Trials, and Clinical Trial Registries for randomized controlled trials comparing glucocorticoids with other non-immunosuppressive agents in patients with IgAN. RESULTS The present meta-analysis, including 10 RCTs and 791 patients from 12 published studies, showed that using glucocorticoids agents relatively preserves kidney function(RR 0.06, 95% CI 0.14-0.61) and plays an effective role on reducing the proteinuria(SMD, - 0.69; 95% CI 0.85 to - 0.53, p < 0.00001; heterogeneity I2 = 0%; p = 0.09) compared with a control group. Moreover, adverse events cannot be neglected, especially gastrointestinal tract (RR 3.10, 95% CI 1.37-6.98, p = 0.006; heterogeneity I2 = 0%, p = 0.86), and corticosteroid regimens in IgAN should be reviewed with regard to safety. CONCLUSIONS Glucocorticoids were wildly used to treat various diseases including IgAN. Meanwhile, adverse events cannot be neglected, such as gastrointestinal adverse events, infection and so on. Corticosteroid should be used with reserve, especially in those patients with hypertension and impaired renal function or older patients.
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Affiliation(s)
- Ge Qian
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China
| | - Xiaoyu Zhang
- Department of Non-communicable Disease Control and Prevention, Xi'an Municipal Center for Disease Control and Prevention, Xi'an, 710054, China
| | - Weicheng Xu
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China
| | - Hequn Zou
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China
| | - Yongqiang Li
- Department of Nephrology, Institute of Nephrology and Urology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China.
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van Roeyen CRC, Martin IV, Drescher A, Schuett KA, Hermert D, Raffetseder U, Otten S, Buhl EM, Braun GS, Kuppe C, Liehn E, Boor P, Weiskirchen R, Eriksson U, Gross O, Eitner F, Floege J, Ostendorf T. Identification of platelet-derived growth factor C as a mediator of both renal fibrosis and hypertension. Kidney Int 2019; 95:1103-1119. [PMID: 30827511 DOI: 10.1016/j.kint.2018.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 11/15/2018] [Accepted: 11/21/2018] [Indexed: 02/06/2023]
Abstract
Platelet-derived growth factors (PDGF) have been implicated in kidney disease progression. We previously found that PDGF-C is upregulated at sites of renal fibrosis and that antagonism of PDGF-C reduces fibrosis in the unilateral ureteral obstruction model. We studied the role of PDGF-C in collagen 4A3-/- ("Alport") mice, a model of progressive renal fibrosis with greater relevance to human kidney disease. Alport mice were crossbred with PDGF-C-/- mice or administered a neutralizing PDGF-C antibody. Both PDGF-C deficiency and neutralization reduced serum creatinine and blood urea nitrogen levels and mitigated glomerular injury, renal fibrosis, and renal inflammation. Unexpectedly, systolic blood pressure was also reduced in both Alport and wild-type mice treated with a neutralizing PDGF-C antibody. Neutralization of PDGF-C reduced arterial wall thickness in the renal cortex of Alport mice. Aortic rings isolated from anti-PDGF-C-treated wildtype mice exhibited reduced tension and faster relaxation than those of untreated mice. In vitro, PDGF-C upregulated angiotensinogen in aortic tissue and in primary hepatocytes and induced nuclear factor κB (NFκB)/p65-binding to the angiotensinogen promoter in hepatocytes. Neutralization of PDGF-C suppressed transcript expression of angiotensinogen in Alport mice and angiotensin II receptor type 1 in Alport and wildtype mice. Finally, administration of neutralizing PDGF-C antibodies ameliorated angiotensin II-induced hypertension in healthy mice. Thus, in addition to its key role in mediating renal fibrosis, we identified PDGF-C as a mediator of hypertension via effects on renal vasculature and on the renin-angiotensin system. The contribution to both renal fibrosis and hypertension render PDGF-C an attractive target in progressive kidney disease.
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Affiliation(s)
- Claudia R C van Roeyen
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany.
| | - Ina V Martin
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
| | - Ana Drescher
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
| | | | - Daniela Hermert
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
| | - Ute Raffetseder
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
| | - Stephanie Otten
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
| | - Eva M Buhl
- Institute of Pathology, RWTH Aachen University, Aachen, Germany
| | - Gerald S Braun
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
| | - Christoph Kuppe
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
| | - Elisa Liehn
- Institute for Molecular Cardiovascular Research, RWTH Aachen University, Aachen, Germany
| | - Peter Boor
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany; Institute of Pathology, RWTH Aachen University, Aachen, Germany
| | - Ralf Weiskirchen
- Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry RWTH Aachen University, Aachen, Germany
| | - Ulf Eriksson
- Department of Medical Biochemistry and Biophysics, Karolinska Institutet, Stockholm, Sweden
| | - Oliver Gross
- Division of Nephrology and Rheumatology, University Medicine Göttingen, Göttingen, Germany
| | - Frank Eitner
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany; Kidney Diseases Research, Bayer AG, Wuppertal, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
| | - Tammo Ostendorf
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany
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Coppo R. Treatment of IgA nephropathy: Recent advances and prospects. Nephrol Ther 2018; 14 Suppl 1:S13-S21. [PMID: 29606258 DOI: 10.1016/j.nephro.2018.02.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 02/09/2018] [Indexed: 01/06/2023]
Abstract
IgA nephropathy, identified 50 years ago in France, is the most frequent glomerular disease worldwide. The course is variable, but in most of the cases there is a relentless decline in renal function, reaching end-stage renal failure in 10-60% of the cases after 10 years and in 40% after 20 years. These data justify the interest for finding a suitable therapeutic approach particularly in progressive cases. A supportive care, including renin-angiotensin system inhibitors is the priority in cases with slowly declining renal function, particularly when developing proteinuria. The recent supportive versus immunosuppressive therapy for the treatment of progressive IgA nephropathy (STOP-IgAN) randomized and controlled trial has further stressed the benefit of a strict supportive care including also life-style changes, protein and salt restriction. However, there is clear evidence from observational studies (including the European Validation Study of the Oxford Classification of IgA nephropathy [VALIGA]) and a new randomized and controlled trial (Therapeutic Evaluation of Steroids in IgA Nephropathy Global [TESTING]) of additional benefits of corticosteroid treatment in patients with proteinuric IgA nephropathy. However, the present treatment schedules carry severe side effects, mostly infectious complications, which indicate the need for less toxic interventions. The recent focus on the role of gut-kidney axis in IgA nephropathy has led to the search of corticosteroid formulations targeting the intestinal mucosal immune system (gut-associated lymphoid tissue). The NEFIGAN trial obtained interesting results in terms of reduction of proteinuria and stabilization of renal function using a budesonide formulation allowing a selective drug delivery at intestinal gut-associated lymphoid tissue sites. The adverse events, particularly infections, were found to be not clinically relevant. The possibility of a personalized approach to the treatment according to the renal biopsy lesions (Oxford MEST score) is supported by several uncontrolled studies and deserves great attention in the next future. New treatments options for IgA nephropathy include drugs targeting BAFF, a B-cell factor crucial for IgA synthesis or targeting the complement system, and also the possibility of acting directly on the deposited IgA by selective protease digestion.
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Affiliation(s)
- Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, 94, Piazza Polonia, 10126 Torino, TO, Italy.
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Chan TM. Corticosteroids in the treatment of IgA nephropathy: any light beyond the clouds of confusion? Postgrad Med J 2018; 94:371-373. [PMID: 29891644 DOI: 10.1136/postgradmedj-2017-135239] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 11/03/2022]
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[Progressive renal insufficiency in a 55-year-old man with psoriasis]. Internist (Berl) 2018; 59:1204-1207. [PMID: 29872889 DOI: 10.1007/s00108-018-0446-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Treatment with tumor necrosis factor alpha (TNF-α) inhibitors is a well-established therapeutic strategy for various autoimmune diseases. However, little is known about renal complications and possible causality of renal injury due to this treatment. The following case of a patient with psoriasis demonstrates the difficulties in classifying renal complications of anti-TNF-α therapy versus kidney involvement caused by the underlying disease.
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Praga M, Caravaca F, Yuste C, Cavero T, Hernández E, Morales E, Mérida E, Moreno JA, Sevillano A, Gutiérrez E. IgA nephropathy: What patients are at risk of progression to end-stage renal disease and how should they be treated? Nefrologia 2018; 38:347-352. [PMID: 29636281 DOI: 10.1016/j.nefro.2018.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/04/2018] [Accepted: 01/15/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España; Departamento de Medicina, Universidad Complutense, Madrid, España.
| | - Fernando Caravaca
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Claudia Yuste
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Teresa Cavero
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Eduardo Hernández
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Enrique Morales
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Eva Mérida
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Juan Antonio Moreno
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, España
| | - Angel Sevillano
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Eduardo Gutiérrez
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
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Chen D, Liu J, Duan S, Chen P, Tang L, Zhang L, Feng Z, Cai G, Wu J, Chen X. Clinicopathological Features to Predict Progression of IgA Nephropathy with Mild Proteinuria. Kidney Blood Press Res 2018. [PMID: 29529608 DOI: 10.1159/000487901] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS In the past, little attention has been paid to patients with IgA nephropathy (IgAN) who had minimal proteinuria upon the onset. The aim of this study was to analyze the clinicopathological features and the prognostic factors in patients with IgA nephropathy. METHODS Data of patients that had their first renal biopsy in our hospital and were diagnosed with primary IgAN with proteinuria <1 g/d from January 1995 to December 2014 were retrospectively examined. Clinical records of the clinicopathological features, renal function, and proteinuria were collected and investigated. The factors affecting the renal function and proteinuria were analyzed by Cox regression. The predictive efficiencies of clinical and pathological models were evaluated by Harrell concordance index (C-index). RESULTS A total of 506 patients with IgA nephropathy were included in this study. (1) Baseline proteinuria greater than 0.5 g/d was positively associated with Oxford M, S, and T lesions. eGFR less than 90 mL/min/1.73 m2 were positively associated with Oxford T. (2) In the follow-up with a median of 50 months, 82 patients (16.2%) achieved complete clinical remission (CCR), whereas 54 patients (10.6%) showed an increase in creatinine by more than 50% (not progressing to end-stage renal disease). The cumulative proportion of creatinine increased >50%, and the values obtained by life-table analysis in 10, 15, and 20 years were 15%, 21%, and 22%, respectively. Significant differences were found in baseline age, proteinuria, and Oxford T between the group of creatinine increase >50% and the CCR group. (4) Multivariate COX regression showed that baseline age and proteinuria > 0.5 g/d were independent risk factors of adverse outcome. C-index suggested that the clinical model was more effective than the pathological models in predicting endpoint events. (5) Effect of the mean value during the follow-up on adverse endpoint events: Multivariate COX regression found that the mean proteinuria during follow-up was an independent influencing factor for the increase of creatinine by more than 50%. CONCLUSION (1) Proteinuria > 0.5g/d and eGFR < 90 mL/min/1.73 m2 may predict more severe pathological changes; (2) With the increase in age and baseline proteinuria, the risks of adverse endpoint events would increase significantly; (3) Pathology could roughly predict the adverse endpoint events but is less efficient than the clinical indicators; (4) Data during follow-up suggested that the patients should regularly test their renal function and proactively control their proteinuria.
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Rituximab therapy for IgA-vasculitis with nephritis: a case series and review of the literature. Immunol Res 2018; 65:186-192. [PMID: 27449502 DOI: 10.1007/s12026-016-8827-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Henoch-Schonlein purpura, also called IgA-vasculitis, is a systemic small vessels vasculitis with immunoglobulin A1-dominant immune deposits. The optimal treatment remains controversial. Because IgA-vasculitis is characterized by leukocyte infiltration of the blood vessel walls along with immunoglobulin A deposition, and because glucocorticosteroids inhibit inflammatory processes, early administration of glucocorticosteroids has been postulated to be effective, but this indication remains controversial. Immunosuppressive agents (azathioprine, cyclophosphamide, cyclosporine, mycophenolate) have been used in combination with glucocorticosteroids without definitive evidence of effectiveness. The efficacy of rituximab in adult IgA-vasculitis has been reported in few cases. We described a monocentric experience on the use of rituximab in adult IgA-vasculitis with biopsy-proven nephritis. The patients achieved a complete remission of nephritis and syndromic manifestations, and no patients experienced adverse reactions. These data have been compared with the limited literature nowadays available.
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Abstract
Immunoglobulin A nephropathy (IgAN) is the most frequently occurring primary glomerulonephritis in Caucasian and Asian populations. Nonetheless, therapeutic recommendations are based on weak evidence, large controlled trials are scarce and, in particular, the additional value of immunosuppression beyond comprehensive supportive measures is not well-established. The use of immunosuppressants is supported by experimental insights into IgAN pathogenesis that suggest an autoimmune component in disease development. The so-called "multi-hit" theory comprises multiple steps, starting with defective glycosylation of IgA subclass IgA1 that results in overproduction of galactose-deficient IgA1 (Gd-IgA1), occurrence of anti-Gd-IgA1 autoantibodies, and mesangial deposition of nephritogenic immune complexes. This eventually results in an increased mesangial cell proliferation, inflammatory responses, and complement activation. Recent genome-wide association studies have identified several susceptibility genes, many of which support the "multi-hit" concept. In light of these discoveries, it is astonishing that the vast majority of adult IgAN patients obviously do not need and/or benefit from immunosuppressive therapies in the first place. In fact, a number of supportive measures are highly effective in reducing the risk for disease progression in many patients. These measures need to be optimized before immunosuppression should be considered at all. In this review we focus on the underlying pathogenetic cornerstones and the central question of whether systemic inflammation in adult IgAN patients should be treated. Treatment options in children with IgAN are also discussed.
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Wang Z, Yu C, Zhou LN, Chen X. Effects of Tripterygium wilfordii Induction Therapy to IgA Nephropathy Patients with Heavy Proteinuria. Biol Pharm Bull 2017; 40:1833-1838. [PMID: 28867717 DOI: 10.1248/bpb.b17-00134] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Although some new drugs have been developed, Tripterygium wilfordii HOOK F. (TWHF) has the merits of relatively lower price and fewer side effects. Unfortunately, the efficacy and safety of the TWHF (especially dosage 120 mg/d) in the immunoglobulin A (IgA) nephropathy (IgAN) are still lacking. A cohort study including 49 IgAN patients with heavy proteinuria who received induction therapy was undertaken. Patients were divided into three groups: Prednisone (PRE), conventional-dose TWHF (CTW) and double-dose TWHF (DTW). The clinical features, laboratory data, histological manifestations and outcomes of the groups were compared. We found that urinary protein excretion and rates of elevated n-acetyl-β-D-glucosaminidase (NAG) and retinol binding protein (RBP) were prominent in all groups. Neither histopathological changes nor the rates of renal insufficiency were significantly different among groups. Patients in the PRE (69.2%) and DTW groups (87.5%) achieved complete remission; none of the CTW group did. Furthermore, the total remission rate of the DTW group was substantially higher than that of the CTW group. The degree of hypoproteinemia, improved considerably in the PRE and DTW groups. Treatment was well tolerated in all patients, and no serious adverse events were observed. Our findings suggested that induction therapy with double dose TWHF significantly improved response rates in IgAN patients with heavy proteinuria, and did not considerably increase side effects.
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Affiliation(s)
- Zhen Wang
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine
| | - Chao Yu
- Department of Nephrology & Rheumatology, Shanghai Tenth People's Hospital, Tongji University School of Medicine
| | - Li-Na Zhou
- Department of Nephrology, Yancheng Third People's Hospital
| | - Xin Chen
- Department of Nephrology, Yancheng Third People's Hospital
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Sevillano AM, Gutiérrez E, Yuste C, Cavero T, Mérida E, Rodríguez P, García A, Morales E, Fernández C, Martínez MA, Moreno JA, Praga M. Remission of Hematuria Improves Renal Survival in IgA Nephropathy. J Am Soc Nephrol 2017; 28:3089-3099. [PMID: 28592423 DOI: 10.1681/asn.2017010108] [Citation(s) in RCA: 89] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 04/29/2017] [Indexed: 11/03/2022] Open
Abstract
Hematuria is a cardinal symptom in IgA nephropathy, but its influence on the risk of disease progression has been scarcely investigated. We followed a cohort of 112 patients with IgA nephropathy for a mean±SEM period of 14±10.2 years, during which clinical and analytic risk factors (including urine sediment examination) were regularly recorded. According to the magnitude of time-averaged hematuria, we classified patients as those with persistent hematuria and those with negative or minimal hematuria. We also classified patients according to the magnitude of time-averaged proteinuria (>0.75 or ≤0.75 g/d). The proportion of patients reaching ESRD or a 50% reduction of renal function was significantly greater among patients with persistent hematuria than patients with minimal or negative hematuria (30.4% and 37.0% versus 10.6% and 15.2%, respectively; P=0.01). Multivariable analysis revealed time-averaged hematuria, time-averaged proteinuria, renal function at baseline, and the presence of tubulointerstitial fibrosis on renal biopsy as independent predictors of ESRD. After hematuria disappearance, which occurred in 46% of the patients, the rate of renal function decline changed from -6.45±14.66 to -0.18±2.56 ml/min per 1.73 m2 per year (P=0.001). Patients with time-averaged proteinuria >0.75 g/d had significantly poorer renal survival than those with time-averaged proteinuria ≤0.75 g/d. However, on further classification by time-averaged hematuria, only those patients with time-averaged proteinuria >0.75 g/d and persistent hematuria had significantly worse renal survival than those in the other three groups. In conclusion, remission of hematuria may have a significant favorable effect on IgA nephropathy outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Cristina Fernández
- Research and Clinical Epidemiology Unit, Department of Preventive Medicine, Hospital Clinic, San Carlos, Madrid, Spain
| | | | - Juan Antonio Moreno
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Autónoma University, Madrid, Spain; and
| | - Manuel Praga
- Departments of Nephrology and .,Department of Medicine, Complutense University, Madrid, Spain
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Abstract
The optimal role of immunosuppressive therapy in the treatment of IgA nephropathy is controversial. Results of a recently completed randomized controlled trial provide strong support for comprehensive supportive care rather than immunosuppressive therapy in patients at high risk for progression.
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Affiliation(s)
- Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH University of Aachen, Aachen, Germany.
| | - Thomas Rauen
- Division of Nephrology and Clinical Immunology, RWTH University of Aachen, Aachen, Germany
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Lundberg S, Westergren E, Smolander J, Bruchfeld A. B cell-depleting therapy with rituximab or ofatumumab in immunoglobulin A nephropathy or vasculitis with nephritis. Clin Kidney J 2016. [PMID: 28638602 PMCID: PMC5469569 DOI: 10.1093/ckj/sfw106] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Approximately 30% of adult patients with immunoglobulin A (IgA) nephropathy (IgAN) or IgA vasculitis with nephritis (IgAVN) develop end-stage renal disease during long-term follow-up. In particular, patients with nephritic–nephrotic syndrome have an increased risk of rapid progression. Conventional immunosuppressive therapy with corticosteroids (CSs) may be insufficient for disease control and is associated with a number of side effects. Rituximab (RTX) has been shown to be well tolerated and effective in a range of glomerular diseases, but there is little information on its therapeutic potential in IgAN. The humanized anti-CD20 monoclonal antibody ofatumumab (OFAB) may be an alternative drug for patients intolerant or unresponsive to RTX, but so far there is no report on its use in IgAVN or IgAN. Methods We describe clinical outcomes after 17–22 months in four adult patients with biopsy-confirmed IgAVN or IgAN treated with RTX or OFAB as well as CS soon after diagnosis. All presented with nephritic–nephrotic syndrome and one had crescentic IgAN. Rebiopsy was performed in two cases. Results RTX and OFAB were well tolerated. Albuminuria was <250 mg/day in three patients at last evaluation and two regained normal renal function. In all cases, renal function improved after therapy. In one patient with severe IgA vasculitis, rebiopsy showed disappearance of subendothelial but not mesangial immune complexes. In the case with crescentic IgAN, rebiopsy after 9 months showed no active necrotic lesions. Conclusions B cell–depleting therapy may be an alternative treatment for patients with IgAN or IgAVN and nephritic–nephrotic syndrome. A possible CS-sparing effect should be further evaluated in randomized controlled clinical trials.
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Affiliation(s)
- Sigrid Lundberg
- Department of Nephrology, Karolinska University Hospital and Division of Renal Medicine, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, SE-17176 Stockholm, Sweden
| | - Emelie Westergren
- Department of Nephrology, Karolinska University Hospital and Division of Renal Medicine, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, SE-17176 Stockholm, Sweden
| | - Jessica Smolander
- Department of Nephrology, Karolinska University Hospital and Division of Renal Medicine, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, SE-17176 Stockholm, Sweden
| | - Annette Bruchfeld
- Department of Nephrology, Karolinska University Hospital and Division of Renal Medicine, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, SE-17176 Stockholm, Sweden
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Rauen T, Eitner F, Fitzner C, Floege J. Con: STOP immunosuppression in IgA nephropathy. Nephrol Dial Transplant 2016; 31:1771-1774. [PMID: 27515693 DOI: 10.1093/ndt/gfw286] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 04/07/2016] [Indexed: 11/12/2022] Open
Abstract
A comprehensive supportive therapy approach constitutes the mainstay treatment of IgA nephropathy (IgAN) patients. In our recent Supportive versus immunosuppressive Therapy Of Progressive IgA Nephropathy (STOP-IgAN) trial, we systematically selected for patients at high risk of a progressive disease course and evaluated the effect of immunosuppression, combined with supportive care, on renal end points in these patients. There was a higher rate of full clinical remission and transient proteinuria reduction in immunosuppressed patients. However, deterioration of renal function (i.e. number of patients with an estimated glomerular filtration rate (eGFR) decrease of at least 15 mL/min over the 3-year trial phase) was remarkably slow in both groups, compared with previous studies, and was not slowed further by adding immunosuppression to supportive care. Here, we address several concerns raised on the design and interpretation of our trial. In our randomized patients, we confirmed a lower baseline proteinuria to be predictive of clinical remission in IgAN. However, the observed transient drop in proteinuria in the immunosuppressed patients did not translate into an improved overall renal outcome in these patients. Although longer follow-up would be desirable, there was not even a trend for the eGFR course to diverge between our two treatment arms during the trial phase. Finally, it is important to note that we excluded specific infrequent patient groups during our run-in phase. Therefore, IgAN patients with a rapidly progressing course and those with persistent proteinuria >3.5 g/day would require further evaluation regarding potential benefits of immunosuppressive therapies.
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Affiliation(s)
- Thomas Rauen
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Frank Eitner
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany.,Kidney Diseases Research, Bayer Pharma AG, Wuppertal, Germany
| | - Christina Fitzner
- Department of Medical Statistics, RWTH Aachen University, Aachen, Germany
| | - Jürgen Floege
- Department of Nephrology, RWTH University of Aachen, Aachen, Germany
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Abstract
Most glomerulonephritides, even the more common types, are rare diseases. They are nevertheless important since they frequently affect young people, often cannot be cured, and can lead to chronic kidney disease, including end-stage renal failure, with associated morbidity and cost. For example, in young adults, IgA nephropathy is the most common cause of end-stage renal disease. In this Seminar, we summarise existing knowledge of clinical signs, pathogenesis, prognosis, and treatment of glomerulonephritides, with a particular focus on data published between 2008 and 2015, and the most common European glomerulonephritis types, namely IgA nephropathy, membranous glomerulonephritis, minimal change disease, focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, and the rare complement-associated glomerulonephritides such as dense deposit disease and C3 glomerulonephritis.
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Affiliation(s)
- Jürgen Floege
- Department of Nephrology and Clinical Immunology, University Hospital, Rheinisch Westfälische Technische Hochschule Aachen, Aachen, Germany.
| | - Kerstin Amann
- Department of Nephropathology, Department of Pathology, University of Erlangen-Nürnberg, Erlangen, Germany
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Silva LSD, Almeida BLF, Melo AKGD, Brito DCSED, Braz AS, Freire EAM. Nefropatia por IgA em paciente portadora de lúpus eritematoso sistêmico: relato de caso e revisão de literatura. REVISTA BRASILEIRA DE REUMATOLOGIA 2016. [DOI: 10.1016/j.rbr.2014.10.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Salvadori M, Rosso G. Update on immunoglobulin a nephropathy. Part II: Clinical, diagnostic and therapeutical aspects. World J Nephrol 2016; 5:6-19. [PMID: 26788460 PMCID: PMC4707169 DOI: 10.5527/wjn.v5.i1.6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 11/13/2015] [Accepted: 12/03/2015] [Indexed: 02/06/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is characterized by different clinical manifestations and by long-term different outcomes. Major problem for the physicians is to understanding which patients are at risk of a disease evolution and to prescribe the right therapy to the right patients. Indeed, in addition to patients with a stable disease with no trend to evolution or even with a spontaneous recovery, patients with an active disease and patients with a rapidly evolving glomerulonephritis are described. Several histopathological, biological and clinical markers have been described and are currently used to a better understanding of patients at risk, to suggest the right therapy and to monitor the therapy effect and the IgAN evolution over time. The clinical markers are the most reliable and allow to divide the IgAN patients into three categories: The low risk patients, the intermediate risk patients and the high risk patients. Accordingly, the therapeutic measures range from no therapy with the only need of repeated controls, to supportive therapy eventually associated with low dose immunosuppression, to immunosuppressive treatment in the attempt to avoid the evolution to end stage renal disease. However the current evidence about the different therapies is still matter of discussion. New drugs are in the pipeline and are described. They are object of randomized controlled trials, but studies with a number of patients adequately powered and with a long follow up are needed to evaluate efficacy and safety of these new drugs.
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Rauen T, Eitner F, Fitzner C, Sommerer C, Zeier M, Otte B, Panzer U, Peters H, Benck U, Mertens PR, Kuhlmann U, Witzke O, Gross O, Vielhauer V, Mann JFE, Hilgers RD, Floege J. Intensive Supportive Care plus Immunosuppression in IgA Nephropathy. N Engl J Med 2015; 373:2225-36. [PMID: 26630142 DOI: 10.1056/nejmoa1415463] [Citation(s) in RCA: 432] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND The outcomes of immunosuppressive therapy, when added to supportive care, in patients with IgA nephropathy are uncertain. METHODS We conducted a multicenter, open-label, randomized, controlled trial with a two-group, parallel, group-sequential design. During a 6-month run-in phase, supportive care (in particular, blockade of the renin-angiotensin system) was adjusted on the basis of proteinuria. Patients who had persistent proteinuria with urinary protein excretion of at least 0.75 g per day were randomly assigned to receive supportive care alone (supportive-care group) or supportive care plus immunosuppressive therapy (immunosuppression group) for 3 years. The primary end points in hierarchical order were full clinical remission at the end of the trial (protein-to-creatinine ratio <0.2 [with both protein and creatinine measured in grams] and a decrease in the estimated glomerular filtration rate [eGFR] of <5 ml per minute per 1.73 m(2) of body-surface area from baseline) and a decrease in the eGFR of at least 15 ml per minute per 1.73 m(2) at the end of the trial. The primary end points were analyzed with the use of logistic-regression models. RESULTS The run-in phase was completed by 309 of 337 patients. The proteinuria level decreased to less than 0.75 g of urinary protein excretion per day in 94 patients. Of the remaining 162 patients who consented to undergo randomization, 80 were assigned to the supportive-care group, and 82 to the immunosuppression group. After 3 years, 4 patients (5%) in the supportive-care group, as compared with 14 (17%) in the immunosuppression group, had a full clinical remission (P=0.01). A total of 22 patients (28%) in the supportive-care group and 21 (26%) in the immunosuppression group had a decrease in the eGFR of at least 15 ml per minute per 1.73 m(2) (P=0.75). There was no significant difference in the annual decline in eGFR between the two groups. More patients in the immunosuppression group than in the supportive-care group had severe infections, impaired glucose tolerance, and weight gain of more than 5 kg in the first year of treatment. One patient in the immunosuppression group died of sepsis. CONCLUSIONS The addition of immunosuppressive therapy to intensive supportive care in patients with high-risk IgA nephropathy did not significantly improve the outcome, and during the 3-year study phase, more adverse effects were observed among the patients who received immunosuppressive therapy, with no change in the rate of decrease in the eGFR. (Funded by the German Federal Ministry of Education and Research; STOP-IgAN ClinicalTrials.gov number, NCT00554502.).
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Affiliation(s)
- Thomas Rauen
- From the Division of Nephrology and Clinical Immunology (T.R., F.E., J.F.) and Department of Medical Statistics (C.F., R.-D.H.), RWTH Aachen University, Aachen, Bayer Pharma, Kidney Diseases Research, Wuppertal (F.E.), Department of Nephrology, University of Heidelberg, Heidelberg (C.S., M.Z.), Internal Medicine D, Department of Nephrology, Hypertension and Rheumatology, University Hospital Muenster, Muenster (B.O.), University Medical Center Hamburg-Eppendorf, Hamburg (U.P.), Department of Nephrology and Dieter Scheffner Center for Medical Education, Charité Campus Mitte, Charité-Universitätsmedizin Berlin, Berlin (H.P.), Department of Medicine V, University Medical Center Mannheim, University of Heidelberg, Mannheim (U.B.), Department of Nephrology and Hypertension, Diabetes and Endocrinology, Otto-von-Guericke University, Magdeburg (P.R.M.), Medical Clinic III, Central Hospital Bremen, Bremen (U.K.), Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen (O.W.), Clinic for Nephrology and Rheumatology, University Medical Center Goettingen, Goettingen (O.G.), and Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität (V.V.), and Department of Nephrology, Hypertension and Rheumatology, Munich General Hospital (J.F.E.M.), Munich - all in Germany
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Chan MM, Gale DP. Isolated microscopic haematuria of glomerular origin: clinical significance and diagnosis in the 21st century. Clin Med (Lond) 2015; 15:576-80. [PMID: 26621952 PMCID: PMC4953265 DOI: 10.7861/clinmedicine.15-6-576] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Isolated microscopic, or non-visible, haematuria of glomerular origin was previously regarded a benign finding, but it is now known that, even in the absence of proteinuria, hypertension or renal impairment at presentation, haematuria is associated with increased risk of kidney failure in the long term. The most common causes of isolated microscopic haematuria among children and young adults are IgA nephropathy, Alport syndrome (AS), and thin basement membrane nephropathy (TBMN). AS, which is usually inherited as an X-linked or autosomal recessive trait, and TBMN, which is usually autosomal dominant, are caused by mutations in the genes encoding type-IV collagen, an abundant component of the glomerular basement membrane. A detailed family history with screening of at-risk relatives is important, allowing prompt diagnosis of affected relatives and helping determine the mode of transmission. As costs fall and availability increases, genetic testing is increasingly being used in clinical practice to provide diagnostic and predictive information for patients and their families.
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Affiliation(s)
- Melanie My Chan
- Centre for Nephrology, University College London, Royal Free Hospital, London, UK
| | - Daniel P Gale
- Centre for Nephrology, University College London, Royal Free Hospital, London, UK
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Guo SM, Han M, Chen MX, Ning Y, Pei GC, Li YQ, Dai W, Ge SW, Deng YJ, Guo YY, Li XQ, Haller H, Xu G, Rong S. Soluble Urokinase Receptor Levels Are Correlated with Focal Segmental Glomerulosclerosis Lesions in IgA Nephropathy: A Cohort Study from China. PLoS One 2015; 10:e0138718. [PMID: 26380984 PMCID: PMC4575041 DOI: 10.1371/journal.pone.0138718] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/02/2015] [Indexed: 12/12/2022] Open
Abstract
Background Soluble urokinase receptor (suPAR) may be involved in the pathological mechanisms of focal segmental glomerulosclerosis (FSGS) changes. However, it remains unclear whether suPAR is correlated with the FSGS-like lesions in IgA nephropathy (IgAN). Methods We measured the plasma suPAR levels in 138 patients with IgAN, and then their clinical and pathological relationships were analyzed. Results We found that the plasma suPAR levels were significantly correlated with age and renal function by both univariate and multivariate analysis in our IgAN patient cohort. Female had higher plasma suPAR levels and no significant correlation was observed between plasma suPAR levels and 24-h urine protein and highly sensitive C-reaction protein with multivariate analysis. In our cohort, sixty of these IgAN patients could be diagnosed with a type of FSGS lesions. The plasma suPAR levels were higher in the IgAN patients with FSGS lesions than in the IgAN patients without FSGS lesions by univariate (P < 0.0001) and multivariate (P < 0.001) analysis adjusting for other predictor variables, which might be helpful to differentiate the pathological changes with and without FSGS lesions. And the optimal cutoff value was 1806 pg/ml in this study. The plasma suPAR concentrations were also associated with the degree of tubular atrophy/interstitial fibrosis in both univariate and multivariate analysis. In multivariate analysis, the plasma suPAR levels were correlated with the percentage of crescents, not global sclerosis and arterial lesions. Conclusions Our study suggested that the plasma suPAR levels were associated with age, gender, renal function, the degree of tubular atrophy/interstitial fibrosis and the percentage of crescent formation. The plasma suPAR might be a potential predictor for the presence of FSGS pathological lesions in Chinese patients with IgAN.
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Affiliation(s)
- Shui-Ming Guo
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Min Han
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- * E-mail: (GX); (MH)
| | - Mei-Xue Chen
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yong Ning
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Guang-Chang Pei
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yue-Qiang Li
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Dai
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shu-Wang Ge
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yuan-Jun Deng
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yan-Yan Guo
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiao-Qing Li
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hermann Haller
- Department of Nephrology, Hannover Medical School, Hannover, Germany
| | - Gang Xu
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- * E-mail: (GX); (MH)
| | - Song Rong
- Department of Nephrology, Division of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Department of Nephrology, Hannover Medical School, Hannover, Germany
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Bernardino V, Mendes-Bastos P, Rodrigues A, Riso N. IgA vasculitis (formerly Henoch-Schönlein purpura) in an adult with systemic lupus erythematosus. BMJ Case Rep 2015; 2015:bcr-2015-210121. [PMID: 26354836 DOI: 10.1136/bcr-2015-210121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report a case of a 65-year-old man with systemic lupus erythematosus (SLE) and antiphospholipid syndrome, presenting palpable purpuric lesions, necrotic blisters and swelling ankles, after a previous tracheobronchitis episode. Laboratory data were remarkable for mild proteinuria and imaging studies were normal. A skin biopsy showed IgA deposits on superficial dermal capillaries and IgA vasculitis (IgAV) (former Henoch-Schönlein purpura) was assumed. The patient was treated with colchicine, deflazacort and azathioprine, but as a regression in the purpuric lesions was noted, a decline in renal function was detected. A kidney biopsy revealed mesangial proliferation with IgA deposition and IgAV nephritis was considered. Immunosuppressive treatment was adjusted, with progressive normalisation of renal function and disappearance of proteinuria over a monthly follow-up; after 6 months, total remission was achieved. To the best of our knowledge, this is the first reported case of IgAV in an adult patient with SLE.
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Affiliation(s)
- Vera Bernardino
- Autoimmune Disease Unit, Internal Medicine 2 Department, Hospital Curry Cabral, Lisbon, Portugal
| | | | - Ana Rodrigues
- Autoimmune Disease Unit, Internal Medicine 2 Department, Hospital Curry Cabral, Lisbon, Portugal
| | - Nuno Riso
- Autoimmune Disease Unit, Internal Medicine 2 Department, Hospital Curry Cabral, Lisbon, Portugal Hospital Curry Cabral, Lisbon, Portugal
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Ring T, Pedersen BB, Salkus G, Goodship THJ. Use of eculizumab in crescentic IgA nephropathy: proof of principle and conundrum? Clin Kidney J 2015; 8:489-91. [PMID: 26413271 PMCID: PMC4581393 DOI: 10.1093/ckj/sfv076] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 07/27/2015] [Indexed: 11/13/2022] Open
Abstract
IgA nephropathy (IgAN) is characterized by a variable clinical course and multifaceted pathophysiology. There is substantial evidence to suggest that complement activation plays a pivotal role in the pathogenesis of the disease. Therefore, complement inhibition using the humanized anti-C5 monoclonal antibody eculizumab could be a rational treatment. We report here a 16-year-old male with the vasculitic form of IgAN who failed to respond to aggressive conventional therapy including high-dose steroids, cyclophosphamide and plasma exchange and who was treated with four weekly doses of 900 mg eculizumab followed by a single dose of 1200 mg. He responded rapidly to this treatment and has had a stable creatinine around 150 µmol/L (1.67 mg/dL) for >6 months. However, proteinuria was unabated on maximal conventional anti-proteinuric treatment, and a repeat renal biopsy 11 months after presentation revealed severe chronic changes. We believe this case provides proof of principle that complement inhibition may be beneficial in IgAN but also that development of chronicity may be independent of complement.
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Affiliation(s)
- Troels Ring
- Department of Nephrology , Aalborg University Hospital , Aalborg , Denmark
| | | | - Giedrius Salkus
- Department of Pathology , Aalborg University Hospital , Aalborg , Denmark
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Turnover of type III collagen reflects disease severity and is associated with progression and microinflammation in patients with IgA nephropathy. Nephrol Dial Transplant 2015; 31:472-9. [DOI: 10.1093/ndt/gfv301] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 07/06/2015] [Indexed: 01/06/2023] Open
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Floege J. Glomerular disease: Efficacy of corticosteroids in high-risk IgA nephropathy. Nat Rev Nephrol 2015; 11:319-20. [PMID: 25848878 DOI: 10.1038/nrneph.2015.47] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Jürgen Floege
- Division of Nephrology and Immunology, Rheinisch-Westfälische Technische Hochschule Aachen, Pauwelsstrasse 30, 52074 Aachen, Germany
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Matsushita S, Ishikura K, Okamoto S, Okuda Y, Nagaoka Y, Harada R, Hamada R, Sakai T, Hamasaki Y, Hataya H, Ando T, Ogata K, Honda M. Long-term morbidity of IgA nephropathy in children evaluated with newly proposed remission criteria in Japan. Clin Exp Nephrol 2015; 19:1149-56. [PMID: 25800961 DOI: 10.1007/s10157-015-1105-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/02/2015] [Indexed: 12/01/2022]
Abstract
BACKGROUND The long-term outcome of pediatric IgA nephropathy (IgAN) is unclear. Objective IgAN remission criteria were proposed by the Japanese Society of Nephrology in 2013. METHODS Children with newly developed IgAN followed for >5 years were analyzed. They were divided into two groups based on histological findings at initial kidney biopsy: the focal mesangial proliferation group (Focal group) and diffuse mesangial proliferation group (Diffuse group). The primary outcome was the remission rate according to the newly proposed IgAN remission criteria. RESULTS The patients comprised 53 children (31 boys; mean age at IgAN onset, 10.0 years). The Focal and Diffuse groups comprised 21 and 32 patients, respectively. No significant differences in patient characteristics were found between the groups except for steroid administration. The median follow-up period from onset was 9.9 years. Sixteen patients in the Diffuse group and 10 in the Focal group had not achieved remission at the last observation. Patient conditions 2 years after the initial treatment were almost identical to those at the last observation. Multivariate analysis revealed that proteinuria, particularly <0.5 g/g Cr at 2 years, was significantly associated with remission at the last observation regardless of proteinuria status at the start of treatment. CONCLUSIONS Pediatric IgAN has a prolonged course that is longer than expected regardless of severity at diagnosis. Patient conditions 2 years after initial treatment predicted their conditions at the last observation. Although the final renal function of these patients is presently unclear, children with IgAN should be followed beyond adolescence and further into adulthood.
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Affiliation(s)
- Shoko Matsushita
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.,Division of Allergy, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Kenji Ishikura
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.
| | - Shojiro Okamoto
- Department of Pediatrics, Tokai University Hachioji Hospital, 1838 Ishikawa-cho, Hachioji, Tokyo, 192-0032, Japan
| | - Yusuke Okuda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.,Department of Pediatrics, Shiga University of Medical Science, Tsukinowa, Seta, Otsu, Shiga, 520-2192, Japan
| | - Yoshinobu Nagaoka
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.,Department of Pediatrics, National Hospital Organization, Hokkaido Medical Center, 5-7-1-1 Yamanote, Nishi-ku, Sapporo, Hokkaido, 063-0005, Japan
| | - Ryoko Harada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Tomoyuki Sakai
- Department of Pediatrics, Shiga University of Medical Science, Tsukinowa, Seta, Otsu, Shiga, 520-2192, Japan
| | - Yuko Hamasaki
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, 6-11-1 Omori-Nishi, Ota-ku, Tokyo, 143-8541, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Takashi Ando
- Japan Clinical Research Support Unit, 1-10-5 Yushima, Bunkyo-ku, Tokyo, 113-0034, Japan
| | - Kentaro Ogata
- Division of Pathology, Federation of National Public Service Personnel Mutual Aid Associations, Tachikawa Hospital, 4-2-22 Nishiki-cho, Tachikawa, Tokyo, 190-8531, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
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da Silva LS, Almeida BLF, de Melo AKG, de Brito DCSE, Braz AS, Freire EAM. IgA nephropathy in systemic lupus erythematosus patients: case report and literature review. REVISTA BRASILEIRA DE REUMATOLOGIA 2015; 56:270-3. [PMID: 27267646 DOI: 10.1016/j.rbre.2014.10.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Accepted: 10/19/2014] [Indexed: 11/30/2022] Open
Abstract
Systemic erythematosus lupus (SLE) is a multisystemic autoimmune disease which has nephritis as one of the most striking manifestations. Although it can coexist with other autoimmune diseases, and determine the predisposition to various infectious complications, SLE is rarely described in association with non-lupus nephropathies etiologies. We report the rare association of SLE and primary IgA nephropathy (IgAN), the most frequent primary glomerulopathy in the world population. The patient was diagnosed with SLE due to the occurrence of malar rash, alopecia, pleural effusion, proteinuria, ANA 1: 1280, nuclear fine speckled pattern, and anticardiolipin IgM and 280U/mL. Renal biopsy revealed mesangial hypercellularity with isolated IgA deposits, consistent with primary IgAN. It was treated with antimalarial drug, prednisone and inhibitor of angiotensin converting enzyme, showing good progress. Since they are relatively common diseases, the coexistence of SLE and IgAN may in fact be an uncommon finding for unknown reasons or an underdiagnosed condition. This report focus on the importance of the distinction between the activity of renal disease in SLE and non-SLE nephropathy, especially IgAN, a definition that has important implications on renal prognosis and therapeutic regimens to be adopted in both the short and long terms.
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