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Trujillo H, Caravaca-Fontán F, Praga M. Ten tips on immunosuppression in primary membranous nephropathy. Clin Kidney J 2024; 17:sfae129. [PMID: 38915435 PMCID: PMC11195618 DOI: 10.1093/ckj/sfae129] [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] [Received: 02/29/2024] [Indexed: 06/26/2024] Open
Abstract
Membranous nephropathy (MN) management poses challenges, particularly in selecting appropriate immunosuppressive treatments (IST) and monitoring disease progression and complications. This article highlights 10 key tips for the management of primary MN based on current evidence and clinical experience. First, we advise against prescribing IST to patients without nephrotic syndrome (NS), emphasizing the need for close monitoring of disease progression. Second, we recommend initiating IST in patients with persistent NS or declining kidney function. Third, we suggest prescribing rituximab (RTX) or RTX combined with calcineurin inhibitors in medium-risk patients. Fourth, we propose cyclophosphamide-based immunosuppression for high-risk patients. Fifth, we discourage the use of glucocorticoid monotherapy or mycophenolate mofetil as initial treatments. Sixth, we underscore the importance of preventing infectious complications in patients receiving IST. Seventh, we emphasize the need for personalized monitoring of IST by closely measuring kidney function, proteinuria, serum albumin and anti-M-type phospholipase A2 receptor levels. Eighth, we recommend a stepwise approach in the treatment of resistant disease. Ninth, we advise adjusting treatment for relapses based on individual risk profiles. Finally, we caution about the potential recurrence of MN after kidney transplantation and suggest appropriate monitoring and treatment strategies for post-transplantation MN. These tips provide comprehensive guidance for clinicians managing MN, aiming to optimize patient outcomes and minimize complications.
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Affiliation(s)
- Hernando Trujillo
- Department of Nephrology, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Fernando Caravaca-Fontán
- Department of Nephrology, Hospital Universitario, 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital, 12 de Octubre (i+12), Madrid, Spain
| | - Manuel Praga
- Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Lum EL, Zuckerman JE, Abdelnour L, Terenzini J, Singh G, Bunnapradist S. Pretransplant Treatment to Avoid Recurrent Membranous Nephropathy in a Kidney Transplant Recipient: A Case Report. Kidney Med 2024; 6:100822. [PMID: 38736639 PMCID: PMC11078694 DOI: 10.1016/j.xkme.2024.100822] [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] [Indexed: 05/14/2024] Open
Abstract
Kidney transplant candidates with high anti-M-type phospholipase A2 receptor antibody activity may be at increased risk for early postkidney transplant recurrence and allograft loss. Pretransplant treatment to induce serological remission may be warranted to improve allograft survival. In this case report, a patient seeking their third kidney transplant, who lost 2 prior living donor transplants from early recurrent membranous nephropathy, underwent pretransplant treatment for membranous nephropathy with serological remission and no evidence of recurrent disease.
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Affiliation(s)
- Erik L. Lum
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Jonathan E. Zuckerman
- Department of Pathology and Laboratory Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Lama Abdelnour
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Jennifer Terenzini
- Department of Transplant Services, Kidney and Pancreas Transplant, UCLA, Los Angeles, California
| | - Gurbir Singh
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Suphamai Bunnapradist
- Division of Nephrology, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California
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Locatelli F, Del Vecchio L, Ponticelli C. Systemic and targeted steroids for the treatment of IgA nephropathy. Clin Kidney J 2023; 16:ii40-ii46. [PMID: 38053978 PMCID: PMC10695509 DOI: 10.1093/ckj/sfad224] [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: 05/15/2023] [Indexed: 12/07/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is a common glomerulonephritis partially correlated with mucosal immune system dysfunction. Progressive renal failure occurs in many patients, with about 30-50% of the patients with IgAN developing end-stage kidney disease (ESKD). Many treatments have been used for decades, despite uncertainty about their effectiveness and the ideal dose. Randomised controlled trials reported that systemic glucocorticoids can be an effective treatment for patients with persistent and significant proteinuria despite renin-angiotensin system inhibitors use possibly causing systemic side effects. The primary focus of IgAN management should be based on optimised supportive care, including renin-angiotensin system (RAS) blockade and now SGLT2 inhibitors. The novel targeted-release formulation (TRF) of budesonide has been tested to reduce the adverse events of systemic steroids by delivering the drug to the distal ileum. The local efficacy of TRF-budesonide may represent a novel and promising approach to treating IgAN. Two clinical trials showed that TRF-budesonide could significantly reduce proteinuria and haematuria and possibly preserve renal function while significantly reducing the side effects. However, the limited number of treated patients and the relatively short follow-up suggest caution before considering budesonide superior to the current six-months steroid pulses scheme. Long-term data on the efficacy and safety of TRF budesonide are awaited, together with the design of trials with a head-to-head comparison with systemic steroids before considering TRF-budesonide as the standard of care treatment for IgAN nephropathy.
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Affiliation(s)
- Francesco Locatelli
- Department of Nephrology and Dialysis, Alessandro Manzoni Hospital, Lecco, Italy
| | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’ Anna Hospital, ASST Lariana, Como, Italy
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Peritore L, Labbozzetta V, Maressa V, Casuscelli C, Conti G, Gembillo G, Santoro D. How to Choose the Right Treatment for Membranous Nephropathy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1997. [PMID: 38004046 PMCID: PMC10673286 DOI: 10.3390/medicina59111997] [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: 09/19/2023] [Revised: 10/30/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023]
Abstract
Membranous nephropathy is an autoimmune disease affecting the glomeruli and is one of the most common causes of nephrotic syndrome. In the absence of any therapy, 35% of patients develop end-stage renal disease. The discovery of autoantibodies such as phospholipase A2 receptor 1, antithrombospondin and neural epidermal growth factor-like 1 protein has greatly helped us to understand the pathogenesis and enable the diagnosis of this disease and to guide its treatment. Depending on the complications of nephrotic syndrome, patients with this disease receive supportive treatment with diuretics, ACE inhibitors or angiotensin-receptor blockers, lipid-lowering agents and anticoagulants. After assessing the risk of progression of end-stage renal disease, patients receive immunosuppressive therapy with various drugs such as cyclophosphamide, steroids, calcineurin inhibitors or rituximab. Since immunosuppressive drugs can cause life-threatening side effects and up to 30% of patients do not respond to therapy, new therapeutic approaches with drugs such as adrenocorticotropic hormone, belimumab, anti-plasma cell antibodies or complement-guided drugs are currently being tested. However, special attention needs to be paid to the choice of therapy in secondary forms or in specific clinical contexts such as membranous disease in children, pregnant women and patients undergoing kidney transplantation.
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Affiliation(s)
- Luigi Peritore
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Vincenzo Labbozzetta
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Veronica Maressa
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Chiara Casuscelli
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Giovanni Conti
- Pediatric Nephrology Unit, AOU Policlinic “G Martino”, University of Messina, 98125 Messina, Italy;
| | - Guido Gembillo
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
| | - Domenico Santoro
- Unit of Nephrology and Dialysis, Department of Clinical and Experimental Medicine, University of Messina, 98125 Messina, Italy; (V.L.); (V.M.); (C.C.)
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Xu W, Zhang Z, Li D, Dai W, Pan C, Guo M, Zhao Y, Cui X. Immunosuppressive therapy for progressive idiopathic membranous nephropathy: a cost-effectiveness analysis in China. BMC Health Serv Res 2023; 23:361. [PMID: 37046255 PMCID: PMC10091593 DOI: 10.1186/s12913-023-09365-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 04/04/2023] [Indexed: 04/14/2023] Open
Abstract
BACKGROUND This study aims to evaluate the cost-effectiveness of immunosuppressive therapy for patients with progressive idiopathic membranous nephropathy (IMN) from the Chinese healthcare system perspective. METHODS To estimate the cost-effectiveness of four regimens namely cyclophosphamide, cyclosporine, rituximab and tacrolimus-rituximab in treatment of IMN recommended by the updated Kidney Disease: Improving Global Outcomes (KDIGO) guideline 2021, a Markov model with five discrete states (active disease, remission, dialysis, kidney transplant and death) based on IMN patients aged 50 or above over a 30-years time horizon was constructed. Total costs were imputed from the Chinese healthcare system perspective, and health outcomes were converted into quality-adjusted life years (QALYs). The incremental cost-effectiveness ratio (ICER) was used to describe the results. The willingness-to-pay (WTP) threshold was set at $12,044 (China's 2021 Gross Domestic Product per capita). Sensitivity analyses were performed to test the uncertainties of the results. RESULT Compared with cyclophosphamide, both cyclosporine (incremental cost $28,337.09, incremental QALY-1.63) and tacrolimus-rituximab (incremental cost $28,324.13, incremental QALY -0.46) were considered at strictly dominated for their negative values in QALYs, and the ICER value of rituximab was positive (incremental cost $9,162.19, incremental QALY 0.44). Since the ICER of rituximab exceeds the pre-determined threshold, cyclophosphamide was likely to be the best choice for the treatment of IMN within the acceptable threshold range. The results of the sensitivity analysis revealed that the model outcome was mostly affected by the probability of remission in rituximab. In a probabilistic sensitivity analysis, cyclophosphamide had 62.4% probability of being cost-effective compared with other regimens when the WTP was $12,044 per QALY. When WTP exceeded $18,300, rituximab was more cost-effective than cyclophosphamide. CONCLUSION Compared with cyclosporine, rituximab and tacrolimus-rituximab, our model results indicated that cyclophosphamide represented the most cost-effective regimen for patients with progressive IMN in China.
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Affiliation(s)
- Wanyi Xu
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Yong-an Road, Xi-Cheng District, Beijing, 100050, PR China
| | - Zhiqi Zhang
- School of Pharmacy, Capital Medical University, Beijing, PR China
| | - Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Yong-an Road, Xi-Cheng District, Beijing, 100050, PR China
| | - Wendi Dai
- Department of Nephrology, Beijing Friendship Hospital, Capital Medical University, Beijing, PR China
| | - Chen Pan
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Yong-an Road, Xi-Cheng District, Beijing, 100050, PR China
| | - Mingxing Guo
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Yong-an Road, Xi-Cheng District, Beijing, 100050, PR China
| | - Ying Zhao
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Yong-an Road, Xi-Cheng District, Beijing, 100050, PR China
| | - Xiangli Cui
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Yong-an Road, Xi-Cheng District, Beijing, 100050, PR China.
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Claudio P. Primary membranous nephropathy: an endless story. J Nephrol 2023; 36:563-574. [PMID: 36251213 DOI: 10.1007/s40620-022-01461-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 08/29/2022] [Indexed: 10/24/2022]
Abstract
Primary membranous nephropathy (PMN) is an autoimmune disease caused by the attack of autoantibodies against podocyte antigens leading to the in situ production of immune complexes. However, the etiology is unknown and the pathogenesis is still far from being completely elucidated. MN is prevalently idiopathic or primary, but in about 20-30% of cases it is secondary to chronic infections, systemic diseases, exposure to drugs, or malignancy. The differentiation between primary and secondary MN may be difficult, particularly when MN precedes signs and symptoms of the original disease, as in some cases of cancer or systemic lupus erythematosus. The natural course of PMN is variable, but in the long term 40-60% of patients with nephrotic syndrome progress to end-stage renal disease (ESRD) or die from thrombotic or cardiovascular events. PMN is a treatable disease. Patients with asymptomatic proteinuria should receive supportive care. Immunosuppressive treatments should be given to patients with nephrotic syndrome or risk of progression. The most frequently adopted treatments rely on cyclical therapy alternating steroids with a cytotoxic agent every other month, i.e., rituximab at different doses, or calcineurin inhibitors plus low-dose steroids. A good rate of response may be obtained but relapses can occur. Randomized controlled trials, with adequate size, long-term follow-up, and fair definition of endpoints are needed to identify treatment with the best therapeutic index.
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Bao N, Gu M, Yu X, Wang J, Gao L, Miao Z, Kong W. Immunosuppressive treatment for idiopathic membranous nephropathy: An updated network meta-analysis. Open Life Sci 2023; 18:20220527. [PMID: 36694696 PMCID: PMC9835199 DOI: 10.1515/biol-2022-0527] [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] [Received: 06/06/2022] [Revised: 08/23/2022] [Accepted: 11/02/2022] [Indexed: 01/11/2023] Open
Abstract
This network meta-analysis (NMA) aims to investigate the efficacy and safety of different pharmacological treatments for idiopathic membranous nephropathy (IMN). Thirty-four relevant studies were extracted from PubMed, Embase, Cochrane database, and MEDLINE. Treatment with tacrolimus (TAC), cyclophosphamide (CTX), mycophenolate mofetil, chlorambucil (CHL), cyclosporin A (CSA), steroids, rituximab (RTX), and conservative therapy were compared. Outcomes were measured using remission rate and incidence of side effects. Summary estimates were expressed as the odds ratio (OR) and 95% confidence intervals (CIs). The quality of findings was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation approach. In the direct meta-analysis for comparison of complete remission (CR) rate, the curative effect of RTX is inferior to CTX (OR 0.37; CI 0.18, 0.75). In the NMA of CR rate, the results showed that the curative effects of CTX, CHL, and TAC were significantly higher than those of the control group. The efficacy of RTX is not inferior to the CTX (OR 0.81; CI 0.32, 2.01), and the level of evidence was moderate; CSA was not as effective as RTX, and the difference was statistically significant with moderate evidence (OR 2.98, CI 1.00, 8.91). In summary, we recommend CTX and RTX as the first-line drug for IMN treatment.
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Affiliation(s)
- Neng Bao
- Department of Nephrology, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, 157 Daming Road, Nanjing City, Jiangsu, 210000, PR China
| | - Mingjia Gu
- Department of Nephrology, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, 6 Huanghe Road, Changshu City, Jiangsu, 215500, PR China
| | - Xiang Yu
- Department of Nephrology, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing City, Jiangsu, 210000, PR China
| | - Jin Wang
- Department of Gastroenterology, Affiliated Hospital of Jiangnan University, 1000 Hefeng Road, Binhu District of Wuxi, Jiangsu, 214000, PR China
| | - Leiping Gao
- Department of Nephrology, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, 6 Huanghe Road, Changshu City, Jiangsu, 215500, PR China
| | - Zhiwei Miao
- Department of Gastroenterology, Zhangjiagang TCM Hospital Affiliated to Nanjing University of Chinese Medicine, 77 Changan South Road, Zhangjiagang, 215600, PR China
| | - Wei Kong
- Department of Nephrology, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, 157 Daming Road, Nanjing City, Jiangsu, 210000, PR China
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Chung EYM, Wang YM, Keung K, Hu M, McCarthy H, Wong G, Kairaitis L, Bose B, Harris DCH, Alexander SI. Membranous nephropathy: Clearer pathology and mechanisms identify potential strategies for treatment. Front Immunol 2022; 13:1036249. [PMID: 36405681 PMCID: PMC9667740 DOI: 10.3389/fimmu.2022.1036249] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022] Open
Abstract
Primary membranous nephropathy (PMN) is one of the common causes of adult-onset nephrotic syndrome and is characterized by autoantibodies against podocyte antigens causing in situ immune complex deposition. Much of our understanding of the disease mechanisms underpinning this kidney-limited autoimmune disease originally came from studies of Heymann nephritis, a rat model of PMN, where autoantibodies against megalin produced a similar disease phenotype though megalin is not implicated in human disease. In PMN, the major target antigen was identified to be M-type phospholipase A2 receptor 1 (PLA2R) in 2009. Further utilization of mass spectrometry on immunoprecipitated glomerular extracts and laser micro dissected glomeruli has allowed the rapid discovery of other antigens (thrombospondin type-1 domain-containing protein 7A, neural epidermal growth factor-like 1 protein, semaphorin 3B, protocadherin 7, high temperature requirement A serine peptidase 1, netrin G1) targeted by autoantibodies in PMN. Despite these major advances in our understanding of the pathophysiology of PMN, treatments remain non-specific, often ineffective, or toxic. In this review, we summarize our current understanding of the immune mechanisms driving PMN from animal models and clinical studies, and the implications on the development of future targeted therapeutic strategies.
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Affiliation(s)
- Edmund Y. M. Chung
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
| | - Yuan M. Wang
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
| | - Karen Keung
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Min Hu
- The Centre for Transplant and Renal Research, Westmead Institute of Medical Research, Westmead, NSW, Australia
| | - Hugh McCarthy
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, Sydney Children’s Hospital, Randwick, NSW, Australia
| | - Germaine Wong
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, Westmead Hospital, Westmead, NSW, Australia
| | - Lukas Kairaitis
- Department of Nephrology, Blacktown Hospital, Blacktown, NSW, Australia
| | - Bhadran Bose
- Department of Nephrology, Nepean Hospital, Kingswood, NSW, Australia
| | - David C. H. Harris
- The Centre for Transplant and Renal Research, Westmead Institute of Medical Research, Westmead, NSW, Australia
- Department of Nephrology, Westmead Hospital, Westmead, NSW, Australia
| | - Stephen I. Alexander
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, The Children’s Hospital at Westmead, Westmead, NSW, Australia
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Storrar J, Gill-Taylor T, Chinnadurai R, Chrysochou C, Poulikakos D, Rainone F, Ritchie J, Lamerton E, Kalra PA, Sinha S. A low rate of end-stage kidney disease in membranous nephropathy: A single centre study over 2 decades. PLoS One 2022; 17:e0276053. [PMID: 36228014 PMCID: PMC9560622 DOI: 10.1371/journal.pone.0276053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/27/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Membranous nephropathy is the commonest cause of nephrotic syndrome in non-diabetic Caucasian adults over the age of 40 years. Primary membranous nephropathy is limited to the kidneys. Clinical management aims to induce remission, either spontaneously with supportive care, or with immunosuppression. Here, we describe the natural history of this condition in a large tertiary centre in the UK. METHODS 178 patients with primary membranous nephropathy were identified over 2 decades. We collected data on demographics, baseline laboratory values, treatment received and outcomes including progression to renal replacement therapy and death. Analysis was performed on the whole cohort and specific subgroups. Univariate and multivariate Cox regression was also performed. RESULTS Median age was 58.3 years with 63.5% male. Median baseline creatinine was 90μmol/L and urine protein-creatinine ratio 664g/mol. Remission (partial or complete) was achieved in 134 (75.3%), either spontaneous in 60 (33.7%) or after treatment with immunosuppression in 74 (41.6%), and of these 57 (42.5%) relapsed. Progression to renal replacement therapy was seen in 10.1% (much lower than classically reported) with mortality in 29.8%. Amongst the whole cohort, those who went into remission had improved outcomes compared to those who did not go into remission (less progression to renal replacement therapy [4.5% vs 28%] and death [20.1% vs 67%]. Those classified as high-risk (based on parameters including eGFR, proteinuria, serum albumin, PLA2R antibody level, rate of renal function decline) also had worse outcomes than those at low-risk (mortality seen in 52.6% vs 10.8%, p<0.001). The median follow-up period was 59.5 months. CONCLUSION We provide a comprehensive epidemiologic analysis of primary membranous nephropathy at a large tertiary UK centre. Only 10.1% progressed to renal replacement therapy. For novelty, the KDIGO risk classification was linked to outcomes, highlighting the utility of this classification system for identifying patients most likely to progress.
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Affiliation(s)
- Joshua Storrar
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
- University of Manchester, Manchester, United Kingdom
- * E-mail:
| | - Tarra Gill-Taylor
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Rajkumar Chinnadurai
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Constantina Chrysochou
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Dimitrios Poulikakos
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Francesco Rainone
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - James Ritchie
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Elizabeth Lamerton
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Philip A. Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
| | - Smeeta Sinha
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
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10
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Liu J, Li X, Huang T, Xu G. Efficacy and safety of 12 immunosuppressive agents for idiopathic membranous nephropathy in adults: A pairwise and network meta-analysis. Front Pharmacol 2022; 13:917532. [PMID: 35959430 PMCID: PMC9358043 DOI: 10.3389/fphar.2022.917532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/27/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Immunosuppressants have been applied in the remedy of idiopathic membranous nephropathy (IMN) extensively. Nevertheless, the efficacy and safety of immunosuppressants do not have final conclusion. Thus, a pairwise and network meta-analysis (NMA) was carried out to seek the most recommended therapeutic schedule for patients with IMN. Methods: Randomized controlled trials (RCTs) including cyclophosphamide (CTX), mycophenolate mofetil (MMF), tacrolimus-combined mycophenolate mofetil (TAC + MMF), cyclosporine (CsA), tacrolimus (TAC), leflunomide (LEF), chlorambucil (CH), azathioprine (AZA), adrenocorticotropic hormone (ACTH), non-immunosuppressive therapies (CON), steroids (STE), mizoribine (MZB), and rituximab (RIT) for patients with IMN were checked. Risk ratios (RRs) and standard mean difference (SMD) were reckoned to assess dichotomous variable quantities and continuous variable quantities, respectively. Total remission (TR) and 24-h urine total protein (24-h UTP) were compared using pairwise and NMA. Then interventions were ranked on the basis of the surface under the cumulative ranking curve (SUCRA). Results: Our study finally included 51 RCTs and 12 different immunosuppressants. Compared with the CON group, most regimens demonstrated better therapeutic effect in TR, with RR of 2.1 (95% CI) (1.5–2.9) for TAC, 1.9 (1.3–2.8) for RIT, 2.5 (1.2–5.2) for TAC + MMF, 1.9 (1.4–2.7) for CH, 1.8 (1.4–2.4) for CTX, 2.2 (1.0–4.7) for ACTH, 1.6 (1.2–2.1) for CsA, 1.6 (1.0–2.5) for LEF, and 1.6 (1.1–2.2) for MMF. In terms of 24-h UTP, TAC (SMD, −2.3 (95% CI −3.5 to −1.1)), CTX (SMD, −1.7 (95% CI −2.8 to −0.59)), RIT (SMD, −1.8 (95% CI −3.5 to −0.11)), CH (SMD, −2.4 (95% CI −4.3 to −0.49)), AZA (SMD, −−4.2 (95% CI −7.7 to −0.68)), and CsA (SMD, −1.7 (95% CI −3 to −0.49)) were significantly superior than the CON group. As for adverse effects (AEs), infections, nausea, emesia, myelosuppression, and glucose intolerance were the collective adverse events for most immunosuppressants. Conclusion: This study indicates that TAC + MMF performed the best in terms of TR, and TAC shows the best effectiveness on 24-h UTP compared with other regimens. On the contrary, there seems to be little advantage on STE alone, LEF, AZA, and MZB in treating patients with IMN compared with CON. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021287013]
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Scolari F, Alberici F, Mescia F, Delbarba E, Trujillo H, Praga M, Ponticelli C. Therapies for Membranous Nephropathy: A Tale From the Old and New Millennia. Front Immunol 2022; 13:789713. [PMID: 35300332 PMCID: PMC8921478 DOI: 10.3389/fimmu.2022.789713] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/07/2022] [Indexed: 11/13/2022] Open
Abstract
Primary Membranous Nephropathy (PMN) is the most frequent cause of nephrotic syndrome in adults. If untreated, PMN can lead to end-stage renal disease; moreover, affected patients are at increased risk of complications typical of nephrotic syndrome such as fluid overload, deep vein thrombosis and infection. The association of PMN with HLA-DQA1 and the identification in around 70% of cases of circulating autoantibodies, mainly directed towards the phospholipase A2 receptor, supports the autoimmune nature of the disease. In patients not achieving spontaneous remission or in the ones with deteriorating kidney function and severe nephrotic syndrome, immunosuppression is required to increase the chances of achieving remission. The aim of this review is to discuss the evidence base for the different immunosuppressive regimens used for PMN in studies published so far; the manuscript also includes a section where the authors propose, based upon current evidence, their recommendations regarding immunosuppression in the disease, while highlighting the still significant knowledge gaps and uncertainties.
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Affiliation(s)
- Francesco Scolari
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Federica Mescia
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Elisa Delbarba
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Hernando Trujillo
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Department of Nephrology, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.,Department of Nephrology, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
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12
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Neuen BL, Tighiouart H, Heerspink HJ, Vonesh EF, Chaudhari J, Miao S, Chan TM, Fervenza FC, Floege J, Goicoechea M, Herrington WG, Imai E, Jafar TH, Lewis JB, Li PKT, Locatelli F, Maes BD, Perrone RD, Praga M, Perna A, Schena FP, Wanner C, Wetzels JF, Woodward M, Xie D, Greene T, Inker LA. Acute Treatment Effects on GFR in Randomized Clinical Trials of Kidney Disease Progression. J Am Soc Nephrol 2022; 33:291-303. [PMID: 34862238 PMCID: PMC8819983 DOI: 10.1681/asn.2021070948] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/28/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Acute changes in GFR can occur after initiation of interventions targeting progression of CKD. These acute changes complicate the interpretation of long-term treatment effects. METHODS To assess the magnitude and consistency of acute effects in randomized clinical trials and explore factors that might affect them, we performed a meta-analysis of 53 randomized clinical trials for CKD progression, enrolling 56,413 participants with at least one estimated GFR measurement by 6 months after randomization. We defined acute treatment effects as the mean difference in GFR slope from baseline to 3 months between randomized groups. We performed univariable and multivariable metaregression to assess the effect of intervention type, disease state, baseline GFR, and albuminuria on the magnitude of acute effects. RESULTS The mean acute effect across all studies was -0.21 ml/min per 1.73 m2 (95% confidence interval, -0.63 to 0.22) over 3 months, with substantial heterogeneity across interventions (95% coverage interval across studies, -2.50 to +2.08 ml/min per 1.73 m2). We observed negative average acute effects in renin angiotensin system blockade, BP lowering, and sodium-glucose cotransporter 2 inhibitor trials, and positive acute effects in trials of immunosuppressive agents. Larger negative acute effects were observed in trials with a higher mean baseline GFR. CONCLUSION The magnitude and consistency of acute GFR effects vary across different interventions, and are larger at higher baseline GFR. Understanding the nature and magnitude of acute effects can help inform the optimal design of randomized clinical trials evaluating disease progression in CKD.
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Affiliation(s)
- Brendon L. Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands
| | - Edward F. Vonesh
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Fernando C. Fervenza
- Division of Nephrology and Hypertension and Department of Medicine, Mayo Clinic Rochester, Minnesota
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - William G. Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Julia B. Lewis
- Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Philip Kam-Tao Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Bart D. Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | | | - Manuel Praga
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P. Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Jack F.M. Wetzels
- Department of Nephrology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Imperial College London, United Kingdom
| | - Di Xie
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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13
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von Groote TC, Williams G, Au EH, Chen Y, Mathew AT, Hodson EM, Tunnicliffe DJ. Immunosuppressive treatment for primary membranous nephropathy in adults with nephrotic syndrome. Cochrane Database Syst Rev 2021; 11:CD004293. [PMID: 34778952 PMCID: PMC8591447 DOI: 10.1002/14651858.cd004293.pub4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Primary membranous nephropathy (PMN) is a common cause of nephrotic syndrome in adults. Without treatment, approximately 30% of patients will experience spontaneous remission and one third will have persistent proteinuria. Approximately one-third of patients progress toward end-stage kidney disease (ESKD) within 10 years. Immunosuppressive treatment aims to protect kidney function and is recommended for patients who do not show improvement of proteinuria by supportive therapy, and for patients with severe nephrotic syndrome at presentation due to the high risk of developing ESKD. The efficacy and safety of different immunosuppressive regimens are unclear. This is an update of a Cochrane review, first published in 2004 and updated in 2013. OBJECTIVES The aim was to evaluate the safety and efficacy of different immunosuppressive treatments for adult patients with PMN and nephrotic syndrome. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 1 April 2021 with support from the Cochrane Kidney and Transplant Information Specialist using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) investigating effects of immunosuppression in adults with PMN and nephrotic syndrome were included. DATA COLLECTION AND ANALYSIS Study selection, data extraction, quality assessment, and data synthesis were performed using Cochrane-recommended methods. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS Sixty-five studies (3807 patients) were included. Most studies exhibited a high risk of bias for the domains, blinding of study personnel, participants and outcome assessors, and most studies were judged unclear for randomisation sequence generation and allocation concealment. Immunosuppressive treatment versus placebo/no treatment/non-immunosuppressive treatment In moderate certainty evidence, immunosuppressive treatment probably makes little or no difference to death, probably reduces the overall risk of ESKD (16 studies, 944 participants: RR 0.59, 95% CI 0.35 to 0.99; I² = 22%), probably increases total remission (complete and partial) (6 studies, 879 participants: RR 1.44, 95% CI 1.05 to 1.97; I² = 73%) and complete remission (16 studies, 879 participants: RR 1.70, 95% CI 1.05 to 2.75; I² = 43%), and probably decreases the number with doubling of serum creatinine (SCr) (9 studies, 447 participants: RR 0.46, 95% CI 0.26 to 0.80; I² = 21%). However, immunosuppressive treatment may increase the number of patients relapsing after complete or partial remission (3 studies, 148 participants): RR 1.73, 95% CI 1.05 to 2.86; I² = 0%) and may lead to a greater number experiencing temporary or permanent discontinuation/hospitalisation due to adverse events (18 studies, 927 participants: RR 5.33, 95% CI 2.19 to 12.98; I² = 0%). Immunosuppressive treatment has uncertain effects on infection and malignancy. Oral alkylating agents with or without steroids versus placebo/no treatment/steroids Oral alkylating agents with or without steroids had uncertain effects on death but may reduce the overall risk of ESKD (9 studies, 537 participants: RR 0.42, 95% CI 0.24 to 0.74; I² = 0%; low certainty evidence). Total (9 studies, 468 participants: RR 1.37, 95% CI 1.04 to 1.82; I² = 70%) and complete remission (8 studies, 432 participants: RR 2.12, 95% CI 1.33 to 3.38; I² = 37%) may increase, but had uncertain effects on the number of patients relapsing, and decreasing the number with doubling of SCr. Alkylating agents may be associated with a higher rate of adverse events leading to discontinuation or hospitalisation (8 studies 439 participants: RR 6.82, 95% CI 2.24 to 20.71; I² = 0%). Oral alkylating agents with or without steroids had uncertain effects on infection and malignancy. Calcineurin inhibitors (CNI) with or without steroids versus placebo/no treatment/supportive therapy/steroids We are uncertain whether CNI with or without steroids increased or decreased the risk of death or ESKD, increased or decreased total or complete remission, or reduced relapse after complete or partial remission (low to very low certainty evidence). CNI also had uncertain effects on decreasing the number with a doubling of SCr, temporary or permanent discontinuation or hospitalisation due to adverse events, infection, or malignancy. Calcineurin inhibitors (CNI) with or without steroids versus alkylating agents with or without steroids We are uncertain whether CNI with or without steroids increases or decreases the risk of death or ESKD. CNI with or without steroids may make little or no difference to total remission (10 studies, 538 participants: RR 1.01, 95% CI 0.89 to 1.15; I² = 53%; moderate certainty evidence) or complete remission (10 studies, 538 participants: RR 1.15, 95% CI 0.84 to 1.56; I² = 56%; low certainty evidence). CNI with or without steroids may increase relapse after complete or partial remission. CNI with or without steroids had uncertain effects on SCr increase, adverse events, infection, and malignancy. Other immunosuppressive treatments Other interventions included azathioprine, mizoribine, adrenocorticotropic hormone, traditional Chinese medicines, and monoclonal antibodies such as rituximab. There were insufficient data to draw conclusions on these treatments. AUTHORS' CONCLUSIONS This updated review strengthened the evidence that immunosuppressive therapy is probably superior to non-immunosuppressive therapy in inducing remission and reducing the number of patients that progress to ESKD. However, these benefits need to be balanced against the side effects of immunosuppressive drugs. The number of included studies with high-quality design was relatively small and most studies did not have adequate follow-up. Clinicians should inform their patients of the lack of high-quality evidence. An alkylating agent (cyclophosphamide or chlorambucil) combined with a corticosteroid regimen had short- and long-term benefits, but this was associated with a higher rate of adverse events. CNI (tacrolimus and cyclosporin) showed equivalency with alkylating agents however, the certainty of this evidence remains low. Novel immunosuppressive treatments with the biologic rituximab or use of adrenocorticotropic hormone require further investigation and validation in large and high-quality RCTs.
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Affiliation(s)
- Thilo C von Groote
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University Hosptial Münster, Münster, Germany
| | | | - Eric H Au
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
- Department of Renal Medicine, Westmead Hospital, Westmead, Australia
| | - Yizhi Chen
- Department of Nephrology, Hainan Hospital of Chinese PLA General Hospital, Hainan Provincial Academician Team Innovation Center, Sanya, China
- Senior Department of Nephrology, the First Medical Center of Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Kidney Disease Research, Beijing, China
| | - Anna T Mathew
- Department of Nephrology, McMaster University, Hamilton, Canada
| | - Elisabeth M Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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14
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Dong Z, Dai H, Gao Y, Jiang H, Liu M, Liu F, Liu W, Feng Z, Zhang X, Ren A, Li X, Rui H, Tian X, Li G, Liu B. Effect of Mahuang Fuzi and Shenzhuo Decoction on Idiopathic Membranous Nephropathy: A Multicenter, Nonrandomized, Single-Arm Clinical Trial. Front Pharmacol 2021; 12:724744. [PMID: 34733157 PMCID: PMC8558382 DOI: 10.3389/fphar.2021.724744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/09/2021] [Indexed: 11/23/2022] Open
Abstract
Objective: To explore the clinical effect of Mahuang Fuzi and Shenzhuo Decoction on idiopathic membranous nephropathy. Methods: This study is a multicenter, nonrandomized, single-arm clinical trial carried out as per the objective performance criteria, with the target being set at 35.0%. 184 cases of patients suffering from idiopathic membranous nephropathy with Shaoyin Taiyin syndrome were collected. These patients were treated with Mahuang Fuzi and Shenzhuo Decoction with a follow-up period of 3 years. The 24-hour urine protein and blood albumin were observed, and the remission rates of the patients were compared with the target. Results: The mean follow-up time was 18 (12.5, 30) months, and the remission rate was 61.4%, which is a statistically significant difference from the target group of 35%. The remission rates for patients who had and had not used immunosuppressive therapy were 59.6 and 65.5%, respectively, but the difference was not statistically significant (p = 0.254). However, the albumin before the treatment and the course of treatment of the patients was significantly correlated with the disease remission (p < 0.05). However, the albumin before the treatment and the course of treatment of the patients was significantly correlated with the disease remission (p < 0.05). There were no significant changes in renal function before and after treatment, and no severe adverse events occurred during treatment. Conclusion: Mahuang Fuzi and Shenzhuo Decoction have significant effects on idiopathic membranous nephropathy, and has the same effect on patients with membranous nephropathy who are newly treated as well as those who have been treated with immunosuppressive therapy without remission. In addition, the efficacy of this regimen is related to the albumin and the duration of the therapy, but not to 24-hour urine protein or other factors.
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Affiliation(s)
- Zhaocheng Dong
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Haoran Dai
- Shunyi Branch, Beijing Traditional Chinese Medicine Hospital, Beijing, China
| | - Yu Gao
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China.,Capital Medical University, Beijing, China
| | - Hanxue Jiang
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Meiqi Liu
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China.,Beijing University of Chinese Medicine, Beijing, China
| | - Fei Liu
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China.,Beijing University of Chinese Medicine, Beijing, China
| | - Wenbin Liu
- Beijing University of Chinese Medicine, Beijing, China
| | - Zhendong Feng
- Beijing Chinese Medicine Hospital Pinggu Hospital, Beijing, China
| | - Xiaoyan Zhang
- Yanqing Hospital of Beijing Chinese Medicine Hospital, Beijing, China
| | - Aijie Ren
- Tangshan Fengrun Hospital of Traditional Chinese Medicine, Tangshan, China
| | - Xiaolan Li
- Zhangjiakou Hospital of Traditional Chinese Medicine, Zhangjiakou, China
| | - Hongliang Rui
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Xuefei Tian
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Guiming Li
- Department of Nephrology, Feicheng Mining Center Hospital, Tai'an, China
| | - Baoli Liu
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China.,Shunyi Branch, Beijing Traditional Chinese Medicine Hospital, Beijing, China
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15
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 787] [Impact Index Per Article: 262.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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16
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Ponticelli C, Patrizia P, Del Vecchio L, Locatelli F. The evolution of the therapeutic approach to membranous nephropathy. Nephrol Dial Transplant 2021; 36:768-773. [PMID: 32206786 DOI: 10.1093/ndt/gfaa014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Indexed: 01/12/2023] Open
Abstract
Primary membranous nephropathy (MN) is a frequent cause of nephrotic syndrome (NS) in adults. In untreated patients, the outcome is variable, with one-third of the patients entering remission while the remaining ones show persisting proteinuria or progression to end-stage renal disease. Randomized clinical trials reported the efficacy of a 6-month regimen alternating intravenous and oral glucocorticoids with an alkylating agent every other month. The potential side effects of this regimen were limited by the fact that the use of glucocorticoids and alkylating agent did not exceed 3 months each. Two randomized trials with follow-ups (FU) up to 10 years provided assurance about the long-term efficacy and safety of this cyclical therapy. Calcineurin inhibitors have also been used successfully. However, in most responders, NS relapsed after the drug was withdrawn. Conflicting results have been reported with mycophenolate salts and adrenocorticotropic hormone. Observational studies reported good results with rituximab (RTX). Two controlled trials demonstrated the superiority of RTX over antiproteinuric therapy alone and cyclosporine. However, the FUs were relatively short and no randomized trial has been published against cyclical therapy. The available results, together with the discovery that most patients with MN have circulating antibodies against the phospholipase A2 receptor 1, support the use of cytotoxic drugs or RTX in MN. It is difficult to choose between these two different treatments. RTX is easier to use, but the FUs of the available studies are short, thus doubts remain about the long-term risk of relapses and the safety of repeated administrations of RTX.
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Affiliation(s)
| | - Passerini Patrizia
- Nephrology, Dialysis and Renal Transplant Unit, Fondazione IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Francesco Locatelli
- Past Director, Department of Nephrology and Dialysis, ASST Lecco, Lecco, Italy
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17
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Sabiu G, Podestà MA. Membranous Nephropathy: It Is Time to Go Back to the Future. Nephron Clin Pract 2021; 145:721-727. [PMID: 34225270 DOI: 10.1159/000516984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 05/01/2021] [Indexed: 11/19/2022] Open
Abstract
CONTEXT Membranous nephropathy (MN) is an immune-mediated glomerular disease that can lead to nephrotic syndrome and progressive kidney function loss. The cyclic steroid-cyclophosphamide regimen (the modified Ponticelli protocol) and the monoclonal anti-CD20 antibody rituximab have been advocated as effective therapies to improve renal outcomes, but a direct comparison of these treatments had never been carried out in a prospective study. Subject of Review: Scolari et al. [J Am Soc Nephrol. 2021;32:972-82] recently reported the results of a pilot randomized controlled trial (RI-CYCLO) designed to provide direct estimates of the effect of rituximab (1 g × 2) compared to the cyclic steroid-cyclophosphamide regimen in 74 patients with MN. The proportion of patients with complete remission at 12 months was higher in the cyclic regimen arm than that of rituximab (32 and 16%, respectively), but the difference was not statistically significant in intention-to-treat analyses. Interestingly, differences in the cumulative incidence of complete and partial remissions between treatment arms progressively reduced over the follow-up and became virtually nonexistent from 24 months (>80% in both groups). The frequency of serious and nonserious adverse events was similar between the 2 treatment arms. Infusion reactions and drug discontinuation were more common with rituximab, while infections and leukopenia were more frequently observed with the cyclic regimen. The risk of cancer was similar in the 2 allocation groups, but the limited follow-up length did not allow to draw definitive conclusions. Independent of treatment allocation, 18% of patients experienced at least 1 relapse after achieving complete or partial remission. Second Opinion: Notwithstanding the intrinsic limitations of a pilot study, the RI-CYCLO trial represents an important milestone in the treatment of MN. Findings from this study support the hypothesis that the cyclic regimen and rituximab may have comparable efficacy in inducing disease remission over the long term. Considering its potentially better-albeit not yet formally proven-long-term safety profile, rituximab could be considered as a first-line therapy for most patients with MN. Several questions remain to be addressed, including rituximab ideal dose and its efficacy in patients with a significant reduction in glomerular filtration rate. In light of RI-CYCLO results, a large-scale trial to assess rituximab noninferiority to the cyclic regimen would require the enrollment of thousands of patients, and it would be probably unfeasible within a reasonable time frame. In our opinion, resources should be allocated to provide an answer to the pressing matter of treatment nonresponse and intolerance, which may be addressed in the near future with novel therapeutic strategies.
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Affiliation(s)
- Gianmarco Sabiu
- Nephrology Unit, ASST Fatebenefratelli Sacco, Department of Biomedical and Clinical Sciences "Luigi Sacco," University of Milan, Milan, Italy
| | - Manuel Alfredo Podestà
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
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18
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Dai P, Xie W, Yu X, Sun J, Wang S, Kawuki J. Efficacy and cost of different treatment in patients with idiopathic membranous nephropathy: A network meta-analysis and cost-effectiveness analysis. Int Immunopharmacol 2021; 94:107376. [PMID: 33582591 DOI: 10.1016/j.intimp.2021.107376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/21/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) is the most common pathological type of adult nephrotic syndrome. However, the treatments for IMN patients had not been compared from the perspectives of therapeutic effect and pharmacoeconomics. Therefore, a network meta-analysis and a cost-effectiveness analysis were conducted to find the optimum treatment for IMN patients. METHODS Randomized controlled trials (RCTs) which compared the treatments including cyclophosphamide (CTX), mycophenolate mofetil (MMF), cyclosporine (CsA), tacrolimus (TAC), leflunomide (LEF), chlorambucil (CLB) and rituximab (RTX) for patients with IMN were reviewed. The complete and partial remission rates were extracted and then compared by network meta-analysis. The surface under the cumulative ranking area (SUCRA) was calculated to rank the remission rate for all treatments. Then, the cost-effectiveness analysis was performed to compared the incremental cost-effectiveness ratio (ICER) of different treatments. RESULTS A total of 75 articles with 4806 participants were included according to the inclusion and exclusion criteria. Compared with the glucocorticoids (GC) group, CTX + GC (95%RR 1.02,1.76), CsA + GC (95%RR 1.11,2.13) and TAC + GC (95%RR 1.44,2.59) were associated with a significantly higher rate of complete remission. TAC + GC were most likely to be ranked the best (SUCRA of 92.1%). From the perspective of the cost-effectiveness analysis in China, the ICER of LEF + GC to CTX + GC was $30616.336 per unit utility, and that of TAC + GC to CTX + GC was $670475.210 per unit utility. And the ICER of CTX + GC to LEF + GC in the UK was $-65680.879 per unit utility. CONCLUSIONS CTX + GC was the cheapest treatment with obvious curative effect in China, while LEF + GC was a cost-effective alternative to CTX + GC. The remission rate of TAC + GC was highest despite the high single-dose cost.
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Affiliation(s)
- Pinyuan Dai
- Department of Epidemiology and Health Statistics, School of Public Health, Southeast University, Nanjing, Jiangsu 210009, China.
| | - Weihua Xie
- Department of Quality Management, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
| | - Xiaojin Yu
- Department of Epidemiology and Health Statistics, School of Public Health, Southeast University, Nanjing, Jiangsu 210009, China.
| | - Jinfang Sun
- Department of Epidemiology and Health Statistics, School of Public Health, Southeast University, Nanjing, Jiangsu 210009, China.
| | - Shiyuan Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Southeast University, Nanjing, Jiangsu 210009, China.
| | - Joseph Kawuki
- Centre for Health Behaviours Research, JC School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong 999077, Hong Kong.
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19
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Bobkova IN, Kamyshova ES. Modern view on treatment of membranous nephropathy. TERAPEVT ARKH 2020; 92:99-104. [DOI: 10.26442/00403660.2020.06.000676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Indexed: 11/22/2022]
Abstract
Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in adults. Since the moment of animal model creation and the recognition of podocytes damage as a key mechanism of MN development, the identification of antigens, first of all the phospholipase A2 receptor (PLA2R), and the development of methods of PLA2R autoantibodies detection and its monitoring opened a new era in the idiopathic MN (iMN) diagnosis, treatment and prognosis evaluation. MN continues to be actively studied in the new millennium, since a number of aspects of its pathogenesis still need to be clarified, and there is still no clear opinion on the iMN treatment optimal approach.
Comprehensive clinical and serological assessment of patients with iMN can be the key to individual choice of treatment protocols. In patients with aPLA2R-positive iMN, the predictor of disease remission is the aPLA2R titer decrease or aPLA2R disappearance in the blood serum, and disease relapse is associated with the aPLA2R appearance ore increase of aPLA2R titer in the circulation. Studies which were conducted by today (GEMRITUX, MENTOR, STARMEN, NICE, etc.) confirmed the acceptable safety profile and effectiveness of iMN therapy by anti-CD20 monoclonal antibodies (rituximab): more than half of of iMN patients had remission of nephrotic syndrome or proteinuria decrease, remissions in anti-CD20 monoclonal antibodies treated patients were longer compared to traditional therapy. The obtained data allows us to consider rituximab and anti-CD20 antibody therapy of a new generation not only as an alternative to the more toxic treatment with cyclophosphane and calcineurin inhibitors, but as an independent promising direction of therapy for patients with IMN, which completely changes the paradigm of treatment of this glomerulopathy.
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Chang R, Chen L, Su G, Du L, Qin Y, Xu J, Tan H, Zhou C, Cao Q, Yuan G, Kijlstra A, Yang P. Identification of Ribosomal Protein S4, Y-Linked 1 as a cyclosporin A plus corticosteroid resistance gene. J Autoimmun 2020; 112:102465. [PMID: 32331925 DOI: 10.1016/j.jaut.2020.102465] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 02/06/2023]
Abstract
Combination of corticosteroids (CS) with cyclosporin A (CsA) is widely used in the treatment of autoimmune diseases, autoinflammatory diseases and transplantation rejection. However, some patients fail to respond or develop resistance to the combination regimen. In Vogt-Koyanagi-Harada (VKH) disease model, we performed RNA sequencing (RNA-seq) based transcriptomics, isobaric tags for relative and absolute quantification (iTRAQ) based proteomics and assays in vitro to screen and validate potential resistant molecules. We found that a total of 1697 differentially expressed genes (DEGs) and 21 differentially expressed proteins (DEPs) in CD4+ T cells between CsA & CS-resistant and -sensitive VKH patients. Ribosomal Protein S4, Y-Linked 1 (RPS4Y1) was verified to regulate the resistance of CD4+ T cells from male VKH patients to CsA & CS. Importantly, we showed that chlorambucil (CLB) could reverse the resistance by RPS4Y1 suppression. Taken together, we identify RPS4Y1 as an important CsA & CS resistance gene in VKH disease. Researchers should consider validating the resistant effect of RPS4Y1 in other autoimmune diseases or organ transplantation.
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Affiliation(s)
- Rui Chang
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Lab of Ophthalmology, Chongqing Eye Institute, Chongqing, PR China
| | - Lin Chen
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Lab of Ophthalmology, Chongqing Eye Institute, Chongqing, PR China
| | - Guannan Su
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Lab of Ophthalmology, Chongqing Eye Institute, Chongqing, PR China
| | - Liping Du
- Department of Ophthalmology, The First Affiliated Hospital of Zhengzhou University, Henan Province Eye Hospital, Henan International Joint Research Laboratory for Ocular Immunology and Retinal Injury Repair, Zhengzhou, PR China
| | - Yang Qin
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Lab of Ophthalmology, Chongqing Eye Institute, Chongqing, PR China
| | - Jing Xu
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Lab of Ophthalmology, Chongqing Eye Institute, Chongqing, PR China
| | - Handan Tan
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Lab of Ophthalmology, Chongqing Eye Institute, Chongqing, PR China
| | - Chunjiang Zhou
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Lab of Ophthalmology, Chongqing Eye Institute, Chongqing, PR China
| | - Qingfeng Cao
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Lab of Ophthalmology, Chongqing Eye Institute, Chongqing, PR China
| | - Gangxiang Yuan
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Lab of Ophthalmology, Chongqing Eye Institute, Chongqing, PR China
| | - Aize Kijlstra
- University Eye Clinic Maastricht, Maastricht, the Netherlands
| | - Peizeng Yang
- The First Affiliated Hospital of Chongqing Medical University, Chongqing Key Lab of Ophthalmology, Chongqing Eye Institute, Chongqing, PR China.
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Zheng Q, Yang H, Liu W, Sun W, Zhao Q, Zhang X, Jin H, Sun L. Comparative efficacy of 13 immunosuppressive agents for idiopathic membranous nephropathy in adults with nephrotic syndrome: a systematic review and network meta-analysis. BMJ Open 2019; 9:e030919. [PMID: 31511292 PMCID: PMC6738938 DOI: 10.1136/bmjopen-2019-030919] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 07/05/2019] [Accepted: 08/19/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study aimed to compare the effectiveness of 13 types of immunosuppressive agents used to treat idiopathic membranous nephropathy (IMN) in adults with nephrotic syndrome. DESIGN Systematic review and network meta-analysis. DATA SOURCES PubMed, EMbase, Cochrane Library, Web of Science, Clinical trials, SinoMed, Chinese Biomedicine, CNKI, WanFang and Chongqing VIP Information databases were comprehensively searched until February 2018. ELIGIBILITY CRITERIA Randomised clinical trials (RCTs) comparing the effects of different immunosuppressive treatments in adult patients with IMN and nephrotic syndrome were included, and all included RCTs had a study-duration of at least 6 months. DATA EXTRACTION AND SYNTHESIS Two reviewers independently screened articles, extracted data and assessed study quality. Standard pairwise meta-analysis was performed using DerSimonian-Laird random-effects model. RESULTS This study ultimately included 48 RCTs with 2736 patients and 13 immunosuppressive agents. The network meta-analysis results showed that most regimens, except for leflunomide (LEF), mizoribine (MZB) and steroids (STE), showed significantly higher probabilities of total remission (TR) when compared with non-immunosuppressive therapies (the control group),with risk ratios (RRs) of 2.71 (95% CI) 1.81 to 4.06)for tacrolimus+tripterygium wilfordii (TAC+TW), 2.16 (1.27 to 3.69) foradrenocorticotropic hormone, 2.02 (1.64 to 2.49) for TAC, 2.03 (1.13 to3.64) for azathioprine (AZA), 1.91 (1.46 to 2.50) for cyclosporine (CsA), 1.86 (1.44 to2.42) for mycophenolate mofetil (MMF), 1.85 (1.52 to 2.25) for cyclophosphamide (CTX),1.81 (1.10 to 2.98) for rituximab (RIT), 1.80 (1.38 to 2.33) for TW, 1.72 (1.35 to 2.19) for chlorambucil. As for 24 hours UTP, the direct andindirect comparisons showed that AZA (standard mean difference (SMD), -1.02(95% CI -1.90 to -0.15)), CsA (SMD, -0.70 (95% CI -1.33 to -0.08)),CTX (SMD, -1.01 (95% CI -1.44 to -0.58)), MMF (SMD, -0.98 (95% CI -1.64 to -0.32)), MZB (SMD, -0.97 (95% CI -1.90 to-0.04]), TAC (SMD, -1.16 (95% CI -1.72 to -0.60)) and TAC+TW(SMD, -2.03 (95% CI -2.94 to -1.12)) could significantly superior thancontrol, except for chlorambucil, LEF, RIT and STE. Thechanges of serum creatinine (Scr) was not significantly different between eachtreatments of immunosuppressive agents and the control, except for STE whichhas the possibility of increasing Scr (SMD, 1.00 (95% CI 0.36 to 1.64)).Comparisons among all treatments of immunosuppressive agents showed nostatistical significance in the outcome of relapse. A drenocorticotropichormone (85.1%) showed the lowest probability of relapse under the cumulativeranking curve values among all immunosuppressants. Infection,gastrointestinal symptoms, and bone marrow suppression were the common adverseevents associated with most of the immunosuppressive therapies. CONCLUSIONS This study demonstrates that TAC+TW, TAC and CTX are superior to other immunosuppressive agents in terms of TR and 24 hours UTP. Moreover, they are all at risk of infection, gastrointestinal symptoms, and myelosuppression. Furthermore, TAC could increase the risk of glucose intolerance or new-onset diabetes mellitus. Conversely, STE alone, LEF and MZB seem to have little advantage in clinical treatment of IMN. PROSPERO REGISTRATION NUMBER CRD42018094228.
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Affiliation(s)
- Qiyan Zheng
- First Clinical Medical College, Beijing University of Chinese Medicine, Beijing, China
- Department of nephrology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Huisheng Yang
- Institute of Acupuncture and Moxibustion, China Academy of Chinese Medicine Science, Beijing, China
| | - Weijing Liu
- Department of nephrology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Weiwei Sun
- Department of nephrology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Qing Zhao
- First Clinical Medical College, Beijing University of Chinese Medicine, Beijing, China
- Department of nephrology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Xiaoxiao Zhang
- First Clinical Medical College, Beijing University of Chinese Medicine, Beijing, China
- Department of nephrology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Huanan Jin
- Department of nephrology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
| | - Luying Sun
- Department of nephrology, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Beijing University of Chinese Medicine Affiliated Dongzhimen Hospital, Beijing, China
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Inker LA, Heerspink HJL, Tighiouart H, Levey AS, Coresh J, Gansevoort RT, Simon AL, Ying J, Beck GJ, Wanner C, Floege J, Li PKT, Perkovic V, Vonesh EF, Greene T. GFR Slope as a Surrogate End Point for Kidney Disease Progression in Clinical Trials: A Meta-Analysis of Treatment Effects of Randomized Controlled Trials. J Am Soc Nephrol 2019; 30:1735-1745. [PMID: 31292197 DOI: 10.1681/asn.2019010007] [Citation(s) in RCA: 160] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/26/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Surrogate end points are needed to assess whether treatments are effective in the early stages of CKD. GFR decline leads to kidney failure, but regulators have not approved using differences in the change in GFR from the beginning to the end of a randomized, controlled trial as an end point in CKD because it is not clear whether small changes in the GFR slope will translate to clinical benefits. METHODS To assess the use of GFR slope as a surrogate end point for CKD progression, we performed a meta-analysis of 47 RCTs that tested 12 interventions in 60,620 subjects. We estimated treatment effects on GFR slope (mean difference in GFR slope between the randomized groups), for the total slope starting at baseline, chronic slope starting at 3 months after randomization, and on the clinical end point (doubling of serum creatinine, GFR<15 ml/min per 1.73 m2, or ESKD) for each study. We used Bayesian mixed-effects analyses to describe the association of treatment effects on GFR slope with the clinical end point and to test how well the GFR slope predicts a treatment's effect on the clinical end point. RESULTS Across all studies, the treatment effect on 3-year total GFR slope (median R 2=0.97; 95% Bayesian credible interval [BCI], 0.78 to 1.00) and on the chronic slope (R 2 0.96; 95% BCI, 0.63 to 1.00) accurately predicted treatment effects on the clinical end point. With a sufficient sample size, a treatment effect of 0.75 ml/min per 1.73 m2/yr or greater on total slope over 3 years or chronic slope predicts a clinical benefit on CKD progress with at least 96% probability. CONCLUSIONS With large enough sample sizes, GFR slope may be a viable surrogate for clinical end points in CKD RCTs.
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Affiliation(s)
| | | | - Hocine Tighiouart
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts.,Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | | | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ron T Gansevoort
- Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Jian Ying
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Gerald J Beck
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Philip Kam-Tao Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong;
| | - Vlado Perkovic
- George Institute for Global Health, University of New South Wales, Sydney, Australia; and
| | - Edward F Vonesh
- Department of Preventive Medicine, Division of Biostatistics, Northwestern University, Chicago, Illinois
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
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23
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Fervenza FC, Appel GB, Barbour SJ, Rovin BH, Lafayette RA, Aslam N, Jefferson JA, Gipson PE, Rizk DV, Sedor JR, Simon JF, McCarthy ET, Brenchley P, Sethi S, Avila-Casado C, Beanlands H, Lieske JC, Philibert D, Li T, Thomas LF, Green DF, Juncos LA, Beara-Lasic L, Blumenthal SS, Sussman AN, Erickson SB, Hladunewich M, Canetta PA, Hebert LA, Leung N, Radhakrishnan J, Reich HN, Parikh SV, Gipson DS, Lee DK, da Costa BR, Jüni P, Cattran DC. Rituximab or Cyclosporine in the Treatment of Membranous Nephropathy. N Engl J Med 2019; 381:36-46. [PMID: 31269364 DOI: 10.1056/nejmoa1814427] [Citation(s) in RCA: 287] [Impact Index Per Article: 57.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND B-cell anomalies play a role in the pathogenesis of membranous nephropathy. B-cell depletion with rituximab may therefore be noninferior to treatment with cyclosporine for inducing and maintaining a complete or partial remission of proteinuria in patients with this condition. METHODS We randomly assigned patients who had membranous nephropathy, proteinuria of at least 5 g per 24 hours, and a quantified creatinine clearance of at least 40 ml per minute per 1.73 m2 of body-surface area and had been receiving angiotensin-system blockade for at least 3 months to receive intravenous rituximab (two infusions, 1000 mg each, administered 14 days apart; repeated at 6 months in case of partial response) or oral cyclosporine (starting at a dose of 3.5 mg per kilogram of body weight per day for 12 months). Patients were followed for 24 months. The primary outcome was a composite of complete or partial remission of proteinuria at 24 months. Laboratory variables and safety were also assessed. RESULTS A total of 130 patients underwent randomization. At 12 months, 39 of 65 patients (60%) in the rituximab group and 34 of 65 (52%) in the cyclosporine group had a complete or partial remission (risk difference, 8 percentage points; 95% confidence interval [CI], -9 to 25; P = 0.004 for noninferiority). At 24 months, 39 patients (60%) in the rituximab group and 13 (20%) in the cyclosporine group had a complete or partial remission (risk difference, 40 percentage points; 95% CI, 25 to 55; P<0.001 for both noninferiority and superiority). Among patients in remission who tested positive for anti-phospholipase A2 receptor (PLA2R) antibodies, the decline in autoantibodies to anti-PLA2R was faster and of greater magnitude and duration in the rituximab group than in the cyclosporine group. Serious adverse events occurred in 11 patients (17%) in the rituximab group and in 20 (31%) in the cyclosporine group (P = 0.06). CONCLUSIONS Rituximab was noninferior to cyclosporine in inducing complete or partial remission of proteinuria at 12 months and was superior in maintaining proteinuria remission up to 24 months. (Funded by Genentech and the Fulk Family Foundation; MENTOR ClinicalTrials.gov number, NCT01180036.).
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Affiliation(s)
- Fernando C Fervenza
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Gerald B Appel
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Sean J Barbour
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Brad H Rovin
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Richard A Lafayette
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Nabeel Aslam
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Jonathan A Jefferson
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Patrick E Gipson
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Dana V Rizk
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - John R Sedor
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - James F Simon
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Ellen T McCarthy
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Paul Brenchley
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Sanjeev Sethi
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Carmen Avila-Casado
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Heather Beanlands
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - John C Lieske
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - David Philibert
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Tingting Li
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Lesley F Thomas
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Dolly F Green
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Luis A Juncos
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Lada Beara-Lasic
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Samuel S Blumenthal
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Amy N Sussman
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Stephen B Erickson
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Michelle Hladunewich
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Pietro A Canetta
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Lee A Hebert
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Nelson Leung
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Jay Radhakrishnan
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Heather N Reich
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Samir V Parikh
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Debbie S Gipson
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Dominic K Lee
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Bruno R da Costa
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Peter Jüni
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
| | - Daniel C Cattran
- From the Mayo Clinic, Rochester, MN (F.C.F., S.S., J.C.L., S.B.E., N.L.); Columbia University (G.B.A., P.A.C., J.R.) and the New York University Medical Center (L.B.-L.) - both in New York; the University of British Columbia, Division of Nephrology, Vancouver (S.J.B.), the University Health Network, Toronto General Hospital (C.A.-C., H.N.R., D.C.C.), the Faculty of Community Services, Ryerson University (H.B.), and the Sunnybrook Health Science Centre (M.H.), the Applied Health Research Centre, Li Ka Shing Knowledge Institute of St. Michael's Hospital (D.K.L., B.R.C., P.J.), and the Department of Medicine and Institute of Health Policy, Management, and Evaluation, University of Toronto (B.R.C., P.J.), Toronto, and Centre Hospitalier Universitaire de Québec, Quebec, QC (D.P.) - all in Canada; Ohio State University, Columbus (B.H.R., L.A.H., S.V.P.); Stanford University, Stanford, CA (R.A.L.); the Mayo Clinic, Jacksonville (N.A.), and Florida International University, Miami (D.F.G.) - both in Florida; the University of Washington Medical Center, Seattle (J.A.J.); the University of Michigan Medical Center, Ann Arbor (P.E.G., D.S.G.); the University of Alabama at Birmingham, Birmingham (D.V.R.); Case Western Reserve University (J.R.S.) and the Cleveland Clinic (J.F.S.) - both in Cleveland; Kansas University Medical Center, Kansas City (E.T.M.); Manchester University, Manchester, United Kingdom (P.B.); Washington University School of Medicine, St. Louis (T.L.); the Mayo Clinic, Scottsdale (L.F.T.), and the University of Arizona, Tucson (A.N.S.) - both in Arizona; the University of Mississippi Medical Center, Jackson (L.A.J.); and the Medical College of Wisconsin, Froedtert Hospital, Milwaukee (S.S.B.)
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Yamamoto R, Imai E, Maruyama S, Yokoyama H, Sugiyama H, Nitta K, Tsukamoto T, Uchida S, Takeda A, Sato T, Wada T, Hayashi H, Akai Y, Fukunaga M, Tsuruya K, Masutani K, Konta T, Shoji T, Hiramatsu T, Goto S, Tamai H, Nishio S, Shirasaki A, Nagai K, Yamagata K, Hasegawa H, Yasuda H, Ichida S, Naruse T, Fukami K, Nishino T, Sobajima H, Tanaka S, Akahori T, Ito T, Yoshio T, Katafuchi R, Fujimoto S, Okada H, Ishimura E, Kazama JJ, Hiromura K, Mimura T, Suzuki S, Saka Y, Sofue T, Suzuki Y, Shibagaki Y, Kitagawa K, Morozumi K, Fujita Y, Mizutani M, Shigematsu T, Kashihara N, Sato H, Matsuo S, Narita I, Isaka Y. Regional variations in immunosuppressive therapy in patients with primary nephrotic syndrome: the Japan nephrotic syndrome cohort study. Clin Exp Nephrol 2018; 22:1266-1280. [PMID: 29679356 DOI: 10.1007/s10157-018-1579-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 03/25/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The lack of high-quality clinical evidences hindered broad consensus on optimal therapies for primary nephrotic syndromes. The aim of the present study was to compare prevalence of immunosuppressive drug use in patients with primary nephrotic syndrome across 6 regions in Japan. METHODS Between 2009 and 2010, 380 patients with primary nephrotic syndrome in 56 hospitals were enrolled in a prospective cohort study [Japan Nephrotic Syndrome Cohort Study (JNSCS)], including 141, 151, and 38 adult patients with minimal change disease (MCD), membranous nephropathy (MN), and focal segmental glomerulosclerosis (FSGS), respectively. Their clinical characteristics were compared with those of patients registered in a large nationwide registry of kidney biopsies [Japan Renal Biopsy Registry (J-RBR)]. The regional prevalence of use of each immunosuppressive drug was assessed among adult MCD, MN, and FSGS patients who underwent immunosuppressive therapy in the JNSCS (n = 139, 127, and 34, respectively). Predictors of its use were identified using multivariable-adjusted logistic regression models. RESULTS The clinical characteristics of JNSCS patients were comparable to those of J-RBR patients, suggesting that the JNSCS included the representatives in the J-RBR. The secondary major immunosuppressive drugs were intravenous methylprednisolone [n = 33 (24.6%), 24 (19.7%), and 9 (28.1%) in MCD, MN, and FSGS, respectively] and cyclosporine [n = 25 (18.7%), 62 (50.8%), and 16 (50.0%), respectively]. The region was identified as a significant predictor of use of intravenous methylprednisolone in MCD and MN patients. CONCLUSION Use of intravenous methylprednisolone for MCD and MN differed geographically in Japan. Its efficacy should be further evaluated in a well-designed trial.
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Affiliation(s)
- Ryohei Yamamoto
- Health and Counseling Center, Osaka University, 1-17 Machikaneyama-cho, Toyonaka, Osaka, 560-0043, Japan
| | - Enyu Imai
- Nakayamadera Imai Clinic, 2-8-18 Nakayamadera, Takarazuka, Hyogo, 665-0861, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical Univeristy School of Medicine, 1-1 Daigaku, Uchinada, Kahoku, Ishikawa, 920-0293, Japan
| | - Hitoshi Sugiyama
- Department of Nephrology, Rheumatology, Endocrinology and Metabolism, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikatacho, Kita-ku, Okayama, Okayama, 700-8558, Japan
| | - Kosaku Nitta
- Department of Medicine, Kidney Center, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Tatsuo Tsukamoto
- Division of Nephrology and Dialysis, Kitano Hospital, Tazuke Kofukai Medical Research Institute, 2-4-20 Ogimachi, Kita-ku, Osaka, Osaka, 530-8480, Japan
| | - Shunya Uchida
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, 173-8606, Japan
| | - Asami Takeda
- Kidney Disease Center, Japanese Red Cross Nagoya Daini Hospital, 2-9 Myokencho, Showa-ku, Nagoya, Aichi, 466-8650, Japan
| | - Toshinobu Sato
- Department of Nephrology, JCHO Sendai Hospital, 3-16-1 Tsutsumi-machi, Aoba-ku, Sendai, Miyagi, 981-8501, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan
| | - Hiroki Hayashi
- Department of Nephrology, Fujita Health University School of Medicine, 1-98 Dengakugakubo, Kutsukakecho, Toyoake, Aichi, 470-1192, Japan
| | - Yasuhiro Akai
- First Department of Internal Medicine, Nara Medical University, 840 Shijocho, Kashihara, Nara, 634-8522, Japan
| | - Megumu Fukunaga
- Division of Nephrology, Department of Internal Medicine, Toyonaka Municipal Hospital, 4-14-1 Shibaharacho, Toyonaka, Osaka, 560-8565, Japan
| | - Kazuhiko Tsuruya
- Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, Fukuoka, 812-8582, Japan
| | - Kosuke Masutani
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, 7-45-1 Nanakuma, Jonan-ku, Fukuoka, Fukuoka, 814-0180, Japan
| | - Tsuneo Konta
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University School of Medicine, 2-2 Iida-Nishi, Yamagata-shi, Yamagata, Yamagata, 990-9585, Japan
| | - Tatsuya Shoji
- Department of Kidney Disease and Hypertension, Osaka General Medical Center, 3-1-56 Bandaihigashi, Sumiyoshi-ku, Osaka, Osaka, 558-8558, Japan
| | - Takeyuki Hiramatsu
- Department of Nephrology, Konan Kosei Hospital, 137 Omatsubara, Takayacho, Konan, Aichi, 483-8704, Japan
| | - Shunsuke Goto
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, 7-5-1 Kusunokicho, Cuho-ku, Kobe, Hyogo, 650-0017, Japan
| | - Hirofumi Tamai
- Department of Nephrology, Anjo Kosei hospital, 28 Higashihirokute, Anjocho, Anjo, Aichi, 446-8602, Japan
| | - Saori Nishio
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido, 060-8638, Japan
| | - Arimasa Shirasaki
- Department of Nephrology, Ichinomiya Municipal Hospital, 2-2-22 Bunkyo, Ichinomiya, Aichi, 491-8558, Japan
| | - Kojiro Nagai
- Department of Nephrology, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15, Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Kunihiro Yamagata
- Department of Nephrology, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
| | - Hajime Hasegawa
- Department of Nephrology and Hypertension, Saitama Medical Center, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama, 350-850, Japan
| | - Hidemo Yasuda
- Internal Medicine 1, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka, 431-3192, Japan
| | - Shizunori Ichida
- Department of Nephrology, Japanese Red Cross Nagoya Daiichi Hospitail, 3-35 Michishitacho, Nakamura-ku, Nagoya, Aichi, 453-8511, Japan
| | - Tomohiko Naruse
- Department of Nephrology, Kasugai Municipal Hospital, 1-1-1 Takakicho, Kasugai, Aichi, 486-8510, Japan
| | - Kei Fukami
- Division of Nephrology, Department of Medicine, Kurume University School of Medicine, 67 Asahimachi, Kurume, Fukuoka, 830-0011, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki, Nagasaki, 852-8501, Japan
| | - Hiroshi Sobajima
- Department of Diabetology and Nephrology, Ogaki Municipal Hospital, 4-86 Minaminokawacho, Ogaki, Gifu, 503-8502, Japan
| | - Satoshi Tanaka
- Department of Nephrology, Shizuoka General Hospital, 4-27-1 Kitaando, Aoi-ku, Shizuoka, Shizuoak, 420-8527, Japan
| | - Toshiyuki Akahori
- Department of Nephrology, Chutoen General Medical Center, 1-1 Shobugaike, Kakegawa, Shizuoka, 436-8555, Japan
| | - Takafumi Ito
- Division of Nephrology, Shimane University Hospital, 89-1 Enyacho, Izumo, Shimane, 693-8501, Japan
| | - Terada Yoshio
- Department of Endocrinology, Metabolism and Nephrology, Kochi Medical School, Kochi University, Okocho Kohasu, Nankoku, Kochi, 783-8505, Japan
| | - Ritsuko Katafuchi
- Kideny Unit, National Fukuoka Higashi Medical Center, 1-1-1 Chidori, Koga, Fukuoka, 811-3195, Japan
| | - Shouichi Fujimoto
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotakecho, Miyazaki, Miyazaki, 889-1692, Japan
| | - Hirokazu Okada
- Department of Nephrology, Saitama Medical University, 38 Morohongo, Moroyama, Iruma, Saitama, 350-0495, Japan
| | - Eiji Ishimura
- Department of Nephrology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Junichiro James Kazama
- Department of Nephrology and Hypertension, Fukushima Medical University School of Medicine, 1 Hikariga-oka, Fukushima-city, Fukushima, 960-1295, Japan
| | - Keiju Hiromura
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, 3-39-22 Showa-matchi, Maebashi, Gunma, 371-8511, Japan
| | - Tetsushi Mimura
- Department of Nephrology, Gifu Prefectural Tajimi Hospital, 5-161 Maebatacho, Tajimi, Gifu, 507-8522, Japan
| | - Satashi Suzuki
- Department of Nephrology, Kainan Hospital, 396 Minamihonden, Maegasucho, Yatomi, Aichi, 498-8502, Japan
| | - Yosuke Saka
- Department of Nephrology, Yokkaichi Municipal Hospital, Yokkaichi, 2-2-37 Shibata, Yokkaichi, Mie, 510-8567, Japan
| | - Tadashi Sofue
- Department of Cardiorenal and Cerebrovascular Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Yusuke Suzuki
- Division of Nephrology, Department of Internal Medicine, Juntendo University Faculty of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae-ku, Kawasaki, Kanagawa, 216-000, Japan
| | - Kiyoki Kitagawa
- Division of Internal Medicine, National Hospital Organization Kanazawa Medical Center, 1-1 Shimoishibikimachi, Kanazawa, Ishikawa, 920-8650, Japan
| | - Kunio Morozumi
- Department of Nephrology, Masuko Memorial Hospital, 35-28 Takegashicho, Nakamura-ku, Nagoya, Aichi, 453-0016, Japan
| | - Yoshiro Fujita
- Department of Nephrology, Chubu Rosai Hospital, 1-10-6 Komei, Minato-ku, Nagoya, Aichi, 455-8530, Japan
| | - Makoto Mizutani
- Department of Nephrology, Handa City Hospital, 2-29 Toyocho, Handa, Aichi, 475-8599, Japan
| | - Takashi Shigematsu
- Department of Nephrology, Wakayama Medical University, 811-1 Kimiidera, Wakayama, Wakayama, 641-8509, Japan
| | - Naoki Kashihara
- Department of Nephrology and Hypertension, Kawasaki Medical School, 577 Matsushima, Kurashiki, Osakayama, 701-0192, Japan
| | - Hiroshi Sato
- Department of Nephrology, Endocrinology, and Vascular Medicine, Tohoku Univeristy Gradaute School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Seiichi Matsuo
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8550, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, 757 Ichibancho, Asahimachi-dori, Chuo Ward, Niigata, Niigata, 951-8510, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, 2-2-D11 Yamadaoka, Suita, Osaka, 565-0871, Japan.
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Ponticelli C, Locatelli F. Corticosteroids in IgA Nephropathy. Am J Kidney Dis 2017; 71:160-162. [PMID: 29203129 DOI: 10.1053/j.ajkd.2017.10.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 10/18/2017] [Indexed: 11/11/2022]
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Ren S, Wang Y, Xian L, Toyama T, Jardine M, Li G, Perkovic V, Hong D. Comparative effectiveness and tolerance of immunosuppressive treatments for idiopathic membranous nephropathy: A network meta-analysis. PLoS One 2017; 12:e0184398. [PMID: 28898290 PMCID: PMC5595305 DOI: 10.1371/journal.pone.0184398] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/23/2017] [Indexed: 11/17/2022] Open
Abstract
Background Immunosuppressive agents in general are shown to prevent renal progression and all-cause mortality in idiopathic membranous nephropathy (IMN) patients with nephrotic syndrome. However, the efficacy and safety of different immunosuppressive treatments have not been systematic assessed and compared. A network meta-analysis was performed to compare different immunosuppressive treatment in IMN. Methods Cochrane library, MEDLINE, EMBASE and trial register system were searched for randomized controlled trials reporting the treatments for IMN to May 3, 2016. Composite endpoint of mortality or end-stage kidney disease (ESKD), complete or partial proteinuria remission and withdrawal because of treatment adverse events were compared combing direct and indirect comparison using network meta-analysis. Ranking different immunosuppressive treatments in the outcomes were analyzed by using surface under the cumulative ranking curve (SUCRA). Results Total 36 randomized controlled trials (n = 2018) covering 11 kinds of treatments were included. Compared with non-immunosuppressive treatment, only cyclophosphamide (CTX) and chlorambucil significantly reduced the risk of composite outcome of mortality or ESKD while combining the direct and indirect comparison (OR = 0.31, 95%CI: 0.12–0.81 and OR = 0.33, 95%CI: 0.12–0.92). CTX increased the composite outcome of complete remission (CR) or partial remission (PR) (OR = 4.29, 95%CI: 2.30–8.00) but chlorambucil did not (OR = 1.58, 95%CI: 0.80–3.12) as compared with non-immunosuppressive treatment. Chlorambucil also significantly increased the withdrawal risk (OR = 3.34, 95%CI: 1.37–8.17) as compared to CTX. Both tacrolimus (OR = 3.10, 95%CI: 1.36–7.09) and cyclosporine (CsA) (OR = 2.81, 95%CI: 1.08–7.32) also significantly increased the rate of CR or PR as compared with non-immunosuppressive treatment (without significant difference as compared with CTX), while ranking results showed that cyclosporine or tacrolimus was with less possibility of drug withdrawal as compared to CTX. Conclusions Cyclophosphamide and chlorambucil reduce risk of ESKD or death in IMN with nephrotic range proteinuria, but carry substantial toxicity that may be lower for cyclophosphamide. Tacrolimus and cyclosporine increase the possibility of proteinuria remission with less drug withdrawal, but the effects on kidney failure remain uncertain.
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Affiliation(s)
- Song Ren
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Ying Wang
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Li Xian
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Tadashi Toyama
- The George Institute for Global Health, University of Sydney, Sydney, Australia.,Division of Nephrology, Kanazawa University Hospital, Kanazawa city, Japan
| | - Meg Jardine
- The George Institute for Global Health, University of Sydney, Sydney, Australia.,Concord Repatriation General Hospital, Concord, Australia
| | - Guisen Li
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Vlado Perkovic
- The George Institute for Global Health, University of Sydney, Sydney, Australia
| | - Daqing Hong
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.,The George Institute for Global Health, University of Sydney, Sydney, Australia
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van den Brand JAJG, Ruggenenti P, Chianca A, Hofstra JM, Perna A, Ruggiero B, Wetzels JFM, Remuzzi G. Safety of Rituximab Compared with Steroids and Cyclophosphamide for Idiopathic Membranous Nephropathy. J Am Soc Nephrol 2017; 28:2729-2737. [PMID: 28487395 DOI: 10.1681/asn.2016091022] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 03/29/2017] [Indexed: 12/13/2022] Open
Abstract
Guidelines recommend steroid plus cyclical cyclophosphamide (St-Cp) therapy for patients with idiopathic membranous nephropathy at high risk of progression to ESRD. Rituximab (Rtx) may be a safer alternative. In this retrospective, observational cohort study, we compared time to any adverse event (primary outcome); serious or nonserious events; partial and complete remission of the nephrotic syndrome; and a composite of doubling of serum creatinine, ESRD, or death between 100 Rtx-treated patients and 103 patients who received daily St-Cp We monitored patients with standardized protocols and adjusted for baseline characteristics by Cox regression. Over a median follow-up of 40 months, the Rtx group had significantly fewer adverse events than the St-Cp group (63 versus 173; P<0.001), both serious (11 versus 46; P<0.001) and nonserious (52 versus 127; P<0.001). Cumulative incidence of any first (35.5% versus 69.0%; P<0.001), serious (16.4% versus 30.2%; P=0.002), or nonserious (23.6% versus 60.8%; P<0.001) event was significantly lower with Rtx Adjusted hazard ratios (95% confidence intervals) between Rtx and St-Cp groups were 0.27 (0.16 to 0.44) for any first adverse event, 0.32 (0.15 to 0.68) for serious adverse events, and 0.23 (0.13 to 0.41) for nonserious adverse events. Although the cumulative incidence of partial remission was lower in the Rtx group, rates of complete remission and the composite renal end point did not differ significantly between groups. Because of its superior safety profile, we suggest that Rtx might replace St-Cp as first-line immunosuppressive therapy in patients with idiopathic membranous nephropathy and nephrotic syndrome.
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Affiliation(s)
| | - Piero Ruggenenti
- Unit of Nephrology, Azienda Socio Sanitaria Territoriale Ospedale Papa Giovanni XXIII, Bergamo, Italy; and.,IRCCS - Instituto di Ricerche Farmacologiche "Mario Negri", Department of Renal Medicine, Clinical Research Center for Rare Diseases "Ado e Cele Daccò", Ranica, Bergamo, Italy
| | - Antonietta Chianca
- IRCCS - Instituto di Ricerche Farmacologiche "Mario Negri", Department of Renal Medicine, Clinical Research Center for Rare Diseases "Ado e Cele Daccò", Ranica, Bergamo, Italy
| | - Julia M Hofstra
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annalisa Perna
- IRCCS - Instituto di Ricerche Farmacologiche "Mario Negri", Department of Renal Medicine, Clinical Research Center for Rare Diseases "Ado e Cele Daccò", Ranica, Bergamo, Italy
| | - Barbara Ruggiero
- IRCCS - Instituto di Ricerche Farmacologiche "Mario Negri", Department of Renal Medicine, Clinical Research Center for Rare Diseases "Ado e Cele Daccò", Ranica, Bergamo, Italy
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Giuseppe Remuzzi
- Unit of Nephrology, Azienda Socio Sanitaria Territoriale Ospedale Papa Giovanni XXIII, Bergamo, Italy; and .,IRCCS - Instituto di Ricerche Farmacologiche "Mario Negri", Department of Renal Medicine, Clinical Research Center for Rare Diseases "Ado e Cele Daccò", Ranica, Bergamo, Italy
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Factors affecting the long-term outcomes of idiopathic membranous nephropathy. BMC Nephrol 2017; 18:104. [PMID: 28347297 PMCID: PMC5369217 DOI: 10.1186/s12882-017-0525-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 03/23/2017] [Indexed: 11/16/2022] Open
Abstract
Background We attempted to describe the clinical features and determine the factors associated with renal survival in idiopathic membranous nephropathy (iMN) patients with nephrotic syndrome (NS) and to determine the factors associated with spontaneous complete remission (sCR) and progression to NS in iMN patients with subnephrotic proteinuria. Methods This retrospective study involved 166 iMN patients with NS and 65 patients with subnephrotic proteinuria. The primary end point was a doubling of serum creatinine or initiation of dialysis. In patients with subnephrotic proteinuria, we determined the factors associated with sCR and factors associated with progression to NS. Results Remission of NS was achieved in 125 out of 166 patients (75.3%). Of those who reached remission, 26 patients (20.8%) experienced relapse that was followed by second remission. The relapse or persistence of proteinuria was associated with the primary end points (hazard ratio [HR] = 12.40, P = 0.037, HR = 173, P < 0.001, respectively). In patients with subnephrotic proteinuria, sCR occurred in 35.4% of the patients. The patients with sCR had lower proteinuria and serum creatinine levels and higher serum albumin concentrations at baseline. The serum albumin level at diagnosis was a prognostic factor for progression to NS (Odds ratio [OR] = 0.015, P < 0.001). Conclusions The occurrence of relapse or persistence of proteinuria had negative effects on renal survival in iMN patients with NS, and low serum albumin levels at baseline were associated with non-achievement of sCR and progression to NS.
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Qiu TT, Zhang C, Zhao HW, Zhou JW. Calcineurin inhibitors versus cyclophosphamide for idiopathic membranous nephropathy: A systematic review and meta-analysis of 21 clinical trials. Autoimmun Rev 2017; 16:136-145. [DOI: 10.1016/j.autrev.2016.12.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 09/12/2016] [Indexed: 10/20/2022]
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The putative role of MALDI-MSI in the study of Membranous Nephropathy. BIOCHIMICA ET BIOPHYSICA ACTA-PROTEINS AND PROTEOMICS 2016; 1865:865-874. [PMID: 27890680 DOI: 10.1016/j.bbapap.2016.11.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 11/15/2016] [Accepted: 11/20/2016] [Indexed: 12/27/2022]
Abstract
Membranous Nephropathy (MN) is an immunocomplex mediated renal disease that represents one of the most frequent glomerulopathies worldwide. This glomerular disease can manifest as primary (idiopathic) or secondary and this distinction is crucial when choosing the most appropriate course of treatment. In secondary cases, the best strategy involves treating the underlying disease, whereas in primary forms, the identification of confirmatory markers of the idiopathic etiology underlining the process is requested by clinicians. Among those currently reported, the positivity to circulating antigens (PLA2R, IgG4 and THSD7A) was demonstrated in approximately 75% of iMN patients, while approximately 1 in 4 patients with iMN still lack a putative diagnostic marker. Ultimately, the discovery of biomarkers to help further stratify these two different forms of glomerulopathy seems mandatory. Here, MALDI-MSI was applied to FFPE renal biopsies from histologically diagnosed primary and secondary MN patients (n=20) in order to detect alterations in their tissue proteome. MALDI-MSI was able to generate molecular signatures of primary and secondary MN, with one particular signal (m/z 1459), identified as Serine/threonine-protein kinase MRCK gamma, being over-expressed in the glomeruli of primary MN patients with respect to secondary MN. Furthermore, a number of signals that could differentiate the different forms of iMN that were positive to PLA2R or IgG4 were detected, as well as a further set of signals (m/z 1094, 1116, 1381 and 1459) that could distinguish these patients from those who were negative to both. These signals could potentially represent future targets for the further stratification of iMN patients. This article is part of a Special Issue entitled: MALDI Imaging, edited by Dr. Corinna Henkel and Prof. Peter Hoffmann.
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Cravedi P. Rituximab in Membranous Nephropathy: Not All Studies Are Created Equal. Nephron Clin Pract 2016; 135:46-50. [PMID: 27676651 DOI: 10.1159/000450659] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 09/05/2016] [Indexed: 12/31/2022] Open
Abstract
Many prospective studies and a recent randomized controlled trial have shown that the B-cell-depleting monoclonal antibody, rituximab, safely promotes the remission of nephrotic syndrome in approximately 65% of patients with membranous nephropathy (MN). Mechanistic studies have indicated that rituximab-induced proteinuria reduction is associated with clearance of anti-podocyte antigens phospholipase 2 receptor autoantibodies and subepithelial immune complexes, the hallmarks of the disease. A recently published study reported results which, at first sight, looked less favorable and implied that, due to a publication bias against negative results, the efficacy of rituximab in MN might be overestimated. Since patients received only one or 2 rituximab administrations, the authors suggest that when rituximab is used, higher doses and longer treatments should be considered. In this study, we highlight limitations of the study and warn against an oversimplified interpretation of the data. Though information on the optimal dose of rituximab to use in MN is still limited, available data from studies with predefined rituximab administration protocols collectively support the concept of titrating rituximab to the number of circulating B-cells that are invariably depleted after the first or second administration. Additional doses may increase the risk of adverse effects and related costs without augmenting efficacy. Importantly, underpowered studies with inconclusive results should not be confused with negative studies formally proving a neutral effect of a treatment. Until data from ad hoc designed clinical trials are available, the B-cell-driven protocol should be the preferred regimen, since it is similarly effective, but safer and more cost effective than other protocols employing multiple rituximab administrations.
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Affiliation(s)
- Paolo Cravedi
- Renal Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, N.Y., USA
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L'Imperio V, Ajello E, Garozzo M, Tosoni A, Ferrario F, Pagni F. Immunosuppression in idiopathic membranous nephropathy: A double-edge sword. Int J Immunopathol Pharmacol 2016; 29:775-777. [PMID: 27382985 DOI: 10.1177/0394632016655170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2015] [Accepted: 05/24/2016] [Indexed: 11/15/2022] Open
Affiliation(s)
- Vincenzo L'Imperio
- The Department of Medicine and Surgery, University Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Elena Ajello
- The Department of Medicine and Surgery, University Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Maurizio Garozzo
- The Renal Unit, Santa Marta e Santa Venera Hospital, Acireale, Catania, Italy
| | | | - Franco Ferrario
- The Department of Medicine and Surgery, University Milan Bicocca, San Gerardo Hospital, Monza, Italy
| | - Fabio Pagni
- The Department of Medicine and Surgery, University Milan Bicocca, San Gerardo Hospital, Monza, Italy
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Xie H, Fang M, Lin H, Li P, Chen J, Sun Y, Kang Z. Intermittent high-volume hemofiltration promotes remission in steroid-resistant idiopathic nephrotic syndrome. Ren Fail 2015; 37:966-73. [PMID: 26329674 DOI: 10.3109/0886022x.2015.1040698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Inflammation is a key part in the etiology and progression of idiopathic nephrotic syndrome (INS), we hypothesize that removing pro-inflammatory cytokines with intermittent high-volume hemofiltration (IHVHF) could improve the outcome in INS patients. The purpose of the current study is to examine whether IHVHF promotes remission in steroid-resistant INS. Fifty-one steroid-resistant INS patients were followed up on an open-label basis with prospective evaluations. Thirty-five patients received mycophenolate mofetil (SRD group) and 16 patients received drugs and IHVHF due to volume overload despite of diuretics (SRDF group). The rate of complete remission (CR) was analyzed. We also recruited 30 healthy individuals and 36 steroid-sensitive (SS) INS patients as controls to investigate the correlation of interleukin (IL)-8, IL-10, IL-6 and IL-17 with INS activity. Compared with the patients in the SRD group, the 6-month CR rate was higher (44% vs. 9%, p < 0.001) and time to first CR was significantly shorter (7.3 ± 3.6 vs. 11.1 ± 5.3 months, p = 0.02) in the SRDF group. Serum IL-8 was highest in the SRDF group and reduced by IHVHF clearance. Serum IL-8 was lower during remission than at onset or recurrence of INS, whereas no significant difference was seen in the other cytokines. Receiver operating characteristic curve analysis demonstrated that serum IL-8 predicted steroid sensitivity with moderate accuracy (area under the curve = 0.79, 95% CI: 0.69-0.87). IHVHF promotes remission in patients with steroid-resistant INS and it may be partly due to serum IL-8 clearance.
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Affiliation(s)
- Hua Xie
- a Graduate School of Dalian Medical University , Dalian , China and.,b Division of Nephrology , the First Hospital of Dalian Medical University , Dalian , China
| | - Ming Fang
- b Division of Nephrology , the First Hospital of Dalian Medical University , Dalian , China
| | - Hongli Lin
- b Division of Nephrology , the First Hospital of Dalian Medical University , Dalian , China
| | - Ping Li
- b Division of Nephrology , the First Hospital of Dalian Medical University , Dalian , China
| | - Jilin Chen
- b Division of Nephrology , the First Hospital of Dalian Medical University , Dalian , China
| | - Yanling Sun
- b Division of Nephrology , the First Hospital of Dalian Medical University , Dalian , China
| | - Zhe Kang
- b Division of Nephrology , the First Hospital of Dalian Medical University , Dalian , China
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Thompson A, Cattran DC, Blank M, Nachman PH. Complete and Partial Remission as Surrogate End Points in Membranous Nephropathy. J Am Soc Nephrol 2015; 26:2930-7. [PMID: 26078365 DOI: 10.1681/asn.2015010091] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Absent a remission of proteinuria, primary membranous nephropathy (MN) can lead to ESRD over many years. Therefore, use of an earlier end point could facilitate the conduct of clinical trials. This manuscript evaluates complete remission (CR) and partial remission (PR) of proteinuria as surrogate end points for a treatment effect on ESRD in patients with primary MN with heavy proteinuria. CR is associated with a low relapse rate and excellent long-term renal survival, and it plausibly reflects remission of the disease process that leads to ESRD. Patients who achieve PR have better renal outcomes than those who do not but may have elevated relapse rates. How long PR must be maintained to yield a benefit on renal outcomes is also unknown. Hence, available data suggest that CR could be used as a surrogate end point in primary MN, whereas PR seems reasonably likely to predict clinical benefit. In the United States, surrogate end points that are reasonably likely to predict clinical benefit can be used as a basis for accelerated approval; treatments approved under this program must verify the clinical benefit in postmarketing trials. Additional analyses of the relationship between treatment effects on CR and PR and subsequent renal outcomes would inform the design of future clinical trials in primary MN.
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Affiliation(s)
- Aliza Thompson
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Daniel C Cattran
- Division of Clinical Investigation and Human Physiology, Toronto General Research Institute, Toronto General Hospital, Toronto, Ontario, Canada; and
| | - Melanie Blank
- Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Patrick H Nachman
- University of North Carolina Kidney Center, University of North Carolina, Chapel Hill, North Carolina
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Tran TH, J. Hughes G, Greenfeld C, Pham JT. Overview of Current and Alternative Therapies for Idiopathic Membranous Nephropathy. Pharmacotherapy 2015; 35:396-411. [DOI: 10.1002/phar.1575] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Tran H. Tran
- College of Pharmacy and Health Sciences; St. John's University; Queens New York
- NewYork-Presbyterian Hospital/Columbia University Medical Center; New York New York
| | - Gregory J. Hughes
- College of Pharmacy and Health Sciences; St. John's University; Queens New York
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Chen Y, Schieppati A, Chen X, Cai G, Zamora J, Giuliano GA, Braun N, Perna A. Immunosuppressive treatment for idiopathic membranous nephropathy in adults with nephrotic syndrome. Cochrane Database Syst Rev 2014; 2014:CD004293. [PMID: 25318831 PMCID: PMC6669245 DOI: 10.1002/14651858.cd004293.pub3] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) is the most common form of nephrotic syndrome in adults. The disease shows a benign or indolent course in the majority of patients, with a rate of spontaneous complete or partial remission of nephrotic syndrome as high as 30% or more. Despite this, 30% to 40% of patients progress toward end-stage kidney disease (ESKD) within five to 15 years. The efficacy and safety of immunosuppression for IMN with nephrotic syndrome are still controversial. This is an update of a Cochrane review first published in 2004. OBJECTIVES The aim of this review was to evaluate the safety and efficacy of immunosuppressive treatments for adult patients with IMN and nephrotic syndrome. Moreover it was attempted to identify the best therapeutic regimen, when to start immunosuppression and whether the above therapies should be given to all adult patients at high risk of progression to ESKD or only restricted to those with impaired kidney function. SEARCH METHODS We searched Cochrane Renal Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Chinese databases, reference lists of articles, and clinical trial registries to June 2014. We also contacted principal investigators of some of the studies for additional information. SELECTION CRITERIA Randomised controlled trials (RCTs) investigating the effects of immunosuppression in adults with IMN and nephrotic syndrome. DATA COLLECTION AND ANALYSIS Study selection, data extraction, quality assessment, and data synthesis were performed using the Cochrane-recommended methods. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS Thirty nine studies with 1825 patients were included, 36 of these could be included in our meta-analyses. The data from two studies could not be extracted and one study was terminated due to poor accrual. Immunosuppression significantly reduced all-cause mortality or risk of ESKD ((15 studies, 791 patients): RR 0.58 (95% CI 0.36 to 0.95, P = 0.03) and risk of ESKD ((15 studies, 791 patients): RR 0.55, 95% CI 0.31 to 0.95, P = 0.03), increased complete or partial remission ((16 studies, 864 patients): RR 1.31, 95% CI 1.01 to 1.70, P = 0.04), and decreased proteinuria ((9 studies,(393 patients): MD -0.95 g/24 h, 95% CI -1.81 to -0.09, P = 0.03) at the end of follow-up (range 6 to 120 months). However this regimen was associated with more discontinuations or hospitalisations ((16 studies, 880 studies): RR 5.35, 95% CI 2.19 to 13.02), P = 0.0002). Combined corticosteroids and alkylating agents significantly reduced death or risk of ESKD ((8 studies, 448 patients): RR 0.44, 95% CI 0.26 to 0.75, P = 0.002) and ESKD ((8 studies, 448 patients): RR 0.45, 95% CI 0.25 to 0.81, P = 0.008), increased complete or partial remission ((7 studies, 422 patients): RR 1.46, 95% CI 1.13 to 1.89, P = 0.004) and complete remission ((7 studies, 422 patients): RR 2.32, 95% CI 1.61 to 3.32, P < 0.00001), and decreased proteinuria ((6 studies, 279 patients): MD -1.25 g/24 h, 95% CI -1.93 to -0.57, P = 0.0003) at the end of follow-up (range 9 to 120 months). In a population with an assumed risk of death or ESKD of 181/1000 patients, this regimen would be expected to reduce the number of patients experiencing death or ESKD to 80/1000 patients (range 47 to 136). In a population with an assumed complete or partial remission of 408/1000 patients, this regimen would be expected to increase the number of patients experiencing complete or partial remission to 596/1000 patients (range 462 to 772). However this combined regimen was associated with a significantly higher risk of discontinuation or hospitalisation due to adverse effects ((4 studies, 303 patients): RR 4.20, 95% CI 1.15 to 15.32, P = 0.03). Whether this combined therapy should be indicated in all adult patients at high risk of progression to ESKD or only restricted to those with deteriorating kidney function still remained unclear. Cyclophosphamide was safer than chlorambucil ((3 studies, 147 patients): RR 0.48, 95% CI 0.26 to 0.90, P = 0.02). There was no clear evidence to support the use of either corticosteroid or alkylating agent monotherapy. Cyclosporine and mycophenolate mofetil failed to show superiority over alkylating agents. Tacrolimus and adrenocorticotropic hormone significantly reduced proteinuria. The numbers of corresponding studies related to tacrolimus, mycophenolate mofetil, adrenocorticotropic hormone, azathioprine, mizoribine, and Tripterygium wilfordii are still too sparse to draw final conclusions. AUTHORS' CONCLUSIONS In this update, a combined alkylating agent and corticosteroid regimen had short- and long-term benefits on adult IMN with nephrotic syndrome. Among alkylating agents, cyclophosphamide was safer than chlorambucil. This regimen was significantly associated with more withdrawals or hospitalisations. It should be emphasised that the number of included studies with high-quality design was relatively small and most of included studies did not have adequate follow-up and enough power to assess the prespecified definite endpoints. Although a six-month course of alternating monthly cycles of corticosteroids and cyclophosphamide was recommended by the KDIGO Clinical Practice Guideline 2012 as the initial therapy for adult IMN with nephrotic syndrome, clinicians should inform their patients of the lack of high-quality evidence for these benefits as well as the well-recognised adverse effects of this therapy. Cyclosporine or tacrolimus was recommended by the KDIGO Clinical Practice Guideline 2012 as the alternative regimen for adult IMN with nephrotic syndrome; however, there was no evidence that calcineurin inhibitors could alter the combined outcome of death or ESKD.
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Affiliation(s)
| | - Arrigo Schieppati
- Azienda Ospedaliera "Ospedali Riuniti di Bergamo"Unit of NephrologyMario Negri Institute for Pharmacological ResearchVia Gavazzeni, 11BergamoItaly24125
| | - Xiangmei Chen
- Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney DiseasesDepartment of NephrologyBeijingChina100853
| | - Guangyan Cai
- Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney DiseasesDepartment of NephrologyBeijingChina100853
| | | | - Giovanni A Giuliano
- Mario Negri Institute for Pharmacological ResearchDepartment of Renal Medicine, Laboratory of Biostatistics, Clinical Research Center for Rare Diseases "Aldo e Cele Daccò"Ranica (Bergamo)Italy24020
| | | | - Annalisa Perna
- Mario Negri Institute for Pharmacological ResearchDepartment of Renal Medicine, Laboratory of Biostatistics, Clinical Research Center for Rare Diseases "Aldo e Cele Daccò"Ranica (Bergamo)Italy24020
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Inker LA, Lambers Heerspink HJ, Mondal H, Schmid CH, Tighiouart H, Noubary F, Coresh J, Greene T, Levey AS. GFR decline as an alternative end point to kidney failure in clinical trials: a meta-analysis of treatment effects from 37 randomized trials. Am J Kidney Dis 2014; 64:848-59. [PMID: 25441438 DOI: 10.1053/j.ajkd.2014.08.017] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 08/19/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND There is increased interest in using alternative end points for trials of kidney disease progression. The currently established end points of end-stage renal disease and doubling of serum creatinine level, equivalent to a 57% decline in estimated glomerular filtration rate (eGFR), are late events in chronic kidney disease (CKD), requiring large clinical trials with long follow-up. As part of a comprehensive evaluation of lesser declines in eGFR as alternative end points, we describe the consistency of treatment effects of intervention on the alternative and established end points in past trials. STUDY DESIGN Diagnostic test study. SETTING & POPULATION 9,488 participants from 37 randomized controlled trials of CKD progression across 5 intervention types. INDEX TEST Alternative end points including percentage change in eGFR from baseline (20%, 30%, 40%, and 57%) throughout study duration and to 12, 18, and 24 months. eGFR change confirmed versus nonconfirmed at the next visit. REFERENCE TEST The historically established end point of time to composite of treated kidney failure (end-stage renal disease), untreated kidney failure (GFR<15mL/min/1.73m(2)), or doubling of serum creatinine level throughout study duration. RESULTS Over a median of 3.62 years' follow-up, there were 3,070 established end points. Compared to the established end point, the number of alternative end points was greater for smaller versus larger declines in eGFR and longer versus shorter follow-up intervals. There was a general trend toward attenuation of the treatment effect with end points defined by a lesser eGFR decline, with greater attenuation with nonconfirmed end points, except for the low-protein-diet intervention, for which a stronger treatment effect was observed. The ratio (95% credible interval) of the HR for the alternative to established end point for the 5 intervention types ranged from 0.91 (0.64-1.43) to 1.12 (0.89-1.40) for 40% decline and from 0.88 (0.63-1.39) to 1.15 (0.88-1.54) for 30% decline for the overall study duration, indicating consistency of treatment effects. LIMITATIONS Limited variety of interventions tested and low statistical power for many CKD clinical trials. CONCLUSIONS These results provide some support for the use of lesser eGFR declines as a surrogate end point, with stronger support for the 40% than 30% decline.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA.
| | - Hiddo J Lambers Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Hasi Mondal
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Christopher H Schmid
- Department of Biostatistics, Brown University School of Public Health, Providence, RI
| | - Hocine Tighiouart
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Farzad Noubary
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center and Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins, Baltimore, MD
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, UT
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
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Caro J, Gutiérrez-Solís E, Rojas-Rivera J, Agraz I, Ramos N, Rabasco C, Espinosa M, Valera A, Martín M, Frutos MÁ, Perea L, Juárez GF, Ocaña J, Arroyo D, Goicoechea M, Fernández L, Oliet A, Hernández Y, Romera A, Segarra A, Praga M. Predictors of response and relapse in patients with idiopathic membranous nephropathy treated with tacrolimus. Nephrol Dial Transplant 2014; 30:467-74. [PMID: 25274748 DOI: 10.1093/ndt/gfu306] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although tacrolimus is recommended by KDIGO Clinical Practice Guideline for Glomerulonephritis for the treatment of idiopathic membranous nephropathy (MN), little is known about factors that influence response and relapse of the disease after tacrolimus therapy. METHODS Multicentre study that collected 122 MN patients with nephrotic syndrome and stable renal function treated with tacrolimus. Duration of treatment was 17.6 ± 7.2 months, including a full-dose and a tapering period. RESULTS The percentage of remission was 60, 78 and 84% after 6, 12 and 18 months of treatment, respectively. The amount of proteinuria at baseline significantly predicted remission, the lower the baseline proteinuria the higher the probability of remission. Only 10 patients (8%) received concomitantly corticosteroids, and their rate of remission was similar (80% at 18 months). Among responders, 42% achieved complete remission (CR) and 58% partial remission (PR). Almost half (44%) of the responder patients relapsed. The amount of proteinuria at the onset of tacrolimus tapering was significantly higher in relapsing patients. By multivariable analysis, the presence of a PR versus CR at the onset of tacrolimus tapering and a shorter duration of the tapering period significantly predicted relapses. Tolerance was good and the number of adverse events low. CONCLUSIONS Tacrolimus monotherapy is an effective and safe option for the treatment of MN with stable renal function. Relapses are frequent in patients with PR and can be partially prevented by a longer tapering period.
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Affiliation(s)
- Jara Caro
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | | | | | | | | | | | - Alfonso Valera
- Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Mónica Martín
- Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | | | - Lara Perea
- Hospital Universitario Regional de Málaga, Málaga, Spain
| | | | - Javier Ocaña
- Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - David Arroyo
- Hospital Universitario Gregorio Marañón, Madrid, Spain
| | | | | | - Aniana Oliet
- Hospital Universitario Severo Ochoa, Leganés, Spain
| | | | - Ana Romera
- Hospital General Universitario de Ciudad Real, Spain
| | | | - Manuel Praga
- Hospital Universitario 12 de Octubre, Madrid, Spain Department of Medicine, Complutense University, Madrid, Spain
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Inker LA, Levey AS, Pandya K, Stoycheff N, Okparavero A, Greene T. Early change in proteinuria as a surrogate end point for kidney disease progression: an individual patient meta-analysis. Am J Kidney Dis 2014; 64:74-85. [PMID: 24787763 PMCID: PMC4070618 DOI: 10.1053/j.ajkd.2014.02.020] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 02/24/2014] [Indexed: 01/13/2023]
Abstract
BACKGROUND It is controversial whether proteinuria is a valid surrogate end point for randomized trials in chronic kidney disease. STUDY DESIGN Meta-analysis of individual patient-level data. SETTING & POPULATION Individual patient data for 9,008 patients from 32 randomized trials evaluating 5 intervention types. SELECTION CRITERIA FOR STUDIES Randomized controlled trials of kidney disease progression until 2007 with measurements of proteinuria both at baseline and during the first year of follow-up, with at least 1 further year of follow-up for the clinical outcome. PREDICTOR Early change in proteinuria. OUTCOMES Doubling of serum creatinine level, end-stage renal disease, or death. RESULTS Early decline in proteinuria was associated with lower risk of the clinical outcome (pooled HR, 0.74 per 50% reduction in proteinuria); this association was stronger at higher levels of baseline proteinuria. Pooled estimates for the proportion of treatment effect on the clinical outcome explained by early decline in proteinuria ranged from -7.0% (95%CI, -40.6% to 26.7%) to 43.9% (95%CI, 25.3% to 62.6%) across 5 intervention types. The direction of the pooled treatment effects on early change in proteinuria agreed with the direction of the treatment effect on the clinical outcome for all 5 intervention types, with the magnitudes of the pooled treatment effects on the 2 end points agreeing for 4 of the 5 intervention types. The pooled treatment effects on both end points were simultaneously stronger at higher levels of proteinuria. However, statistical power was insufficient to determine whether differences in treatment effects on the clinical outcome corresponded to differences in treatment effects on proteinuria between individual studies. LIMITATIONS Limited variety of interventions tested and low statistical power for many chronic kidney disease clinical trials. CONCLUSIONS These results provide new evidence supporting the use of an early reduction in proteinuria as a surrogate end point, but do not provide sufficient evidence to establish its validity in all settings.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA.
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Kruti Pandya
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | | | | | - Tom Greene
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
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Abstract
Membranous nephropathy (MN) is an autoimmune disease usually associated with a nephrotic syndrome and it may progress to ESRD in the long term. Its etiology is often unknown (idiopathic MN), whereas other cases have a recognizable etiology (secondary MN). In idiopathic MN, the glomerular lesions are mainly caused by autoantibodies against a podocyte membrane protein, the M-type of phospholipase A2 receptor 1. The natural course of idiopathic MN is quite varied with spontaneous complete or partial remissions a relatively common occurrence. Patients with asymptomatic non-nephrotic proteinuria seldom progress and need only conservative management. Those with persistent full-blown nephrotic syndrome and those with declining renal function are candidates for specific treatment with any of several regimens. Cyclical therapy with alternating monthly intravenous and oral glucocorticoids combined with a cytotoxic agent can induce remission and preserve renal function in the long term. Cyclosporine or tacrolimus can induce remission, but relapses are frequent after the drug withdrawal. Mycophenolate mofetil monotherapy seems to be ineffective, but may be beneficial when administered together with steroids. The experience with adrenocorticotropic hormone, natural or synthetic, is limited to a few studies with short-term follow-up, but high rates of remission can be seen after prolonged treatment. A high rate of remission and good tolerance have also been reported with rituximab. Patients with moderate renal insufficiency may also benefit from treatment, but at a price of frequent and serious side effects. With these limitations in mind, idiopathic MN may be considered a treatable disease in many patients.
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Affiliation(s)
- Claudio Ponticelli
- Division of Nephrology, IRCCS Humanitas Hospital, Rozzano, Milan, Italy; and
| | - Richard J. Glassock
- David Geffen School of Medicine, University of California, Los Angeles, California
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Shin DH, Lee MJ, Oh HJ, Koo HM, Doh FM, Kim HR, Han JH, Park JT, Han SH, Choi KH, Yoo TH, Kang SW. Stepwise treatment using corticosteroids alone and in combination with cyclosporine in korean patients with idiopathic membranous nephropathy. Yonsei Med J 2013; 54:973-82. [PMID: 23709434 PMCID: PMC3663215 DOI: 10.3349/ymj.2013.54.4.973] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
PURPOSE We undertook an observational study to investigate the effects of immunosuppressive treatment on proteinuria and renal function in 179 Korean idiopathic membranous nephropathy patients with nephrotic syndrome. MATERIALS AND METHODS The primary outcome was regarded as the first appearance of remission and the secondary outcomes as a decline in estimated glomerular filtration rate (eGFR) >50% or initiation of dialysis, and all-cause mortality. Seventy-two (40.2%) and 50 (27.9%) patients were treated with corticosteroids alone (C) and corticosteroids plus cyclosporine (C+C), respectively, whereas 57 (31.8%) did not receive immunosuppressants (NTx). Cyclosporine was added if there was no reduction in proteinuria of >50% from baseline by corticosteroids alone within 3 months. RESULTS There were no differences in baseline renal function and the amount of proteinuria among the three groups. Overall, complete remission (CR) was achieved in 88 (72.1%) patients by immunosuppressants. In a multivariate analysis adjusted for covariates associated with adverse renal outcome, the probability of reaching CR was significantly higher in the C [hazard ratio (HR), 4.09; p<0.001] and C+C groups (HR, 2.57; p=0.003) than in the NTx group. Kaplan-Meier analysis revealed that 5-year CR rates of C, C+C, and NTx groups were 88.5%, 86.2%, and 56.7% (p<0.001). Ten-year event-free rates for the secondary endpoints in these three groups were 91.7%, 79.9%, and 57.2% (p=0.01). CONCLUSION Immunosuppressive treatment was effective in inducing remission and preserving renal function in these patients. Therefore, stepwise treatment using corticosteroids alone and in combination with cyclosporine is warranted in these patients.
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Affiliation(s)
- Dong Ho Shin
- Department of Internal Medicine, Kangdong Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea
| | - Mi Jung Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyung Jung Oh
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyang Mo Koo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Fa Mee Doh
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyoung Rae Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Hyun Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Tak Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Kyu Hun Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Severance Biomedical Science Institute, Brain Korea 21 Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
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Chen Y, Schieppati A, Cai G, Chen X, Zamora J, Giuliano GA, Braun N, Perna A. Immunosuppression for membranous nephropathy: a systematic review and meta-analysis of 36 clinical trials. Clin J Am Soc Nephrol 2013; 8:787-96. [PMID: 23449768 DOI: 10.2215/cjn.07570712] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The efficacy and safety of immunosuppression for idiopathic membranous nephropathy (IMN) with nephrotic syndrome are still controversial. A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Cochrane Library, PUBMED, EMBASE, Chinese Database, and Clinical Trial Registries (June 2012) were searched to identify RCTs investigating the effect of immunosuppression on adults with IMN and nephrotic syndrome. RESULTS This review was an update (36 RCTs, 1762 participants) of the 2004 version (18 RCTs, 1025 participants). Immunosuppression significantly reduced all-cause mortality or ESRD (15 RCTs, 791 participants; risk ratio, 0.58 [95% confidence interval, 0.36-0.95]; P=0.03). However, the result was not consistent when prespecified subgroup analyses were undertaken. Immunosuppression increased complete or partial remission (CR + PR) (16 RCTs, 864 participants; 1.31 [1.01-1.70]; P=0.04) but resulted in more withdrawals or hospitalizations (16 RCTs, 880 participants; 5.35 [2.19-13.02]; P=0.002). Corticosteroids combined with alkylating agents significantly reduced all-cause mortality or ESRD (8 RCTs, 448 participants; 0.44 [0.26-0.75]; P=0.002) and increased CR + PR (7 RCTs, 422 participants; 1.46 [1.13-1.89]; P=0.004) but led to more adverse events (4 RCTs, 303 participants; 4.20 [1.15-15.32]; P=0.03). Cyclophosphamide was safer than chlorambucil (3 RCTs, 147 participants; 0.48 [0.26-0.90]; P=0.02). Cyclosporine and mycophenolate mofetil failed to show superiority over alkylating agents. Tacrolimus and adrenocorticotropic hormone significantly reduced proteinuria. CONCLUSIONS Alkylating agents plus corticosteroids had long-term and short-term benefits for adult IMN, but resulted in more withdrawals or hospitalizations.
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Affiliation(s)
- Yizhi Chen
- Chinese People's Liberation Army General Hospital, Beijing, China
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Ruggenenti P, Cravedi P, Chianca A, Perna A, Ruggiero B, Gaspari F, Rambaldi A, Marasà M, Remuzzi G. Rituximab in idiopathic membranous nephropathy. J Am Soc Nephrol 2012; 23:1416-25. [PMID: 22822077 DOI: 10.1681/asn.2012020181] [Citation(s) in RCA: 201] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Selective depletion of B cells with the mAb rituximab may benefit the autoimmune glomerular disease idiopathic membranous nephropathy (IMN). Here, we describe our experience treating 100 consecutive IMN patients with persistent nephrotic syndrome with rituximab. We defined complete remission as persistent proteinuria <0.3 g/24 h and partial remission as persistent proteinuria <3 g/24 h, each also having >50% reduction in proteinuria from baseline. During a median follow-up of 29 months after rituximab administration, 65 patients achieved complete or partial remission. The median time to remission was 7.1 months. All 24 patients who had at least 4 years of follow-up achieved complete or partial remission. Rates of remission were similar between patients with or without previous immunosuppressive treatment. Four patients died and four progressed to ESRD. Measured GFR increased by a mean 13.2 (SD 19.6) ml/min per 1.73 m(2) among those who achieved complete remission. Serum albumin significantly increased and albumin fractional clearance decreased among those achieving complete or partial remission. Proteinuria at baseline and the follow-up duration each independently predicted the decline of proteinuria. Furthermore, the magnitude of proteinuria reduction significantly correlated with slower GFR decline (P=0.0001). No treatment-related serious adverse events occurred. In summary, rituximab achieved disease remission and stabilized or improved renal function in a large cohort of high-risk patients with IMN.
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Affiliation(s)
- Piero Ruggenenti
- Mario Negri Institute for Pharmacological Research, Clinical Research Center for Rare Diseases, Aldo e Cele Daccò, Villa Camozzi, Ranica, Italy
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McQuarrie EP, Stirling CM, Geddes CC. Idiopathic membranous nephropathy and nephrotic syndrome: outcome in the era of evidence-based therapy. Nephrol Dial Transplant 2011; 27:235-42. [PMID: 21558430 DOI: 10.1093/ndt/gfr220] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
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.
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Aaltonen S, Honkanen E. Outcome of idiopathic membranous nephropathy using targeted stepwise immunosuppressive treatment strategy. Nephrol Dial Transplant 2011; 26:2871-7. [DOI: 10.1093/ndt/gfq841] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Naumovic R, Furuncic D, Jovanovic D, Stosovic M, Basta-Jovanovic G, Lezaic V. Application of artificial neural networks in estimating predictive factors and therapeutic efficacy in idiopathic membranous nephropathy. Biomed Pharmacother 2011; 64:633-8. [PMID: 20888177 DOI: 10.1016/j.biopha.2010.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Accepted: 06/19/2010] [Indexed: 11/15/2022] Open
Abstract
Idiopathic membranous nephropathy (IMN) is one of the most frequent causes of the nephrotic syndrome in adults and one of the most common cause of chronic renal failure among primary glomerular diseases. The aim of this study was to develop artificial neural networks (ANN) to investigate factors of poor outcome for IMN and to evaluate the efficacy of different therapeutic protocols. Data were collected retrospectively for 124 patients with IMN (82 males, mean based on the received therapy patients were divided into three groups: corticosteroids only (group 1), cyclophsophamide with corticosteroids (group 2), and so called Ponticelli protocol (group 3). After achieving satisfactory truthfulness of the transcription function of ANN through clustering, we have applied the efficacy analysis to all patients and then compared them to each group separately, and evaluated the influence of initial characteristics on disease outcome as well as the therapy efficacy. The greatest therapy inefficiency was recorded for isolated corticosteroid therapy (29.41%) and the smallest inefficiency for Ponticelli protocol, for which the greatest accuracy of prognosis was recorded (82.09%). The greatest negative prognostic influence had kidney insufficiency (22%), quantitative proteinuria (15%) and index of interstitial infiltration (14%). Based on our results, we can recommend that patients diagnosed with IMN with renal insufficiency, nephrotic syndrome or a high degree of interstitial infiltration at the time of diagnosis should be treated concomitantly with cytotoxic drugs and corticosteroids, particularly with the Ponticelli protocol.
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Affiliation(s)
- R Naumovic
- Clinic of Nephrology, Clinical Center of Serbia, Institute of Urology and Nephrology, Pasterova 2, 11000 Belgrade, Serbia.
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Abstract
IMPORTANCE OF THE FIELD Idiopathic membranous nephropathy (IMN) can have a variable natural course. Treatments able to induce remission can improve the long-term prognosis. However, the optimal therapy for IMN remains controversial. AREA COVERED IN THIS REVIEW We reviewed the historical and current literature from 1979 to 2010 regarding the natural course of IMN and the possible treatments giving special emphasis to randomized controlled trials and to more recent approaches. WHAT THE READER WILL GAIN The reader will gain a comprehensive review of the available treatments of IMN. A personal therapeutic algorithm for nephrotic patients with IMN is also provided. TAKE HOME MESSAGE At least five different treatments showed efficacy in many (but not all) patients with IMN.
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Affiliation(s)
- Claudio Ponticelli
- Humanitas Hospital, Division of Nephrology, Via Manzoni 56, 20089 Rozzano, Milan, Italy.
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