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Pan Y, Chen WD, Liu L, Yang H, Chang B, Cui C. Clinical Features and Pathology of PLA2R and THSD7A-Associated Membranous Nephropathy: A Single-Center Study from China. Immunotargets Ther 2024; 13:385-398. [PMID: 39081263 PMCID: PMC11287465 DOI: 10.2147/itt.s450413] [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: 11/18/2023] [Accepted: 06/12/2024] [Indexed: 08/02/2024] Open
Abstract
Objective Serum-specific antibodies as a non-invasive means to effectively diagnose idiopathic membranous nephropathy and assess clinicopathology. Methods Immunofluorescence of anti-PLA2R and THSD7A antibodies and kidney tissue PLA2R, THSD7A and IgG4 expression in IMN and non-IMN (2020-2021) was detected to assess the efficacy of diagnosing IMN. IMN patients were divided into two groups, anti-PLA2R antibody positive (161 cases) and negative (26 cases), and two groups, kidney tissue PLA2R (40 cases) and PLA2R+THSD7A (6 cases), to compare the clinical and pathological features, and to carry out a prognostic analysis of THSD7A-positive patients, with a focus on correlation with malignancy. Results The positive rate of anti-PLA2R antibodies was significantly higher in IMN (P<0.05); anti-PLA2R antibodies, kidney tissue PLA2R and IgG4 and THSD7A had some diagnostic value. Anti-PLA2R antibodies correlated with proteinuria levels in IMN patients, and their levels were negatively correlated with blood albumin (r=-0.146, P=0.042); correlated with pathological stage and C3 and IgG4 immunodeposition; there was no significant difference in clinical pathology between kidney tissue THSD7A+PLA2R positive compared to kidney tissue PLA2R positive patients, but the probability of achieving complete remission was low and time longer, and no malignancy events were detected during follow-up. Conclusion Anti-PLA2R antibodies, kidney tissue PLA2R, THSD7A and IgG4 have high diagnostic efficacy for IMN; anti-PLA2R antibodies can be used as diagnostic markers to assist in the assessment of clinical and pathological features; co-expression of kidney tissue PLA2R and THSD7A is not significantly different from kidney tissue PLA2R in assessing the clinical features, pathological manifestations and prognosis, but requires long-term. However, long-term follow-up is needed to monitor the potential risk, and a larger multicentre study with long-term follow-up is expected to be conducted to comprehensively assess IMN characteristics.
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Affiliation(s)
- Yan Pan
- Department of Nephrology, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, People’s Republic of China
| | - Wei Dong Chen
- Department of Nephrology, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, People’s Republic of China
| | - Lei Liu
- Department of Nephrology, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, People’s Republic of China
| | - Huijuan Yang
- Department of Nephrology, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, People’s Republic of China
| | - Baochao Chang
- Department of Nephrology, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, People’s Republic of China
| | - Caixia Cui
- Department of Nephrology, First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui Province, People’s Republic of China
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Kamyshova ES, Bobkova IN, Kakhsurueva PА, Abdulaeva AS, Rudenko TЕ, Stavrovskaya EV, Andreeva EY, Li OА, Suvorov AY. [Idiopathic membranous nephropathy with focal segmental sclerosis]. TERAPEVT ARKH 2024; 96:580-586. [PMID: 39106498 DOI: 10.26442/00403660.2024.06.202725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Accepted: 07/06/2024] [Indexed: 08/09/2024]
Abstract
AIM To evaluate the clinical and pathological features and prognosis of idiopathic membranous nephropathy (IMN) with focal segmental sclerosis (FSGS) in a group of Russian patients. MATERIALS AND METHODS 101 patients with morphologically verified IMN were enrolled in our single-center cohort retrospective study. The patients were divided into IMN group and IMN+FSGS group. The primary and secondary outcomes were analyzed in 59 patients, which had follow-up data for period more than 6 months. RESULTS At the time of renal biopsy the median age was 46.0 (33.0; 55.0) years and the median follow-up was 6.8 (4.0; 15.6) months. Secondary FSGS was revealed in 15 (14.9%) patients with IMN. The IMN and IMN+FSGS groups did not differ in gender, age of onset IMN and age of renal biopsy. In the IMN+FSGS group proteinuria was higher and estimated glomerular filtration rate was lower than that in the IMN group (p<0.05). The systolic arterial pressure and creatinine levels in the IMN+FSGS group were slightly higher than in the IMN group, but the difference was not significant. Anti-PLA2R positivity was similar in both groups. Chronic kidney disease (CKD) progression was observed in 10/52 (19.2%) and 5/7 (71.4%) patients in IMN and IMN+FSGS groups, respectively. In a multivariate Cox regression model, age of renal biopsy (odds ratio - OR 1.12, 95% confidence interval - CI 1.03-1.22; р=0.07), FSGS (OR 0.05, 95% CI 0.01-0.34; р=0.002) и response to initial course of immunosuppression (OR 0.33, 95% CI 0.12-0.95; р=0.039) were associated with the CKD progression. CONCLUSION In patients with IMN secondary FSGS is associated with a greater severity of proteinuria and a decrease in estimated glomerular filtration rate, and is also an independent factor of the CKD progression.
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Affiliation(s)
- E S Kamyshova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - I N Bobkova
- Sechenov First Moscow State Medical University (Sechenov University)
| | | | - A S Abdulaeva
- Sechenov First Moscow State Medical University (Sechenov University)
| | - T Е Rudenko
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E V Stavrovskaya
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E Y Andreeva
- Sechenov First Moscow State Medical University (Sechenov University)
| | - O А Li
- Sechenov First Moscow State Medical University (Sechenov University)
| | - A Y Suvorov
- Sechenov First Moscow State Medical University (Sechenov University)
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Wang M, Yang J, Fang X, Lin W, Yang Y. Membranous nephropathy: pathogenesis and treatments. MedComm (Beijing) 2024; 5:e614. [PMID: 38948114 PMCID: PMC11214595 DOI: 10.1002/mco2.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 07/02/2024] Open
Abstract
Membranous nephropathy (MN), an autoimmune disease, can manifest at any age and is among the most common causes of nephrotic syndrome in adults. In 80% of cases, the specific etiology of MN remains unknown, while the remaining cases are linked to drug use or underlying conditions like systemic lupus erythematosus, hepatitis B virus, or malignancy. Although about one-third of patients may achieve spontaneous complete or partial remission with conservative management, another third face an elevated risk of disease progression, potentially leading to end-stage renal disease within 10 years. The identification of phospholipase A2 receptor as the primary target antigen in MN has brought about a significant shift in disease management and monitoring. This review explores recent advancements in the pathophysiology of MN, encompassing pathogenesis, clinical presentations, diagnostic criteria, treatment options, and prognosis, with a focus on emerging developments in pathogenesis and therapeutic strategies aimed at halting disease progression. By synthesizing the latest research findings and clinical insights, this review seeks to contribute to the ongoing efforts to enhance our understanding and management of this challenging autoimmune disorder.
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Affiliation(s)
- Mengqiong Wang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Jingjuan Yang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Xin Fang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Weiqiang Lin
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Yi Yang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
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Joseph J, Subramanian T, Vellaisamy M, Nd S, Surendran S, Kaliaperumal T, Annadurai P, Haridas N, Fernando E. The Association of Lower Levels of Baseline Proteinuria With Earlier Remission in Primary Membranous Nephropathy. Cureus 2024; 16:e61918. [PMID: 38978879 PMCID: PMC11230608 DOI: 10.7759/cureus.61918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2024] [Indexed: 07/10/2024] Open
Abstract
Aim To study the clinical profile and course and to assess the outcome of patients with biopsy-proven primary membranous nephropathy (MN). Methods This study was carried out in a tertiary care hospital between December 2017 and December 2021 on four-year retrospective biopsy-proven patients with membranous nephropathy (MN). Urinary proteins, serum albumin, and serum creatinine were the baseline investigations that were performed. Special tests were done whenever necessary. Patients were treated with a modified Ponticelli (MP) regimen whenever needed. Patients were followed up after treatment administration for a minimum of a year. Results The study was done in 48 biopsy-proven MN patients. Thirty-six patients had primary MN with a mean age of 47+/-11.7 years. The male-female ratio was 2.6:1. Hypertension was present in 39% (14 patients), microscopic hematuria in 28% (10 patients), and acute kidney injury in 22% (8 patients). The mean 24-hour urinary protein was 11.2+/-2.9 g/day. PLA2R was positive in 78% (28 patients) of primary MN patients. Spontaneous remission was noted in 13.8% (5 patients) who were treated conservatively. Spontaneous remission was associated with lower baseline proteinuria (p<0.001), higher baseline serum albumin (p<0.001), and PLA2R negativity (p=0.04). Complete or partial treatment response was noted in 74.2% (23 patients). Treatment remission was associated with lower baseline proteinuria (p=0.018). Secondary membranous nephropathy (secondary MN) was diagnosed in 12 patients. Eleven were class V lupus nephritis, all women, and one male person living with HIV/AIDS (PLHA). Conclusions The majority of our primary MN patients were PLA2R positive on renal biopsy. Statistically significant factors associated with spontaneous remission were lower proteinuria, higher serum albumin at baseline, and PLA2R negativity. Treatment response was associated with lower proteinuria at presentation. The most common cause of secondary MN was lupus nephritis.
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Affiliation(s)
- Jerry Joseph
- Nephrology, Government Stanley Medical College and Hospital, Chennai, IND
| | | | | | - Srinivasaprasad Nd
- Nephrology, Government Stanley Medical College and Hospital, Chennai, IND
| | - Sujith Surendran
- Nephrology, Government Stanley Medical College and Hospital, Chennai, IND
| | | | - Poongodi Annadurai
- Nephrology, Government Stanley Medical College and Hospital, Chennai, IND
| | - Nived Haridas
- Nephrology, Government Stanley Medical College and Hospital, Chennai, IND
| | - Edwin Fernando
- Nephrology, Government Stanley Medical College and Hospital, Chennai, IND
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Uchida T, Oda T. The Prevalence, Characteristics, and Putative Mechanisms of Dual Antigen-Positive Membranous Nephropathy: The Underestimated Condition. Int J Mol Sci 2024; 25:5931. [PMID: 38892120 PMCID: PMC11172907 DOI: 10.3390/ijms25115931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Following the discovery of podocyte phospholipase A2 receptor and thrombospondin type-1 domain-containing 7A, various potential target antigens for membranous nephropathy (MN) have been reported one after another. MN target antigens have now been identified in a significant proportion of patients, and a new classification framework classifies patients with MN based on the detected antigen and associated disease phenotype. A serology-based approach that does not require a histological diagnosis for patients suspected of having MN has also been proposed. However, there have been cases in which dual positivity for MN antigens and/or corresponding antibodies has been shown. Importantly, some of them showed a transition of the affected patient's immune responses to MN antigens, suggesting that serological diagnosis changes depending on the timing of the analysis. In this review, we provide detailed information on these cases and present an overview of our recent understanding of their putative mechanisms involved in these cases. Greater awareness is required to adequately recognize and develop appropriate therapeutic strategies for this condition.
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Affiliation(s)
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji 193-0998, Japan;
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Cheng P, Xie Q, Liu S, Liu X, Wang L, Hao CM. Aggressive treatment may be needed for idiopathic membranous nephropathy with focal segmental glomerulosclerosis lesions. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e20230871. [PMID: 38716932 PMCID: PMC11068386 DOI: 10.1590/1806-9282.20230871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 11/30/2023] [Indexed: 05/12/2024]
Abstract
OBJECTIVE The purpose of this study was to analyze the clinical, pathological, prognostic features and treatment response of the coexistence of focal segmental glomerulosclerosis lesions with idiopathic membranous nephropathy. METHODS This is a two-center retrospective cohort study. Patients of idiopathic membranous nephropathy were enrolled and divided into two groups with or without focal segmental glomerulosclerosis lesions according to the renal biopsy. Laboratory data and pathological manifestation were compared. Renal phospholipase A2 receptor was detected by immunofluorescence. During the follow-up, the effects of different therapies and renal function were estimated. RESULTS A total of 236 patients were finally enrolled in this study, of which 60 and 176 idiopathic membranous nephropathy patients were enrolled in the FSGS+ and FSGS- groups, respectively. The FSGS+ group showed a higher percentage of hypertension history (38.3 vs. 20.0%, p=0.004), with a significantly higher level of systolic pressure [137 (120, 160) mmHg vs. 130 (120, 140) mmHg, p=0.009]. Main laboratory findings, including serial albumin (20.4±7.8 g/L vs. 24.5±6.7 g/L, p<0.001), 24-h proteinuria [5.61 (3.10, 7.87) g/day vs. 3.82 (2.31, 5.79) g/day, p=0.002], serial creatinine [80.8 (65.8, 97.9) μmol/L vs. 72.0 (58.7, 84.9) μmol/L, p=0.003], and estimated glomerular filtration rate [86 (66, 101) mL/min/1.73 m2 vs. 95 (81, 108) mL/min/1.73 m2, p=0.007] showed significant differences between the two groups. Pathologically, patients with focal segmental glomerulosclerosis lesions appeared with a higher percentage of crescents, a more severe degree of interstitial fibrosis, and a higher level of membranous nephropathy stage. Renal phospholipase A2 receptor showed a relatively lower positive rate of only 75.0% in the FSGS+ group in comparison with the positive rate of 90.3% in the FSGS- group (p=0.031). The prognosis was generally similar between the two groups. Among patients who were given non-immunosuppression treatment, those with focal segmental glomerulosclerosis lesions took a relatively longer period of time to achieve complete remission (29.3±7.0 m vs. 15.4±8.9 m, p=0.025) and experienced a higher rate of renal function deterioration (37.5 vs. 5.4%, p=0.033) compared with the other ones. While among those receiving immunosuppression treatment, both groups received similar remission rates. CONCLUSION Compared with FSGS- group, idiopathic membranous nephropathy with focal segmental glomerulosclerosis lesions represented more severe nephrotic syndrome and worse renal function. In view of the renal function decline during the follow-up, more aggressive treatment with the use of immunosuppressants should be considered for idiopathic membranous nephropathy patients with focal segmental glomerulosclerosis lesions.
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Affiliation(s)
- Ping Cheng
- Huashan Hospital Affiliated to Fudan University, Department of Nephrology - Shanghai, China
| | - Qionghong Xie
- Huashan Hospital Affiliated to Fudan University, Department of Nephrology - Shanghai, China
| | - Shaojun Liu
- Huashan Hospital Affiliated to Fudan University, Department of Nephrology - Shanghai, China
| | - Xiaobin Liu
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Department of Nephrology - Jiangsu, China
| | - Liang Wang
- Wuxi People's Hospital Affiliated to Nanjing Medical University, Department of Nephrology - Jiangsu, China
| | - Chuan-Ming Hao
- Huashan Hospital Affiliated to Fudan University, Department of Nephrology - Shanghai, China
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Lu S, Xiao J, Liu D, Zhang Y, Dong Y, Zhao Z. Diagnostic value of renal biopsy in anti-phospholipase A2 receptor antibody-positive patients with proteinuria in China. Sci Rep 2024; 14:2907. [PMID: 38316889 PMCID: PMC10844597 DOI: 10.1038/s41598-024-53445-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 01/31/2024] [Indexed: 02/07/2024] Open
Abstract
Renal biopsy remains the gold standard for diagnosing membranous nephropathy (MN). Recent studies have suggested that renal biopsy can be replaced with the serum phospholipase A2 receptor (PLA2R) antibody test for MN diagnosis in patients with nephrotic syndrome. However, this test has not been validated in the Chinese population. In this study, we investigated whether renal biopsy provides additional diagnostic information on patients with proteinuria who are seropositive for PLA2R antibodies (SAb +). We retrospectively reviewed the clinicopathological characteristics of SAb + adult patients (aged ≥ 18 years) with proteinuria (≥ 0.5 g/24 h) assessed at the Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, from June 2021 to March 2022. Among a total of 801 SAb + patients who received renal biopsy, those with incomplete pathological data, diabetes or any potential cause of secondary MN were excluded. Among the 491 remaining patients, 474 had primary MN (PMN), 16 had atypical MN (AMN, 9 patients with "full house" and 2 patients with HBsAg + /HBcAg + immunofluorescence results), and 1 had focal segmental glomerulosclerosis. In patients with an eGFR of ≥ 60 mL/min/1.73 m2 (n = 451), 436 had PMN, and 71 (16.3%) exhibited additional biopsy findings, with obesity-related glomerulopathy being the most common. In patients with an impaired eGFR (n = 40), 38 had PMN, and 31 (81.6%) showed additional findings, with acute tubular injury being the most common. In conclusion, anti-PLA2R antibody positivity is highly predictive of PMN in Chinese adults but often coexists with other pathological diagnoses. The advantages of renal biopsy for detecting other pathologies should be weighed against the potential risks of the biopsy procedure.
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Affiliation(s)
- Shan Lu
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China.
| | - Jing Xiao
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China
| | - Dong Liu
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China
| | - Yan Zhang
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China
| | - Yijun Dong
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China
| | - Zhanzheng Zhao
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, No. 1 Jianshe Road, Zhengzhou, 450052, China
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Guan M, Wu L, Cheng Y, Qi D, Chen J, Song H, Hu H, Wan Q. Defining the threshold: triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio's non-linear impact on tubular atrophy in primary membranous nephropathy. Front Endocrinol (Lausanne) 2024; 15:1322646. [PMID: 38327562 PMCID: PMC10847559 DOI: 10.3389/fendo.2024.1322646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/03/2024] [Indexed: 02/09/2024] Open
Abstract
Background Hyperlipidemia is common in primary membranous nephropathy (PMN) patients, and tubular atrophy (TA) is an unfavorable prognostic factor. However, the correlation between the triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio and TA is controversial. Therefore, our study aimed to investigate the association between the TG/HDL-C ratio and TA in PMN patients. Methods We conducted a cross-sectional study and collected data from 363 PMN patients at Shenzhen Second People's Hospital from January 2008 to April 2023. The primary objective was to evaluate the independent correlation between the TG/HDL-C ratio and TA using binary logistic regression model. We used a generalized additive model along with smooth curve fitting and multiple sensitivity analyses to explore the relationship between these variables. Additionally, subgroup analyses were conducted to delve deeper into the results. Results Of the 363 PMN patients, 75 had TA (20.66%). The study population had a mean age of 46.598 ± 14.462 years, with 217 (59.78%) being male. After adjusting for sex, age, BMI, hypertension, history of diabetes, smoking, alcohol consumption, UPRO, eGFR, HB, FPG, and ALB, we found that the TG/HDL-C ratio was an independent risk factor for TA in PMN patients (OR=1.29, 95% CI: 1.04, 1.61, P=0.0213). A non-linear correlation was observed between the TG/HDL-C ratio and TA, with an inflection point at 4.25. The odds ratios (OR) on the left and right sides of this inflection point were 1.56 (95% CI: 1.17, 2.07) and 0.25 (95% CI: 0.04, 1.54), respectively. Sensitivity analysis confirmed these results. Subgroup analysis showed a consistent association between the TG/HDL-C ratio and TA, implying that factors such as gender, BMI, age, UPRO, ALB, hypertension and severe nephrotic syndrome had negligible effects on the link between the TG/HDL-C ratio and TA. Conclusion Our study demonstrates a non-linear positive correlation between the TG/HDL-C ratio and the risk of TA in PMN patients, independent of other factors. Specifically, the association is more pronounced when the ratio falls below 4.25. Based on our findings, it would be advisable to decrease the TG/HDL-C ratio below the inflection point in PMN patients as part of treatment strategies.
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Affiliation(s)
- Mijie Guan
- Department of Nephrology, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Liling Wu
- Department of Nephrology, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Yuan Cheng
- Department of Nephrology, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Dongli Qi
- Department of Nephrology, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Jia Chen
- Department of Nephrology, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Haiying Song
- Department of Nephrology, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Haofei Hu
- Department of Nephrology, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
| | - Qijun Wan
- Department of Nephrology, Shenzhen Second People’s Hospital, Shenzhen, Guangdong, China
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, Guangdong, China
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Duan S, Sun L, Zhang C, Zeng M, Sun B, Yuan Y, Mao H, Xing C, Zhang B. The thickness of glomerular basement membrane predicts complete remission in primary membranous nephropathy. Ren Fail 2023; 45:2179335. [PMID: 36856323 PMCID: PMC9980401 DOI: 10.1080/0886022x.2023.2179335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
Objective: Glomerular basement membrane (GBM) thickening is a typical and essential histopathological characteristic for the diagnosis of primary membranous nephropathy (PMN). The present study aimed to explore the relationship between GBM thickness and treatment response in PMN patients.Methods: A total of 128 patients with nephrotic syndrome concurrent with PMN were studied. The highest GBM thickness was measured from at least five glomerular capillary loops using an electron microscope, and the mean value was obtained. Patients were categorized into three groups according to the tertiles of GBM thickness as follows: Group 1 (GBM thickness ≤ 1100 nm, n = 48), Group 2 (1100 nm < GBM thickness ≤ 1300 nm, n = 40), Group 3 (GBM thickness >1300 nm, n = 40). Clinicopathological features and treatment response were compared among the three groups. The associations of GBM thickness with complete remission (CR) were assessed by Cox proportional hazard analyses and a cubic spline curve.Results: During a median follow-up period of 25.80 months, 69 (53.9%) patients achieved CR. Kaplan-Meier analysis showed that the non-CR probability was significantly higher in the highest tertile of GBM thickness (p˂0.001). Univariate Cox proportional hazard analysis indicated that GBM thickness was associated with CR (HR per SD 0.617, 95% CI [0.471-0.809], p˂0.001). After adjusting for age, duration of PMN, estimated glomerular filtration rate (eGFR), urinary protein excretion, grade of C3 deposition, and titer of serum anti-phospholipase A2 receptor (PLA2R) antibody, GBM thickness remained an independent predictor of CR (HR per SD 0.580, 95% CI [0.436-0.772], p˂0.001). Further multivariable-adjusted restricted cubic spline analysis confirmed a significant reverse linear association between GBM thickness and CR (p for nonlinear = 0.1261).Conclusions: GBM thickness is an independent risk factor of CR. PMN patients with an increased level of GBM thickening at diagnosis have a lower probability of achieving CR.
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Affiliation(s)
- Suyan Duan
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Lianqin Sun
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Chengning Zhang
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Ming Zeng
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Bin Sun
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Yanggang Yuan
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Huijuan Mao
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Changying Xing
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China,Changying Xing, Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, Jiangsu Province, P. R. China
| | - Bo Zhang
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China,Department of Nephrology, Pukou Branch of JiangSu Province Hospital (Nanjing Pukou Central Hospital), Nanjing, P.R. China,CONTACT Bo Zhang
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He HG, Huang YY, Liang QQ, Ye QR, Li AD, Ye K, Wu QX, You YW. Calcineurin inhibitors or cyclophosphamide in the treatment of membranous nephropathy superimposed with FSGS lesions: a retrospective study from China. Ren Fail 2023; 45:2253930. [PMID: 37724535 PMCID: PMC10512924 DOI: 10.1080/0886022x.2023.2253930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/25/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Cyclophosphamide (CTX) and calcineurin inhibitors (CNIs) based regimens are recommended as immunosuppressive therapies for patients with idiopathic membranous nephropathy (IMN). Focal and segmental glomerular sclerosis (FSGS) lesions, which are common in membranous nephropathy (MN), are poor predictors of outcome. This study compared the differences of prognosis between two regimens in patients with IMN combined with FSGS lesions. METHODS This retrospective study enrolled 108 patients with biopsy-proven IMN, accompanied with FSGS lesions, nephrotic syndrome and an estimated glomerular filtration rate (eGFR)≥60 mL/min/1.73 m2 who were treated with CTX or CNIs. We used propensity score matching (PSM) for balancing the confounding variables. RESULTS During follow-up, 10 patients (10/55 [18.2%]; nine males) in the CNIs group showed a 50% decline in eGFR; eight had a not otherwise specified variant. Patients initially treated with CNIs had a significantly higher risk of progression to the primary outcome and a lower probability of complete or total remission. The relapse rate was higher in patients who initially received CNIs- than in those who received CTX-based treatment. Before PSM, age and 24-h urine protein level differed significantly between the groups. The PSM model included data from 72 patients. Worse outcomes were also noted among patients who initially received CNIs than those who received CTX-based treatments after matching. CONCLUSIONS Patients with MN combined with FSGS lesions have a higher risk of renal functional decline and a higher rate of relapse after CNIs than after CTX therapy.
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Affiliation(s)
- Hong-Guang He
- Department of Nephrology, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yi-Yun Huang
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Qin-Qing Liang
- Department of Pathology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Qiu-Rong Ye
- Department of Pathology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - An-Dong Li
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Kun Ye
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Qiu-Xia Wu
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Yan-Wu You
- Department of Nephrology, The People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
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Stefan G, Balcan GT, Petre N, Cinca S, Zugravu A, Stancu S. Anti-phospholipase A2 receptor positive membranous nephropathy: investigating the link between electron microscopy stages and clinical outcome. Ultrastruct Pathol 2023; 47:365-372. [PMID: 37449497 DOI: 10.1080/01913123.2023.2236225] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 07/05/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023]
Abstract
This retrospective, observational study sought to examine the relationship between Ehrenreich-Churg electron microscopy (EM) stages and long-term outcomes in anti-PLA2R membranous nephropathy (MN). Seventy-one patients with anti-PLA2R MN (median titer 185.7RU/mL) were followed for a median of 46 months, with end-stage kidney disease (ESKD) as the primary endpoint, and response to treatment as a secondary endpoint. Patients were grouped into stages I-II (41 patients) and stages III-IV (30 patients) for analytical purposes. Notably, the III-IV group demonstrated a lower eGFR, lower anti-PLA2R titer, but a higher chronicity score. Kaplan-Meier analysis showed shorter mean kidney survival time in stages III-IV compared to I-II (p 0.03). However, multivariate analysis using Cox regression indicated that Ehrenreich-Churg stages did not significantly influence kidney survival, but lower eGFR at diagnosis and higher histopathological chronicity score did. Remission was achieved by 64% of patients and no relationship between Ehrenreich-Churg stages and treatment response was found. The only identified risk factor for not achieving remission was the severity of hyposerinemia at diagnosis. In conclusion, while EM stages III-IV are associated with more chronic lesions and stages I-II with more active immunologic disease, the histological chronicity score seems to be a stronger predictor of long-term outcomes.
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Affiliation(s)
- Gabriel Stefan
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Nephrology Department, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - George Terinte Balcan
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Ultrastructural Pathology Laboratory, "Victor Babes" National Institute of Pathology, Bucharest, Romania
| | - Nicoleta Petre
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Nephrology Department, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Simona Cinca
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Nephrology Department, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Adrian Zugravu
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Nephrology Department, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
| | - Simona Stancu
- Nephrology Department, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania
- Nephrology Department, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, Romania
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Cheng Y, Li W, Chen J, Qi D, Guan M, Cao T, Hu H, Wu L, Rao Q, Wan Q. Correlation Analysis between Intrarenal Small Artery Intimal Thickening and Clinicopathological Features and Prognosis in Primary Membranous Nephropathy Patients. Nephron Clin Pract 2023; 148:95-103. [PMID: 37611552 DOI: 10.1159/000533414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/02/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Primary membranous nephropathy (PMN) is the most common pathological type of nephrotic syndrome in adults. Intrarenal small artery intimal thickening can be observed in most renal biopsies. The purpose of this study was to investigate the association between intrarenal small artery intimal thickening and clinicopathological features and prognosis in PMN patients. METHODS Data were continuously collected from patients who were diagnosed with PMN in Shenzhen Second People's Hospital (The First Affiliated Hospital of Shenzhen University) from 2008 to 2021 for a retrospective cohort study. Regression analysis and survival analysis were used to analyze the relationship between intrarenal small artery intimal thickening and renal prognosis in PMN patients. RESULTS 300 PMN patients were enrolled in this study, including 165 patients (55%) with intrarenal small artery intimal thickening. Patients with intimal thickening were older, with higher BMI, systolic blood pressure and diastolic blood pressure, serum uric acid, a higher proportion of hypertension, acute kidney injury, nephrotic syndrome, more urine protein, and lower eGFR. Multivariate Cox regression analysis showed that after adjusting for age, gender, hypertension, BMI, urine protein, eGFR, and the use of ACEI/ARB and hormone immunosuppressants, intimal thickening was a risk factor for renal prognosis in PMN patients (HR = 3.68, 95% CI 1.36-9.96, p < 0.05). Kaplan-Meier survival curve analysis showed that the incidence of reaching the renal composite outcome was higher in the intimal thickening group (p < 0.05). CONCLUSION The prognosis of PMN patients with intrarenal small artery intimal thickening is worse, so early intervention is very important for these patients.
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Affiliation(s)
- Yuan Cheng
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | | | - Jia Chen
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Dongli Qi
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Mijie Guan
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Tao Cao
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Haofei Hu
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | - Liling Wu
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, China
| | | | - Qijun Wan
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen, China
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McDonnell T, Wu HHL, Sinha S, Chinnadurai R. The Role of PLA2R in Primary Membranous Nephropathy: Do We Still Need a Kidney Biopsy? Genes (Basel) 2023; 14:1343. [PMID: 37510247 PMCID: PMC10380005 DOI: 10.3390/genes14071343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/24/2023] [Accepted: 06/24/2023] [Indexed: 07/30/2023] Open
Abstract
Membranous nephropathy (MN) is the most prevalent cause of nephrotic syndrome amongst the non-diabetic adult population. A fifth of idiopathic nephrotic syndrome cases can be attributed to MN, rising to more than 40% in older patients over 60 years. Most MN cases are classified as being of a primary cause, where there is absence of a secondary disease process explaining its manifestation. Traditionally, the standard approach of diagnosing MN involves performing a kidney biopsy as histological evaluation offers not only conclusive evidence of the diagnosis but also provides valuable information regarding disease chronicity and the presence of any other kidney histopathological features. Nevertheless, kidney biopsy is an invasive procedure which poses risks for the patient including bleeding and pain and bears greater costs for the health system. The identification of the phospholipase A2 receptor (PLA2R) antigen in 2009 was a landmark discovery, one which has evolved our understanding of the disease processes in MN and subsequently our management approach of this condition. Antibodies against PLA2R (PLA2RAb) have since emerged as an attractive non-invasive test option to be applied for the diagnosis and prognostication of primary MN. However, much debate and unknowns remain about the accuracy and reliability of testing for PLA2RAb across various primary MN scenarios. We provide a review summarizing the historical journey of PLA2R in relation to its significance in primary MN and, more importantly, evidence emerging over the years which contemplated the role of PLA2RAb as a diagnostic and prognostic tool in primary MN.
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Affiliation(s)
- Thomas McDonnell
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (T.M.); (S.S.); (R.C.)
| | - Henry H. L. Wu
- Renal Research Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, The University of Sydney, Sydney, NSW 2065, Australia
| | - Smeeta Sinha
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (T.M.); (S.S.); (R.C.)
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (T.M.); (S.S.); (R.C.)
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK
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Okabayashi Y, Tsuboi N, Marumoto H, Sasaki T, Haruhara K, Kanzaki G, Koike K, Ueda H, Shimizu A, Puelles VG, D'Agati V, Yokoo T. Single-Nephron GFR in Different Glomerular Basement Membrane Stages of Membranous Nephropathy. KIDNEY360 2023; 4:e777-e786. [PMID: 37166967 PMCID: PMC10371379 DOI: 10.34067/kid.0000000000000142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/22/2023] [Indexed: 05/12/2023]
Abstract
Key Points The first study that estimated single-nephron GFR (SNGFR) in patients with membranous nephropathy (MN). Associations of SNGFR with MN staging by electron microscopy and clinicopathologic findings were cross-sectionally investigated. This study illustrates a role for disease-specific GBM structural lesions as determinants of SNGFR in patients with MN. Background Alterations in single-nephron dynamics have been demonstrated in animal models of membranous nephropathy (MN). This study applied a recently developed technique to estimate single-nephron parameters in human MN. Methods Single-nephron GFR (SNGFR) and single-nephron urinary protein excretion (SNUPE) were calculated by dividing total GFR and UPE by the total estimated number of nonglobally sclerotic glomeruli (NSG). The NSG number per kidney was estimated using cortical volume assessment and biopsy-based stereology. MN staging by electron microscopy was performed using Ehrenreich-Churg (EC) criteria. Single-nephron parameters were analyzed in relation to clinicopathological factors known to associate with disease outcomes. Results The study included 109 patients with MN (mean age 65 years; 73% male; eGFR 62 ml/min, 36% on renin-angiotensin-aldosterone system inhibitors prebiopsy). EC stages were I, 19%; II, 49%; III, 26%; and IV, 6%. There was no difference in glomerular volume among EC stage groups. With advancing EC stage, SNGFR and SNUPE decreased from mean 56–42 nl/min and 5.1–3.8 µ g/d, respectively. In multivariable models, EC stage was associated with SNGFR even after adjustment for key clinicopathological factors, such as reduced GFR, serum albumin, UPE, segmental glomerulosclerosis, chronic tubulointerstitial damage, and prebiopsy use of renin-angiotensin-aldosterone system inhibitors. By contrast, EC stage was not associated with glomerular volume and SNUPE after multivariable adjustment. Conclusions These results provide the first clinical evidence of alterations in single-nephron dynamics with advancing EC stage of human MN and support a role for disease-specific glomerular basement membrane structural lesions as determinants of SNGFR.
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Affiliation(s)
- Yusuke Okabayashi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
- Ill. Department of Medicine, University Medical Center Hamburg-Eppendorf, Germany
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hirokazu Marumoto
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Takaya Sasaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kotaro Haruhara
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Go Kanzaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Kentaro Koike
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Hiroyuki Ueda
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Victor G. Puelles
- Ill. Department of Medicine, University Medical Center Hamburg-Eppendorf, Germany
| | - Vivette D'Agati
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
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15
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Shah M, DeLaat A, Cavanaugh C. Treatment of membranous nephropathy: Perspectives on current and future therapies. FRONTIERS IN NEPHROLOGY 2023; 3:1110355. [PMID: 37675368 PMCID: PMC10479573 DOI: 10.3389/fneph.2023.1110355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/09/2023] [Indexed: 09/08/2023]
Abstract
Primary membranous nephropathy remains one of the most frequent causes of nephrotic syndrome in adults. It is an autoimmune disorder in which auto-antibodies target antigens at the podocytes cell membrane-basement membrane interface. Our understanding of membranous nephropathy has expanded dramatically as of late. After the initial discovery of the phospholipase A2 receptor auto-antibody in 2009, eight more antigens have been discovered. These discoveries have led to refinement in our understanding of the pathogenesis, diagnosis, and natural history of primary membranous nephropathy. Now, many experts advocate for redefining primary membranous nephropathy based on antigen, potentially shedding the primary and secondary nomenclature. Recently, therapies for primary membranous have also expanded. Immunosuppressive therapies like cyclophosphamide and rituximab, which primarily target B-cells, remain the cornerstone of therapy. However, there is still significant room for improvement, as many as 30-40% do not respond to this therapy according to recent trials. Additionally, drugs targeting complement, and other novel therapies are also under investigation. In this review we will discuss the available therapies for primary membranous nephropathy in light of recent clinic trials like GEMRITUX, MENTOR, RI-CYCLO, and STARMEN, as well as management strategies. While the last 10 years have seen a boom in our mechanistic understanding of this ever-diversifying disease, we are likely to see a similar boom in the therapeutic options in the years to come.
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Affiliation(s)
- Monarch Shah
- Division of Nephrology, University of Virginia, Charlottesville, VA, United States
| | - Andrew DeLaat
- Liberty University College of Osteopathic Medicine, Lynchburg, VA, United States
| | - Corey Cavanaugh
- Division of Nephrology, University of Virginia, Charlottesville, VA, United States
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Yildiz A, Ulu S, Oruc A, Ucar AR, Ozturk S, Alagoz S, Eren N, Kocyigit I, Koksal Cevher S, Haras AB, Sumnu A, Arinsoy T, Sahin G, Suleymanlar G, Cavdar C, Kumru Sahin G, Kurultak I, Unsal A, Sahin G, Kazan S, Tatar E, Dıkec M, Dursun B, Sayarlioglu H, Turkmen K, Artan AS, Aktas N, Yilmaz Z, Behlul A, Dheir H, Kutlay S, Seyahi N. Clinical and pathologic features of primary membranous nephropathy in Turkey: a multicenter study by the Turkish Society of Nephrology Glomerular Diseases Working Group. Ren Fail 2022; 44:1048-1059. [PMID: 35786180 PMCID: PMC9258435 DOI: 10.1080/0886022x.2022.2079526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background We aimed to evaluate the features of primary membranous nephropathy (MNP) in Turkish people. Methods This is a retrospective analysis of patients with biopsy-proven primary MNP. We obtained the data collected between 2009 and 2019 in the primary glomerulonephritis registry of the Turkish Society of Nephrology Glomerular Diseases Study Group (TSN-GOLD). Patients with a secondary cause for MNP were excluded. Clinical, demographic, laboratory, and histopathological findings were analyzed. Results A total of 995 patients with primary MNP were included in the analyses. Males constituted the majority (58.8%). The mean age was 48.4 ± 13.9 years. The most common presentation was the presence of nephrotic syndrome (81.7%) and sub nephrotic proteinuria (10.3%). Microscopic hematuria was detected in one-third of patients. The median estimated glomerular filtration rate (eGFR) was 100.6 mL/min/1.73 m2 (IQR, 75.4–116.3), and median proteinuria was 6000 mg/d (IQR, 3656–9457). Serum C3 and C4 complement levels were decreased in 3.7 and 1.7% of patients, respectively. Twenty-four (2.4%) patients had glomerular crescents in their kidney biopsy samples. Basal membrane thickening was detected in 93.8% of cases under light microscopy. Mesangial proliferation and interstitial inflammation were evident in 32.8 and 55.9% of the patients, respectively. The most commonly detected depositions were IgG (93%), C3 complement (68.8%), and kappa and lambda immunoglobulin light chains (70%). Although renal functions were normal at presentation, vascular, interstitial, and glomerular findings were more prominent on biopsy in hypertensive patients. No significant effect of BMI on biopsy findings was observed. Conclusions Despite some atypical findings, the main features of primary MNP in Turkey were similar to the published literature. This is the largest MNP study to date conducted in Turkish people.
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Affiliation(s)
| | - Sena Ulu
- Department of Nephrology, Med Fac, Afyon Kocatepe Univ, Afyon, Turkey
| | - Aysegul Oruc
- Department of Nephrology, Med Fac, Uludag Univ, Bursa, Turkey
| | - Ali Riza Ucar
- Department of Nephrology, Istanbul Fac Med, Istanbul Univ, Istanbul, Turkey
| | - Savas Ozturk
- Department of Nephrology, Haseki Training and Res Hosp, Istanbul, Turkey
| | - Selma Alagoz
- Department of Nephrology, Cerrahpasa Med Fac, Istanbul Univ, Istanbul, Turkey
| | - Necmi Eren
- Department of Nephrology, Med Fac, Kocaeli Univ, Kocaeli, Turkey
| | - Ismail Kocyigit
- Department of Nephrology, Med Fac, Erciyes Univ, Kayseri, Turkey
| | - Simal Koksal Cevher
- Department of Nephrology, Ankara Numune Training and Res Hosp, Ankara, Turkey
| | - Ali Burak Haras
- Department of Nephrology, Dr Lutfi Kirdar Kartal Training and Res Hosp, Istanbul, Turkey
| | - Abdullah Sumnu
- Department of Nephrology, Med Fac, Medipol Univ, Istanbul, Turkey
| | - Turgay Arinsoy
- Department of Nephrology, Med Fac, Gazi Univ, Ankara, Turkey
| | - Garip Sahin
- Department of Nephrology, Med Fac, Eskisehir Osmangazi Univ, Eskisehir, Turkey
| | | | - Caner Cavdar
- Department of Nephrology, Med Fac, Dokuz Eylul Univ, Izmir, Turkey
| | | | - Ilhan Kurultak
- Department of Nephrology, Med Fac, Trakya Univ, Edirne, Turkey
| | - Abdulkadir Unsal
- Department of Nephrology, Hamidiye Sisli Etfal Training and Res Hosp, Istanbul, Turkey
| | - Gulizar Sahin
- Department of Nephrology, Sultan Abdulhamit Han Res and Training Hosp, Istanbul, Turkey
| | - Sinan Kazan
- Department of Nephrology, Med Fac, Afyon Kocatepe Univ, Afyon, Turkey
| | - Erhan Tatar
- Department of Nephrology, Bozyaka Training & Res Hosp, Izmir, Turkey
| | - Mehmet Dıkec
- Department of Nephrology, Bakirkoy Sadi Konuk Training and Res Hosp, Istanbul, Turkey
| | - Belda Dursun
- Department of Nephrology, Med Fac, Pamukkale Univ, Denizli, Turkey
| | | | - Kultigin Turkmen
- Department of Nephrology, Meram Med Fac, Necmettin Erbakan Univ, Konya, Turkey
| | - Ayse Serra Artan
- Department of Nephrology, Med Fac, Bezmialem Vakif Univ, Istanbul, Turkey
| | - Nimet Aktas
- Department of Nephrology, Med Fac, Bezmialem Vakif Univ, Istanbul, Turkey
| | - Zulfikar Yilmaz
- Department of Nephrology, Med Fac, Dicle Univ, Diyarbakir, Turkey
| | - Ahmet Behlul
- Department of Nephrology, Burhan Nalbantoglu State Hosp, Nicosia, Cyprus
| | - Hamad Dheir
- Department of Nephrology, Med Fac, Sakarya Univ, Sakarya, Turkey
| | - Sim Kutlay
- Med Fac, Ibni Sina Hosp, Ankara Univ, Ankara, Turkey
| | - Nurhan Seyahi
- Department of Nephrology, Cerrahpasa Med Fac, Istanbul Univ, Istanbul, Turkey
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Lu H, Shen J, Sun J, Sun J. Efficacy and Safety of Rituximab in the Treatment of Idiopathic Membranous Nephropathy: A Meta-Analysis. Appl Bionics Biomech 2022; 2022:5393797. [PMID: 36276580 PMCID: PMC9581616 DOI: 10.1155/2022/5393797] [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: 08/17/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background Primary membranous nephropathy (MN), sometimes referred to as idiopathic membranous nephropathy (IMN), is a kind of MN whose pathogenesis is yet unclear. According to research reports, the incidence of IMN is about 9.8-26.8%, and it is on the rise. Methods The computer retrieves eight databases to obtain controlled trials at home and abroad on the rituximab (RTX) actions in IMN management. After a rigorous literature quality evaluation, software called RevMan 5.3 was used for data analysis. Results This meta-analysis finally contained 8 papers. They were all regarded as controlled trials. Six studies reported serum creatinine (standardized mean difference [SMD]: -6.87; 95% CI: -14.09, 0.35; P = 0.062), ALB (SMD: 1.91; 95% CI: -0.31, 4.14; P = 0.092), and adverse reactions (OR: 0.56; 95% CI: 0.36, 0.90; P < 0.01), all of which were significantly higher in the test group than in the control group (OR: 1.37; 95% CI: 1.07, 1.76; P < 0.01). Conclusion The overall effective rate, serum creatinine, adverse effects, and ALB of this trial indicate that RTX may be beneficial for individuals with IMN, but further high-quality research is required to confirm these findings.
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Affiliation(s)
- Huijuan Lu
- Department of Nephrology, First People's Hospital of Linping District, No. 369, Yingbin Road, Linping District, Hangzhou, Zhejiang 311199, China
| | - Jun Shen
- Department of Nephrology, First People's Hospital of Linping District, No. 369, Yingbin Road, Linping District, Hangzhou, Zhejiang 311199, China
| | - Jieqiong Sun
- Department of Nephrology, First People's Hospital of Linping District, No. 369, Yingbin Road, Linping District, Hangzhou, Zhejiang 311199, China
| | - Jia Sun
- Department of Nephrology, First People's Hospital of Linping District, No. 369, Yingbin Road, Linping District, Hangzhou, Zhejiang 311199, China
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18
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Bobart SA, Han H, Tehranian S, De Vriese AS, Roman JCL, Sethi S, Zand L, Andrades Gomez C, Giesen CD, Soler MJ, Bomback AS, Fervenza FC. Noninvasive Diagnosis of PLA2R-Associated Membranous Nephropathy: A Validation Study. Clin J Am Soc Nephrol 2021; 16:1833-1839. [PMID: 34782349 PMCID: PMC8729491 DOI: 10.2215/cjn.05480421] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/10/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Kidney biopsy is the current gold standard to diagnose membranous nephropathy. Approximately 70%-80% of patients with primary membranous nephropathy have circulating anti-phospholipase A2 receptor antibodies. We previously demonstrated that in proteinuric patients with preserved eGFR and absence of associated conditions (e.g., autoimmunity, malignancy, infection, drugs, and paraproteinemia), a positive anti-phospholipase A2 receptor antibody test by ELISA and immunofluorescence assay confirms the diagnosis of membranous nephropathy noninvasively. These data have not been externally validated. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The clinical and pathologic characteristics of patients with a positive anti-phospholipase A2 receptor antibody test at the Mayo Clinic, the University Hospital Vall D'Hebron (Barcelona), and the Columbia University Medical Center (New York) were retrospectively reviewed. Biopsy findings and presence or absence of a potential associated condition were assessed. RESULTS From a total of 276 patients with positive anti-phospholipase A2 receptor serology, previously reported patients (n=33), kidney transplant recipients (n=9), pediatric patients (n=2), and patients without kidney biopsy (n=69) were excluded. Among the 163 remaining patients, associated conditions were identified in 47 patients, and 15 patients had diabetes mellitus. All 101 patients of the final cohort had a primary diagnosis of membranous nephropathy on kidney biopsy. In the 79 patients with eGFR≥60 ml/min per 1.73 m2, none of the biopsy findings altered diagnosis or management. Among the 22 patients with decreased eGFR, additional findings included superimposed acute interstitial nephritis (n=1). CONCLUSIONS In patients with preserved eGFR and absence of associated conditions or diabetes, a positive anti-phospholipase A2 receptor test by either ELISA >20 RU/ml or a positive immunofluorescence assay confirms the diagnosis of membranous nephropathy, precluding the requirement for a kidney biopsy.
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Affiliation(s)
- Shane A. Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
- Department of Nephrology and Hypertension, Cleveland Clinic Florida, Weston, Florida
| | - Heedeok Han
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Shahrzad Tehranian
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | - An S. De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
| | | | - Callen D. Giesen
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Maria Jose Soler
- Nephrology Department, University Hospital Vall D’Hebron, Barcelona, Spain
| | - Andrew S. Bomback
- Division of Nephrology, Columbia University Medical Center, New York, New York
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19
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Dong L, Wei W, Han M, Xu G. Utility of non-HDL-C in predicting proteinuria remission of idiopathic membranous nephropathy: a retrospective cohort study. Lipids Health Dis 2021; 20:122. [PMID: 34587945 PMCID: PMC8482680 DOI: 10.1186/s12944-021-01558-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 09/14/2021] [Indexed: 11/10/2022] Open
Abstract
Background Idiopathic membranous nephropathy (IMN) may have various clinical outcomes. Hyperlipidemia is quite common in IMN. However, the utility of the lipid profile in predicting outcomes remains unknown. This study aimed to explore the correlation between hyperlipidemia and proteinuria remission in IMN. Methods 256 patients who diagnosed with IMN confirmed by renal biopsy in Wuhan Tongji Hospital from January 2016 to October 2020 were included in this study. The end point was defined as a combination of partial and complete remission. Cox proportional-hazards regression analysis and Kaplan–Meier curve were applied to assess the prognostic value of the lipid profile for proteinuria remission. Results A total of 153 (59.8%) patients achieved remission and 103 (40.2%) did not. The levels of total cholesterol, low-density lipoprotein, and non-high-density lipoprotein were significantly lower in the remission group than in the non-remission group. Non-high-density lipoprotein level revealed the strongest correlation with proteinuria (Spearman’s rho = 0.42; P < 0.001). The multivariate analysis demonstrated that serum total cholesterol [hazard ratio (HR): 0.883; 95% confidence interval (CI): 0.813–0.958; P = 0.003] and non-high-density lipoprotein cholesterol (HR: 0.892; 95% CI: 0.820–0.970; P = 0.007) levels were independent markers to predict proteinuria remission in IMN. Conclusions Among the lipid profile, the non-high-density lipoprotein level exhibited the strongest correlation with proteinuria in IMN. Moreover, elevated serum cholesterol and non-high-density lipoprotein cholesterol concentrations at baseline predicted probability of proteinuria non-remission in IMN.
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Affiliation(s)
- Lei Dong
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, D-430030, Hubei, China
| | - Wang Wei
- Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, D-430030, Hubei, China
| | - Min Han
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, D-430030, Hubei, China.
| | - Gang Xu
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan, D-430030, Hubei, China.
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20
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Chen T, Zhou Y, Chen X, Chen B, Pan J. Acute kidney injury in idiopathic membranous nephropathy with nephrotic syndrome. Ren Fail 2021; 43:1004-1011. [PMID: 34157952 PMCID: PMC8231360 DOI: 10.1080/0886022x.2021.1942913] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The impact of acute kidney injury (AKI) on the progression of renal function in idiopathic membranous nephropathy (iMN) with nephrotic syndrome (NS) patients have not yet been reported, we sought to investigate the incidence, clinical features and prognosis of AKI in iMN with NS patients and determine clinical predictors for progression from AKI to advanced chronic kidney disease (CKD) stage. METHODS We analyzed clinical and pathological data of iMN with NS patients retrospectively collected from Jan 2012 to Dec 2018. The primary renal endpoint was defined as persistent eGFR <45ml/min per 1.73 m2 more than 3 months. Comparisons of survival without primary renal endpoint were performed by Kaplan-Meier curves and log-rank test. Univariate and multivariate Cox proportional hazard models were constructed to determine independent variables associated with primary renal endpoint . RESULTS 434 iMN with NS patients were enrolled. The incidence of AKI 1 stage, AKI 2 stage and AKI 3 stage was 23.1, 4.8 and 0.7% respectively. 66 (53.2%) patients with AKI had complete renal function recovery and 42 (33.9%) patients with AKI reached primary renal endpoint. Survival without primary renal endpoint was worse in AKI patients than No AKI patients (67.1 ± 5.3 and 43.7 ± 7.3% vs 99.5 ± 0.5 and 92.5 ± 4.2% at 2 and 4 years,p < 0.001). AKI was independently associated with primary renal endpoint, with an adjusted hazard ratio(HR) of 25.1 (95%CI 7.7-82.1, p < 0.001). CONCLUSIONS AKI was usually mild and overlooked in iMN patients with NS, but it had a strong association with poor clinical outcomes and was an independent risk factor for CKD progression.
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Affiliation(s)
- Tianxin Chen
- Department of nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ying Zhou
- Department of nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xinxin Chen
- Department of nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bo Chen
- Department of nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jingye Pan
- Department of ICU, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejian province, P.R.China; Key Laboratory of Intelligent Critical Care and Life Support Research of Zhejiang Province
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21
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Lerner GB, Virmani S, Henderson JM, Francis JM, Beck LH. A conceptual framework linking immunology, pathology, and clinical features in primary membranous nephropathy. Kidney Int 2021; 100:289-300. [PMID: 33857571 DOI: 10.1016/j.kint.2021.03.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/07/2021] [Accepted: 03/25/2021] [Indexed: 12/22/2022]
Abstract
Primary membranous nephropathy is a leading cause of adult nephrotic syndrome. The field took a major step forward with the identification of phospholipase A2 receptor (PLA2R) as a target antigen in the majority of cases and with the ability to measure circulating autoantibodies to PLA2R. Since then, the existence of additional target antigens such as thrombospondin type-1 domain-containing 7A, exostosin 1 and 2, neural EGFL like 1, and semaphorin 3B has been demonstrated. The ability to detect and monitor levels of circulating autoantibodies has opened a new window onto the humoral aspect of primary membranous nephropathy. Clinicians now rely on clinical parameters such as proteinuria, as well as levels of circulating autoantibodies against PLA2R and the results of immunofluorescence staining for PLA2R within kidney biopsy tissue, to guide the management of this disease. The relationship between immunologic and clinical disease course is consistent, but not necessarily intuitive. In addition, kidney biopsy provides only a single snapshot of disease that needs to be interpreted in light of changing clinical and serological findings. A clear understanding of these dynamic parameters is essential for staging, treatment, and management of this disease. This review aims to shed light on current knowledge regarding the development and time course of changes in the serum levels of autoantibodies against PLA2R, proteinuria, and histological findings that underlie the pathophysiology of primary membranous nephropathy.
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Affiliation(s)
- Gabriel B Lerner
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samarth Virmani
- Department of Internal Medicine, University of Central Florida College of Medicine, Gainesville, Florida, USA
| | - Joel M Henderson
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Jean M Francis
- Department of Medicine, Section of Nephrology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Laurence H Beck
- Department of Medicine, Section of Nephrology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.
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22
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Cheng W, Sun L, Dong H, Wang G, Ye N, Wang Y, Cheng H. Clinicopathologic characteristic and prognosis in idiopathic membranous nephropathy patients with focal segmental sclerosis lesion: A retrospective observational study. Medicine (Baltimore) 2021; 100:e23988. [PMID: 33545990 PMCID: PMC7837959 DOI: 10.1097/md.0000000000023988] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 12/01/2020] [Indexed: 11/25/2022] Open
Abstract
To explore the clinicopathological characteristics and prognosis of idiopathic membranous nephropathy (IMN) with focal segmental sclerosis lesions (FSL). A total of 70 IMN patients with FSL (FSL+group) were enrolled in this study, and 140 patients were randomly selected by age and sex matching as disease controls (FSL-group). The clinical and renal histopathological data on renal biopsy and clinical data of patients regularly followed were collected. Serum anti-phospholipase A2 receptor (PLA2R) autoantibody, thrombospondin type-1 domain-containing 7A (7A) autoantibody, glomerular PLA2R and 7A expression, and IgG4 deposition were detected. First, the clinical and pathological significance of IMN combined with the FSL group was analyzed. Whether FSL is a risk factor for renal outcomes was further analyzed. 1. Compared with the FSL- group, patients in the FSL+ group had a significantly higher incidence of hypertension and a longer duration of hypertension as well as higher levels of systolic blood pressure, serum creatinine, serum triglycerides, serum cholesterol, 24-hour urinary protein excretion, and lower eGFR and urine osmotic pressure. Patients in the FSL+ group had an increased frequency of Churg stage III and more severe glomerulosclerosis and interstitial fibrosis. The remission rate was significantly lower in the FSL+ group than in the FSL- group (50.0% vs 75.9%, P = .027). 2. Multivariate Cox regression analysis showed that FSL (HR = 3.01, 95%CI = 1.07–8.52, P = .038) was an independent risk factor for progression of renal function deterioration, and FSL (HR = 3.25, 95%CI = 1.43–7.38, P = .005) and high levels of serum anti-PLA2R antibody (HR = 1.89, 95%CI = 1.27–2.82, P = .002) were independent risk factors for nonremission of IMN. IMN patients who developed FSL had more severe clinical and pathological characteristics than those without FSL. FSL was an independent risk factor for poorer prognosis. When the appearance of FSL in IMN patients with a high level of serum anti-PLA2R antibody, the treatment needs to be more aggressive to promote remission and to delay the progression of renal function.
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MESH Headings
- Adult
- Autoantibodies/blood
- Female
- Glomerulonephritis, Membranous/blood
- Glomerulonephritis, Membranous/complications
- Glomerulonephritis, Membranous/pathology
- Glomerulonephritis, Membranous/therapy
- Glomerulosclerosis, Focal Segmental/blood
- Glomerulosclerosis, Focal Segmental/etiology
- Glomerulosclerosis, Focal Segmental/pathology
- Glomerulosclerosis, Focal Segmental/therapy
- Humans
- Kidney Glomerulus/metabolism
- Kidney Glomerulus/pathology
- Male
- Middle Aged
- Prognosis
- Proteinuria/etiology
- Receptors, Phospholipase A2/immunology
- Receptors, Phospholipase A2/metabolism
- Remission Induction
- Retrospective Studies
- Thrombospondins/immunology
- Thrombospondins/metabolism
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23
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Oto OA, Demir E, Mirioglu S, Dirim AB, Ozluk Y, Cebeci E, Basturk T, Ucar AR, Soltanova L, Nuriyev K, Kilicaslan I, Yazici H, Caliskan Y. Clinical significance of glomerular C3 deposition in primary membranous nephropathy. J Nephrol 2021; 34:581-587. [PMID: 33387338 DOI: 10.1007/s40620-020-00915-w] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 11/11/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND We aimed to investigate the effects of glomerular C3 deposition on clinical, histopathological features, and outcomes of patients with primary membranous nephropathy (MN). METHODS A total of 261 patients with biopsy-proven primary MN, who were on follow up for at least 6 months, were included in the study. The patients were grouped according to their C3 immunostaining in kidney biopsy samples at the time of diagnosis: Low intensity [LI; (C3 1 +)] and high intensity [HI; (C3 2 + or C3 3 +)]. The primary outcome was the development of kidney failure. Complete (CR) or partial remission (PR) was defined as secondary outcome. RESULTS Sixteen patients reached the primary outcome after a median follow-up of 33.8 months. Patients in the high intensity group (119 cases) had lower eGFR and higher proteinuria at admission and last follow-up compared to patients in the low intensity group (142 cases). Also, more patients in the high intensity group reached the primary outcome compared to patients in the low intensity group: twelve patients (10.1%) in the high intensity group and four patients (2.8%) in the low intensity group reached the primary outcome (p = 0.015). Kaplan-Meier analysis demonstrated that patients in the high intensity group had a higher risk for kidney failure (p = 0.02). In multivariate logistic regression analysis, high intensity C3 deposition and initial estimated glomerular filtration rate (eGFR) indepenently predicted primary outcome. CONCLUSION Extensive glomerular C3 deposition is a predictor of kidney failure in patients with MN.
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Affiliation(s)
- Ozgur Akin Oto
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Erol Demir
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Safak Mirioglu
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ahmet Burak Dirim
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yasemin Ozluk
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Egemen Cebeci
- Division of Nephrology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Taner Basturk
- Division of Nephrology, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Ali Riza Ucar
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Lala Soltanova
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Kanan Nuriyev
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Isin Kilicaslan
- Department of Pathology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Halil Yazici
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Yasar Caliskan
- Division of Nephrology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey. .,Division of Nephrology and Hypertension, Saint Louis University School of Medicine, Saint Louis, MO, USA.
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24
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Cavanaugh C, Okusa MD. The Evolving Role of Novel Biomarkers in Glomerular Disease: A Review. Am J Kidney Dis 2021; 77:122-131. [DOI: 10.1053/j.ajkd.2020.06.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 06/06/2020] [Indexed: 02/06/2023]
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25
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Choi JY, Chin HJ, Lee H, Bae EH, Chang TI, Lim JH, Jung HY, Cho JH, Kim CD, Kim YL, Park SH. Idiopathic membranous nephropathy in older patients: Clinical features and outcomes. PLoS One 2020; 15:e0240566. [PMID: 33035278 PMCID: PMC7546503 DOI: 10.1371/journal.pone.0240566] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/28/2020] [Indexed: 12/25/2022] Open
Abstract
Background Various factors can affect renal and patient outcome in idiopathic membranous nephropathy (iMN). We aimed to identify predictors of renal and patient survival in patients with iMN, with a special focus on outcomes among older patients. Methods We retrieved data on 1,776 patients (mean age 53.0 ± 14.7 years; 1,075 [60.5%] males) diagnosed with iMN from the Korean GlomeruloNEphritis sTudy (KoGNET), a database compiled from 18 centers in Korea. Results The cohort included 428 (24.1%) patients over 65 years old. Compared to younger patients, this group had lower hemoglobin and serum albumin levels, a higher incidence of nephrotic-range proteinuria, and higher prevalences of hypertension and diabetes. At last follow-up, complete or partial remission rates were not significantly different between the older and younger groups. Older age (HR: 0.98, 95%CI: 0.97–0.99), elevated hemoglobin (HR: 0.82, 95%CI: 0.72–0.93), high serum albumin (HR: 0.66, 95%CI: 0.44–0.99), and a high estimated glomerular filtration rate (HR: 0.96, 95%CI: 0.95–0.97) at biopsy were good predictors of renal outcomes. Significant risk factors for patient survival were older age (HR: 1.04, 95%CI: 1.01–1.10) and hypertension at biopsy (HR: 2.76, 95%CI: 1.30–5.90). Conclusions Older patients with iMN had favorable renal outcomes, but poor patient survival, compared to younger patients. Prognostic information on outcomes in this study might be helpful for optimizing the management of patients with iMN.
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Affiliation(s)
- Ji-Young Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University College of Medicine and Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Hospital, Seoul, Republic of Korea
| | - Tae Ik Chang
- Department of Internal Medicine, National Health Insurance Service Medical Center, Ilsan Hospital, Goyangshi, Gyeonggi-do, Republic of Korea
| | - Jeong-Hoon Lim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Hee-Yeon Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Sun-Hee Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
- * E-mail:
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26
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Bobart SA, Fervenza FC. Kidney Biopsy Is Required for Nephrotic Syndrome with PLA2R+ and Normal Kidney Function: The Con View. KIDNEY360 2020; 1:890-893. [PMID: 35369550 PMCID: PMC8815595 DOI: 10.34067/kid.0003262020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 06/04/2020] [Indexed: 06/14/2023]
Affiliation(s)
- Shane A. Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota
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27
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Wei C, He Y, Li T, Hu H, Song H, Qi D, Cheng Y, Chen J, Guan M, Xiao X, Li J. Glomerulosclerosis predicts poor renal outcome in patients with idiopathic membranous nephropathy. Int Urol Nephrol 2020; 53:505-514. [PMID: 32960397 DOI: 10.1007/s11255-020-02641-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 09/07/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to investigate the association between the proportion of glomerulosclerosis (focal segmental glomerulosclerosis and/or global glomerulosclerosis) and renal prognosis in patients with idiopathic membranous nephropathy (IMN). METHODS A retrospective analysis performed from January 2008 to December 2017 in the First Affiliated Hospital of Shenzhen University by renal biopsy confirmed 200 patients with IMN, and their clinical pathology and prognosis were compared. Patients were divided into three groups on the basis of glomerular sclerosis proportion tertiles: low (Tertile1 group, proportion of glomerulosclerosis, 0-0%), middle (Tertile2 group, proportion of glomerulosclerosis, 0-5.5%) and high (Tertile3 group, proportion of glomerulosclerosis, 5.8-72.7%) tertiles. The follow-up endpoints were decreased estimated glomerular filtration rate (eGFR) by 20%, end-stage renal disease, and all-cause mortality. RESULTS (1) Both, the Tertile1 and Tertile2, groups had significantly lower albumin level and higher 24-h urine protein level than that in the Tertile3 group. Regarding treatment, as the proportion of glomerulosclerosis increases, a more aggressive treatment with glucocorticoids and immunosuppressants should be provided. (2) Correlation analysis showed that the proportion of glomerulosclerosis was positively associated with age (P < 0.05). However, it was negatively associated with eGFR (P < 0.05). (3) Renal tubular atrophy and renal interstitial inflammatory cell infiltration were considered independent correlative factors for glomerulosclerosis. Kaplan-Meier analysis revealed that renal survival rate was significantly lower in patients with a proportion of glomerulosclerosis ≥ 6.45% than in patients with a proportion of glomerulosclerosis < 6.45%. Cox regression analysis revealed that as the proportion of glomerulosclerosis increases, the risk of renal outcomes increases gradually. CONCLUSIONS Patients in the Tertile3 (higher proportion of glomerulosclerosis) group had more severe renal pathological damage compared to patients in the Tertile1 and Tertile2 groups. Glomerulosclerosis is a risk factor for renal function progression and poor renal prognosis in patients with IMN. As the proportion of glomerulosclerosis increases, the risk of renal endpoint events increases gradually.
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Affiliation(s)
- Cuimei Wei
- Department of Geriatrics, The First Affiliated Hospital of Shenzhen University, No. 3002 Sungang Road, Futian, Shenzhen, 518035, Guangdong, China.,Shenzhen Second People's Hospital, Shenzhen, 518000, Guangdong, China
| | - Yongcheng He
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, 518035, Guangdong, China.,Shenzhen Second People's Hospital, Shenzhen, 518000, Guangdong, China
| | - Tong Li
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, 518035, Guangdong, China. .,Shenzhen Second People's Hospital, Shenzhen, 518000, Guangdong, China.
| | - Haofei Hu
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, 518035, Guangdong, China.,Shenzhen Second People's Hospital, Shenzhen, 518000, Guangdong, China
| | - Haiying Song
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, 518035, Guangdong, China.,Shenzhen Second People's Hospital, Shenzhen, 518000, Guangdong, China
| | - Dongli Qi
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, 518035, Guangdong, China.,Shenzhen Second People's Hospital, Shenzhen, 518000, Guangdong, China
| | - Yuan Cheng
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, 518035, Guangdong, China.,Shenzhen Second People's Hospital, Shenzhen, 518000, Guangdong, China
| | - Jia Chen
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, 518035, Guangdong, China.,Shenzhen Second People's Hospital, Shenzhen, 518000, Guangdong, China
| | - Mijie Guan
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen, 518035, Guangdong, China.,Shenzhen Second People's Hospital, Shenzhen, 518000, Guangdong, China
| | - Xiaohua Xiao
- Department of Geriatrics, The First Affiliated Hospital of Shenzhen University, No. 3002 Sungang Road, Futian, Shenzhen, 518035, Guangdong, China.,Shenzhen Second People's Hospital, Shenzhen, 518000, Guangdong, China
| | - Junyi Li
- Department of Applied Statistics, School of Applied Mathematics, Guangdong University of Technology, Guangzhou, 510643, China
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28
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Lu W, Gong S, Li J, Wang Y. Clinicopathological features and prognosis in patients with idiopathic membranous nephropathy with hypertension. Exp Ther Med 2020; 19:2615-2621. [PMID: 32256741 PMCID: PMC7086205 DOI: 10.3892/etm.2020.8506] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 11/06/2019] [Indexed: 12/30/2022] Open
Abstract
The present study analyzed the clinicopathological features and prognosis in patients with idiopathic membranous nephropathy (IMN) with hypertension. In the hypertension group, significant differences were found in the age, hypertension history, systolic blood pressure, diastolic blood pressure (DBP), mean arterial pressure, albumin, serum creatinine, low-density lipoprotein, 24 h urine protein levels, calculated estimated glomerular filtration rate (e-GFR), glomerular sclerosis, segmental sclerosis, ischemic sclerosis, interstitial fibrosis, tubular atrophy and vascular lesion compared with the non-hypertension group (P<0.05). The average follow-up time was 35.70 months (5.10-103.77 months). In total, 54 patients reported a 50% decline in e-GFR, eight patients reported progression of disease to end-stage renal disease (ESRD) and nine cases of mortality were reported. Survival analysis results suggested that patients with hypertension had a lower cumulative renal survival rate than those without hypertension (P=0.034). Multivariate Cox hazards regression analysis results suggested that DBP [hazard ratio (H), 5.160; CI, 0.865-0.989; P=0.023], age (H, 4.839; CI, 1.008-1.142; P=0.028), sex (H, 5.680; CI, 0.031-0.714; P=0.017), serum creatinine (H, 20.920; CI, 1.035-1.089; P<0.001), uric acid (H, 4.783; CI, 0.982-0.0.999; P=0.029), 24 h urine protein (H, 6.318; CI, 1.079-1.850; P=0.012), e-GFR (H, 4.008; CI, 1.001-1.062; P=0.045) and glomerular sclerosis (H, 8.722; CI, 1.860-21.559; P=0.003), segmental sclerosis (H, 7.737; CI, 7.770-13.219; P=0.005), percentage of ischemic sclerosis (H, 4.729; CI, 1.444-11.945; P=0.030), crescents (H, 5.938; CI, 0.003-0.526; P=0.015), interstitial fibrosis and tubular atrophy (H, 8.128; CI, 0.005-1.052; P=0.043), and vascular lesion (H, 4.049; CI, 1.030-9.766; P=0.044) were risk factors for the development of IMN into ESRD. The results suggested that DBP may be an independent risk factor for the development of IMN with hypertension.
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Affiliation(s)
- Wanjun Lu
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Shuhao Gong
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Juan Li
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
| | - Ying Wang
- Department of Nephrology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, P.R. China
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Xie Z, Dong W, Li Z, Chen Y, Song L, Li R, Wu Y, Fu L, Liang H, Tao Y, Xie J, Wang W, Liu S, Ye Z, Shi W, Liang X. Clinical value of renal phospholipase A2 receptor deposit in the prognosis evaluation and treatment options of idiopathic membranous nephropathy: A retrospective cohort study. Nephrology (Carlton) 2020; 25:219-229. [PMID: 31900967 PMCID: PMC7065056 DOI: 10.1111/nep.13691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/04/2019] [Accepted: 12/11/2019] [Indexed: 11/29/2022]
Abstract
Aim Phospholipase A2 receptor (PLA2R) is a target antigen for idiopathic membranous nephropathy (IMN). However, the association between renal PLA2R antigen and disease prognosis had not been fully investigated. In addition, there was a paucity of studies investigating the difference of therapeutic effects between cyclophosphamide and cyclosporine A in PLA2R‐associated IMN. Methods This retrospective cohort study recruited 300 eligible patients diagnosed with biopsy‐proven IMN between September 2015 and July 2018 in Guangdong Provincial People's Hospital. The remission of proteinuria was compared between PLA2R‐associated and non‐PLA2R‐associated IMN. The difference of therapeutic effects between cyclophosphamide and cyclosporine A were also investigated in PLA2R‐associated IMN. Results The positive rate of renal PLA2R antigen in recruited IMN patients was 82.3%. Non‐PLA2R‐associated IMN patients had a higher probability to achieve remission than PLA2R‐associated IMN patients (Log–rank test, P = .013). Multivariate COX analysis showed that renal PLA2R antigen was an independent risk factor for not achieving remission in IMN patients (Hazard Ratio: 1.619; 95% confidence interval: 1.133 to 2.313; P = .008). In PLA2R‐associated IMN, patients receiving cyclophosphamide had a higher probability to achieve remission compared with those receiving cyclosporine A (Log–rank test, P = .018) while there was no difference in renal survival. Multivariate COX regression analysis showed that compared with cyclosporine A, patients receiving cyclophosphamide had a higher probability to achieve remission. Conclusion Phospholipase A2 receptor ‐associated IMN patients had a lower probability to achieve remission compared with non‐PLA2R‐associated IMN. Compared with cyclosporine A, cyclophosphamide exerted better therapeutic effects in remission of proteinuria and may be the preferred immunosuppressant for PLA2R‐associated IMN.
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Affiliation(s)
- Zhiyong Xie
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Wei Dong
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhilian Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuanhan Chen
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Li Song
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruizhao Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yanhua Wu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Lei Fu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Huaban Liang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yiming Tao
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jianteng Xie
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wenjian Wang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuangxin Liu
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhiming Ye
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wei Shi
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xinling Liang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Zhang D, Zhang C, Bian F, Zhang W, Jiang G, Zou J. Clinicopathological features in membranous nephropathy with cancer: A retrospective single-center study and literature review. Int J Biol Markers 2019; 34:406-413. [PMID: 31617780 DOI: 10.1177/1724600819882698] [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] [Indexed: 11/17/2022]
Abstract
BACKGROUND Membranous nephropathy is the most common glomerular disease related to malignancy. However, it is difficult to distinguish between true malignancy-related membranous nephropathy and idiopathic membranous nephropathy coincident with cancer. It has been reported that phospholipase A2 receptor (PLA2R) is the first autoantigen involved in idiopathic membranous nephropathy and thrombospondin type-1 domain-containing 7A (THSD7A) may have a close relationship with malignancy-related membranous nephropathy. Therefore, the aim of this study was to compare the clinicopathological characteristics between membranous nephropathy patients with cancer and idiopathic membranous nephropathy patients without cancer to better detect malignancy-related membranous nephropathy, including glomerular PLA2R and THSD7A depositions and their circulating antibodies, together with glomerular IgG4 deposition. METHODS Twelve membranous nephropathy patients with cancer and 257 idiopathic membranous nephropathy patients without cancer were included in this study and had been followed up for more than 1 year. The glomerular expression of PLA2R, THSD7A, and IgG4 was analyzed by immunohistochemistry. Circulating anti-PLA2R and anti-THSD7A antibodies were assessed by enzyme-linked immunosorbent assay and indirect immunofluorescence testing, respectively. RESULTS Membranous nephropathy patients with cancer were significantly older and had higher serum creatinine and a lower estimated glomerular filtration rate than idiopathic membranous nephropathy patients (P<0.05). The positive rates of glomerular PLA2R and IgG4 depositions and circulating anti-PLA2R antibodies in membranous nephropathy patients with cancer were significantly lower than those in idiopathic membranous nephropathy patients without cancer (P<0.01). CONCLUSION The absence of glomerular PLA2R deposition and negative circulating anti-PLA2R antibodies, along with negative glomerular IgG4 staining, may be useful clues to more accurately screen underlying malignancies in membranous nephropathy patients.
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Affiliation(s)
- Dan Zhang
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Chong Zhang
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Fan Bian
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Wenzhu Zhang
- Department of Pathology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Gengru Jiang
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Jun Zou
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
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Stangou MJ, Marinaki S, Papachristou E, Liapis G, Pateinakis P, Gakiopoulou H, Nikolaidou C, Kolovou K, Lampropoulou IT, Zerbala S, Papadea P, Dounousi E, Balafa O, Pavlakou P, Andrikos A, Balassi E, Manolakaki P, Moustakas G, Galitsiou D, Mitsopoulos E, Vourlakou C, Choulitoudi V, Andronikidi PE, Stefanidis I, Golfinopoulos S, Dafnis E, Stylianou K, Panagoutsos S, Papadogianakis A, Tzanakis I, Sioulis A, Vlahakos D, Grapsa I, Tsilivigkou M, Kaperonis N, Paliouras C, Dioudis C, Spaia S, Apostolou T, Iatrou C, Boletis J, Goumenos D, Papagianni A. Histological grading in primary membranous nephropathy is essential for clinical management and predicts outcome of patients. Histopathology 2019; 75:660-671. [PMID: 31318463 PMCID: PMC6856983 DOI: 10.1111/his.13955] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/09/2019] [Accepted: 07/14/2019] [Indexed: 01/06/2023]
Abstract
Aims Diagnosis of primary membranous nephropathy (PMN) is mainly based on immunofluorescence/immunohistochemistry findings. However, assessment of specific features on optical microscopy can help to estimate the severity of the disease, guide treatment and predict the response. The aim of this study was to identify, classify and grade the precise histological findings in PMN to predict renal function outcome and guide treatment. Methods and results Histological parameters, including focal segmental sclerosis (FSGS), tubular atrophy (TA), interstitial fibrosis (IF) and vascular hyalinosis (VH), were re‐evaluated in 752 patients with PMN. Their predictive value was estimated separately, and also in a combination score (FSTIV) graded from 0 to 4. Finally, the impact of histology was assessed in the response to immunosuppressive treatment. Mean age of patients was 53.3 (15–85) years and most presented with nephrotic syndrome. FSGS was present in 32% and VH in 51% of the patients, while TA and IF were graded as stage ≥1 in 52% and 51.4%, respectively. The follow‐up period was 122.3 (112–376) months. FSGS, TA and IF and VH were associated with impaired renal function at diagnosis (P = 0.02, P < 0.0001, P = 0.001 and P = 0.02, respectively) and at the end of follow‐up (P = 0.004, P < 0.0001, P < 0.0001 and P = 0.04, respectively). In multiple regression and binary logistic analysis, the presence of FSGS and degree of TA were the most significant parameters predicting renal function outcome, defined either by eGFR (end), FSGS (r = 0.6, P < 0.0001) and TA (r = 0.6, P < 0.0001), or by the endpoint of >50% eGFR reduction, FSGS (P = 0.001) and TA (P = 0.02). Also, patients presented with FSGS, IF, VH and/or with FSTIV > 1 could benefit from immunosuppression, regardless of clinical presentation. Conclusions The presence and degree of four histological indices, FSGS, VH, TA and IF, assessed separately or in combination, and FSTIV score not only predict renal function outcome after long‐term follow‐up, but can also help in the choice of appropriate treatment. Decisions concerning immunosuppressive treatment can be guided by pathology regardless of clinical findings.
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Affiliation(s)
- Maria J Stangou
- Hippokration General Hospital, Aristotle University, Thessaloniki, Greece
| | - Smaragdi Marinaki
- National and Kapodistrian University, Laiko General Hospital, Athens, Greece
| | | | - George Liapis
- National and Kapodistrian University, Laiko General Hospital, Athens, Greece
| | | | - Hara Gakiopoulou
- National and Kapodistrian University, Laiko General Hospital, Athens, Greece
| | | | - Kyriaki Kolovou
- National and Kapodistrian University, Laiko General Hospital, Athens, Greece
| | | | | | | | | | - Olga Balafa
- University Hospital of Ioannina, Ioannina, Greece
| | | | | | | | | | | | | | | | | | | | | | | | | | - Eugene Dafnis
- University Hospital of Heraklion, Heraklion, Crete, Greece
| | | | | | | | | | | | - Demetrios Vlahakos
- Attikon University Hospital, National and Kapodistrian University, Athens, Greece
| | - Irene Grapsa
- Aretaieio Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | - Sophia Spaia
- General Hospital of Thessaloniki 'Agios Pavlos', Thessaloniki, Greece
| | | | | | - John Boletis
- National and Kapodistrian University, Laiko General Hospital, Athens, Greece
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He HG, Wu CQ, Ye K, Zeng C, Huang YY, Luo SW, Yin W, Ye QR, Peng XM. Focal segmental glomerulosclerosis, excluding atypical lesion, is a predictor of renal outcome in patients with membranous nephropathy: a retrospective analysis of 716 cases. BMC Nephrol 2019; 20:328. [PMID: 31438882 PMCID: PMC6704573 DOI: 10.1186/s12882-019-1498-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 07/29/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Focal segmental lesions (FSLs) are not uncommon in idiopathic membranous nephropathy (IMN). The reported percentage of IMN patients with focal segmental glomerulosclerosis (FSGS) lesions varies widely between studies. The objective of this study was to differentiate atypical FSL (aFSL) from typical FSGS in IMN and to analyse the clinicopathological predictors of primary outcome of IMN patients. METHODS A total of 716 patients with biopsy-proven IMN between January 1, 2007 and December 31, 2017 were enrolled in the study. An atypical focal segmental lesion was defined as pure synechia, segmental hyperplasia of podocytes or thickening of the GBM accompanied by proliferation of the mesangial matrix, and absence of typical FSGS. The patients were divided into three groups: patients without FSL (FSL-), patients with typical FSGS (FSGS+), and patients with aFSL (aFSL+).The primary outcome was a 50% decline in the initial estimated glomerular filtration rate or end-stage renal disease (ESRD) incidence. Secondary outcomes included all-cause death and ESRD. RESULTS FSGS was present in 174 patients, while aFSL was noted in 161 patients. Systolic blood pressure was higher in both aFSL+ group and FSGS+ groups compared with the FSL- group. IMN patients without FSL and with aFSL had lower serum creatinine levels than IMN patients with FSGS. Both the FSGS+ and aFSL+ groups had higher levels of proteinuria and lower albumin levels than the FSL- group. Renal tissue lesions, including tubulointerstitial fibrosis, glomerular obsolescence, and vascular sclerosis were significantly more severe in the FSGS+ group. Cox multivariate analysis showed that older age ≥ 60 years, eGFR< 60 ml/(min·1.73m2), tubulointerstitial fibrosis area ≥ 15% and FSGS at biopsy were independent risk factors for the primary outcome. CONCLUSIONS No significant difference in outcome was found between the FSL- and aFSL+ groups, although the patients with aFSL had lower levels of serum albumin and eGFR, higher level of urinary protein, more severe renal lesions with proliferation of the mesangial area,tubulointerstitial fibrosis and vascular sclerosis. FSGS, excluding atypical lesions, was an independent predictor of the primary outcome.
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Affiliation(s)
- Hong-Guang He
- Department of Nephrology, The People's Hospital of Guangxi Zhuang Autonomous Region, 6 Taoyuan Road, Qingxiu District, Nanning, 530000, China
| | - Chao-Qing Wu
- Department of Nephrology, The People's Hospital of Guangxi Zhuang Autonomous Region, 6 Taoyuan Road, Qingxiu District, Nanning, 530000, China
| | - Kun Ye
- Department of Nephrology, The People's Hospital of Guangxi Zhuang Autonomous Region, 6 Taoyuan Road, Qingxiu District, Nanning, 530000, China
| | - Chun Zeng
- Department of Nephrology, The People's Hospital of Guangxi Zhuang Autonomous Region, 6 Taoyuan Road, Qingxiu District, Nanning, 530000, China
| | - Yi-Yun Huang
- Department of Nephrology, The People's Hospital of Guangxi Zhuang Autonomous Region, 6 Taoyuan Road, Qingxiu District, Nanning, 530000, China
| | - Shu-Wen Luo
- Department of Nephrology, The People's Hospital of Guangxi Zhuang Autonomous Region, 6 Taoyuan Road, Qingxiu District, Nanning, 530000, China
| | - Wu Yin
- Department of Pathology, The People's Hospital of Guangxi Zhuang Autonomous Region, 6 Taoyuan Road, Qingxiu District, Nanning, 530000, China
| | - Qiu-Rong Ye
- Department of Pathology, The People's Hospital of Guangxi Zhuang Autonomous Region, 6 Taoyuan Road, Qingxiu District, Nanning, 530000, China
| | - Xiao-Mei Peng
- Department of Nephrology, The People's Hospital of Guangxi Zhuang Autonomous Region, 6 Taoyuan Road, Qingxiu District, Nanning, 530000, China.
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Metabolomic Analysis of Membranous Glomerulonephritis: Identification of a Diagnostic Panel and Pathogenic Pathways. Arch Med Res 2019; 50:159-169. [DOI: 10.1016/j.arcmed.2019.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 07/08/2019] [Accepted: 08/07/2019] [Indexed: 12/11/2022]
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Xiaofan H, Jing X, Chenni G, Yifan W, Xialian Y, Li L, Hong R, Wen Z, Weiming W, Xiaoxia P, Jingyuan X, Nan C. New risk score for predicting progression of membranous nephropathy. J Transl Med 2019; 17:41. [PMID: 30736804 PMCID: PMC6368730 DOI: 10.1186/s12967-019-1792-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 02/05/2019] [Indexed: 11/29/2022] Open
Abstract
Background Patients with Idiopathic membranous nephropathy (IMN) have various outcomes. The aim of this study is to construct a tool for clinicians to precisely predict outcome of IMN. Methods IMN patients diagnosed by renal biopsy from Shanghai Ruijin Hospital from 2009.01 to 2013.12 were enrolled in this study. Primary outcome was defined as a combination of renal function progression [defined as a reduction of estimated glomerular filtration rate (eGFR) equal to or over 30% comparing to baseline], ESRD or death. Risk models were established by Cox proportional hazard regression analysis and validated by bootstrap resampling analysis. ROC curve was applied to test the performance of risk score. Results Totally 439 patients were recruited in this study. The median follow-up time was 38.73 ± 19.35 months. The enrolled patients were 56 (15–83) years old with a male predominance (sex ratio: male vs female, 1:0.91). The median baseline serum albumin, eGFR-EPI and proteinuria were 23(8–43) g/l, 100.31(12.81–155.98) ml/min/1.73 m2 and 3.98(1.50–22.98) g/24 h, respectively. In total, there were 36 primary outcomes occurred. By Cox regression analysis, the best risk model included age [HR: 1.04(1.003–1.08), 95% CI from bootstrapping: 1.01–1.08), eGFR [HR: 0.97 (0.96–0.99), 95% CI from bootstrapping: 0.96–0.99) and proteinuria [HR: 1.09 (1.01–1.18), 95% CI from bootstrapping: 1.02–1.16). One unit increasing of the risk score based on the best model was associated with 2.57 (1.97–3.36) fold increased risk of combined outcome. The discrimination of this risk score was excellent in predicting combined outcome [C statistics: 0.83, 95% CI 0.76–0.90]. Conclusions Our study indicated that older IMN patients with lower eGFR and heavier proteinuria at the time of renal biopsy were at a higher risk for adverse outcomes. A risk score based on these three variables provides clinicians with an effective tool for risk stratification. Electronic supplementary material The online version of this article (10.1186/s12967-019-1792-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hu Xiaofan
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China
| | - Xu Jing
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China
| | - Gao Chenni
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China
| | - Wu Yifan
- Insititution of KECC, University of Michigan, Ann Arbor, USA
| | - Yu Xialian
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China
| | - Lin Li
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China
| | - Ren Hong
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China
| | - Zhang Wen
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China
| | - Wang Weiming
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China
| | - Pan Xiaoxia
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China
| | - Xie Jingyuan
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China.
| | - Chen Nan
- Department of Nephrology, Institute of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, 200001, China.
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Bobart SA, De Vriese AS, Pawar AS, Zand L, Sethi S, Giesen C, Lieske JC, Fervenza FC. Noninvasive diagnosis of primary membranous nephropathy using phospholipase A2 receptor antibodies. Kidney Int 2019; 95:429-438. [DOI: 10.1016/j.kint.2018.10.021] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 10/02/2018] [Accepted: 10/11/2018] [Indexed: 01/23/2023]
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An C, Akankwasa G, Liu J, Wang D, Cheng G, Zhang J, Qin X. Urine markers of renal tubular injury in idiopathic membranous nephropathy: A cross sectional study. Clin Chim Acta 2019; 492:7-11. [PMID: 30684459 DOI: 10.1016/j.cca.2019.01.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/13/2019] [Accepted: 01/16/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Idiopathic membranous nephropathy (IMN) is a primary glomerular disease and a major cause of adult nephrotic syndrome. Presently, little is known about the capabilities of the urine markers to reflect the severity of IMN. We aimed at establishing whether urinary N-acetyl-β-glucosaminidase (NAG), Retinol binding protein (RBP), Kidney injury molecule-1 (KIM-1) and Neutrophil gelatianse-associated lipocalin (NGAL) are related with renal parameters and the histological grades tubular injury. METHODS The levels of urinary NAG, RBP, KIM-1 and NGAL were determined in 165 biopsy-proven patients and 64 healthy controls. Their levels were then compared between patients and healthy subjects, and between patients with and without nephrotic syndrome. Their linearity with renal parameters and associations with histological grades of renal tubular injury were also assessed. RESULTS All biomarkers were significantly increased in patients (p < .001). However, no significant increase was observed between patients exhibiting moderate and severe grades tubular injury and those exhibiting mild histological grade. With exception of RBP, all biomarkers were higher in patients with nephrotic syndrome (p < .001) and significantly correlated with majority of renal parameters including proteinuria. CONCLUSION Our findings suggest that although urine markers of tubular injury are increased in IMN, they may not offer a reflection of histological grades.
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Affiliation(s)
- Changjuan An
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, China
| | - Gilbert Akankwasa
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, China
| | - Jianhua Liu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, China
| | - Dandan Wang
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, China
| | - Guixue Cheng
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, China
| | - Jin Zhang
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, China
| | - Xiaosong Qin
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, China.
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Lin C, Zheng D, Wang Y, Wang S. Clinical and pathological features of idiopathic membranous nephropathy in young people. Nephrology (Carlton) 2018; 24:599-604. [PMID: 30175519 DOI: 10.1111/nep.13486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2018] [Indexed: 11/28/2022]
Abstract
AIM To investigate the clinico-pathological features of idiopathic membranous nephropathy (IMN) in youth. METHODS Patients with biopsy-proven IMN in Peking University Third Hospital from May 2015 to October 2017 (n = 147) were enrolled in this study. Patients were divided into youth (≤35 years old), middle-age (35-65 years old) and elderly group (>65 years old) accordingly. Medical records of patients were retrospectively analyzed. RESULTS Youth group exhibited shorter duration from onset to biopsy (3.49 ± 4.25 months in youth vs 8.71 ± 12.24 months in elderly) and milder clinical presentations in terms of less proteinuria and higher serum albumin (P < 0.05). Furthermore, lower anti-phospholipase A2 receptor (PLA2R) antibody titre (65.36 ± 101.14 RU/mL in youth vs 137.45 ± 215.12 RU/mL in middle-age), less C3 deposits (35.14% in youth vs 65.00% in elderly) and higher 6-month remission rate (63.64% in youth vs 36.00% in middle-age) were observed in youth (P < 0.05). Multiple linear regression confirmed C3 deposits (P = 0.005) and anti-PLA2R (P = 0.040) were independent factors influencing proteinuria, and age is an independent influencing factor for time from onset to biopsy (P = 0.043). Older age (OR = 2.044, 95% CI: 1.073-3.896, P = 0.030) and higher anti-PLA2R (OR = 1.413, 95% CI: 1.020-1.959, P = 0.038) were significantly associated with non-remission by 6 months. CONCLUSION Younger patients with IMN tend to have rapider onset and quicker remission than older patients. Milder clinical presentations in youth are associated with lower anti-PLA2R antibody titre and less C3 deposits.
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Affiliation(s)
- Chu Lin
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Danxia Zheng
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Yue Wang
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Song Wang
- Department of Nephrology, Peking University Third Hospital, Beijing, China
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Zhang XD, Cui Z, Zhang MF, Wang J, Zhang YM, Qu Z, Wang X, Huang J, Wang F, Meng LQ, Cheng XY, Wang SX, Liu G, Zhao MH. Clinical implications of pathological features of primary membranous nephropathy. BMC Nephrol 2018; 19:215. [PMID: 30153817 PMCID: PMC6114049 DOI: 10.1186/s12882-018-1011-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 08/13/2018] [Indexed: 11/17/2022] Open
Abstract
Background The clinical outcome varies considerably in primary membranous nephropathy (pMN). Risk factors for kidney prognosis include ageing, male gender, persistent heavy proteinuria, decreased eGFR at presentation, persistent elevation of anti-PLA2R antibodies, no remission, and so on. It was controversial whether the histopathological features of pMN could predict treatment response and kidney outcome. Methods A retrospective study was conducted in 371 patients with biopsy-proven pMN. Pathological parameters included immunofluorescence staining, membranous Churg’s stages, sclerosis, crescent, focal segmental sclerosis lesion, chronic and acute tubulointerstitial injury. The fluorescence intensity was determined: 0, negative; 1, weak; 2, moderate; 3, strong; 4, glaring. Chronic tubulointerstitial injury was graded by the involved area: 0, 0–5%; 1, 6–25%; 2, 26–50%; 3, > 50%. Results We found that patients with higher intensity of C3 staining, advanced membranous stage, and more severe chronic tubulointerstitial injury presented with higher positivity rate of anti-PLA2R antibodies, higher levels of urinary protein excretion and serum creatinine, and lower level of serum albumin. Univariate Cox regression analysis showed that severe (grade = 3) chronic tubulointerstitial injury was a risk factor to the kidney outcome of ESKD (HR = 61.02, 95%CI, 7.75–480.57, P < 0.001) and over 50% reduction of eGFR (HR = 4.43, 95%CI, 1.26–15.6, P = 0.021). Multivariate analysis demonstrated it as an independent risk factor to ESKD (HR = 25.77, 95% CI, 1.27–523.91, P = 0.035). None of the pathological parameters exerted any influence on treatment response (P > 0.05). Conclusions We found the prognostic role of chronic tubulointerstitial injury to the kidney outcome of pMN. This study highlighted the value of kidney biopsy under the widespread usage of anti-PLA2R antibodies for diagnosis and prognosis. Electronic supplementary material The online version of this article (10.1186/s12882-018-1011-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiao-Dan Zhang
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Zhao Cui
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.
| | - Mu-Fan Zhang
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Jia Wang
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Yi-Miao Zhang
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Zhen Qu
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Xin Wang
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Jing Huang
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Fang Wang
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Li-Qiang Meng
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Xu-Yang Cheng
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Su-Xia Wang
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, People's Republic of China
| | - Gang Liu
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China
| | - Ming-Hui Zhao
- Renal Division, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Peking University First Hospital, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Peking-Tsinghua Center for Life Sciences, Beijing, 100871, PR, China
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Zhang D, Zou J, Zhang C, Zhang W, Lin F, Jiang G. Clinical and Histological Features of Phospholipase A2 Receptor-Associated and Thrombospondin Type-I Domain-containing 7A-Associated Idiopathic Membranous Nephropathy: A Single Center Retrospective Study from China. Med Sci Monit 2018; 24:5076-5083. [PMID: 30032157 PMCID: PMC6067031 DOI: 10.12659/msm.909815] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background M-type phospholipase A2 receptor (PLA2R) was identified as the major target antigen in idiopathic membranous nephropathy (IMN). Another target antigen, namely thrombospondin type-1 domain-containing 7A (THSD7A), was recently detected in approximately 10% of non-PLA2R-associated IMN. In this single center retrospective study, clinical and histological features of PLA2R-associated and THSD7A-associated IMN patients were evaluated. Material/Methods A total of 192 IMN patients, who were receiving no glucocorticoids or immunosuppressant before renal biopsy, were enrolled in this study and followed for a median duration of 25.5 months. IMN with enhanced glomerular PLA2R and THSD7A staining by immunohistochemistry (IHC) were designated as PLA2R-associated IMN and THSD7A-associated IMN respectively. Serum anti-PLA2R and anti-THSD7A antibodies levels were assessed by enzyme linked immunosorbent assay and indirect immunofluorescence testing in PLA2R-associated and THSD7A-associated IMN. Results Of 192 IMN patients, 164 patients (85.4%) had PLA2R-associated IMN and 3 patients (1.6%) had THSD7A-associated IMN. Compared with non-PLA2R-associated IMN patients, the 24-hour urinary protein levels were significantly higher (P=0.008), whereas, the proteinuria remission rates were significantly lower (P=0.03) in PLA2R-associated IMN patients. No pathological differences were found between PLA2R-associated IMN and non-PLA2R-associated IMN. Among 3 THSD7A-associated IMN patients, 1 patient had elevated serum anti-THSD7A antibody levels, which was below detectable levels after achieving partial proteinuria remission with combined glucocorticoid and cyclosporine treatment. Conclusions Compared with non-PLA2R-associated IMN patients in our cohort, PLA2R-associated IMN patients presented with more severe proteinuria and lower remission rates after treatment, with no distinct histological differences. Glomerular expression of PLA2R could be a useful marker to indicate the severity, treatment response, and prognosis of IMN.
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Affiliation(s)
- Dan Zhang
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Jun Zou
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Chong Zhang
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Wenzhu Zhang
- Department of Pathology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Fujun Lin
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
| | - Gengru Jiang
- Department of Nephrology, Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China (mainland)
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Shang SL, Cai GY, Duan SW, Li P, Li QG, Chen XM. Retrospective analysis of tacrolimus combined with Tripterygium wilfordii polyglycoside for treating idiopathic membranous nephropathy. BMC Nephrol 2018; 19:182. [PMID: 30021637 PMCID: PMC6052665 DOI: 10.1186/s12882-018-0967-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 06/26/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) is one of the most common adult nephrotic syndromes. Some patients with this disorder require immunosuppressive therapy. This retrospective case series was performed to assess the effects of tacrolimus (TAC) combined with Tripterygium wilfordii polyglycoside (TWG) in treating IMN. METHODS From January 2015 to August 2016, kidney-biopsy-proven IMN patients treated with TAC in the Chinese PLA General Hospital were screened. Data were retrieved from the patients' medical records. The first efficacy evaluation index was remission rate (complete remission and partial remission), and the secondary efficacy evaluation indices included relapse rate, proteinuria, serum albumin and estimated glomerular filtration rate (eGFR). Adverse events were also assessed. RESULTS The included patients' treatments were tacrolimus monotherapy (TAC group, n = 33), tacrolimus combined with methylprednisolone (MP) (TAC + MP group, n = 24) and tacrolimus combined with Tripterygium wilfordii polyglycoside (TAC + TWG group, n = 21). The remission rates of the TAC, TAC + MP, and TAC + TWG groups in the 10th month were 54.5, 62.5, and 85.7%, respectively (TAC + TWG group vs TAC group, P = 0.037, TAC + TWG group vs TAC + MP group, P = 0.125). Moreover, the complete remission rates of the TAC, TAC + MP, and TAC + TWG groups in the 10th month were 21.2, 20.8, and 57.1%, respectively (TAC + TWG group vs TAC group, P = 0.007, TAC + TWG group vs TAC + MP group, P = 0.012). Compared with the TAC group, the TAC + TWG group had a higher remission rate during these ten months (log-rank, P = 0.005). Compared with the TAC and TAC + MP groups, the TAC + TWG group had a higher complete remission rate (log-rank, P = 0.019 and log-rank, P = 0.005, respectively). CONCLUSION This retrospective study showed that TAC combined with TWG may be effective for treating IMN. Further randomized controlled trials (RCTs) are needed to assess the efficacy and safety of TAC combined with TWG.
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Affiliation(s)
- Shun-Lai Shang
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Guang-Yan Cai
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Shu-Wei Duan
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Ping Li
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China
| | - Qing-Gang Li
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
| | - Xiang-Mei Chen
- Department of Nephrology, Medical School of Chinese PLA, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853, China.
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Dobronravov VA, Mayer DA, Berezhnaya OV, Lapin SV, Mazing AV, Sipovsky VG, Smirnov AV. [Membranous nephropathy in a Russian population]. TERAPEVT ARKH 2017; 89:21-29. [PMID: 28745685 DOI: 10.17116/terarkh201789621-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To analyze the clinical and morphological manifestations of membranous nephropathy (MN) and to evaluate the efficiency of its therapy. MATERIAL AND METHODS MN cases in 2009 to 2016 were retrospectively detected with a subsequent analysis of patients with primary MN (PMN). The titer of IgG-autoantibodies to phospholipase A2 receptor (anti-PLA2R Ab) was determined by an indirect immunofluorescence assay. Treatment outcomes, such as the time course of changes in proteinuria, nephrotic syndrome (NS), and the development of complete and partial remissions (CR and PR), were assessed. RESULTS MN was detected in 201 cases; the secondary etiology of the disease was established in 24.9%. The prevalence of MN among morphologically confirmed glomerulopathies was 14%; that of PMN was 10.4%. The median period to diagnosis PMN was 8 (5; 19) months. 150 patients with PMN (66.7% were men; age was 50±15 years) were distributed according to the following morphological stages: Stages I (23.9%), II (48.5%), III (26.1%), and IV (1.5%). Elevated anti-PLA2R Ab levels were found in 51.6% of cases; NS in the presence of proteinuria was detected in 85.6% of patients. An estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2 was seen in 25% of cases. Treatment outcomes were evaluated in 80 cases; the median follow-up period was 19 (8; 40) months. 68% of cases had CR (32%) or PR (36%) with a median follow-up of 26 (13; 44) months. Spontaneous CRs or PRs were observed in 7.5% of the patients. Multivariate analysis showed that the probability of CR or PR increased 3.2-fold in the use of cyclophosphamide and/or cyclosporine and decreased as eGFR dropped. CONCLUSION In Russia, PMN is a common type of glomerulopathy, the specific features of which should include the low rates of spontaneous remissions and detection of anti-PLA2R Abs. For renal protection, the majority of patients with PMN require timely diagnosis and treatment; individualization of the choice of treatment and its enhanced efficiency call for further investigations.
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Affiliation(s)
- V A Dobronravov
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - D A Mayer
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - O V Berezhnaya
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - S V Lapin
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - A V Mazing
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - V G Sipovsky
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - A V Smirnov
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
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Cattran D, Brenchley P. Membranous nephropathy: thinking through the therapeutic options. Nephrol Dial Transplant 2017; 32:i22-i29. [PMID: 28391348 DOI: 10.1093/ndt/gfw404] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 10/18/2016] [Indexed: 11/13/2022] Open
Abstract
Idiopathic membranous nephropathy (IMN) remains the most common cause of the nephrotic syndrome in adults and one of the leading identifiable causes of end-stage kidney disease. Prior to considering the best approach to treatment, three important components need to be considered. First, the natural history of the typical membranous patient today; second, the importance of identifying the causative factors; and third, the integration of the current data on the known autoantibody/antigen systems involved in IMN into the diagnosis and management of the patient. Combining this with information on the known indicators associated with a poor prognosis plus new data on surrogate markers that provide important clues that the treatment plan is correct has provided us with a more secure platform for choosing the right treatment for each patient. This already provides a more rational and precise approach to the use of our current therapeutic options. Even today, we can slow disease progression and in the future new approaches and new therapies are likely to lead to prevention of progression or even reversal of the injury in IMN, thereby leading to improved quality of life of our patients.
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Affiliation(s)
- Daniel Cattran
- Department of Nephrology, University of Toronto, Toronto General Hospital, Toronto, Ontario, Cananda
| | - Paul Brenchley
- Department of Renal Medicine, University of Manchester, Manchester, UK
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Roy S, Korula A, Basu G, Jacob S, Varughese S, Tamilarasi V. Immunohistochemical Glomerular Expression of Phospholipase A2 Receptor in Primary and Secondary Membranous Nephropathy: A Retrospective Study in an Indian Cohort with Clinicopathological Correlations. NEPHRON EXTRA 2017; 7:1-9. [PMID: 28413416 PMCID: PMC5346929 DOI: 10.1159/000453675] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 11/17/2016] [Indexed: 11/25/2022]
Abstract
Background Limited published literature exists on the utility and standardization of anti-phospholipase A2 receptor (anti-PLA2R) immunohistochemistry (IHC) for the diagnosis of primary membranous nephropathy (MN). The study aimed to validate anti-PLA2R IHC for the diagnosis of primary MN and clinicopathological correlations in an Indian cohort. Methods Subjects included patients with primary and secondary MN diagnosed between January 2012 and August 2014 with an adequate renal biopsy and at least 1 year of clinical follow-up. Anti-PLA2R IHC was performed in all cases with miscellaneous renal lesions as controls. Electron microscopy was performed in selected cases. Sensitivity and specificity of anti-PLA2R IHC to identify primary MN was evaluated. Histopathological analyses of primary and secondary MN were done with clinicopathological correlations including serum creatinine, eGFR, chronic kidney disease stage, 24-h urine protein, serum cholesterol, serum albumin, and hypertension at presentation and follow-up, using the Kruskal-Wallis test and Spearman rank correlation. A p value of ≤0.05 was considered statistically significant. Results In 153 MN patients (99 primary, 54 secondary) and 37 miscellaneous controls, anti-PLA2R IHC differentiated primary from secondary MN with a sensitivity of 70.2% and a specificity of 96.6%. Secondary MN had increased mesangial matrix expansion compared to primary MN (p = 0.001). Severe nephrotic syndrome, impaired renal function, and hypertension were all more common in primary than in secondary MN. Conclusion Anti-PLA2R IHC is a specific marker to distinguish primary MN from secondary MN.
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Affiliation(s)
- Sanjeet Roy
- Department of Pathology, Christian Medical College, Vellore, India
| | - Anila Korula
- Department of Pathology, Christian Medical College, Vellore, India
| | - Gopal Basu
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Shibu Jacob
- Department of Nephrology, Christian Medical College, Vellore, India
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Gudipati A, Uppin MS, Kalidindi RK, Swarnalatha G, Das U, Taduri G, Raju SB, Rajasekhar L, Prayaga AK. Immunohistochemical Analysis of Anti-phospholipase A2 Receptor Antibody on Renal Biopsies: A Single Tertiary Care Center Study. Indian J Nephrol 2017; 27:353-358. [PMID: 28904430 PMCID: PMC5590411 DOI: 10.4103/ijn.ijn_79_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Membranous nephropathy (MN) is one of the common cause of nephrotic syndrome. The discrimination between primary MN (iMN) and secondary MN is essential because of treatment implications. Immunohistochemical (IHC) evaluation with the help of anti-phospholipase A2 receptor (PLA2R) antibody helps in tissue evaluation of iMN, which is an easy, cost-effective, and pathologist-friendly technique. The study included 82 cases of MN over a period of 3 years. IHC using PLA2R antibody was performed on iMN and secondary cases with adequate tissue. Cases of minimal change disease (MCD) were included as control. Granular staining along the basement membrane in the absence of staining of podocytes was considered positive. Medical records were verified for clinical information, baseline biochemical parameters, details of viral markers, connective tissue disease profile, and basic imaging workup. Of the 82 cases of MN, 51 were iMN and 31 secondary MN (sMN). Thirteen MCD cases were included as control. IHC with PLA2R antibody showed a sensitivity of 91.8% and specificity of 95.1%, positive predictive value of 95.7%, and negative predictive value of 90.7% in the diagnosis of iMN. The other parameters, either clinical or laboratory, did not show significant differences between iMN and sMN groups. The results of PLA2R staining by IHC were comparable with other studies and showed a higher sensitivity (91.8%) and specificity (95.1%). IHC with anti-PLA2R antibody can be considered as the standard diagnostic approach to identify iMN and offer scope for individualized treatment.
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Affiliation(s)
- A Gudipati
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - M S Uppin
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - R K Kalidindi
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - G Swarnalatha
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - U Das
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - G Taduri
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - S B Raju
- Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - L Rajasekhar
- Department of Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Aruna K Prayaga
- Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
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Gu QH, Cui Z, Huang J, Zhang YM, Qu Z, Wang F, Wang X, Wang SX, Liu G, Zhao MH. Patients With Combined Membranous Nephropathy and Focal Segmental Glomerulosclerosis Have Comparable Clinical and Autoantibody Profiles With Primary Membranous Nephropathy: A Retrospective Observational Study. Medicine (Baltimore) 2016; 95:e3786. [PMID: 27227951 PMCID: PMC4902375 DOI: 10.1097/md.0000000000003786] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Patients with combined membranous nephropathy (MN) and focal segmental glomerulosclerosis (FSGS) have been reported with different clinical significance. Investigations on the possible mechanisms of the combined glomerular lesions are necessary but scarce. Twenty patients with both MN and FSGS lesions were enrolled in the study. Sixty-five patients with primary MN and 56 patients with primary FSGS were used as disease controls. Clinical data on renal biopsy and during follow-up were collected. Circulating anti-phospholipase A2 receptor (PLA2R) antibody, glomerular PLA2R expression, IgG4 deposition, and soluble urokinase receptor (suPAR) levels were detected. We found that patients with combined lesions presented with older age, less proteinuria, higher albumin, and better renal function on biopsy. These were comparable to the patients with primary MN, but differed from the patients with primary FSGS. Patients with combined lesions showed higher stages of MN, no cellular variant on FSGS classification, and more common (100.0%) tubulointerstitial injury than both primary MN and primary FSGS patients. In the patients with combined lesions, 80.0% had circulating anti-PLA2R antibody and 68.4% had IgG4 predominant deposition in glomeruli, which were comparable to primary MN. The patients with combined lesions had significantly lower urinary suPAR concentrations, than the primary FSGS patients (315.6 ± 151.0 vs 752.1 ± 633.9 pg/μmol; P = 0.002), but similar to the primary MN patients (267.9 ± 147.5 pg/μmol). We conclude that patients with combined MN and FSGS may share the same underlying pathogenesis with primary MN. The FSGS lesion might be secondary to primary MN.
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Affiliation(s)
- Qiu-Hua Gu
- From the Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China (Q-hG, ZC, JH, Y-MZ, ZQ, FW, XW, GL, M-hZ); Electron Microscopy Laboratory, Peking University First Hospital (S-xW); and Peking-Tsinghua Center for Life Sciences, Beijing, China (M-hZ)
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Zhang BO, Cheng M, Yang M, Han S, Zhang YH, Shi HG, Zhu L, Zhao XZ. Analysis of the prognostic risk factors of idiopathic membranous nephropathy using a new surrogate end-point. Biomed Rep 2015; 4:147-152. [PMID: 26893829 PMCID: PMC4734144 DOI: 10.3892/br.2015.555] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 12/04/2015] [Indexed: 01/13/2023] Open
Abstract
Idiopathic membranous nephropathy (IMN) is one of the most common causes of nephrotic syndrome (NS) in adults. The latest study of the chronic kidney disease-prognosis consortium showed that a 30% decrease in the estimated glomerular filtration rate (eGFR) within 2 years could cover more patients and showed a better correlation with end-stage renal disease (ESRD), as compared with serum creatinine (SCr). The aim of the present study was to analyze prognostic factors of ESRD using a 30% decrease in eGFR within 2 years as the end-point. The medical records of patients who were diagnosed as having IMN by clinical pathology between February 2011 and August 2012 and had been followed up for ≥24 months were analyzed retrospectively. A 30% decrease in eGFR or the occurrence of ESRD were the end-points. Factors affecting the prognosis were analyzed by the χ2 test and multivariate logistic regression analysis, and the cumulative risk of risk factors was analyzed by Kaplan-Meier curve. A total of 73 patients with IMN were confirmed by clinical pathology. Blood pressure, tubulointerstitial injury area (TIA), glomerular sclerosis ratio, SCr, blood urea nitrogen, cystatin C, serum albumin and 24-h urine protein. In total, 28 patients (38.4%) reached the observation end-point. Multivariate logistic regression analysis showed that only age ≥60 years, serum albumin <25 g/l and TIA >25% were independent risk factors for predicting the occurrence of end-point events in the two groups (P<0.05), which increased the risk of the occurrence of end-point events in IMN patients by 3.471-, 3.195- and 6.724-fold, respectively. Kaplan-Meier curve showed that the occurrence of end-point events within 2 years was significantly higher in IMN patients whose age was ≥60 years, serum albumin <25 g/l and TIA >25% (log-rank P=0.004, P=0.024 and P=0.001). The results of the present study revealed that age ≥60 years, low serum albumin concentrations and severe tubulointerstitial injury are independent risk factors for the occurrence of ESRD in IMN patients.
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Affiliation(s)
- B O Zhang
- Department of Gastroenterology, Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003, P.R. China
| | - Ming Cheng
- Department of Nephrology, Changzheng Hospital Affiliated to the Second Military Medical University and the Kidney Institute of CPLA, Shanghai 200003, P.R. China
| | - Ming Yang
- Department of Nephrology, Changzheng Hospital Affiliated to the Second Military Medical University and the Kidney Institute of CPLA, Shanghai 200003, P.R. China
| | - Shuai Han
- Department of Osteology, Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003, P.R. China
| | - Ying-Hui Zhang
- Department of Nephrology, Changzheng Hospital Affiliated to the Second Military Medical University and the Kidney Institute of CPLA, Shanghai 200003, P.R. China
| | - Hong-Guang Shi
- Department of Nephrology, No. 401 Hospital of CPLA, Shandong 266000, P.R. China
| | - Liang Zhu
- Department of Gastroenterology, Changzheng Hospital Affiliated to the Second Military Medical University, Shanghai 200003, P.R. China
| | - Xue-Zhi Zhao
- Department of Nephrology, Changzheng Hospital Affiliated to the Second Military Medical University and the Kidney Institute of CPLA, Shanghai 200003, P.R. China
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Glomerular endothelial cell injury and focal segmental glomerulosclerosis lesion in idiopathic membranous nephropathy. PLoS One 2015; 10:e0116700. [PMID: 25875837 PMCID: PMC4398543 DOI: 10.1371/journal.pone.0116700] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 12/12/2014] [Indexed: 11/19/2022] Open
Abstract
Background Focal segmental glomerulosclerosis (FSGS) lesions have often been discussed as a negative predictor in idopathic membranous nephropathy (MN). The mechanism of the development of FSGS lesion in MN is still uncertain. Methods From 250 cases of MN, 26 cases contained FSGS lesion. We compared the clinicopathological characteristics between MN cases with FSGS lesion [MN-FSGS(+)] and MN without FSGS lesion [MN-FSGS(−)], matched for gender, age, stage of MN. Results The glomerular filtration rate (eGFR) was significantly lower in MN-FSGS(+) cases compared to MN-FSGS(−), although nephrotic syndrome, hematuria, and systolic blood pressure levels were not significantly different between the two groups. Pathologically, glomeruli in MN-FSGS(+) cases showed narrowing and loss of glomerular capillaries with separating from GBM or disappearance of CD34+ endothelial cells, and accumulation of extracellular matrix (ECM) in capillary walls, indicating the development of glomerular capillary injury. These findings of endothelial injury were seen even in MN-FSGS(−) cases, but they were more prominent in MN-FSGS(+) than MN-FSGS(−) by computer assessed morphometric analysis. In MN-FSGS(+) cases, 44 out of 534 glomeruli (8.2%) contained FSGS lesions (n = 31, NOS lesion; n = 13, perihilar lesion). Significant thickness of GBM with ECM accumulation was evident in MN-FSGS(+) cases. Podocyte injury with effacement of foot processes was also noted, but the expression of VEGF on podocytes was not different between the two groups, which suggests that the significant thickness of capillary walls may influence the function of VEGF from podocyte resulting in the glomerular capillary injury that contribute to the development of FSGS lesion in MN. Conclusion Glomerular capillary injury was seen in all MN cases. Furthermore, the prominent injuries of glomerular capillaries may be associated with the deterioration of eGFR and the formation of FSGS lesions in MN.
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Urokinase gene 3'-UTR T/C polymorphism is associated with malignancy and ESRD in idiopathic membranous nephropathy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:425095. [PMID: 24822208 PMCID: PMC4009112 DOI: 10.1155/2014/425095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 03/23/2014] [Accepted: 03/24/2014] [Indexed: 11/17/2022]
Abstract
Idiopathic membranous nephropathy (MN) is one of the most common causes of nephrotic syndrome in adults, and 25% of MN patients proceed to ESRD. Urokinase plasminogen activator (uPA) may play an important role in reducing renal fibrosis. This study was conducted to clarify the relationship between uPA gene polymorphisms and clinical manifestations of MN. We recruited 91 biopsy-diagnosed MN patients and 105 healthy subjects. Genotyping of uPA gene 3'-UTR T/C polymorphism was performed by polymerase chain reaction methods. The genotype distribution had no effect on the development of MN. Thirteen patients (15.9%; P = 0.008) acquired malignancies and seventeen (20.7%; P = 0.006) patients progressed to ESRD with the C/C genotype, but no patients with the T/C genotype did. In conclusion, we demonstrated that the presence of the uPA gene 3'-UTR C/C genotype was associated with ESRD as well as acquired malignancies in MN patients. These findings should prompt specific considerations for the treatment of MN patients to maintain a balance between treating disease entities and protecting the immune system from cancers.
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Chen Y, Tang L, Feng Z, Cao X, Sun X, Liu M, Liu S, Zhang X, Li P, Wei R, Qiu Q, Cai G, Chen X. Pathological predictors of renal outcomes in nephrotic idiopathic membranous nephropathy with decreased renal function. J Nephrol 2014; 27:307-16. [PMID: 24523071 DOI: 10.1007/s40620-014-0057-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 12/05/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES The outcome of idiopathic membranous nephropathy (IMN) in adults with nephrotic-range proteinuria and decreased renal function has seldom been described and the predictive value of pathological features is debated. This study aimed to describe the clinical course of this patient subgroup and to identify independently predictive pathological features. MATERIALS AND METHODS We evaluated 129 adults with biopsy-proven IMN diagnosed from 2002 to 2011. All patients had chronic kidney disease (CKD) stages 2-4 and nephrotic-range proteinuria (≥3.5 g/day). Primary outcomes were a 20 or 50 % decline in renal function, progression to end-stage renal disease (ESRD), or all-cause mortality. RESULTS Of 129 patients, 38 (30 %) presented with proteinuria ≥8.0 g/day and 37 (29 %) with CKD stages 3-4. Thirteen (10 %) presented with segmental sclerosis, 97 (75 %) with arteriosclerosis, 42 (33 %) with moderate-to-severe tubulointerstitial injury, and 86 (67 %) with C3 deposition. Over a median follow-up of 34 months (range 12-135), 51 patients (40 %) had a 20 % decline in renal function, 27 (21 %) a 50 % decline, 14 (11 %) developed ESRD, and 19 (15 %) died. Segmental sclerosis and tubulointerstitial injury but not arteriosclerosis or C3 deposition were independent risk factors for 20 and 50 % renal function decline and progression to ESRD. CONCLUSIONS Segmental sclerosis and tubulointerstitial injury predict renal outcomes independent of clinical data in nephrotic IMN patients with decreased renal function.
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Affiliation(s)
- Yizhi Chen
- Division of Nephrology, State Key Discipline of Internal Medicine (Nephrology), State Key Laboratory of Kidney Disease (2011DAV00088), National Clinical Medical Research Center for Kidney Disease (2013BAI09B05), Medical Quality Control Center for Kidney Disease, Chinese People's Liberation Army (PLA) General Hospital (301 Hospital), Chinese PLA Medical Academy, 28 Fuxing Road, Haidian District, Beijing, 100853, People's Republic of China
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Wickman L, Afshinnia F, Wang SQ, Yang Y, Wang F, Chowdhury M, Graham D, Hawkins J, Nishizono R, Tanzer M, Wiggins J, Escobar GA, Rovin B, Song P, Gipson D, Kershaw D, Wiggins RC. Urine podocyte mRNAs, proteinuria, and progression in human glomerular diseases. J Am Soc Nephrol 2013; 24:2081-95. [PMID: 24052633 DOI: 10.1681/asn.2013020173] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Model systems demonstrate that progression to ESRD is driven by progressive podocyte depletion (the podocyte depletion hypothesis) and can be noninvasively monitored through measurement of urine pellet podocyte mRNAs. To test these concepts in humans, we analyzed urine pellet mRNAs from 358 adult and pediatric kidney clinic patients and 291 controls (n=1143 samples). Compared with controls, urine podocyte mRNAs increased 79-fold (P<0.001) in patients with biopsy-proven glomerular disease and a 50% decrease in kidney function or progression to ESRD. An independent cohort of patients with Alport syndrome had a 23-fold increase in urinary podocyte mRNAs (P<0.001 compared with controls). Urinary podocyte mRNAs increased during active disease but returned to baseline on disease remission. Furthermore, urine podocyte mRNAs increased in all categories of glomerular disease evaluated, but levels ranged from high to normal, consistent with individual patient variability in the risk for progression. In contrast, urine podocyte mRNAs did not increase in polycystic kidney disease. The association between proteinuria and podocyturia varied markedly by glomerular disease type: a high correlation in minimal-change disease and a low correlation in membranous nephropathy. These data support the podocyte depletion hypothesis as the mechanism driving progression in all human glomerular diseases, suggest that urine pellet podocyte mRNAs could be useful for monitoring risk for progression and response to treatment, and provide novel insights into glomerular disease pathophysiology.
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