Long-term risk of cancer in membranous nephropathy patients

Neural epidermal growth factor-like 1 protein (NELL1)-associated membranous nephropathy with heterogeneous underlying diseases: a case report

Neural epidermal growth factor-like 1 protein (NELL1) is a target antigen of membranous nephropathy (MN). NELL1-associated MN (NELL1-MN) was originally described as a primary form but has subsequently been associated with other diseases, including malignancies, pre-exposure to certain drugs, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, and rheumatoid arthritis (RA). We present a case of a 78-year-old woman with long-standing RA who developed persistent proteinuria and was diagnosed with MN. Evaluation of the underlying cause revealed chronic active HCV infection and past HBV infection. The underlying cause was less likely to be drug-related; however, there was no evidence of malignancy. The patient was diagnosed with HCV-associated MN. At 4 years after the diagnosis of MN, the patient died of breast cancer with multiple metastases. Subsequent immunohistological analysis revealed that she had NELL1-MN, and her breast cancer tissue stained positive for NELL1. Our case illustrates the difficulty in establishing the underlying cause of NELL1-MN, even after diagnosis. However, the incidence of malignancies, particularly breast and prostate cancers, is higher in NELL1-MN than in MN with other target antigens. Therefore, malignancies are considered a priority for investigation because of their frequency and prognosis among patients with NELL1-MN.

Genetic association between membranous nephropathy and malignancies: a two-sample Mendelian randomisation study

BACKGROUND

Various studies have reported that individuals with membranous nephropathy (MN) exhibit an elevated susceptibility to cancers. However, a causal relationship has not been clearly established.

METHODS

We constructed a genetic score that predicts MN by utilizing genetic variants linked to this condition as instrumental variables. These genetic scores were then compared with lung, colon, breast, and prostate cancer risks by a two-sample Mendelian randomisation analysis involving the following methods: MR-Egger, weighted median, inverse variance weighted, simple mode, and weighted mode.

RESULTS

This study demonstrated a lack of empirical substantiation for a causal association between genetic variants in MN and the susceptibility to lung, colon, prostate, or breast cancer.

CONCLUSION

Overall, we did not detect a causal link between MN and lung, colon, breast, or prostate cancer. Hence, additional research is imperative to elucidate the underlying factors contributing to the heightened occurrence of tumour in patients with MN.

Malignancy-associated membranous nephropathy: focus on diagnosis and treatment

BACKGROUND

The clinicopathological features of malignancy-associated membranous nephropathy have been described previously, but information about diagnosis and treatment remains limited.

METHODS

Patients with malignancy-associated membranous nephropathy in a tertiary hospital in China between June 2012 and October 2021 were retrospectively reviewed.

RESULTS

Forty-two patients with malignancy-associated membranous nephropathy were identified. Compared to patients with idiopathic membranous nephropathy, patients with malignancy-associated membranous nephropathy were older and less frequently showed glomerular phospholipase A2 receptor staining (37.9% vs 85.0%) and IgG4 predominant deposition (66.7% vs 95.0%). At diagnosis of membranous nephropathy, the malignancy was unknown in 67% (28/42) of patients and was detected only by tumor screening. Among the 19 patients with concurrent diagnosis of cancer and biopsy-proven membranous nephropathy, 15 received anticancer treatment alone initially. Six of the 10 patients who attained cancer remission achieved remission of membranous nephropathy, while none of the 5 patients without remission of cancer did, suggesting a causal relationship between the two diseases. Some patients with persistent or relapsing membranous nephropathy following cancer remission achieved remission of membranous nephropathy after immunosuppressive therapy. Over a median follow-up of 24 months, 25% (10/40) of patients died, mainly due to neoplasia.

CONCLUSIONS

Tumor screening is important in patients with membranous nephropathy, especially in elderly patients and patients with negative phospholipase A2 receptor or non-IgG4 predominant deposition. Remission of membranous nephropathy can be observed following remission of cancer in some cases. Immunosuppressive therapy may be considered if membranous nephropathy does not remit after remission of cancer.

Pulmonary cryptococcosis closely mimicking lung cancer in a membranous nephropathy patient taking calcineurin inhibitor

In patients with membranous nephropathy (MN), malignancy may be either the underlying disease or results of immunosuppressive therapy which may also lead to opportunistic infections including the pulmonary cryptococcosis. On CT scan, nodule is the most common feature in pulmonary cryptococcosis and it can mimic lung cancer both clinically and radiologically. Therefore, pulmonary nodular lesions caused by cryptococcosis may be easily misdiagnosed and require unnecessary surgical treatment. As such, we herein presented an isolated subpleural solitary nodule with satellite lesion that closely mimicked lung cancer on both contrast-enhanced computed tomography (CT) scan and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET)/CT in an MN patient under long-term tacrolimus regimen. Cryptococcosis was ascertained by the finding of oval thick-walled yeast on histopathology of the lung biopsy specimen taken during the Argon-Helium cryotherapy. Further, the pulmonary lesions progressively dissipated after antifungal treatment. Arguably, our experience may help clinicians in general and nephrologists in particular with a better understanding of the cryptococcal infection manifesting as pulmonary nodule(s) in the MN patients and contribute to more efficacious differential diagnosis against the lung cancer.

Paraneoplastic autoimmune Laminin-332 syndrome (PALS): Anti-Laminin-332 mucous membrane pemphigoid as a prototype

IMPORTANCE

Laminin-332 is an important component of the basement membrane. Recently, autoantibodies to Laminin-332 have been described in several autoimmune diseases. Many of these autoimmune diseases have a high incidence of malignancy. The importance of Laminin-332 autoantibodies and its relationship to malignancy is highlighted by using Laminin-332 Pemphigoid (LM-332Pg) as a prototype.

OBJECTIVE

To identify several autoimmune diseases that have autoantibodies to Laminin-332 present, and to determine the prevalence of malignancy in them. Using Laminin-332 Pemphigoid (LM-332Pg) as a prototype, to compare clinical profiles of LM-332Pg patients with and without cancer. By identifying the temporal detection of cancer, can the influence of autoantibodies to Laminin-332 on prognosis be determined.

EVIDENCE REVIEW

A literature search was conducted to identify autoimmune and inflammatory diseases in which autoantibodies to Laminin-332 were present. Subsequently, the rate of malignancy in these autoimmune diseases was determined. A search for publications on LM-332Pg patients to determine cancer rates and clinical outcomes to examine if a relationship can be proposed, was performed.

FINDINGS

Autoantibodies to Laminin-332 were detected in recent studies of systemic lupus erythematosus (SLE), psoriasis, bronchiolitis obliterans (BO), graft-vs-host disease (GVH), bullous pemphigoid (BP), lichen planus (LP), epidermolysis bullosa acquisita (EBA), and membranous glomerulonephropathy (MGN). A high incidence of cancer rate was reported in these autoimmune diseases including primary Sjögren's syndrome (pSS), systemic sclerosis (SS), dermatomyositis (DM), multiple sclerosis (MS), immune thrombocytopenia purpura (ITP), and rheumatoid arthritis (RA). Data analysis demonstrated that LM-332Pg patients had a higher risk of developing ovarian, uterine, lung, gastric cancers and leukemia. The incidence for breast cancer was lower, when compared with global cancer rates. Patients diagnosed with cancer after the presence of LM-332Pg had higher rates of mortality and lower rates of remission, compared to those diagnosed with cancer prior to the discovery/diagnosis of LM-332Pg. When studied, levels of Laminin-332 autoantibodies correlated with the presence or absence of malignancy.

CONCLUSIONS AND RELEVANCE

Preliminary analysis suggests that autoantibodies to Laminin-332 are present in multiple autoimmune diseases, which also have a high incidence of malignancy. Detailed analysis of available data highlights that patients who developed LM-332Pg after cancer was diagnosed, had a more favorable prognosis, compared to patients who developed cancer when LM-332Pg was previously present. Preliminary data would suggest that autoantibodies to Laminin-332 could serve as an important biomarker in certain patients, for correlation with possible incidence of malignancy.

Two-sample mendelian randomization reveals a causal association between membranous nephropathy and lung cancer

A risk association between membranous nephropathy (MN) and lung cancer is reported, but traditional observational studies cannot provide strong evidence of its causality. This study aimed to assess genome-wide association studies data for a causal relationship between MN and lung cancer using a two-sample Mendelian randomization (MR) approach. Inverse-variance weighted, and MR Egger regression techniques were used to determine the association of genetic variants from cohorts of MN and lung cancer patients. Independent genetic variants with genome-wide significance (P < 5×10-8) were used to determine the direction of chance. Sensitivity analyses confirmed the accuracy of the results. The results suggest that MN is an exposure factor for lung cancer, validated using a second cohort of lung cancer patients (P < 0.001). There is insufficient evidence to suggest a causal relationship between lung cancer and MN; however, cigarette smoking may be a confounding factor for lung cancer due to MN. The findings provide causal evidence for the effect of MN on lung cancer risk and may be useful for patient management, especially in older patients with MN who should be systematically screened regularly.

The Onco-Nephrology Field: The Role of Personalized Chemotherapy to Prevent Kidney Damage

In recent years, the onco-nephrology field has acquired a relevant role in internal medicine due to the growing number of cases of renal dysfunction that have been observed in cancer patients. This clinical complication can be induced by the tumor itself (for example, due to obstructive phenomena affecting the excretory tract or by neoplastic dissemination) or by chemotherapy, as it is potentially nephrotoxic. Kidney damage can manifest as acute kidney injury or represent a worsening of pre-existing chronic kidney disease. In cancer patients, physicians should try to set preventive strategies to safeguard the renal function, avoiding the concomitant use of nephrotoxic drugs, personalizing the dose of chemotherapy according to the glomerular filtration rate (GFR) and using an appropriate hydration therapy in combination with nephroprotective compounds. To prevent renal dysfunction, a new possible tool useful in the field of onco-nephrology would be the development of a personalized algorithm for the patient based on body composition parameters, gender, nutritional status, GFR and genetic polymorphisms.

IDA-MIL: Classification of Glomerular with Spike-like Projections via Multiple Instance Learning with Instance-level Data Augmentation

BACKGROUND AND OBJECTIVE

Tiny spike-like projections on the basement membrane of glomeruli are the main pathological feature of membranous nephropathy at stage II (MN II), which is the most significant stage for the diagnosis and treatment of renal disease. Pathological technology is the gold standard in the diagnosis of spike-like and other MNs, and automatic classification of spike-like projection is a crucial step in assisting pathologists in their diagnosis. However, owing to hard-to-label spile-like projections and the scarcity of patient data, classification of glomeruli with spike-like projections based on supervised learning methods is a challenging task.

METHOD

To overcome the aforementioned problems, the idea of integrating weakly-supervised learning and data augmentation methods is utilized in designing the classification framework. Specifically, a multiple instance learning with instance-level data augmentation (IDA-MIL) method for the classification of glomeruli with spike-like projections is established in this paper. The proposed classification framework first trains the MIL model on a dataset with image-level labels, and the well-trained MIL model is used to extract instances that include spike-like projections in the whole glomerular image. Then, rather than using an image-level generative adversarial network (ImgGAN), an instance-level generative adversarial network (InsGAN) based on the StyleGAN2-ADA model is trained on the spike-like instances obtained by the MIL model and synthesizes new spike-like projection instances. Finally, the synthesized spike-like instances are extended to the training dataset to further improve the classification performance of MIL.

RESULTS

The designed IDA-MIL model is verified and evaluated from two aspects based on the in-house dataset. On the one hand, the performance comparisons between InsGAN and ImgGAN on five metrics, which involve FID, KID, Precision, Recall and IS, show that InsGAN obtains a better score and can synthesize effective spike-like projections. However, the proposed IDA-MIL model achieves the best classification performance with an accuracy of 0.9405. Then, to make nephrologists believe the inference result of the proposed model, we use heatmap technology to visualize the basis of the model inferences and show the top 4 probability spike-like instances per glomerulus. Furthermore, we analyze the correlation between the disease and the proportion of spike-like instances in bags from historical cases.

CONCLUSION

Compared with the ImgGAN, the InsGAN can synthesize natural and varied spike-like projections, which results in the classification performance of the MIL model achieving great improvement by adding synthesized instance samples into the training dataset. The heatmap of spike-like inferences and the proportion of spike-like instances can help nephrologists to make a preliminary reliable diagnosis in clinical practice. This work provides a valuable reference for medical image classification with limited data and small-scale lesions based on deep learning.

Lung cancer patients with nephropathy as the first manifestation: Literature review and clinical study report

Background

To investigate the relationship between membranous nephropathy (MN) and lung cancer.

Methods

To report patients with lung cancer detected by follow-up after the diagnosis of MN by renal biopsy in China-Japan Friendship Hospital from January 2010 to December 2019, and to study the prognosis of lung cancer-associated MN and have a review of the literature.

Results

Lung cancer was detected in six patients followed for 1–27 months (median 8 months) after the diagnosis of MN: including four cases of lung adenocarcinoma, one case of carcinoma in situ, and one case of small cell lung cancer with multiple metastases. Five cases were in remission after surgical resection, and one case was remitted after chemotherapy. Six patients were negative for serum anti-PLA2R antibodies, and glomerular IgG subclass deposition detected by immunofluorescence was positive for IgG1 and IgG2. Glomerular PLA2R, THSD7A, and NELL-1 stainings were assessed in all six patients; one patient was positive for glomerular PLA2R staining, two patients were positive for glomerular THSD7A staining, and all patients were negative for NELL-1 staining. A literature review of the relationship between MN and lung cancer was performed: seven articles about cancer-associated MN were searched, reporting 32 cases of MN associated with lung cancer, among which 14 cases had nephropathy as the first manifestation and only five patients had remission of MN after treatment of lung cancer.

Conclusions

A few lung cancer patients have nephropathy as the first clinical manifestation, and MN can also be remitted after treatment of lung cancer.

Construction of a Nomogram Discriminating Malignancy-Associated Membranous Nephropathy From Idiopathic Membranous Nephropathy: A Retrospective Study

Background

Based on the etiology, membranous nephropathy (MN) can be categorized into idiopathic membranous nephropathy (IMN) and secondary membranous nephropathy. Malignancy-associated membranous nephropathy (MMN) is a common type of secondary MN. Its incidence is only second to that of lupus nephritis. As the treatment and prognosis of MMN differ significantly from those of other MNs, the identification of MMN is crucial for clinical practice. The purpose of this study was to develop a model that could efficiently discriminate MMN, to guide more precise selection of therapeutic strategies.

Methods

A total of 385 with IMN and 62 patients with MMN, who were hospitalized at the First Affiliated Hospital of Zhengzhou University between January 2017 and December 2020 were included in this study. We constructed a discriminant model based on demographic information and laboratory parameters for distinguishing MMN and IMN. To avoid an increased false positivity rate resulting from the large difference in sample numbers between the two groups, we matched MMN and IMN in a 1:3 ratio according to gender. Regression analysis was subsequently performed and a discriminant model was constructed. The calibration ability and clinical utility of the model were assessed via calibration curve and decision curve analysis.

Results

We constructed a discriminant model based on age, CD4⁺ T cell counts, levels of cystatin C, albumin, free triiodothyronine and body mass index, with a diagnostic power of 0.860 and 0.870 in the training and test groups, respectively. The model was validated to demonstrate good calibration capability and clinical utility.

Conclusion

In clinical practice, patients demonstrating higher scores after screening with this model should be carefully monitored for the presence of tumors in order to improve their outcome.

Critical evaluation of cancer risks in glomerular disease

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The increased cancer incidence in patients with glomerular disease can be secondary to an intrinsic immune dysfunction associated with the disease or/and extrinsic factors, especially immunosuppressants.

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Paraneoplastic glomerulopathy is sometimes misdiagnosed as primary glomerulopathy.

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The treatment for paraneoplastic glomerulopathy is different from primary glomerular disease.

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In membranous nephropathy, serum circulating autoantibodies against PLA2R and THSD7A, immunohistochemical tissue markers for glomerular PLA2R, THSD7A and specific types of immunoglobulin G (IgG) may be used for identifying underlying malignancies.

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A scheme of screening of cancers frequently reported in the setting of glomerular disease is important.

The increased cancer incidence in patients with glomerular disease can be secondary to an intrinsic immune dysfunction associated with the disease or/and extrinsic factors, especially immunosuppressants. The treatment for paraneoplastic glomerulopathy is different from primary glomerular disease. Immunosuppressive therapy often used for primary glomerulopathy may aggravate concomitant cancers in patients with paraneoplastic glomerulopathy. In membranous nephropathy (MN), measurement of serum circulating autoantibodies against podocyte transmembrane glycoprotein M-type phospholipase A2 receptor (PLA2R) and thrombospondin type 1 domain-containing 7A (THSD7A), immunohistochemical staining of kidney tissue for glomerular PLA2R, THSD7A, neural epidermal growth factor-like 1 protein (NELL-1) and specific types of immunoglobulin G (IgG) may be useful adjuncts when screening for underlying malignancies. This review addresses overall cancer risks in individuals with glomerular diseases and employment of biomarkers available for MN. We propose a scheme of screening of cancers frequently reported in the setting of glomerular disease.

Prevalence of neural epidermal growth factor-like 1- and exostosin 1/exostosin 2-associated membranous nephropathy: a single-center retrospective study in Japan

Membranous nephropathy (MN) is the leading cause of nephrotic syndrome in adults. We previously reported that the prevalence of phospholipase A2 receptor (PLA2R)- and thrombospondin type 1 domain containing 7A (THSD7A)-associated MN patients in Japan is 52.7% and 9.1%, respectively. In addition to PLA2R and THSD7A, we assessed the presence of newly discovered target antigens, neural epidermal growth factor-like 1 (NELL-1), semaphorin 3B (SEMA3B), and exostosin 1/exostosin 2 (Ext1/Ext2), in renal specimens from patients with primary and secondary MN by immunohistochemistry. We found enhanced glomerular staining of PLA2R, THSD7A, NELL-1, and Ext1/Ext2 in 53.6%, 8.7%, 1.5%, and 13.0% of the renal samples, respectively, in patients with primary MN. None of the patient specimens showed enhanced staining of SEMA3B. Enhanced glomerular staining of PLA2R, NELL-1, and Ext1/Ext2 was detected in 5.7%, 8.6%, and 22.9% of the patients with secondary MN, respectively. Based on our findings, we recommend the assessment of PLA2R, THSD7A and NELL-1 in addition to clinical information and IgG4 staining to differentiate between primary and secondary MN. This would aid in distinguishing secondary MN patients from primary MN patients who coincidentally have some secondary characteristics.

Six Autoimmune Disorders Are Associated With Increased Incidence of Gastric Cancer: A Systematic Review and Meta-Analysis of Half a Million Patients

Background

Gastric cancer is one of the most common cancers worldwide, with a high mortality rate. The potential etiological role of autoimmune (AI) disorders has been described in gastric cancer; however, the literature is controversial. This study aims to provide a comprehensive summary of the association between autoimmune disorders and the incidence of gastric cancer.

Methods

This study was registered on PROSPERO under registration number CRD42021262875. The systematic literature search was conducted in four scientific databases up to May 17, 2021. Studies that reported standardized incidence rate (SIR) of gastric cancer in autoimmune disorders were eligible. We calculated pooled SIRs with 95% confidence intervals (CIs) in this meta-analysis.

Results

We included 43 articles describing 36 AI disorders with data of 499,427 patients from four continents in our systematic review and meta-analysis. Significantly increased incidence of gastric cancer was observed in dermatomyositis (SIR = 3.71; CI: 2.04, 6.75), pernicious anemia (SIR = 3.28; CI: 2.71, 3.96), inflammatory myopathies (SIR = 2.68; CI:1.40; 5.12), systemic lupus erythematosus (SIR = 1.48; CI: 1.09, 2.01), diabetes mellitus type I (SIR = 1.29; CI:1.14, 1,47), and Graves’ disease (SIR = 1.28; CI: 1.16, 1.41). No significant associations could be found regarding other AI disorders.

Conclusions

Pernicious anemia, Graves’ disease, dermatomyositis, diabetes mellitus type I, inflammatory myopathies, and systemic lupus erythematosus are associated with higher incidence rates of gastric cancer. Therefore, close gastroenterological follow-up or routinely performed gastroscopy and application of other diagnostic measures may be cost-effective and clinically helpful for patients diagnosed with these autoimmune diseases.

How Times Have Changed! A Cornucopia of Antigens for Membranous Nephropathy

The identification of the major target antigen phospholipase A2 receptor (PLA2R) in the majority of primary (idiopathic) cases of membranous nephropathy (MN) has been followed by the rapid identification of numerous minor antigens that appear to define phenotypically distinct forms of disease. This article serves to review all the known antigens that have been shown to localize to subepithelial deposits in MN, as well as the distinctive characteristics associated with each subtype of MN. We will also shed light on the novel proteomic approaches that have allowed identification of the most recent antigens. The paradigm of an antigen normally expressed on the podocyte cell surface leading to in-situ immune complex formation, complement activation, and subsequent podocyte injury will be discussed and challenged in light of the current repertoire of multiple MN antigens. Since disease phenotypes associated with each individual target antigens can often blur the distinction between primary and secondary disease, we encourage the use of antigen-based classification of membranous nephropathy.

Secondary Membranous Nephropathy. A Narrative Review

Membranous nephropathy (MN) is a common cause of proteinuria and nephrotic syndrome all over the world. It can be subdivided into primary and secondary forms. Primary form is an autoimmune disease clinically characterized by nephrotic syndrome and slow progression. It accounts for ~70% cases of MN. In the remaining cases MN may be secondary to well-defined causes, including infections, drugs, cancer, or autoimmune diseases, such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), urticarial vasculitis, sarcoidosis, thyroiditis, Sjogren syndrome, systemic sclerosis, or ankylosing spondylitis. The clinical presentation is similar in primary and secondary MN. However, the outcome may be different, being often related to that of the original disease in secondary MN. Also, the treatment may be different, being targeted to the etiologic cause in secondary MN. Thus, the differential diagnosis between primary and secondary MN is critical and should be based not only on history and clinical features of the patient but also on immunofluorescence and electron microscopy analysis of renal biopsy as well as on the research of circulating antibodies. The identification of the pathologic events underlying a secondary MN is of paramount importance, since the eradication of the etiologic factors may be followed by remission or definitive cure of MN. In this review we report the main diseases and drugs responsible of secondary MN, the outcome and the pathogenesis of renal disease in different settings and the possible treatments.

Immune checkpoint inhibitor associated reactivation of primary membranous nephropathy responsive to rituximab

The same mechanisms that mediate antitumor immunity from checkpoint inhibitors (CPIs) can also lead to unintended targeting of normal tissues, characterized as immune-related adverse events (irAEs). Those with pre-existing autoimmune disease are believed to be particularly vulnerable for exacerbating underlying autoimmunity or inducing severe irAEs. We report the first case of CPI-associated reactivation of primary membranous nephropathy (MN) in a patient with pleural mesothelioma responding to immunotherapy. Due to its specificity in targeting B-lymphocytes, rituximab was used to treat primary MN with the expectation that this would not interfere with the benefits gained from T cell-mediated antitumor immunity. Rituximab was effective in treating CPI-associated reactivation of MN, and the patient was successfully rechallenged with nivolumab and maintained stable kidney function and sustained clinical antitumor effect. While exacerbation of pre-existing autoimmune diseases from CPIs is common, therapy for autoimmune reactivation can be rationally directed by an understanding of the immunosuppressive mechanism with goals of cancer treatment.

Cancer development and mortality differences in patients with glomerulonephritis after renal biopsy: a single center retrospective cohort study

Background

The association between glomerulonephritis (GN) and cancer has been well known for decades. However, studies evaluating long-term de novo cancer development in patients with GN are limited. This study aimed to evaluate the incidence of cancer development among patients with renal biopsy-proven GN during post-biopsy follow-up and the differences in outcomes according to cancer occurrence.

Methods

We conducted a retrospective cohort study of adult patients who underwent renal biopsy at Seoul National Bundang Hospital between 2003 and 2017. After excluding 778 patients with age < 18 years, cancer diagnosis before or within 6 months after renal biopsy, immunosuppressant therapy before renal biopsy, or pathologic diagnoses other than GN, 822 patients were included in the analysis. Data on baseline clinical characteristics, renal biopsy results, and types and doses of immunosuppressant agents were collected from electronic medical records. The incidence of cancer was censored on the date when the first cancer was diagnosed. We evaluated rates of mortality and end-stage renal disease (ESRD) development during follow-up.

Results

During a mean follow-up period of 58.9 ± 44.5 months, 45 subjects (5.5%) developed de novo cancer. A comparison of clinical characteristics between subjects who did and did not develop cancer revealed that cancer patients were older and had higher comorbidities and immunosuppressant use. Overall, patients with GN had an elevated standardized incidence ratio (SIR) of 7.16 (95% confidence interval (CI): 5.22–9.61) relative to the age- and sex-matched general population. In particular, the SIR was significantly higher in GNs such as membranous nephropathy (MN), IgA nephropathy, lupus nephritis, and focal segmental glomerulosclerosis. Multivariable Cox proportional hazard model revealed that patients with MN had an increased risk of cancer development, with a hazard ratio of 2.30 [95% CI: 1.06–4.98]. Patients with MN who developed cancer had a significantly higher risk of mortality (hazard ratio: 6.59; 95% CI: 1.22–35.56, P = 0.03) than those without cancer, but there was a non-significant difference in ESRD development. Conclusions: Patients with GN without concurrent cancer, particularly those with MN, have significantly higher risks of cancer development and subsequent mortality and should remain aware of the potential development of malignancy during follow-up.

[Kidney disease care for the elderly]

In our aging population, kidney disease management needs to take into account the frailty of the elderly. Standardized geriatric assessments can be proposed to help clinicians apprehend this dimension in their daily practice. These tools allow to better identify frail patients and offer them more personalized and harmless treatments. This article aims to focus on the kidney diseases commonly observed in elderly patients and analyze their specific nephrogeriatric care modalities. It should be noticed that all known kidney diseases can be also observed in the elderly, most often with a quite similar clinical presentation. This review is thus focused on the diseases most frequently and most specifically observed in elderly patients (except for monoclonal gammopathy associated nephropathies, out of the scope of this work), as well as the peculiarities of old age nephrological care.

Comparison of cancer prevalence between patients with glomerulonephritis and the general population at the time of kidney biopsy

Glomerulonephritis (GN) has been associated with many solid and hematologic malignancies. However, cancer prevalence at the time of GN diagnosis has been rarely examined. We aimed to evaluate the cancer prevalence in patients with GN at the time of kidney biopsy and to compare the results to those of the general population. A total of 1,155 patients who underwent kidney biopsy between 2003 and 2017 were included. We investigated patients diagnosed with cancer within one month of kidney biopsy. The occurrence of cancer was compared with that of the Korean general population using the observed-to-expected rates (O/E ratio). Twenty-nine patients with GN had cancer. The mean age of patients with and without cancer was 49 and 66 years old, respectively. The proportion of male patients with and without cancer was 49.4% and 58.6%, respectively. The glomerular filtration rate was different between the groups (78.1 ± 37.0, 58.0 ± 43.6 ml/min/1.73 m2, p = 0.006), but the urine protein/creatinine ratio was not (3.21 ± 4.01, 5.38 ± 7.47 g/gCr, p = 0.172). Immunoglobulin A nephropathy (IgAN) was the most common GN (37.9%), followed by membranous GN (13.5%), focal segmental glomerulosclerosis (9.7%), minimal change disease (9.2%), amyloidosis (1.2%). Amyloidosis was the most common GN associated with malignancy (20.7%). In patients with amyloidosis, cancer was observed almost 28 times more than expected and these patients showed higher cancer occurrence than patients with other GN (Relative Risk [RR]: 15.73; 95% confidence interval [CI]: 4.82-51.30; p < 0.01). Cancer occurrence was three times greater in GN patients aged > 50 years compared to the general population (O/E ratio: 3.42; 95% CI: 1.37-5.46; p = 0.027). Patients with GN, especially amyloidosis, have higher risk of cancer than the general population at the time of GN diagnosis. Older age (> 50 years) was one of the major determinants of the presence of cancer in GN patients.

Clinicopathological features in membranous nephropathy with cancer: A retrospective single-center study and literature review

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.

Duodenal Schwannoma as a Rare Association With Membranous Nephropathy: A Case Report

Membranous nephropathy (MN) associated with malignancies is a well-known entity. However, its association with benign neoplasm is not broadly recognized. A 69-year-old man with recurrent nephrotic syndrome presented with pedal edema and proteinuria of 5 months' duration. Laboratory results showed hypoalbuminemia and hyperlipidemia. Proteinuria was estimated to be protein excretion of 3.5g/d. Studies were negative for viral hepatitis, syphilis, human immunodeficiency virus, autoimmune diseases, and paraproteinemia. Kidney biopsy disclosed MN with negative phospholipase A₂ receptor (PLA₂R) staining, favoring a secondary form of MN. Computed tomography detected a 7.6-cm duodenal schwannoma. Elective surgical resection was performed. Pathologic study showed that THSD7A (thrombospondin type 1 domain-containing 7A) was positive in both glomeruli and schwannoma. Commonly, secondary MN is related to underlying conditions, including lupus, hepatitis, and neoplasm, and can be medication induced. The risk for developing a concomitant neoplasm among patients with PLA₂R-negative MN is up to 12 times higher than in the general population. Most of these neoplasms are malignancies, and the presence of autoantibodies directed at similar tissue targets is hypothesized as the potential mechanism. In our case, THSD7A may be the autoantibody that has linked the schwannoma and the development of MN. Although benign tumors rarely produce renal manifestations, effective treatment may lead to resolution of nephrotic syndrome.

The frequency of ANCA-associated vasculitis in a national database of hospitalized patients in China

BACKGROUND

Anti-neutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) is a group of life-threatening autoimmune diseases. The epidemiological data on AAV in China are limited. The aim of the present study is to investigate the frequency, geographical distribution, and ethnic distribution of AAV in hospitalized patients in China, and its association with environmental pollution.

METHODS

We investigated the hospitalized patients in a national inpatient database covering 54.1% tertiary hospitals in China from 2010 to 2015. Diagnosis of AAV was extracted according to the definition of International Classification of Diseases (ICD)-10 codes and free text. Variables from the front page of inpatient records were collected and analyzed, including frequency, geographic distribution, demographic characteristics and seasonal variations of AAV. The association between various environmental pollutants and frequency of AAV was further analyzed.

RESULTS

Among 43.7 million inpatients included in the study period, 0.25‰ (10,943) were diagnosed as having AAV. The frequency of AAV was relatively stable during the study period (from 0.34‰ in 2010 to 0.27‰ in 2015). The proportion of AAV increased with latitude (0.44‰ in Northern China and 0.27‰ in Southern China in 2015). Hospitalizations were mostly observed in winter (30.2%). The Dong population, an ethnic minority of the Chinese population, had the highest frequency of patients with AAV (0.67‰). We also found a positive association between the exposure to carbon monoxide and the frequency of AAV (R² = 0.172, p = 0.025). In Yunnan province, the frequency of AAV increased 1.37-fold after the Zhaotong earthquake, which took place in 2014.

CONCLUSIONS

Our present investigation of hospitalized patients provided epidemiological information on AAV in China for the first time. A spatial and ethnic clustering trend and an association between pollution and the frequency of AAV were observed.

Remission of nephrotic syndrome after surgical intervention for bronchogenic carcinoma: the 10-year follow-up of a patient with membranous nephropathy

Nephrotic syndrome (NS) is a pivotal manifestation of glomerular injury associated with various types of neoplasms. It may either precede or act as the presenting feature of the disease, whereas membranous nephropathy (MN) is a major phenotype of paraneoplastic glomerulopathies. However, there is a lack of information regarding the remission from paraneoplastic NS due to MN in patients who achieve favorable long-term survival after the successful removal of malignant tissue. We, herein, describe a case of biopsy-proven MN in a 65-year-old male patient with bronchogenic carcinoma, which was found during the systemic workup for concurrent NS. He was successfully treated with thoracoscopic left lower lobectomy and achieved a complete remission from NS at approximately 10 months after radical surgery. In 10 years of follow-up, there has been no recurrence of the pulmonary cancer and the patient is doing well with no relapse of NS, despite having never received treatment with any type of immunomodulating agent. Several concerns, including diagnostic management and therapeutic strategies for paraneoplastic NS, are discussed.

Quantification of cancer risk in glomerulonephritis

Background

The association of increased cancer risk with glomerulonephritis (GN) is well known, but controversy exists concerning which types of GN are involved, and the size of the association. A national registry survey was performed to assess the size of this association, and the temporal relationship of cancer diagnosis to GN diagnosis.

Methods

All patients with biopsy-proven GN between 1985 and 2015 in Denmark were extracted from The Danish Renal Biopsy Registry and the National Pathology Data Bank. Incident cancer diagnoses between 10 years previous and 10 years subsequent to the GN diagnosis were extracted from the Danish Cancer Registry. Residence, birth and death data were obtained from the National Patient Register. Expected cancer incidence, classified according to cohort, age and sex were extracted from the Nordcan database.

Results

Nine hundred eleven cancers were diagnosed in 5594 patients. Thirty five percent were prevalent at renal biopsy. Prevalence at biopsy was 5.5% (expected 3.1%), but incidence was not increased < 1 year before biopsy. Increased cancer rates were seen for GN forms: minimal change, endocapillary, focal segmental glomerulosclerosis, mesangioproliferative, membranous, focal segmental, membranoproliferative, proliferative, ANCA-associated vasculitis, lupus nephritis and unclassified. Increased cancer rates were seen for lung, prostate, renal, non-Hodgkin lymphoma, myeloma, leukaemia and skin. The increased incidence was mainly limited to − 1 to 1 year after biopsy, but skin cancer showed an increased risk over time. Some diagnoses showed an increase 5–10 years after biopsy. Incidence was raised for patients with uraemia and nephrosis, but less for proteinuria or haematuria. Cancers in patients < 45 years were rare. The risk of developing cancer 0–3 years after biopsy for patients 45–64 years varied from 7.3% (minimal change) to 15.8% (unclassified GN); > 64 years from 11.8 (endocapillary GN) to 20.3% (unclassified). The diagnosis with the highest risk was membranoproliferative GN (8.6 & 19.6%).

Conclusions

Cancer rates are increased for many cancer and most GN diagnoses. Cancer screening for patients < 45 years and for patients without nephrosis or uraemia may not be necessary. The findings suggest that screening programs for specific GN diagnoses can be extended to other GN forms.

Malignancy in Membranous Nephropathy: Evaluation of Incidence

Background

Membranous nephropathy (MN) can be associated with malignancy. However, the relative risk for malignancy remains unclear. It has been reported that higher numbers of inflammatory cells seen in the glomeruli at biopsy correlate with the occurrence of malignancy in patients with MN and might be used to direct screening.

Methods

We examined the occurrence of malignancy in 201 MN patients in Auckland, New Zealand. We also examined the pathology of renal biopsies from 17 MN patients with malignancies and compared the number of inflammatory cells per glomerulus with matched control patients with MN but no malignancy.

Results

40 malignancies were identified in 37 patients, 28 of which occurred after the MN diagnosis. The standardized incidence ratio (SIR) was 2.1 (95% CI, 1.3–2.85) which was similar between patients ≥ 60 years and those <60 years. The median number of inflammatory cells per glomerulus did not differ between MN patients with and without malignancy at 1.86 (IQR, 1.17–2.7) and 2.07 (IQR, 1.17–3.65), respectively (p value 0.56).

Conclusions

The relative risk of malignancy in MN patients was similar across different age groups. The number of inflammatory cells per glomerulus did not differentiate between MN patients with and without malignancies.

A follow-up analysis of positron emission tomography/computed tomography in detecting hidden malignancies at the time of diagnosis of membranous nephropathy

Membranous nephropathy (MN) is the most common kidney disease reported in a variety of malignant diseases. Search for an occult malignancy in MN has presented special challenges. 124 MN patients with a physical examination not suspicious for cancer underwent screening for an occult malignancy with either 18F-Fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) scanning (n = 49) or conventional screening (n = 75) at the time of diagnosis of MN, and were followed up (median,28 months). 154 patients who refused to undergo any screening were followed up (median, 30 months). In FDG-PET/CT cohort, 5 (10.20%) patients were screened and confirmed as malignancy, in contrast, 1 (1.33%) patient in conventional screening cohort. During follow-up, none of malignancy was detected in FDG-PET/CT cohort, 3(4.05%) patients in conventional screening cohort, and 8(5.19%) patients in no-screening cohort. All 6 cases of cancer were detected at early stages and underwent curative resection, and after the resection, proteinuria decreased. In contrast, 11 cases of cancer detected during follow-up died without any remission of proteinuria. These preliminary data provide the first evidence for a potential cancer surveillance that the malignancy screening either through conventional or by PET-CT at the diagnosis of MN led to an early diagnosis and curative treatment.

Glomerular diseases and cancer: evaluation of underlying malignancy

Onconephrology is an emerging medical subspecialty focused on the numerous interconnections between cancer and kidney diseases. Patient with malignancies commonly experience kidney problems including acute kidney injury, tumor lysis syndrome, fluid and electrolyte disorders and chronic kidney disease, often as a consequence of the anti-cancer treatment. Conversely, a number of glomerulopathies, tubulopathies and vascular renal diseases can early signal the presence of an underlying cancer. Furthermore, the administration of immunosuppressive drugs, especially cytotoxic drugs and calcineurin inhibitors, may strongly impair the immune response increasing the risk of cancer. The objective of this review article is to: (i) discuss paraneoplastic glomerular disease, (ii) review cancer as an adverse effect of immunosuppressive agents used to treat glomerulopathies, and (iii) in the absence of international approved guidelines, propose a screening program based on expert opinion aimed at guiding nephrologists to early detect malignancies during their clinical practice.

Successful treatment with s-1 and oxaliplatin combination therapy in an elderly patient with metastatic colorectal cancer initially presenting with membranous nephropathy

The incidence, morbidity, and mortality of colorectal cancer are increasing, largely owing to an increasingly aging population. Additionally, along with the increasing age of cancer patients, the number of patients with various comorbidities such as membranous nephropathy is also rising, and problems associated with the administration of chemotherapy to elderly patients with these conditions are becoming more common. Herein, we describe a case involving an 80-year-old woman who presented with general malaise, edematous limbs, and pleural effusion. An abdominal CT revealed multiple, relatively large, metastatic lesions in a wide area of the liver and left pleural effusion, and she was accordingly diagnosed with membranous nephropathy secondary to ascending colon cancer and multiple liver metastases. Despite her advanced age and the presence of membranous nephropathy, her general condition was favorable and chemotherapy was hence administered. Taking the toxicity profiles and the patient's preference into consideration, S-1 and oxaliplatin (SOX) therapy was selected, which showed a good tolerability. An abdominal CT after 8 cycles of SOX therapy revealed a marked reduction in the metastatic lesions in the liver and a decrease in the left pleural effusion, and the levels of tumor markers also decreased (partial response). At the latest follow-up, after the completion of 16 cycles, the condition of the patient remained stable, without any apparent signs of progressive disease. Based on this case, we conclude that, even for elderly patients with systemic complications or comorbid diseases, standard treatments should be considered after their general conditions, and therapeutic regimens have been sufficiently examined.

Primary glomerular diseases in the elderly

Primary glomerular diseases in the elderly population are a frustrating topic due to difficulties in both the diagnosis and decision making about treatment. The most frequent type of primary glomerular disease in elderly is membranous nephropathy; while its counterpart in younger population is IgA nephropathy. The most frequent cause of nephrotic syndrome in the elderly is also membranous nephropathy. Pauci-immune crescentic glomerulonephritis (GN) rate increases both in elderly and very elderly population. Pauci-immune crescentic GNs should be regarded as urgencies in elderly patients as in their younger counterparts due to potential for causing end-stage renal disease in case of delayed diagnosis and treatment, and also causing mortality due to alveolar hemorrhage in patients with pulmonary involvement. Renal biopsy is the inevitable diagnostic method in the elderly as in all other age groups. Renal biopsy prevents unnecessary treatments and provides prognostic data. So advanced age should not be the sole contraindication for renal biopsy. The course of primary glomerular diseases may differ in the elderly population. Acute kidney injury is more frequent in the course and renal functions may be worse at presentation. These patients are more prone to be hypertensive. The decision about adding immune suppressive therapies to conservative methods should be made considering many factors like co-morbidities, drug side effects and potential drug interactions, risk of infection, patient preference, life expectancy and renal functions at the time of diagnosis.

Membranous nephropathy: a review on the pathogenesis, diagnosis, and treatment

In adults, membranous nephropathy (MN) is a major cause of nephrotic syndrome. However, the etiology of approximately 75% of MN cases is idiopathic. Secondary causes of MN are autoimmune diseases, infection, drugs, and malignancy. The pathogenesis of MN involves formation of immune complex in subepithelial sites, but the definite mechanism is still unknown. There are three hypotheses about the formation of immune complex, including preformed immune complex, in situ immune-complex formation, and autoantibody against podocyte membrane antigen. The formation of immune complex initiates complement activation, which subsequently leads to glomerular damage. Recently, the antiphospholipase A2 receptor antibody was found to be associated with idiopathic MN. This finding may be useful in the diagnosis and prognosis of MN. The current treatment includes best supportive care, which consists of the use of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, lipid-lowering agents, and optimal control of blood pressure. Immunosuppressive agents should be used for patients who suffer from refractory proteinuria or complications associated with nephrotic syndrome. Existing evidence supports the use of a combination of steroid and alkylating agents. This article reviews the epidemiology, pathogenesis, diagnosis, and the treatment of MN.

Risk and prognosis of cancer in patients with nephrotic syndrome

BACKGROUND

Nephrotic syndrome may be a marker of occult cancer, but population-based studies of this association are lacking. Therefore, we examined the risk and prognosis of cancer in patients with nephrotic syndrome.

METHODS

We conducted this population-based cohort study in Denmark, including all individuals diagnosed with nephrotic syndrome between 1980 and 2010 without a preceding cancer history. We computed the 5-year risk of cancer accounting for competing risk by death and standardized incidence ratios (SIRs) of cancer in patients with nephrotic syndrome relative to the general population. We compared the 5-year mortality for patients with cancer after nephrotic syndrome with that for a cancer cohort without a history of nephrotic syndrome using Cox regression adjusted for age, gender, and comorbidity.

RESULTS

Of 4293 individuals with nephrotic syndrome, 338 developed an incident cancer during a median follow-up of 5.7 years. The 5-year risk of any cancer was 4.7% in patients with nephrotic syndrome, a 73% increased risk (SIR, 1.73; 95% confidence interval [CI], 1.55-1.92). The association was most pronounced for lung cancer, kidney cancer, lymphoma, and multiple myeloma. It was highest within 1 year of nephrotic syndrome diagnosis (SIR, 4.49; 95% CI, 3.68-5.42), but remained increased beyond 1 year (SIR, 1.34; 95% CI, 1.17-1.53). The 5-year mortality after cancer was 68.5% in patients with cancer with nephrotic syndrome and 63.4% in the cancer comparison cohort (adjusted hazard ratio, 1.20; 95% CI, 1.02-1.42).

CONCLUSIONS

Nephrotic syndrome is a marker of occult solid tumors and hematologic malignancies and is associated with a worsened cancer prognosis.

Cancer risk after cyclophosphamide treatment in idiopathic membranous nephropathy

BACKGROUND AND OBJECTIVES

Cyclophosphamide treatment improves renal survival in patients with idiopathic membranous nephropathy. However, use of cyclophosphamide is associated with cancer. The incidence of malignancies in patients with idiopathic membranous nephropathy was evaluated, and the cancer risk associated with cyclophosphamide use was estimated.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients who attended the clinic were included prospectively from 1995 on. A crude incidence ratio for the occurrence of malignancy was calculated. Incidence ratios were subsequently standardized to potential confounders. Latency between cyclophosphamide therapy and the occurrence of cancer was estimated by stratifying for time since the start of treatment. Finally, Poisson regression was used to obtain a multiple adjusted incidence ratio and investigate the dose-response relationship between cyclophosphamide and cancer.

RESULTS

Data were available for 272 patients; the mean age was 51 years, and 70% of the patients were men. Median follow-up was 6.0 years (interquartile range=3.6-9.5), and 127 patients were treated with cyclophosphamide. Cancer incidence was 21.2 per 1000 person-years in treated patients compared with 4.6 per 1000 person-years in patients who did not receive cyclophosphamide, resulting in crude and adjusted incidence ratios of 4.6 (95% confidence interval, 1.5 to 18.8) and 3.2 (95% confidence interval, 1.0 to 9.5), respectively.

CONCLUSION

Cyclophosphamide therapy in idiopathic membranous nephropathy gives a threefold increase in cancer risk. For the average patient, this finding translates into an increase in annual risk from approximately 0.3% to 1.0%. The increased risk of malignancy must be balanced against the improved renal survival.

An update on glomerular disease in the elderly

Examination of urinary sediment for dysmorphic erythrocytes as a diagnostic tool in glomerular disease is important. The atypical clinical features of acute and chronic glomerular disease in the elderly should be remembered. The common causes of nephrotic syndrome need to be remembered in patients with edema and marked proteinuria. The predilection of the elderly to develop rapidly progressive glomerulonephritis needs to be appreciated. The development of glomerular disease caused by an underlying neoplastic process also needs to be remembered. Effective treatment regimens are available to ameliorate the adverse consequences of acute, progressive, and chronic glomerular disease in the geriatric population.

Diagnosis and treatment of glomerular diseases in elderly patients

Glomerular diseases are common in elderly patients and are a major cause of kidney failure. Most glomerular diseases in the elderly are caused by chronic systemic diseases, including arterial hypertension, diabetes, and atherosclerotic vascular diseases, although acute systemic vasculitis, especially anti-neutrophil-cytoplamic-antibody-mediated vasculitis, and membranous nephropathy related to malignancy, drug toxicity, and idiopathic form also occur often. Complex age-related changes and sensitivity to drug toxicity can render diagnosis and treatment for elderly patients challenging. As the general population is aging and the rate of CKD rising, updating knowledge on managing these patients is critical for care providers. We provide a comprehensive review and update of the diagnosis and treatment of glomerular diseases in the elderly.

Prevalence of cancer in membranous nephropathy: a systematic review and meta-analysis of observational studies

BACKGROUND

The association between membranous nephropathy (MN) and cancer has been well documented. However, the true prevalence and characteristics of cancer associated with MN have not been well described.

METHODS

A systematic review and meta-analysis of cohort studies was conducted to summarize the prevalence of cancer-associated MN as well as patient characteristics and types of cancer in this population. We used a random-effects meta-analysis model to estimate the prevalence of cancer.

RESULTS

We included 6 studies (n = 785). The estimated prevalence of cancer was 10.0% (95% CI, 6.1-14.6). The mean age of MN patients with cancer was 67 ± 7 years. The diagnosis of cancer preceded the diagnosis of MN in 20 ± 6.8%. Lung cancer was the most common type of tumor, accounting for 22 cases (26%), followed by prostate cancer (13 cases, 15%), hematologic malignancies (12 cases, 14%), colorectal cancer (9 cases, 11%), breast cancer (6 cases, 7%), and stomach and esophageal cancer (5 cases, 6%).

CONCLUSION

The estimated prevalence of cancer in patients with MN is 10% (95% CI, 6.1-14.6). The vast majority of tumors associated with MN are lung and prostate cancer. Hematologic malignancies should also be considered as one of the potential cancers associated with MN. Our study was based on a largely Caucasian population; therefore, the findings might not be applicable to other populations.

Glomerular diseases associated with cancer, chemotherapy, and hematopoietic stem cell transplantation

Many solid and hematological malignancies have been associated with different glomerular diseases. Several case reports and case series of cancer-associated glomerular diseases have shown that treating the cancer may lead to resolution of the glomerular process. Hence, knowledge and approach to cancer-associated glomerular diseases is important for both the caring nephrologists and the cancer specialists. While membranous nephropathy has been classically associated with solid malignancies, minimal change disease has been commonly described with hematologic malignancies, especially non-Hodgkin's lymphoma. Membranoproliferative glomerulonephritis is increasingly being recognized to be associated with chronic hematologic malignancies such as chronic lymphocytic leukemia. In this article, we review various cancer-associated glomerular diseases and their pathogenesis as well as principles of treatment. In addition, we also review glomerular diseases seen after chemotherapy and hematopoietic stem cell transplantation.

Long-term outcomes in idiopathic membranous nephropathy using a restrictive treatment strategy

Recently published Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend limiting the use of immunosuppressive drugs in idiopathic membranous nephropathy to patients at the highest risk of kidney failure. However, recommendations are based on natural history rather than direct assessment of a restrictive treatment strategy. Here, we describe the long-term outcomes of treating a large cohort of patients with idiopathic membranous nephropathy according to a restrictive treatment policy. We analyzed data for 254 patients who visited our outpatient clinic between 1995 and 2009. All patients were treated with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Immunosuppressive therapy was recommended in cases of deteriorating renal function or untreatable nephrotic syndrome. Primary outcomes for the present study were renal replacement therapy and death. Secondary outcomes included adverse events during follow-up and remission of proteinuria. In total, 124 patients (49%) received immunosuppressive therapy, which predominantly consisted of cyclophosphamide combined with steroids. Ten-year cumulative incidence rates were 3% for renal replacement therapy and 10% for death. Partial remission rates were 39%, 70%, and 83% after 1, 3, and 5 years, respectively; complete remission rates were 5%, 24%, and 38% at 1, 3, and 5 years, respectively. A serious adverse event occurred in 23% of all patients. The most notable complications were infections (17%), leukopenia (18%), cardiovascular events (13%), and malignancies (8%). In conclusion, the use of a restrictive treatment strategy in this cohort of patients with idiopathic membranous nephropathy yielded favorable outcomes while limiting the number of patients exposed to toxic drugs. These results support current KDIGO guidelines.

KDOQI US commentary on the 2012 KDIGO clinical practice guideline for glomerulonephritis

Glomerulonephritis (GN) is an important cause of morbidity and mortality in patients of all ages throughout the world. Because these disorders are relatively rare, it is difficult to perform randomized clinical trials to define optimal treatment for many of the specific glomerulopathies. In the absence of high-grade evidence to guide the care of glomerular diseases, in June 2012, KDIGO (Kidney Disease: Improving Global Outcomes) published an international clinical guideline for GN. The Work Group report represents an important review of the literature in this area and offers valid and useful guidelines for the most common situations that arise in the management of patients with glomerular disease. This commentary, developed by a panel of clinical experts convened by the National Kidney Foundation, attempts to put the GN guideline into the context of the US health care system. Overall, we support the vast majority of the recommendations and highlight select areas in which epidemiological factors and medical practice patterns in this country justify modifications and adjustments in order to achieve favorable outcomes. There remain large gaps in our knowledge of the best approaches to treat glomerular disease and we strongly endorse an expanded clinical research effort to improve the health and long-term outcomes of children and adults with GN.

Nephrotic syndrome associated with meningioma

A 58-year-old man presented with recurrent frontal meningioma and nephrotic syndrome. Renal biopsy could not be done in view of the rapid neurological deterioration. The patient underwent surgical resection of the tumor. Within 4 weeks, the edema decreased, serum albumin improved, and proteinuria decreased spontaneously. At three months of followup, the patient had attained complete remission of nephrotic state.

Recent advances in diagnosis and treatment of acute kidney injury in patients with cancer

Acute Kidney Injury (AKI) is a common complication in patients with cancer and even though there are many causes of renal failure in this population the classical classification of prerenal, renal, and postrenal is useful as a diagnostic guide. Important risk factors for AKI are dehydration, use of nephrotoxic drugs, preexisting renal impairment and large tumor burden. The development of AKI is associated with poor prognosis but early recognition and treatment initiation are associated with better outcomes in this population.

Idiopathic membranous nephropathy and nephrotic syndrome: outcome in the era of evidence-based therapy

BACKGROUND

Contemporary studies analysing the long-term outcomes of patients with idiopathic membranous nephropathy and nephrotic syndrome in the era of evidence-based antiproteinuric and immunosuppressive therapies are sparse. Controversy also persists regarding which immunosuppression (IS) regimen to use. In this retrospective cohort study, we aimed to characterize time to partial remission (PR), complete remission (CR), requirement for renal replacement therapy (RRT) or death. We aimed to assess which factors predicted RRT or death and determine the impact of IS on outcome.

METHODS

Ninety-five consecutive adult patients attending two centres between 1997 and 2008 were identified. Baseline demographics and subsequent treatment and outcome were recorded.

RESULTS

Ninety-five percent of patients were prescribed angiotensin-converting enzyme inhibitors and/or angiotensin-receptor blocker (ACEI/ARB) therapy, 78% statin therapy, 70% antiplatelets and 38% IS. The 5-year actuarial rates for PR, CR, RRT and death were 76.4, 24.4, 11.9 and 16.8%, respectively. In patients achieving at least one PR, the 5-year actuarial risk of relapse was 32.8%. Using multivariate survival analysis, achievement of remission was the factor most strongly associated with reduced risk of RRT or death. There was no significant difference in outcomes between patients who did or did not receive IS, although patients receiving IS had more severe disease. Contrary to published findings, 81.8% of patients treated with the Ponticelli regimen (6 months of alternating prednisolone and cyclophosphamide or chlorambucil) suffered significant treatment-related complications compared with 19% of patients prescribed the Cattran regimen (prolonged combined low-dose prednisolone and cyclosporine).

CONCLUSIONS

Using an approach of widespread ACEI/ARB treatment and targeted IS, 76% of patients can expect to have achieved at least one PR by 5 years. Achievement of remission is the factor most strongly associated with reduced risk of RRT and death. Treatment with IS is associated with significant treatment complications.

Membranous nephropathy and malignancy

An association between the glomerular disease membranous nephropathy (MN) and malignancy has long been appreciated, but evidence supporting this relationship remains limited, speculative, and, at times, controversial. Reports that the two disease processes often evolve in parallel, as well as the occasional findings of tumor antigens or tumor-reactive antibodies within glomerular immune deposits, are all supportive of an association. However, the diagnosis of both MN and malignancy in the same individual also may be coincidental, especially in an older demographic group in which both diseases tend to occur. This article briefly reviews the proposed pathogenetic mechanisms of idiopathic and secondary forms of MN, as well as the arguments for and against the contention that malignancy-associated MN is itself a distinct clinical entity. In addition, the recent identification of the M-type phospholipase A₂ receptor as a major glomerular antigen in idiopathic MN has the potential to offer fresh tools that might help resolve some of the controversy, and ultimately aid in the decision of how aggressively to screen for malignancy in an individual diagnosed with MN.