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Chen P, Lv J. Low dose glucocorticoids, mycophenolate mofetil and hydroxychloroquine in IgA nephropathy, an update of current clinical trials. Nephrology (Carlton) 2024. [PMID: 39022897 DOI: 10.1111/nep.14369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 06/30/2024] [Accepted: 07/04/2024] [Indexed: 07/20/2024]
Abstract
This mini-review explores glucocorticoids, mycophenolate mofetil (MMF), and hydroxychloroquine (HCQ) in IgA nephropathy (IgAN). It discusses conflicting findings from pivotal trials like TESTING and STOP-IgAN regarding glucocorticoid efficacy, emphasizing reduced-dose protocols as potentially safer options. MMF's effectiveness varies among populations, demonstrating promise in Chinese cohorts but yielding inconclusive results elsewhere. HCQ shows potential in reducing proteinuria, with ongoing trials investigating its long-term benefits.
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Affiliation(s)
- Pei Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
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2
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Selvaskandan H, Jhaveri KD, Rizk DV. Primary IgA Nephropathy: New Insights and Emerging Therapies. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:180-193. [PMID: 39004458 DOI: 10.1053/j.akdh.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 03/12/2024] [Accepted: 04/01/2024] [Indexed: 07/16/2024]
Abstract
Primary IgA nephropathy (IgAN) is a common glomerular disorder defined by predominant mesangial IgA deposition. Once thought to follow a progressive course in 10-20% of those diagnosed, emerging evidence now suggests most will progress to kidney failure over their lifetimes. Although the lack of safe and effective treatments to impede disease progression continues to present a challenge, the landscape of IgAN has dramatically evolved over the last 2 years. Driven by fundamental changes to accepted end points for IgAN clinical trials as well as fascinating new insights into the pathophysiology of IgAN, a swathe of novel and repurposed therapies are currently being evaluated. Already, two novel drugs, targeted-release formulation budesonide and sparsentan, have received conditional approvals for the treatment of IgAN, with sodium glucose co-transporter 2 inhibitors establishing themselves as further options. Soon to join this ensemble are likely to be treatments that modulate the complement system and B-cell activity; several are currently undergoing clinical trials in IgAN with promising interim results. In this review, we provide an overview of evolving epidemiological insights, disease mechanisms, emerging therapies, and contemporary challenges surrounding the management of IgAN.
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Affiliation(s)
- Haresh Selvaskandan
- Mayer IgA Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK; John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Kenar D Jhaveri
- Northwell Health, New Hyde Park, NY; Glomerular Center at Northwell Health, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY.
| | - Dana V Rizk
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Barr B, Barbour S. New therapies for immunoglobulin A nephropathy: what's the standard of care in 2023? Curr Opin Nephrol Hypertens 2024; 33:311-317. [PMID: 38411173 DOI: 10.1097/mnh.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW As the most common primary glomerulonephritis, immunoglobulin A (IgA) nephropathy (IgAN) is an important cause of kidney failure and mortality. Until recently, therapeutic options were limited. Fortunately, there have been numerous recent clinical trials demonstrating efficacy of new therapies in slowing chronic kidney disease (CKD) progression at varying stages of disease. RECENT FINDINGS The TESTING trial has provided high-quality evidence for slowing estimated glomerular filtration rate (eGFR) decline with a reduced-dose glucocorticoid regimen, while demonstrating an improved safety profile. Targeted-release budesonide represents a well tolerated therapy for reducing eGFR decline. Mycophenolate mofetil may reduce CKD progression in some populations, while hydroxychloroquine is efficacious in reducing proteinuria. Sodium-glucose cotransporter (SGLT2) inhibitors and sparsentan are effective therapies for CKD due to IgAN, but should not be used in lieu of disease-modifying immunosuppressive therapy. Many new therapies are approaching readiness for clinical use. SUMMARY Numerous therapeutic options now exist and include disease-modifying and nephroprotective drugs. Identifying the right treatment for the right patient is now the clinical challenge and, with new drugs on the horizon, represents the primary unmet research need in this rapidly-developing field.
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Affiliation(s)
- Bryce Barr
- Section of Nephrology, Department of Medicine, Max Rady College of Medicine, University of Manitoba
| | - Sean Barbour
- Division of Nephrology, University of British Columbia
- BC Renal, Vancouver, British Columbia, Canada
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Trimarchi H, Fervenza FC, Coppo R. Points of view in nephrology: personalized management of IgA nephropathy, beyond KDIGO. J Nephrol 2024; 37:739-745. [PMID: 38236471 DOI: 10.1007/s40620-023-01833-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/18/2023] [Indexed: 01/19/2024]
Abstract
IgA nephropathy is the most common primary glomerulonephritis worldwide, and an important cause of kidney failure, as 20-40% of patients progress to renal replacement therapy 20-30 years after diagnosis. Its clinical presentation ranges from isolated microscopic hematuria to nephrotic syndrome, and even to a rapidly progressive course. Ethnicity and epigenetics play a key role in its clinical aggressiveness. Selection of patients at risk needing immunosuppressive treatment is a challenge for the nephrologist. Some active and chronic kidney lesions detected on kidney biopsy have been demonstrated to have prognostic value according to the Oxford Classification of IgA nephropathy, later validated by numerous studies. However, KDIGO 2021 guidelines still consider persistent proteinuria > 1 g/24 h to be the most relevant risk factor for the progression of IgA nephropathy and the only one requiring immunosuppressive treatment. KDIGO guidelines have proposed a therapeutic algorithm, but many patients present peculiar characteristics that are not addressed by the current guidelines, pointing to the need for alternative approaches. In these cases, a tailored approach to each patient should be followed in which clinical, histological, laboratory, social and ethical aspects must be considered. In this manuscript we present three cases of IgA nephropathy from different countries, highlighting many of the aspects encountered in clinical practice that illustrate an individualized approach to the treatment of these patients.
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Affiliation(s)
- Hernán Trimarchi
- Nephrology Service, Hospital Británico de Buenos Aires, Buenos Aires, Argentina
| | | | - Rosanna Coppo
- Fondazione Ricerca Molinette, Regina Margherita Hospital, Turin, Italy.
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Lim RS, Yeo SC, Barratt J, Rizk DV. An Update on Current Therapeutic Options in IgA Nephropathy. J Clin Med 2024; 13:947. [PMID: 38398259 PMCID: PMC10889409 DOI: 10.3390/jcm13040947] [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: 01/01/2024] [Revised: 01/30/2024] [Accepted: 02/04/2024] [Indexed: 02/25/2024] Open
Abstract
Immunoglobulin A nephropathy (IgAN) remains the leading cause of primary glomerular disease worldwide. Outcomes are poor with high rates of progressive chronic kidney disease and kidney failure, which contributes to global healthcare costs. Although this disease entity has been described, there were no disease-specific treatments until recently, with the current standard of care focusing on optimal supportive measures including lifestyle modifications and optimization of the renin-angiotensin-aldosterone blockade. However, with significant advances in the understanding of the pathogenesis of IgAN in the past decade, and the acceptance of surrogate outcomes for accelerated drug approval, there have been many new investigational agents tested to target this disease. As these agents become available, we envision a multi-pronged treatment strategy that simultaneously targets the consequences of ongoing nephron loss, stopping any glomerular inflammation, inhibiting pro-fibrotic signals in the glomerulus and tubulo-interstitium, and inhibiting the production of pathogenic IgA molecules. This review is an update on a previous review published in 2021, and we aim to summarize the developments and updates in therapeutic strategies in IgAN and highlight the promising discoveries that are likely to add to our armamentarium.
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Affiliation(s)
- Regina Shaoying Lim
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; (R.S.L.); (S.C.Y.)
| | - See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore; (R.S.L.); (S.C.Y.)
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester LE1 7RH, UK;
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester LE5 4PW, UK
| | - Dana V. Rizk
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, ZRB 614, 1720 2nd Avenue South, Birmingham, AL 35294, USA
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Stamellou E, Seikrit C, Tang SCW, Boor P, Tesař V, Floege J, Barratt J, Kramann R. IgA nephropathy. Nat Rev Dis Primers 2023; 9:67. [PMID: 38036542 DOI: 10.1038/s41572-023-00476-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2023] [Indexed: 12/02/2023]
Abstract
IgA nephropathy (IgAN), the most prevalent primary glomerulonephritis worldwide, carries a considerable lifetime risk of kidney failure. Clinical manifestations of IgAN vary from asymptomatic with microscopic or intermittent macroscopic haematuria and stable kidney function to rapidly progressive glomerulonephritis. IgAN has been proposed to develop through a 'four-hit' process, commencing with overproduction and increased systemic presence of poorly O-glycosylated galactose-deficient IgA1 (Gd-IgA1), followed by recognition of Gd-IgA1 by antiglycan autoantibodies, aggregation of Gd-IgA1 and formation of polymeric IgA1 immune complexes and, lastly, deposition of these immune complexes in the glomerular mesangium, leading to kidney inflammation and scarring. IgAN can only be diagnosed by kidney biopsy. Extensive, optimized supportive care is the mainstay of therapy for patients with IgAN. For those at high risk of disease progression, the 2021 KDIGO Clinical Practice Guideline suggests considering a 6-month course of systemic corticosteroid therapy; however, the efficacy of systemic steroid treatment is under debate and serious adverse effects are common. Advances in understanding the pathophysiology of IgAN have led to clinical trials of novel targeted therapies with acceptable safety profiles, including SGLT2 inhibitors, endothelin receptor blockers, targeted-release budesonide, B cell proliferation and differentiation inhibitors, as well as blockade of complement components.
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Affiliation(s)
- Eleni Stamellou
- Department of Nephrology, School of Medicine, University of Ioannina, Ioannina, Greece
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Claudia Seikrit
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Sydney C W Tang
- Division of Nephrology, Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Peter Boor
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
- Department of Pathology, RWTH Aachen University, Aachen, Germany
| | - Vladimir Tesař
- Department of Nephrology, 1st Faculty of Medicine and General University Hospital, Charles University, Prague, Czech Republic
| | - Jürgen Floege
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Rafael Kramann
- Department of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany.
- Department of Internal Medicine, Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, Netherlands.
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Roccatello D, Careddu A, Ferro M, Naretto C, Quattrocchio G, Fenoglio R, Sciascia S. The steroid-sparing effects of a mycophenolate mofetil-based regimen in the management of immunoglobulin A nephropathy in patients with histologically active lesions: A comparison with a control cohort receiving conventional therapy. J Nephrol 2023; 36:2223-2231. [PMID: 37306917 PMCID: PMC10638182 DOI: 10.1007/s40620-023-01636-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2023] [Indexed: 06/13/2023]
Abstract
INTRODUCTION While the use of different immunosuppressants has been investigated in immunoglobulin A nephropathy, further investigation is needed to assess the effect of a regimen of mycophenolate mofetil combined with a short course of glucocorticosteroids in the subset of patients with histologically active features. We compared the efficacy and safety of a combined regimen of mycophenolate mofetil and glucocorticosteroids to a conventional regimen of glucocorticosteroids alone in patients with immunoglobulin A nephropathy who have active lesions and major urinary abnormalities. METHODS This retrospective study involved 30 immunoglobulin A nephropathy patients with active histological lesions, 15 of whom were treated with both mycophenolate mofetil 2 g/day for 6 months and 3 pulses of 15 mg/kg methylprednisolone, followed by a short tapering schedule of oral prednisone. The control group was made up of the remaining 15 clinically- and histologically-matched patients treated with glucocorticosteroids alone according to a validated schedule, i.e., 1 g of methylprednisolone given intravenously for 3 consecutive days, followed by oral prednisone 0.5 mg/kg every other day for 6 months. At diagnosis, all patients had urinary protein excretion > 1 g/24 h and microscopic hematuria. RESULTS At the end of the first year of follow-up (30 patients) and after 5 years (17 patients), there were no differences between the two groups in terms of urinary abnormalities and functional parameters. Both regimens achieved a statistically significant decrease in 24-h urinary protein excretion (p < 0.001) and a reduction of microscopic hematuria. However, the mycophenolate mofetil-based regimen allowed a cumulative sparing dose of 6 g of glucocorticosteroids. CONCLUSION In this single center study on immunoglobulin A nephropathy patients with active lesions and major urinary abnormalities and at increased risk of glucocorticosteroid-related complications, a mycophenolate mofetil-based regimen demonstrated similar outcomes in terms of complete response and relapse (at 1 and 5 years) compared to a conventional glucocorticosteroid-based protocol, while achieving a consistent reduction of glucocorticosteroid cumulative dose.
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Affiliation(s)
- Dario Roccatello
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy.
| | - Andrea Careddu
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| | - Michela Ferro
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| | - Carla Naretto
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| | - Giacomo Quattrocchio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| | - Roberta Fenoglio
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
| | - Savino Sciascia
- University Center of Excellence on Nephrologic, Rheumatologic and Rare Diseases (ERK-Net, ERN-Reconnect and RITA-ERN Member), Nephrology and Dialysis Unit and Center of Immuno-Rheumatology and Rare Diseases (CMID), Coordinating Center of the Interregional Network for Rare Diseases of Piedmont and Aosta Valley (North-West Italy), Department of Clinical and Biological Sciences, University of Turin and San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy
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Gleeson PJ, O'Shaughnessy MM, Barratt J. IgA nephropathy in adults-treatment standard. Nephrol Dial Transplant 2023; 38:2464-2473. [PMID: 37418237 DOI: 10.1093/ndt/gfad146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Indexed: 07/08/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary form of glomerular disease worldwide and carries a high lifetime risk of kidney failure. The underlying pathogenesis of IgAN has been characterized to a sub-molecular level; immune complexes containing specific O-glycoforms of IgA1 are central. Kidney biopsy remains the gold-standard diagnostic test for IgAN and histological features (i.e. MEST-C score) have also been shown to independently predict outcome. Proteinuria and blood pressure are the main modifiable risk factors for disease progression. No IgAN-specific biomarker has yet been validated for diagnosis, prognosis or tracking response to therapy. There has been a recent resurgence of investigation into IgAN treatments. Optimized supportive care with lifestyle interventions and non-immunomodulatory drugs remains the backbone of IgAN management. The menu of available reno-protective medications is rapidly expanding beyond blockade of the renin-angiotensin-aldosterone system to include sodium-glucose cotransporter 2 and endothelin type A receptor antagonism. Systemic immunosuppression can further improve kidney outcomes, although recent randomized controlled trials have raised concerns regarding infectious and metabolic toxicity from systemic corticosteroids. Studies evaluating more refined approaches to immunomodulation in IgAN are ongoing: drugs targeting the mucosal immune compartment, B-cell promoting cytokines and the complement cascade are particularly promising. We review the current standards of treatment and discuss novel developments in pathophysiology, diagnosis, outcome prediction and management of IgAN.
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Affiliation(s)
- Patrick J Gleeson
- Department of Renal Medicine, Cork University Hospital, Cork, Ireland
- Department of Medicine, School of Microbiology, APC Microbiome Ireland, University College Cork, Cork, Ireland
| | | | - Jonathan Barratt
- The Mayer IgA Nephropathy Laboratories, University of Leicester, Leicester, UK
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Tan Q, Xue H, Ni X, Fan L, Du W. Comparative effectiveness and safety for the treatments despite optimized renin-angiotensin system blockade among IgA nephropathy patients at high-risk of disease progression: A network meta-analysis of randomized controlled trials. Eur J Intern Med 2023; 114:66-73. [PMID: 37179138 DOI: 10.1016/j.ejim.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/08/2023] [Accepted: 04/13/2023] [Indexed: 05/15/2023]
Abstract
OBJECTIVE Approximately 20-40% of IgA nephropathy patients would develop end-stage renal disease, for whom safety concerns remained a major setback when using conventional pharmaceutical treatments. Evidence is lacking for optimal selection of effective and safe pharmaceuticals to slow the disease progression. To compare the effectiveness and safety profile of different treatments despite optimized RAS blockade for IgA nephropathy patients at high-risk of disease progression. STUDY DESIGN PubMed, ScienceDirect and Web of science databases published from 1990 to March 18th, 2023 without language restriction. Immunosuppressant and cortico-steroid treatments were considered as two independent regimens. RESULTS Fifteen trials with 1,983 participants were evaluated for the occurrence of five outcomes. For ESRD, dapagliflozin was superior to placebo (RR: 0.30; 95% CI 0.11, 0.80), immunosuppressant (RR:0.14; 95% CI 0.02,0.81) and RAS (RR:0.10; 95% CI 0.01,0.69). Glucocorticoid was superior to placebo (RR: 0.71; 95%CI 0.52,0.99). For clinical remission, immunosuppressant was superior to placebo (RR: 2.71; 95%CI 1.16, 6.31) and RAS monotherapy (RR: 2.87; 95%CI 1.60, 5.17). For 50% reduction in 24 h proteinuria or UPCR, immunosuppressant was superior to placebo (RR: 2.71; 95%CI 1.16, 6.31) and RAS monotherapy (RR: 2.40; 95%CI 1.04, 5.55). For SAE, dapagliflozin was superior to glucocorticoid (RR: 0.22; 95%CI 0.09, 0.54), whereas glucocorticoid was inferior to placebo (RR: 2.91; 95%CI 1.39, 6.07). Cluster ranking showed dapagliflozin appeared to have the lowest SAE risk and the best comparative therapeutic efficacy in preventing ESRD. CONCLUSIONS The current findings highlighted dapagliflozin was a promising pharmaceutical treatment alternative to achieve optimal outcomes for IgA nephropathy patients at high risk of disease progression. REGISTRATION PROSPERO CRD42022374418.
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Affiliation(s)
- Qiong Tan
- School of Public Health, Southeast University, China.
| | - Hui Xue
- School of Public Health, Southeast University, China
| | - Xiaoyan Ni
- School of Public Health, Southeast University, China
| | - Lijun Fan
- School of Public Health, Southeast University, China
| | - Wei Du
- School of Public Health, Southeast University, China.
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10
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Tziastoudi M, Chronopoulou I, Pissas G, Cholevas C, Eleftheriadis T, Stefanidis I. Tumor Necrosis Factor-α G-308A Polymorphism and Sporadic IgA Nephropathy: A Meta-Analysis Using a Genetic Model-Free Approach. Genes (Basel) 2023; 14:1488. [PMID: 37510392 PMCID: PMC10378840 DOI: 10.3390/genes14071488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/11/2023] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Tumor necrosis factor-α (TNF-α) is a potent pro-inflammatory cytokine, involved in the pathogenesis and progression of immunoglobulin A nephropathy (IgAN). A bi-allelic polymorphism in the promoter region, at position -308 (G/A) of the TNF-α gene (rs1800629) is associated with an increased TNF-a production. However, several previous association studies of TNF-α G-308A polymorphism and IgAN rendered contradictory findings. The objective of the present study is to shed light on these inconclusive results and clarify the role of TNF-α and any possible contribution of this factor in the development and progression of sporadic IgAN. Therefore, a meta-analysis of all available genetic association studies relating the TNF-α G-308A polymorphism to the risk for development and/or progression of IgAN was conducted. Seven studies were included in the meta-analysis. Three of them included populations of European descent (Caucasians) and four involved Asians. The generalized odds ratio (ORG) was used to estimate the risk for the development and/or progression of the disease. Overall, the meta-analysis did not detect any significant association between the G-308A variant and both the risk of developing IgAN and the risk for progression of IgAN. In conclusion, these results suggest that TNF-α does not constitute a key component in the genetic architecture of sporadic IgAN. However, further evidence deciphering the influence of TNF-α on IgAN is still needed.
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Affiliation(s)
- Maria Tziastoudi
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece
| | - Ioanna Chronopoulou
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece
| | - Georgios Pissas
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece
| | - Christos Cholevas
- First Department of Ophthalmology, Faculty of Health Sciences, Aristotle University of Thessaloniki School of Medicine, AHEPA Hospital, 54636 Thessaloniki, Greece
| | - Theodoros Eleftheriadis
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece
| | - Ioannis Stefanidis
- Department of Nephrology, Faculty of Medicine, School of Health Sciences, University of Thessaly, 41500 Larissa, Greece
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11
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Petrou D, Kalogeropoulos P, Liapis G, Lionaki S. IgA Nephropathy: Current Treatment and New Insights. Antibodies (Basel) 2023; 12:40. [PMID: 37366657 DOI: 10.3390/antib12020040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/23/2023] [Accepted: 06/09/2023] [Indexed: 06/28/2023] Open
Abstract
IgA Nephropathy (IgAN) is the most common cause of primary glomerulonephritis worldwide. Despite the histopathologic hallmark of mesangial IgA deposition, IgAN is a heterogenous autoimmune disease not only in terms of clinical presentation but also in long-term disease progression. The pathogenesis of the disease is complex and includes the generation of circulating IgA immune complexes with chemical and biological characteristics that favor mesangial deposition and reaction to mesangial under-glycosylated IgA1 accumulation, which leads to tissue injury with glomerulosclerosis and interstitial fibrosis. Patients with proteinuria over 1 g, hypertension, and impaired renal function at diagnosis are considered to be at high risk for disease progression and end-stage kidney disease (ESKD). Glucocorticoids have been the mainstay of treatment for these patients for years, but without long-term benefit for renal function and accompanied by several adverse events. A better understanding of the pathophysiology of IgAN in recent years has led to the development of several new therapeutic agents. In this review, we summarize the current therapeutic approach for patients with IgAN as well as all novel investigational agents.
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Affiliation(s)
- Dimitra Petrou
- Department of Nephrology, Second Department of Propaedeutic Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Petros Kalogeropoulos
- Department of Nephrology, Second Department of Propaedeutic Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - George Liapis
- Department of Pathology, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Sophia Lionaki
- Department of Nephrology, Second Department of Propaedeutic Internal Medicine, Attikon University Hospital, Medical School, National and Kapodistrian University of Athens, 12462 Athens, Greece
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Noor SM, Abuazzam F, Mathew R, Zhang Z, Abdipour A, Norouzi S. IgA nephropathy: a review of existing and emerging therapies. FRONTIERS IN NEPHROLOGY 2023; 3:1175088. [PMID: 37675358 PMCID: PMC10479631 DOI: 10.3389/fneph.2023.1175088] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/03/2023] [Indexed: 09/08/2023]
Abstract
IgA nephropathy (IgAN) is the most common form of primary glomerulonephritis worldwide. Recently, there have been multiple advances in the understanding of IgAN pathophysiology and therapeutic options. Despite the advent of new treatment options, individual risk stratification of the disease course and choosing the best treatment strategy for the patient remains challenging. A multitude of clinical trials is ongoing, opening multiple opportunities for enrollment. In this brief review we discuss the current approach to the management of IgAN and highlight the ongoing clinical trials.
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Affiliation(s)
| | | | | | | | | | - Sayna Norouzi
- Department of Nephrology, Loma Linda University, Loma Linda, CA, United States
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El-Reshaid K, Al-Bader S, Madda J. The Beneficial Effect of Three-month Induction Therapy with High-dose Prednisone and Mycophenolate Mofetil Followed by Maintenance Therapy in Acute Non-crescentic Nephritis Associated with Immunoglobulin A Deposition Disease in Adults. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2023; 34:161-166. [PMID: 38146726 DOI: 10.4103/1319-2442.391895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
The data available on immunoglobulin A (IgA) deposition disease indicate an inherited predisposition to the disease with autoimmune triggering. Hence, we prospectively evaluated the role of a new autoimmune regimen in the treatment of severe nephrotic or nephritic flares associated with noncrescentic nephritis in adult patients. Thirty-six patients were included, and the regimen consisted of an initial 3-month induction phase of prednisone and mycophenolate mofetil (MMF), followed by a maintenance phase of MMF alone for 21 months. Complete remission (CR) (normalization of creatinine clearance [CrCl] and a decrease in protein output to <500 mg/day) was achieved in 29 of 36 patients, and a partial response (no further decline in CrCl and a decrease in proteinuria to <50%) was seen in seven patients. CrCl was maintained in patients with CR but was mildly reduced in partially responsive ones. Our study showed the short- and longterm safety and efficacy of this autoimmune regimen directed toward the autoimmune triggering factors in severe forms of noncrescentic IgA nephritis.
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Affiliation(s)
- Kamel El-Reshaid
- Department of Medicine, Faculty of Medicine, Kuwait University, Safat, Kuwait
| | - Shaikha Al-Bader
- Department of Medicine, Nephrology Unit, Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
| | - John Madda
- Department of Pathology, Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
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Hou FF, Xie D, Wang J, Xu X, Yang X, Ai J, Nie S, Liang M, Wang G, Jia N. Effectiveness of Mycophenolate Mofetil Among Patients With Progressive IgA Nephropathy: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2254054. [PMID: 36745456 DOI: 10.1001/jamanetworkopen.2022.54054] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
IMPORTANCE The role of mycophenolate mofetil (MMF) in management of immunoglobulin A nephropathy (IgAN) remains highly controversial. OBJECTIVE To evaluate the efficacy and safety of MMF in patients with IgAN at high risk of kidney function loss. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial with open-label, blinded end-point design was conducted among adults with IgAN, proteinuria greater than 1.0 g/d, and estimated glomerular filtration rate (eGFR) greater than 30 and less than 60 mL/min/1.73m2 or with persistent hypertension from September 2013 to December 2015. During a 3-month run-in period, 238 patients received optimized supportive care (SC), including losartan. Patients with a urinary protein excretion rate of 0.75 g/d or greater despite of 3 months optimized SC were enrolled into the trial for 3 years. Survivors of the trial who did not receive dialysis or transplant were followed up after the trial for a median (IQR) of 60 (47-76) months. Data were analyzed from March through June 2022. INTERVENTIONS A total of 170 participants were randomized in a 1:1 ratio to receive MMF (initially, 1.5 g/d for 12 months, maintained at 0.75-1.0 g for at least 6 months) plus SC or SC alone. MAIN OUTCOMES AND MEASURES The primary outcomes were (1) a composite of doubling of serum creatinine, end-stage kidney disease (dialysis, transplant, or kidney failure without receiving kidney replacement therapy), or death due to kidney or cardiovascular cause and (2) progression of chronic kidney disease. RESULTS Among 170 randomized patients (mean [SD] age 36.6 [9.4] years; 94 [55.3%] male patients), 85 patients received MMF with SC and 85 patients received SC alone. The mean (SD) eGFR was 50.1 (17.9) mL/min/1.73m2 and mean (SD) proteinuria level was 1.9 (1.7) g/d; 168 patients (98.8%) completed the trial, and 157 participants (92.4%) survived and did not receive dialysis or transplant. Primary composite outcome events occurred in 6 patients (7.1%) in the MMF group and 18 patients (21.2%) in the SC group (adjusted hazard ratio [aHR], 0.23; 95% CI, 0.09-0.63). Progression of chronic kidney disease occurred in 7 participants (8.2%) in the MMF group and 23 participants (27.1%) in the SC group (aHR, 0.23; 95% CI, 0.10-0.57). The effect of MMF treatment on primary outcomes was consistent across prespecified subgroups, with no significant interaction per subgroup. During posttrial follow-up, annual loss of eGFR accelerated after discontinuation of MMF; mean (SD) annual eGFR loss during the study period was 2.9 (1.0) mL/min/1.73m2 in the MMF group and 6.1 (1.2) mL/min/1.73m2 among 66 patients in the MMF group who discontinued MMF after the trial. Serious adverse events were not more frequent with MMF vs SC alone. CONCLUSIONS AND RELEVANCE This study found that addition of MMF to SC compared with SC alone significantly reduced risk of disease progression among patients with progressive IgAN. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01854814.
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Affiliation(s)
- Fan Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- National Clinical Research Center for Kidney Disease, Guangzhou, Guangdong, China
- State Key Laboratory of Organ Failure Research, Guangzhou, Guangdong, China
- Guangdong Provincial Institute of Nephrology, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, Guangdong, China
| | - Di Xie
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- National Clinical Research Center for Kidney Disease, Guangzhou, Guangdong, China
- State Key Laboratory of Organ Failure Research, Guangzhou, Guangdong, China
- Guangdong Provincial Institute of Nephrology, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, Guangdong, China
| | - Jun Wang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- National Clinical Research Center for Kidney Disease, Guangzhou, Guangdong, China
- State Key Laboratory of Organ Failure Research, Guangzhou, Guangdong, China
- Guangdong Provincial Institute of Nephrology, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, Guangdong, China
| | - Xin Xu
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- National Clinical Research Center for Kidney Disease, Guangzhou, Guangdong, China
- State Key Laboratory of Organ Failure Research, Guangzhou, Guangdong, China
- Guangdong Provincial Institute of Nephrology, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, Guangdong, China
| | - Xiaobing Yang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- National Clinical Research Center for Kidney Disease, Guangzhou, Guangdong, China
- State Key Laboratory of Organ Failure Research, Guangzhou, Guangdong, China
- Guangdong Provincial Institute of Nephrology, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, Guangdong, China
| | - Jun Ai
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- National Clinical Research Center for Kidney Disease, Guangzhou, Guangdong, China
- State Key Laboratory of Organ Failure Research, Guangzhou, Guangdong, China
- Guangdong Provincial Institute of Nephrology, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, Guangdong, China
| | - Sheng Nie
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- National Clinical Research Center for Kidney Disease, Guangzhou, Guangdong, China
- State Key Laboratory of Organ Failure Research, Guangzhou, Guangdong, China
- Guangdong Provincial Institute of Nephrology, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, Guangdong, China
| | - Min Liang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- National Clinical Research Center for Kidney Disease, Guangzhou, Guangdong, China
- State Key Laboratory of Organ Failure Research, Guangzhou, Guangdong, China
- Guangdong Provincial Institute of Nephrology, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, Guangdong, China
| | - Guobao Wang
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- National Clinical Research Center for Kidney Disease, Guangzhou, Guangdong, China
- State Key Laboratory of Organ Failure Research, Guangzhou, Guangdong, China
- Guangdong Provincial Institute of Nephrology, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, Guangdong, China
| | - Nan Jia
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
- National Clinical Research Center for Kidney Disease, Guangzhou, Guangdong, China
- State Key Laboratory of Organ Failure Research, Guangzhou, Guangdong, China
- Guangdong Provincial Institute of Nephrology, Guangzhou, Guangdong, China
- Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, Guangdong, China
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Han SY, Jung CY, Lee SH, Lee DW, Lee S, Kim CD, Choi BS, Kim BS. A multicenter, randomized, open-label, comparative, phase IV study to evaluate the efficacy and safety of combined treatment with mycophenolate mofetil and corticosteroids in advanced immunoglobulin A nephropathy. Kidney Res Clin Pract 2022; 41:452-461. [PMID: 35545228 PMCID: PMC9346400 DOI: 10.23876/j.krcp.21.146] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 12/07/2021] [Indexed: 11/19/2022] Open
Abstract
Background It remains unclear whether immunosuppressive agents are effective in patients with immunoglobulin A nephropathy (IgAN). We investigated the efficacy of a mycophenolate mofetil (MMF) and corticosteroid combination therapy in patients with advanced IgAN. Methods We conducted a multicenter, randomized, placebo-controlled, parallel-group study of 48 weeks administration of MMF and corticosteroids in biopsy-proven advanced IgAN patients with estimated glomerular filtration rate (eGFR) of 20–50 mL/min/1.73 m2 and urine protein-to-creatinine ratio (UPCR) of >0.75 g/day. The primary outcome was complete (UPCR < 0.3 g/day) or partial (>50% reduction of UPCR compared to baseline) remission at 48 weeks. Results Among the 48 randomized patients, the percentage that achieved complete or partial remission was greater in thecombination therapy group than in the control group (4.2% vs. 0% and 29.1% vs. 5.0%, respectively). Compared with the combination therapy group, eGFR in the control group decreased significantly from week 36 onward, resulting in a final adjusted mean change of –4.39 ± 1.22 mL/min/1.73 m2 (p = 0.002). The adjusted mean changes after 48 weeks were 0.62 ± 1.30 and –5.11 ± 1.30 mL/min/1.73 m2 (p = 0.005) in the treatment and control groups, respectively. The UPCR was significantly different between the two groups; the adjusted mean difference was –0.47 ± 0.17 mg/mgCr and 0.07 ± 0.17 mg/mgCr in the treatment and control group, respectively (p = 0.04). Overall adverse events did not differ between the groups. Conclusion In advanced IgAN patients with a high risk for disease progression, combined MMF and corticosteroid therapy appears to be beneficial in reducing proteinuria and preserving renal function.
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Affiliation(s)
- Sang Youb Han
- Department of Internal Medicine, Inje University College of Medicine, Goyang, Republic of Korea
| | - Chan-Young Jung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sang Ho Lee
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Dong Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Republic of Korea
| | - Sik Lee
- Department of Internal Medicine, Chonbuk National University Medical School, Jeonju, Republic of Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Bum Soon Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Bum Soon Choi Department of Internal Medicine, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Republic of Korea. E-mail:
| | - Beom Seok Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Correspondence: Beom Seok Kim Department of Internal Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03772, Republic of Korea. E-mail:
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16
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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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Huerta A, Mérida E, Medina L, Fernandez M, Gutierrez E, Hernandez E, Lopez P, Sevillano A, Portolés J, Trimarchi H, Praga M. Corticosteroids and mycophenolic acid analogs in IgA nephropathy with progressive decline in kidney function. Clin Kidney J 2021; 15:771-777. [PMID: 35371455 PMCID: PMC8967683 DOI: 10.1093/ckj/sfab244] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
A randomized controlled trial (RCT) demonstrated a beneficial effect of corticosteroids (CS) plus cyclophosphamide followed by azathioprine in progressive IgA nephropathy (IgAN). Although treatment with CS and mycophenolic acid analogs (MPAA) remains controversial in IgAN, there is no information about their effect in progressive IgAN.
Methods
Patients with progressive IgAN, defined by a decrease in estimated glomerular filtration rate (eGFR) of at least 10 ml/min/1.73 m2 in the 12 months prior to the start of treatment, proteinuria ≥ 0.75 g/24h despite maximum tolerated doses of renin-angiotensin system blockers (RASB) and persistent hematuria, who had received treatment with CS+MPAA were included in this retrospective study. The main outcome was the difference between the eGFR slope from the start of treatment with CS+MPAA to the last visit with this treatment with respect to the eGFR slope during the 12 months prior to start of treatment.
Results
Twenty-five patients were included in the study. Mean duration of CS+MPAA treatment was 24.7±15.2 months. In the 12 months prior to treatment the median rate of kidney function decline was -23 [-32 to -16] ml/min/1.73 m2 per year. After the onset of treatment, the median eGFR slope was +5 [+3 to +9] ml/min/1.73 m2 per year (P = 0.001 with respect to the 12 months prior to treatment). Proteinuria decreased from 1.8 (1.0-2.5) g/day at baseline to 0.6 (0.3-1.2) g/day at the end of treatment (P = 0.01) and hematuria disappeared in 40% of the patients. There were no serious adverse effects requiring treatment discontinuation.
Conclusions
CS + MPAA is an effective treatment in IgAN patients with a sustained decline in kidney function accompanied by persistent proteinuria and hematuria despite optimized conservative treatment. Prospective studies are needed to confirm these results.
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Affiliation(s)
- Ana Huerta
- Department of Nephrology, Hospital Universitario Puerta del Hierro Majadahonda, Madrid, Spain
- REDInREN ISCIII 016/009, Spain
| | - Eva Mérida
- REDInREN ISCIII 016/009, Spain
- Department of Nephrology, Hospital Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Laura Medina
- Department of Nephrology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Maria Fernandez
- Department of Nephrology, Hospital Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Eduardo Gutierrez
- REDInREN ISCIII 016/009, Spain
- Department of Nephrology, Hospital Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Eduardo Hernandez
- REDInREN ISCIII 016/009, Spain
- Department of Nephrology, Hospital Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Paula Lopez
- Department of Nephrology, Hospital Universitario Puerta del Hierro Majadahonda, Madrid, Spain
| | - Angel Sevillano
- REDInREN ISCIII 016/009, Spain
- Department of Nephrology, Hospital Hospital Universitario Doce de Octubre, Madrid, Spain
| | - Jose Portolés
- Department of Nephrology, Hospital Universitario Puerta del Hierro Majadahonda, Madrid, Spain
- REDInREN ISCIII 016/009, Spain
| | - Hernan Trimarchi
- Department of Nephrology, Hospital Británico de Buenos Aires, Argentina
| | - Manuel Praga
- REDInREN ISCIII 016/009, Spain
- Research Institute Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
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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: 733] [Impact Index Per Article: 244.3] [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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Abstract
IgA nephropathy (IgAN) is the most common type of glomerulonephritis in Asia and the Western world. In most patients, it follows an asymptomatic to oligosymptomatic course and GFR loss, if any, is slow. The mainstay of therapy therefore is optimized supportive care, i.e., measures that lower blood pressure, reduce proteinuria, minimize lifestyle risk factors, and otherwise help to reduce non-specific insults to the kidneys. The value of immunosuppression has become controversial and if at all, systemic high-dose corticosteroid therapy should be considered for a few months taking into account patient characteristics that would caution against or preclude such therapy. In addition, adverse events related to corticosteroid therapy markedly increase as GFR declines. Beyond corticosteroids, there is little evidence that any additional immunosuppression is helpful, with the exception of mycophenolate mofetil in patients of Asian descent. A considerable number of clinical trials ranging from enteric coated budesonide to blockade of B-cell function to complement inhibitors are currently ongoing and will hopefully allow a more targeted therapy of high-risk patients with progressive IgAN in the future.
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20
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Inker LA, Heerspink HJL, Tighiouart H, Chaudhari J, Miao S, Diva U, Mercer A, Appel GB, Donadio JV, Floege J, Li PKT, Maes BD, Locatelli F, Praga M, Schena FP, Levey AS, Greene T. Association of Treatment Effects on Early Change in Urine Protein and Treatment Effects on GFR Slope in IgA Nephropathy: An Individual Participant Meta-analysis. Am J Kidney Dis 2021; 78:340-349.e1. [PMID: 33775708 PMCID: PMC8384669 DOI: 10.1053/j.ajkd.2021.03.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 03/03/2021] [Indexed: 01/18/2023]
Abstract
RATIONALE & OBJECTIVE An early change in proteinuria is considered a reasonably likely surrogate end point in immunoglobulin A nephropathy (IgAN) and can be used as a basis for accelerated approval of therapies, with verification in a postmarketing confirmatory trial. Glomerular filtration rate (GFR) slope is a recently validated surrogate end point for chronic kidney disease progression and may be considered as the end point used for verification. We undertook a meta-analysis of clinical trials in IgAN to compare treatment effects on change in proteinuria versus change in estimated GFR (eGFR) slope. STUDY DESIGN Individual patient-level meta-analysis. SETTING & STUDY POPULATIONS Individual data of 1,037 patients from 12 randomized trials. SELECTION CRITERIA FOR STUDIES Randomized trials of IgAN with proteinuria measurements at baseline and 6 (range, 2.5-14) months and at least a further 1 year of follow-up for the clinical outcome. ANALYTICAL APPROACH For each trial, we estimated the treatment effects on proteinuria and on the eGFR slope, computed as the total slope starting at baseline or the chronic slope starting 3 months after randomization. We used a Bayesian mixed-effects analysis to relate the treatment effects on proteinuria to effects on GFR slope across these studies and developed a prediction model for the treatment effect on the GFR slope based on the effect on proteinuria. RESULTS Across all studies, treatment effects on proteinuria accurately predicted treatment effects on the total slope at 3 years (median R2 = 0.88; 95% Bayesian credible interval [BCI], 0.06-1) and on the chronic slope (R2 = 0.98; 95% BCI, 0.29-1). For future trials, an observed treatment effect of approximately 30% reduction in proteinuria would confer probabilities of at least 90% for nonzero treatment benefits on the total and chronic slopes of eGFR. We obtained similar results for proteinuria at 9 and 12 months and total slope at 2 years. LIMITATIONS Study population restricted to 12 trials of small sample size, leading to wide BCIs. There was heterogeneity among trials with respect to study design and interventions. CONCLUSIONS These results provide new evidence supporting that early reduction in proteinuria can be used as a surrogate end point for studies of chronic kidney disease progression in IgAN.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA.
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA; Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Ulysses Diva
- Biometrics, Travere Therapeutics Inc, San Diego, CA
| | - Alex Mercer
- Clinical Drug Development, JAMCO Pharma Consulting AB, Stockholm, Sweden
| | - Gerald B Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY
| | | | - Jürgen Floege
- Division of Nephrology and Immunology, RWTH Aachen University, Aachen, Germany
| | - Philip K T 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
- Instituto de Investigación Hospital Universitario 12 de Octubre, i+12, Complutense University, Madrid, Spain
| | - Francesco P Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Andrew S Levey
- Division of Nephrology, Tufts Medical Center, Boston, MA
| | - Tom Greene
- Departments of Population Health Sciences and Internal Medicine, University of Utah, Salt Lake City, UT
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21
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Zhang H, Barratt J. Is IgA nephropathy the same disease in different parts of the world? Semin Immunopathol 2021; 43:707-715. [PMID: 34417628 DOI: 10.1007/s00281-021-00884-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/29/2021] [Indexed: 12/30/2022]
Abstract
Since it was first described in 1968, immunoglobulin A nephropathy (IgAN) is understood to be the most common form of glomerulonephritis worldwide. The diagnosis of IgAN depends on the presence of dominant mesangial IgA1 deposition by renal biopsy. To date, a wide spectrum of clinical and pathologic features of IgAN have been observed, implying that IgAN might not be the same disease across the world. Here, we review the characteristics of IgAN from perspectives of epidemiology, clinical-pathological patterns, disease pathogenesis, and treatment response across different ethnic populations. Overall, IgAN is most prevalent in Asians, followed by Caucasians, and relatively rare in Africans. More severe clinical presentation and higher risk of disease progression have been reported in Asians than Europeans. Moreover, active lesions, such as endocapillary hypercellularity and crescents, are more commonly reported in Asians than Europeans. Response to corticosteroid/immunosuppression therapy is variably reported, with greater apparent efficacy reported in Asian than European studies. Although a multi-hit hypothesis has been suggested for IgAN, the relative importance of each "hit" may vary in different ethnic populations and this variation underlies the differences in presentation of IgAN. In the future, a better understanding of pathogenic pathways operating in different ethnic populations may help provide better biomarkers of disease and more precise targeting of treatment strategies for IgAN.
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Affiliation(s)
- Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.
- Institute of Nephrology, Peking University, Beijing, China.
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester and Leicester General Hospital, Leicester, UK.
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22
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Seikrit C, Rauen T, Stamellou E, Floege J. Precision medicine in immunoglobulin A nephropathy: still a journey ahead. Nephrol Dial Transplant 2021; 36:24-30. [PMID: 34153983 DOI: 10.1093/ndt/gfab032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Indexed: 11/12/2022] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerular disease worldwide and since its first description extensive research has identified a number of key central pathogenetic contributors, including genetic, immunological and environmental factors. Along with its multifaceted pathophysiology, the clinical presentation of IgAN varies, ranging from mild forms with only minor urinary findings and preserved renal function to cases that rapidly progress to end-stage renal disease. Because of this, early identification of patients at risk for a progressive course is urgently needed. The search for valid and easily accessible biomarkers showed urinary Dickkopf-3 as a promising candidate to predict the course of kidney function. In addition, a recently established IgAN risk prediction tool derived from an international cohort of IgAN patients allows estimation of the risk of a 50% loss of kidney function over several years upon diagnosis. This might serve as a significant tool to individually predict the course of renal function by combining biometric, clinical, histological and treatment information at the time of diagnosis. Today there is no doubt that a comprehensive supportive treatment regimen is the main pillar for all IgAN patients. The value of an additional immunosuppressive treatment in IgAN patients at risk for disease progression is less clear. Early risk stratification and individualized therapies would be desirable for IgAN patients to facilitate the choice of treatment strategies, which is still a matter of ongoing discussion.
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Affiliation(s)
- Claudia Seikrit
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Thomas Rauen
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Eleni Stamellou
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
| | - Jürgen Floege
- Division of Nephrology and Clinical Immunology, RWTH Aachen University Hospital, Aachen, Germany
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23
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IgA Vasculitis and IgA Nephropathy: Same Disease? J Clin Med 2021; 10:jcm10112310. [PMID: 34070665 PMCID: PMC8197792 DOI: 10.3390/jcm10112310] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/17/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022] Open
Abstract
Many authors suggested that IgA Vasculitis (IgAV) and IgA Nephropathy (IgAN) would be two clinical manifestations of the same disease; in particular, that IgAV would be the systemic form of the IgAN. A limited number of studies have included sufficient children or adults with IgAN or IgAV (with or without nephropathy) and followed long enough to conclude on differences or similarities in terms of clinical, biological or histological presentation, physiopathology, genetics or prognosis. All therapeutic trials available on IgAN excluded patients with vasculitis. IgAV and IgAN could represent different extremities of a continuous spectrum of the same disease. Due to skin rash, patients with IgAV are diagnosed precociously. Conversely, because of the absence of any clinical signs, a renal biopsy is practiced for patients with an IgAN to confirm nephropathy at any time of the evolution of the disease, which could explain the frequent chronic lesions at diagnosis. Nevertheless, the question that remains unsolved is why do patients with IgAN not have skin lesions and some patients with IgAV not have nephropathy? Larger clinical studies are needed, including both diseases, with a common histological classification, and stratified on age and genetic background to assess renal prognosis and therapeutic strategies.
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24
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Zhao J, Ma F, Bai M, Sun S. Low-Dose Corticosteroid Combined With Mycophenolate Mofetil for IgA Nephropathy With Stage 3 or 4 CKD: A Retrospective Cohort Study. Clin Ther 2021; 43:859-870. [PMID: 33863547 DOI: 10.1016/j.clinthera.2021.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/21/2021] [Accepted: 03/10/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE This study assessed the long-term (10-year) tolerability and efficacy of a low-dose corticosteroid combined with mycophenolate mofetil (CS + MMF) in the treatment of immunoglobulin A nephropathy (IgAN) with stage 3/4 chronic kidney disease and proteinuria in clinical practice in China. METHODS Data from patients with biopsy-proven IgAN, stage 3/4 chronic kidney disease (estimated glomerular filtration rate 15-59 mL/min/1.73 m2), and proteinuria (urinary protein excretion ≥1.0 g/d) and who were treated with uncontrolled supportive care (USC), CS, or CS + MMF between January 2008 and December 2017 were included. The primary end point was the prevalence of the composite outcome of any of the following conditions: a reduction in estimated glomerular filtration rate of ≥50%, end-stage renal disease, and death. FINDINGS Of the 120 enrolled patients, 44, 25, and 51 were treated with USC, CS, and CS + MMF, respectively. The median follow-up time was 40.1 months (IQR, 29.1-67.8 months). The prevalences of the composite outcome were 63.6%, 56.0%, and 19.6%, respectively (P < 0.001). The cumulative 5-year renal function-preservation rates were 48.1%, 51.4%, and 83.7%. After adjustment for covariates, the prevalence of the composite outcome was significantly decreased with CS + MMF (HR = 0.094; 95% CI, 0.026-0.335; P < 0.001), but not with CS (HR = 0.749; 95% CI, 0.354-1.583; P = 0.449), compared with USC. However, 4 patients in the CS + MMF group died, of whom 3 had severe pneumonia. IMPLICATIONS CS + MMF may have more promising efficacy than USC or CS in renal-function preservation in patients with IgAN and chronic kidney disease in the Chinese population. However, attention should be paid to the increased risk for death due to severe pneumonia.
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Affiliation(s)
- Jin Zhao
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Feng Ma
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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25
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Scurt FG, Bose K, Canbay A, Mertens PR, Chatzikyrkou C. [Chronic kidney injury in patients with liver diseases - Reappraising pathophysiology and treatment options]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:560-579. [PMID: 33728618 DOI: 10.1055/a-1402-1502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Acute and chronic kidney disease concurs commonly with liver disease and is associated with a wide array of complications including dialysis dependency and increased mortality. Patients with liver disease or liver cirrhosis show a higher prevalence of chronic kidney disease. This is attributed to concomitant comorbidities, such as metabolic syndrome, chronic inflammation, hypercoagulability, hyperfibrinolysis, diabetes mellitus and dyslipidaemias. But chronic progressive kidney disease is not always due to hepatorenal syndrome. Beyond that, other diseases or disease entities should be considered. Among them are diabetic nephropathy, secondary IgA nephropathy, hepatitis C -associated membranoproliferative Glomerulonephritis (MPGN) and hepatitis B-associated membranous nephropathy.Coexisting diseases, similar underlying pathophysiologic mechanisms, or simultaneously concurring pathophysiological processes and overlapping clinical manifestations, impede the etiologic diagnosis and corresponding treatment of chronic kidney disease in the setting of chronic liver disease. In this review, we focus on common and rare pathologies, which can lead to chronic kidney disease in this particular patient group and try to summarize the most recent therapeutic modalities.
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Affiliation(s)
- Florian Gunnar Scurt
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto von Guericke University, Magdeburg, Germany
| | - Katrin Bose
- Health Campus Immunology, Infectiology and Inflammation, Otto von Guericke University, Magdeburg, Germany.,Universitätsklinik für Gastroenterologie, Hepatologie und Infektiologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland
| | - Ali Canbay
- Ruhr-Universität Bochum, Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Bochum, Deutschland
| | - Peter R Mertens
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto von Guericke University, Magdeburg, Germany
| | - Christos Chatzikyrkou
- Klinik für Nieren- und Hochdruckerkrankungen, Diabetologie und Endokrinologie, Medizinische Fakultät der Otto-von-Guericke-Universität, Magdeburg, Deutschland.,Health Campus Immunology, Infectiology and Inflammation, Otto von Guericke University, Magdeburg, Germany
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26
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Peng XJ, Zheng WM, Fu R, Huang YH, Deng MH, Tao SS, Wang TJ, Zhu C. Efficacy and safety of mycophenolate mofetil in the treatment for IgA nephropathy: a meta-analysis of randomized controlled trials. Clin Exp Nephrol 2021; 25:788-801. [PMID: 33710500 DOI: 10.1007/s10157-021-02028-5] [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: 10/23/2019] [Accepted: 01/28/2021] [Indexed: 11/30/2022]
Abstract
AIM IgA nephropathy is virtually known as the most common glomerulopathy to end-stage renal failure in the world. Mycophenolate mofetil is a selective immunosuppressant widely used in organ transplantation, yet its tolerance and effectiveness in IgAN is controversial. METHODS This is a systematic review and random-effects meta-analysis, searching PubMed, Embase, Te Cochrane Library, Science Citation Index, Ovid evidence-based medicine, Chinese Biomedical Literature and Chinese Science and Technology Periodicals. Screen out randomized controlled trials on patients with biopsy-proven IgA nephropathy and analysis mycophenolate mofetil treatment regimens used for therapy of IgA nephropathy. Complete remission and partial remission, doubling of creatinine level, proteinuria, incidence of end-stage kidney disease, infection, Cushing syndrome, diabetes, hepatic dysfunction or gastrointestinal symptoms, neurologic or visual ambiguity, acne, and alopecia were observed. RESULTS Nine relevant trials were conducted with 587 patients enrolled. In Mycophenolate mofetil or plus medium/low-dose steroid comparing full-dose steroid alone or placebo, there was no significant difference. The risk of Cushing syndrome and diabetes had been significantly lowered with Mycophenolate mofetil-treated patients, while the risk of infection had been increased. CONCLUSIONS Mycophenolate mofetil therapy did not differ in reducing proteinuria and Scr in patients with IgAN who had persistent proteinuria, while having fewer Cushing syndrome and diabetes risk and more infection risk. However, larger randomized studies are needed to reveal these results.
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Affiliation(s)
- Xiao-Jie Peng
- Department of Nephrology, Jiangxi Provincial Children's Hospital, 122 Yangming Road, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Wei-Min Zheng
- Department of Nephrology, Jiangxi Provincial Children's Hospital, 122 Yangming Road, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Rui Fu
- Department of Nephrology, Jiangxi Provincial Children's Hospital, 122 Yangming Road, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Yu-Hui Huang
- Department of Nephrology, Jiangxi Provincial Children's Hospital, 122 Yangming Road, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Mei-Hui Deng
- Department of Nephrology, Jiangxi Provincial Children's Hospital, 122 Yangming Road, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Shan-Shan Tao
- Department of Nephrology, Jiangxi Provincial Children's Hospital, 122 Yangming Road, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Ting-Jie Wang
- Department of Nephrology, Jiangxi Provincial Children's Hospital, 122 Yangming Road, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Chunhui Zhu
- Department of Infectious Disease, Jiangxi Provincial Children's Hospital, 122 Yangming Road, Nanchang, 330006, Jiangxi, People's Republic of China.
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27
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Liu T, Wang Y, Mao H, Yang L, Zhan Y. Efficacy and safety of immunosuppressive therapies in the treatment of high-risk IgA nephropathy: A network meta-analysis. Medicine (Baltimore) 2021; 100:e24541. [PMID: 33663060 PMCID: PMC7909110 DOI: 10.1097/md.0000000000024541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND IgA nephropathy (IgAN) is one of the significant contributing factors of end-stage renal disease (ESRD). It is reported that over half of patients with IgAN accompany multiple high-risk factors, which increase the risk of ESRD progression. Studies have shown that immunosuppressive agents were beneficial in high-risk IgAN, but the efficacy and safety have not been fully demonstrated yet. The present study aims to elucidate the efficacy of commonly used immunosuppressants in high-risk IgAN and their relative safety profiles via a network meta-analysis strategy. METHODS Randomized controlled trials (RCTs) eligible for this network meta-analysis were included to evaluate the efficacy and safety of different immunosuppressants for high-risk IgAN. Main outcomes and measures include incidence of renal composite end point, the rate of total remission, adverse events, and proteinuria. Besides, subgroup analysis and cluster analysis were carried out. RESULTS This network meta-analysis of 37 RCTs involving 3012 participants found that Mycophenolate mofetil (MMF) combined with corticosteroids (CS) was superior to other interventions in end point events and proteinuria. Cyclosporine A (CsA) plus CS was the best option for clinical remission rate, and supportive care (SC) was the safest treatment. Cluster analysis showed that MMF+CS and Leflunomide (LEF)+CS were best protocols in efficacy and safety. Subgroup analysis indicated the best benefits of MMF were presented among the Asian population, and the benefits increased with the increase of follow-up duration. The effect of Cyclophosphamide (CTX) +CS on crescent IgAN was better than that of other risk factors. Moreover, the increasing follow-up duration was negatively associated with the effect. CONCLUSIONS MMF+CS and LEF+CS appear to serve as the best choice for treating high-risk IgAN than other immunosuppressive therapies.
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28
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Rajasekaran A, Julian BA, Rizk DV. IgA Nephropathy: An Interesting Autoimmune Kidney Disease. Am J Med Sci 2021; 361:176-194. [PMID: 33309134 PMCID: PMC8577278 DOI: 10.1016/j.amjms.2020.10.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/19/2020] [Accepted: 10/05/2020] [Indexed: 12/27/2022]
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. It is a leading cause of chronic kidney disease and progresses to end-stage kidney disease in up to 40% of patients about 20 years after diagnosis. Additionally, IgAN is associated with significant mortality. The diagnosis currently necessitates a kidney biopsy, as no biomarker sufficiently specific and sensitive is available to supplant the procedure. Patients display significant heterogeneity in the epidemiology, clinical manifestations, renal progression, and long-term outcomes across diverse racial and ethnic populations. Recent advances in understanding the underlying pathophysiology of the disease have led to the proposal of a four-hit hypothesis supporting an autoimmune process. To date, there is no disease-specific treatment but, with a better understanding of the disease pathogenesis, new therapeutic approaches are currently being tested in clinical trials. In this review, we examine the multiple facets and most recent advances of this interesting disease.
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Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Bruce A Julian
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Dana V Rizk
- Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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29
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Han S, Yao T, Lu Y, Chen M, Xu Y, Wang Y. Efficacy and Safety of Immunosuppressive Monotherapy Agents for IgA Nephropathy: A Network Meta-Analysis. Front Pharmacol 2021; 11:539545. [PMID: 33551793 PMCID: PMC7862876 DOI: 10.3389/fphar.2020.539545] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 11/26/2020] [Indexed: 01/10/2023] Open
Abstract
Background: The efficacy and safety of immunosuppressive monotherapy agents were evaluated for immunoglobulin A nephropathy (IgAN) using a network meta-analysis approach. Methods: Randomized controlled trials (RCTs) published prior to October 1, 2019, using immunosuppressive agents for treating IgAN, were systematically searched in PubMed, Embase, Cochrane Library, and Web of Science databases. Relative risks (RRs) or standard mean differences with 95% confidence intervals (CIs) were estimated using the random-effects model. The primary outcomes were clinical remission, end-stage renal disease (ESRD), and serious adverse events (SAEs). The secondary outcomes were urinary protein excretion and serum creatinine. Results: Twenty-five RCTs with 2,005 participants were deemed eligible. Six medications were evaluated: corticosteroids, mycophenolate mofetil (MMF), tacrolimus (TAC), cyclosporine, leflunomide, and hydroxychloroquine (HCQ). Steroids (RR 1.50, 95% CI 1.17-1.93), MMF (RR 2.05, 95% CI 1.15-3.65), TAC (RR 3.67, 95% CI 1.06-12.63), and HCQ (RR 3.25, 95% CI 1.05-10.09) significantly improved clinical remission rates compared to supportive care alone. Only steroids reduced the risk of ESRD (RR 0.35, 95% CI 0.12-0.98); however, there were significantly more SAEs than in the control group (RR 2.90, 95% CI 1.37-6.13). No significantly different effects in serum creatinine levels were found among the therapies. MMF showed no significant improvement in remission when excluding studies with a follow-up of fewer than 2 years in the sensitivity analysis (RR 1.41, 95% CI 0.40-4.92). The effect of TAC in the decrease of proteinuria was reversed after discontinuing medication for 3 months; the long-term effects of HCQ could not be evaluated due to the short follow-up duration. Conclusion: Corticosteroids might induce remission and increase renal survival in IgAN; however, adverse reactions should be taken into consideration. MMF, TAC, and HCQ might improve the remission of proteinuria when treating IgAN, but showed no superiority compared to steroids, and the long-term effects require further study.
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Affiliation(s)
| | | | | | | | | | - Yi Wang
- Department of Nephrology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
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30
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Qin A, Pei G, Tang Y, Tan L, Wei X, Zhong Z, Zhou L, Chen C, Qin W. Corticosteroids Improve Renal Survival: A Retrospective Analysis From Chinese Patients With Early-Stage IgA Nephropathy. Front Med (Lausanne) 2020; 7:585859. [PMID: 33195345 PMCID: PMC7643022 DOI: 10.3389/fmed.2020.585859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/25/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The efficacy and safety of corticosteroids and immunosuppressive therapy remain controversial for the treatment of immunoglobulin A nephropathy (IgAN). This study aimed to evaluate the effects of corticosteroid and immunosuppressant therapy in Chinese patients with early-stage IgAN whose estimated glomerular filtration rate (eGFR) was ≥45 ml/min/1.73 m2 and proteinuria was ≥1 g/24 h at biopsy. Methods: Patients with biopsy-proven IgAN were retrospectively enrolled from four study centers between 2007 and 2016. Patients were regularly followed up for at least 1 year or until the study end point. Patients were categorized into three treatment groups: supportive care (SC), steroids alone (CS), and steroids plus immunosuppressants (IT). The observed responses to therapy included complete remission (CR), partial remission (PR), no response (NR), and end-stage renal disease (ESRD). The primary end point of the current study was defined as a 50% decline in eGFR and/or ESRD. Results: A total of 715 patients (male 47% and female 53%) were recruited and followed up for 44.69 ± 24.13 months. The observed CR rate was 81.8% with corticosteroids alone (CS), 62.7% with corticosteroids + immunosuppresants (IT), and 37% with supportive care alone (SC). Renal outcomes were remarkably better in the CS group compared with the SC and IT groups (the percentage of patients reaching the end point in each group was 4.6 vs. 14.4 vs. 11.5%, respectively; p = 0.001). Moreover, 36 and 80-month renal survival were significantly better for the CS group (98.3 and 86.4%) than for the IT (94.2 and 82.4%) and SC (94.0 and 51.6%) groups. Early CKD stage also presented with better kidney survival (p < 0.001). Renal survival of CKD stage 1 patients was relatively good regardless of the specific treatment regimen. CS and IT treatment significantly improved renal survival for CKD stage 2 patients when compared with the SC group (p < 0.001 and 0.007, respectively). However, renal survival of CKD stage 3a patients was not impacted by any of the three treatment regimens. Subgroup analysis also showed that renal survival of patients with proteinuria >3.5 g, M1, E0, S1, T0, and C0 was significantly better in the CS group than in the SC and IT groups. A multivariate model showed that hypertension, serum creatinine, E1 lesion, and T1/T2 lesion remained independent predictors of poor renal survival. Conclusions: Immunosuppressive therapy does not have further benefit beyond that provided by steroids. Corticosteroids plus optimal supportive care may further be beneficial in treating early-stage IgAN patients in that it could significantly improve the short-term renal outcome.
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Affiliation(s)
- Aiya Qin
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Gaiqin Pei
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Yi Tang
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Li Tan
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Xingfu Wei
- Institute of Epidemiology and Health Statistics, School of Public Health, Lanzhou University, Lanzhou, China
| | - Zhengxia Zhong
- Affiliated Hospital of Zunyi Medical College, Zunyi, China
| | - Ling Zhou
- The Third Hospital of Zigong City, Zigong, China
| | | | - Wei Qin
- Division of Nephrology, Department of Medicine, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Wei Qin
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31
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Gutiérrez E, Carvaca-Fontán F, Luzardo L, Morales E, Alonso M, Praga M. A Personalized Update on IgA Nephropathy: A New Vision and New Future Challenges. Nephron Clin Pract 2020; 144:555-571. [PMID: 32818944 DOI: 10.1159/000509997] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/08/2020] [Indexed: 11/19/2022] Open
Abstract
IgA nephropathy (IgAN) is the most common primary glomerulonephritis in the world among patients undergoing renal biopsy. Approximately 30% of patients with IgAN develop end-stage kidney disease 20 years after renal biopsy. It is a glomerulopathy with a very broad clinical presentation, making it difficult to stratify and treat. IgAN is characterized by dysregulation of the immune system, which causes an abnormal synthesis of IgA1 that is deglycosylated causing its mesangial deposition. IgAN pathogenesis is incompletely understood; the current multi-hit hypothesis of IgAN pathogenesis does not explain the range of glomerular inflammation and renal injury associated with mesangial IgA deposition. Although associations between IgAN and glomerular and circulating markers of complement activation are established, the mechanism of complement activation and contribution to glomerular inflammation and injury are not defined. On the other hand, the renal-gut connection can also play an important role in the pathogenesis of IgAN with possible therapeutic implications. In order to standardize the histological findings, the Oxford Classification has allowed clarifying renal lesions that confer potential risk of progression. Currently, except for the blockade of the renin-angiotensin-aldosterone system, no other therapies are available in clinical setting for the treatment of IgAN, although the range of new drugs under investigation is extensive. The incorporation in the next trials of clinical parameters such as the amount of hematuria and histological lesions may allow more personalized therapeutic approaches. To summarize, in recent years, several important efforts have taken place in the understanding of IgAN, but still, further studies are warranted to elucidate the best therapeutic strategies according to the risk to improve the prognosis of this entity.
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Affiliation(s)
- Eduardo Gutiérrez
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain, .,Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain,
| | - Fernando Carvaca-Fontán
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Leonella Luzardo
- Department of Nephrology and Pathophysiology, School of Medicine, Universidad de la República, Montevideo, Uruguay
| | - Enrique Morales
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Marina Alonso
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.,Department of Pathological Anatomy, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Pei G, Tan J, Tang Y, Tan L, Zhong Z, Zhou L, Chen C, Qin W. Corticosteroids or immunosuppressants were not superior to supportive care in IgA nephropathy patients with mild proteinuria. Medicine (Baltimore) 2020; 99:e20513. [PMID: 32541473 PMCID: PMC7302656 DOI: 10.1097/md.0000000000020513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND We aimed to evaluate the effect of immunosuppressant therapy for immunoglobulin A nephropathy (IgAN) patients with mild proteinuria (<1 g/d). METHODS We recruited patients with biopsy-proven IgAN from 4 study centers. Patients were followed for more than 1 year or up to the study end point. Clinical indexes, renal pathological data, and treatment information were collected during the follow-up period. IgAN patients with mild proteinuria (<1 g/d at biopsy) were included. Patients were divided into a supportive care group (SC) and an immunosuppressant group (IT). Patients in the SC group received the optimal dose of renin angiotensin system inhibitors (RASi). Patients in the IT group received corticosteroids or immunosuppressant therapy plus RASi. Responses to therapy included complete remission (CR), partial remission (PR), no response (NR), and end stage renal disease (ESRD). A 50% decline in estimated glomerular filtration rate (eGFR) and/or ESRD was the primary end point of this study. RESULTS 295 patients (36.3% male and 63.7% female) were included in this study and were followed for 49.46 ± 24.35 months. We found a significant difference in estimated glomerular filtration rate, urine protein, mesangial hypercellularity, segmental glomerulosclerosis, cellular or fibrocellular crescents, and glomerulosclerosis between the 2 treatment groups at baseline. At the final follow-up, 224 patients (75.9%) achieved CR, 7 patients (2.4%) achieved PR, 55 patients (18.6%) had NR, and 9 patients (3.1%) reached ESRD. However, no significant differences were observed between the SC and IT groups with respect to CR (76.4% vs 73.5%, P = .659), PR (2.0% vs 4.1%, P = .329), NR (18.3% vs 20.4%, P = .728), and ESRD (3.3% vs 2.0%, P = 1.000). Kidney survival rates were also comparable between the SC and IT groups (93.7% vs 94.1%, P = .808). We observed similar results after subgroup analysis according to chronic kidney disease stages or pathological manifestations. A multivariate model showed that segmental sclerosis (HR 9.55, 95% CI 1.04-88.16, P = .047) and glomerulosclerosis (HR 21.09, 95% CI 1.39-320.53, P = .028) were independent predictors of poor renal survival. CONCLUSIONS Corticosteroids or immunosuppressants were not superior to supportive care in IgA nephropathy patients with mild proteinuria.
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Affiliation(s)
- Gaiqin Pei
- Division of Nephrology, Department of Medicine, West China Hospital
- West China School of Medicine, Sichuan University, Chengdu, Sichuan
| | - Jiaxing Tan
- Division of Nephrology, Department of Medicine, West China Hospital
- West China School of Medicine, Sichuan University, Chengdu, Sichuan
| | - Yi Tang
- Division of Nephrology, Department of Medicine, West China Hospital
| | - Li Tan
- West China School of Medicine, Sichuan University, Chengdu, Sichuan
| | - Zhengxia Zhong
- Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou
| | - Ling Zhou
- The Third Hospital of Zigong City, Zigong, Sichuan
| | | | - Wei Qin
- Division of Nephrology, Department of Medicine, West China Hospital
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Lundquist AL, Kalim S, Mojtahed A, Tomaszewski KJ. Case 13-2020: A 29-Year-Old Man with High Blood Pressure, Renal Insufficiency, and Hematuria. N Engl J Med 2020; 382:1639-1647. [PMID: 32320573 DOI: 10.1056/nejmcpc1916254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Andrew L Lundquist
- From the Departments of Medicine (A.L.L., S.K.), Radiology (A.M.), and Pathology (K.J.T.), Massachusetts General Hospital, and the Departments of Medicine (A.L.L., S.K.), Radiology (A.M.), and Pathology (K.J.T.), Harvard Medical School - both in Boston
| | - Sahir Kalim
- From the Departments of Medicine (A.L.L., S.K.), Radiology (A.M.), and Pathology (K.J.T.), Massachusetts General Hospital, and the Departments of Medicine (A.L.L., S.K.), Radiology (A.M.), and Pathology (K.J.T.), Harvard Medical School - both in Boston
| | - Amirkasra Mojtahed
- From the Departments of Medicine (A.L.L., S.K.), Radiology (A.M.), and Pathology (K.J.T.), Massachusetts General Hospital, and the Departments of Medicine (A.L.L., S.K.), Radiology (A.M.), and Pathology (K.J.T.), Harvard Medical School - both in Boston
| | - Kristen J Tomaszewski
- From the Departments of Medicine (A.L.L., S.K.), Radiology (A.M.), and Pathology (K.J.T.), Massachusetts General Hospital, and the Departments of Medicine (A.L.L., S.K.), Radiology (A.M.), and Pathology (K.J.T.), Harvard Medical School - both in Boston
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Song H, Hu H, Tang F, Cao C, Wan Q, He Y. Initial serum creatinine concentration affects clinical outcomes in patients with IgA nephropathy treated with mycophenolate mofetil combined with low-dose prednisone. Exp Ther Med 2020; 19:3369-3376. [PMID: 32266035 DOI: 10.3892/etm.2020.8573] [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: 02/22/2019] [Accepted: 01/22/2020] [Indexed: 02/06/2023] Open
Abstract
Indicators for predicting the efficacy of mycophenolate mofetil (MMF) have so far remained elusive. The present study aimed to identify predictive indicators of the efficacy of MMF combined with low-dose prednisone in patients with IgA nephropathy. A total of 598 patients presenting with primary IgA nephropathy at our center were screened. Patients were followed up for 18 months, where the end-point was defined as complete clinical remission. Cox proportional hazards models were performed for analyzing the initial serum creatinine (SCr) concentration to predict incomplete clinical remission. In total, 7 of 71 patients (9.86%) were in complete clinical remission at the final visit. Logistic regression indicated that the hazard ratio (HR) for quartile 4 was significantly higher than the HR for quartile 1 (quartile 4 vs. quartile 1: HR, 2.51; 95% CI, 1.20-5.21; P=0.01). Additional adjustment for the confounding variables, including age, sex, systolic BP, diastolic BP, proteinuria, uric acid, serum triglyceride, hemoglobin, serum albumin, serum total cholesterol and The Oxford classification of the models, did not reduce the HRs for the association between the initial SCr concentration and risk of incomplete clinical remission (quartile 4 vs. quartile 1: HR, 7.27; 95% CI, 1.21-43.63; P=0.03). Each unit increase in the initial SCr concentration was associated with a 67 and 194% increase in the risk of incomplete clinical remission based on model 1 (95% CI, 1.02-2.73; P=0.04) and model 2 (95% CI, 1.01-8.60; P=0.048), respectively. In conclusion, in the present cohort of patients with IgA nephropathy treated with MMF plus low-dose prednisone, the initial SCr concentration was an independent risk factor for incomplete clinical remission.
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Affiliation(s)
- Haiying Song
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China.,Department of Nephrology, Shenzhen University Health Science Center, Shenzhen, Guangdong 518035, P.R. China
| | - Haofei Hu
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China.,Department of Nephrology, Shenzhen University Health Science Center, Shenzhen, Guangdong 518035, P.R. China
| | - Fei Tang
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China.,Department of Nephrology, Shenzhen University Health Science Center, Shenzhen, Guangdong 518035, P.R. China
| | - Changchun Cao
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China.,Department of Nephrology, Shenzhen University Health Science Center, Shenzhen, Guangdong 518035, P.R. China
| | - Qijun Wan
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China.,Department of Nephrology, Shenzhen University Health Science Center, Shenzhen, Guangdong 518035, P.R. China
| | - Yongcheng He
- Department of Nephrology, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong 518035, P.R. China.,Department of Nephrology, Shenzhen University Health Science Center, Shenzhen, Guangdong 518035, P.R. China
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The efficacy and safety of immunosuppressive therapies in the treatment of IgA nephropathy: A network meta-analysis. Sci Rep 2020; 10:6062. [PMID: 32269271 PMCID: PMC7142138 DOI: 10.1038/s41598-020-63170-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 03/19/2020] [Indexed: 02/05/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is a common autoimmune glomerulonephritis that can result in end-stage renal disease (ESRD). Whether immunosuppressants are superior or equivalent to supportive care is still controversial. A network meta-analysis was conducted to compare the efficacy and safety of immunosuppressive treatment for IgAN. Medline, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and EMBASE were searched on December 30, 2018. We used a random-effects model with a Bayesian approach to appraise both renal outcomes and serious adverse effects. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated to present the relative effects. The ranking probabilities were calculated by the surface under the cumulative ranking curve (SUCRA). In total, 24 RCTs comprising 6 interventions were analyzed. Steroids significantly delayed the progression of renal deterioration with acceptable serious adverse effects, compared with supportive care (RR = 0.28, 95% CI = 0.13–0.51, SUCRA = 48.7%). AZA combined with steroids might be an alternative immunosuppressive therapy. Tacrolimus might decrease the proteinuria level (RR = 3.1, 95% CI = 1.2–9.4, SUCRA = 66.5%) but cannot improve renal function, and the side effects of tacrolimus should not be neglected. MMF and CYC showed no superiority in the treatment of IgAN. In summary, steroids might be recommended as the first-line immunosuppressive therapy for IgAN.
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Natale P, Palmer SC, Ruospo M, Saglimbene VM, Craig JC, Vecchio M, Samuels JA, Molony DA, Schena FP, Strippoli GFM. Immunosuppressive agents for treating IgA nephropathy. Cochrane Database Syst Rev 2020; 3:CD003965. [PMID: 32162319 PMCID: PMC7066485 DOI: 10.1002/14651858.cd003965.pub3] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND IgA nephropathy is the most common glomerulonephritis world-wide. IgA nephropathy causes end-stage kidney disease (ESKD) in 15% to 20% of affected patients within 10 years and in 30% to 40% of patients within 20 years from the onset of disease. This is an update of a Cochrane review first published in 2003 and updated in 2015. OBJECTIVES To determine the benefits and harms of immunosuppression strategies for the treatment of IgA nephropathy. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 9 September 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs of treatment for IgA nephropathy in adults and children and that compared immunosuppressive agents with placebo, no treatment, or other immunosuppressive or non-immunosuppressive agents. DATA COLLECTION AND ANALYSIS Two authors independently assessed study risk of bias and extracted data. Estimates of treatment effect were summarised using random effects meta-analysis. Treatment effects were expressed as relative risk (RR) and 95% confidence intervals (95% CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Risks of bias were assessed using the Cochrane tool. Evidence certainty was evaluated using GRADE methodology. MAIN RESULTS Fifty-eight studies involving 3933 randomised participants were included. Six studies involving children were eligible. Disease characteristics (kidney function and level of proteinuria) were heterogeneous across studies. Studies evaluating steroid therapy generally included patients with protein excretion of 1 g/day or more. Risk of bias within the included studies was generally high or unclear for many of the assessed methodological domains. In patients with IgA nephropathy and proteinuria > 1 g/day, steroid therapy given for generally two to four months with a tapering course probably prevents the progression to ESKD compared to placebo or standard care (8 studies; 741 participants: RR 0.39, 95% CI 0.23 to 0.65; moderate certainty evidence). Steroid therapy may induce complete remission (4 studies, 305 participants: RR 1.76, 95% CI 1.03 to 3.01; low certainty evidence), prevent doubling of serum creatinine (SCr) (7 studies, 404 participants: RR 0.43, 95% CI 0.29 to 0.65; low certainty evidence), and may lower urinary protein excretion (10 studies, 705 participants: MD -0.58 g/24 h, 95% CI -0.84 to -0.33;low certainty evidence). Steroid therapy had uncertain effects on glomerular filtration rate (GFR), death, infection and malignancy. The risk of adverse events with steroid therapy was uncertain due to heterogeneity in the type of steroid treatment used and the rarity of events. Cytotoxic agents (azathioprine (AZA) or cyclophosphamide (CPA) alone or with concomitant steroid therapy had uncertain effects on ESKD (7 studies, 463 participants: RR 0.63, 95% CI 0.33 to 1.20; low certainty evidence), complete remission (5 studies; 381 participants: RR 1.47, 95% CI 0.94 to 2.30; very low certainty evidence), GFR (any measure), and protein excretion. Doubling of serum creatinine was not reported. Mycophenolate mofetil (MMF) had uncertain effects on the progression to ESKD, complete remission, doubling of SCr, GFR, protein excretion, infection, and malignancy. Death was not reported. Calcineurin inhibitors compared with placebo or standard care had uncertain effects on complete remission, SCr, GFR, protein excretion, infection, and malignancy. ESKD and death were not reported. Mizoribine administered with renin-angiotensin system inhibitor treatment had uncertain effects on progression to ESKD, complete remission, GFR, protein excretion, infection, and malignancy. Death and SCr were not reported. Leflunomide followed by a tapering course with oral prednisone compared to prednisone had uncertain effects on the progression to ESKD, complete remission, doubling of SCr, GFR, protein excretion, and infection. Death and malignancy were not reported. Effects of other immunosuppressive regimens (including steroid plus non-immunosuppressive agents or mTOR inhibitors) were inconclusive primarily due to insufficient data from the individual studies in low or very low certainty evidence. The effects of treatments on death, malignancy, reduction in GFR at least of 25% and adverse events were very uncertain. Subgroup analyses to determine the impact of specific patient characteristics such as ethnicity or disease severity on treatment effectiveness were not possible. AUTHORS' CONCLUSIONS In moderate certainty evidence, corticosteroid therapy probably prevents decline in GFR or doubling of SCr in adults and children with IgA nephropathy and proteinuria. Evidence for treatment effects of immunosuppressive agents on death, infection, and malignancy is generally sparse or low-quality. Steroid therapy has uncertain adverse effects due to a paucity of studies. Available studies are few, small, have high risk of bias and generally do not systematically identify treatment-related harms. Subgroup analyses to identify specific patient characteristics that might predict better response to therapy were not possible due to a lack of studies. There is no evidence that other immunosuppressive agents including CPA, AZA, or MMF improve clinical outcomes in IgA nephropathy.
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Affiliation(s)
- Patrizia Natale
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Marinella Ruospo
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Valeria M Saglimbene
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
| | | | - Joshua A Samuels
- UT‐Houston Health Science CenterDivision of Pediatric Nephrology and Hypertension6431 Fannin Street, MSB 3‐121HoustonTXUSA77030
| | - Donald A Molony
- UT‐Houston Health Science CenterInternal MedicineDivision of Renal Diseases and Hypertension64312 Fannin StHoustonTXUSA77030
| | | | - Giovanni FM Strippoli
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The University of SydneySydney School of Public HealthSydneyAustralia
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
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Management and treatment of glomerular diseases (part 1): conclusions from a kidney disease: improving global outcomes (KDIGO) controversies conference. ACTA ACUST UNITED AC 2020. [DOI: 10.36485/1561-6274-2020-24-2-22-41] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The Kidney Disease: Improving Global Outcomes (KDIGO) initiative organized a Controversies Conference on glomerular diseases in November 2017. The conference focused on the 2012 KDIGO guideline with the aim of identifying new insights into nomenclature, pathogenesis, diagnostic work-up, and, in particular, therapy of glomerular diseases since the guideline’s publication. It was the consensus of the group that most guideline recommendations, in particular those dealing with therapy, will need to be revisited by the guideline-updating Work Group. This report covers general management of glomerular disease, IgA nephropathy, and membranous nephropathy.
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Floege J, Barbour SJ, Cattran DC, Hogan JJ, Nachman PH, Tang SCW, Wetzels JFM, Cheung M, Wheeler DC, Winkelmayer WC, Rovin BH. Management and treatment of glomerular diseases (part 1): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 95:268-280. [PMID: 30665568 DOI: 10.1016/j.kint.2018.10.018] [Citation(s) in RCA: 162] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/10/2018] [Accepted: 10/24/2018] [Indexed: 01/10/2023]
Abstract
The Kidney Disease: Improving Global Outcomes (KDIGO) initiative organized a Controversies Conference on glomerular diseases in November 2017. The conference focused on the 2012 KDIGO guideline with the aim of identifying new insights into nomenclature, pathogenesis, diagnostic work-up, and, in particular, therapy of glomerular diseases since the guideline's publication. It was the consensus of the group that most guideline recommendations, in particular those dealing with therapy, will need to be revisited by the guideline-updating Work Group. This report covers general management of glomerular disease, IgA nephropathy, and membranous nephropathy.
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Affiliation(s)
- Jürgen Floege
- Division of Nephrology, Rheinisch-Westfälische Technische Hochschule University of Aachen, Aachen, Germany.
| | - Sean J Barbour
- British Columbia Provincial Renal Agency, Vancouver, British Columbia, Canada; Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Health Evaluation and Outcomes Research, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick H Nachman
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota, USA
| | - Sydney C W Tang
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
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Obrișcă B, Sinescu I, Ismail G, Mircescu G. Has The Time Arrived to Refine The Indications of Immunosuppressive Therapy and Prognosis in IgA Nephropathy? J Clin Med 2019; 8:E1584. [PMID: 31581654 PMCID: PMC6833025 DOI: 10.3390/jcm8101584] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most frequent glomerular disease worldwide and a leading cause of end-stage renal disease. Particularly challenging to the clinician is the early identification of patients at high risk of progression, an estimation of the decline in renal function, and the selection of only those that would benefit from additional immunosuppressive therapies. Nevertheless, the pathway to a better prognostication and to the development of targeted therapies in IgAN has been paved by recent understanding of the genetic and molecular basis of this disease. Merging the data from the Oxford Classification validation studies and prospective treatment studies has suggested that a disease-stratifying algorithm would be appropriate for disease management, although it awaits validation in a prospective setting. The emergence of potential noninvasive biomarkers may assist traditional markers (proteinuria, hematuria) in monitoring disease activity and treatment response. The recent landmark trials of IgAN treatment (STOP-IgAN and TESTING trials) have suggested that the risks associated with immunosuppressive therapy outweigh the benefits, which may shift the treatment paradigm of this disease. While awaiting the approval of the first therapies for IgAN, more targeted and less toxic immunotherapies are warranted. Accordingly, the targeting of complement activation, the modulation of mucosal immunity, the antagonism of B-cell activating factors, and proteasomal inhibition are currently being evaluated in pilot studies for IgAN treatment.
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Affiliation(s)
- Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
| | - Ioanel Sinescu
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
- Center of Uronephrology and Renal Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania;
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
| | - Gabriel Mircescu
- Department of Uronephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (I.S.); (G.M.)
- Department of Nephrology, “Dr. Carol Davila” Teaching Hospital of Nephrology, 010731 Bucharest, Romania
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Zhang Z, Yang Y, Jiang SM, Li WG. Efficacy and safety of immunosuppressive treatment in IgA nephropathy: a meta-analysis of randomized controlled trials. BMC Nephrol 2019; 20:333. [PMID: 31455248 PMCID: PMC6710882 DOI: 10.1186/s12882-019-1519-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 08/09/2019] [Indexed: 02/06/2023] Open
Abstract
Background Immunosuppressive agents have been widely used in the treatment of IgA nephropathy (IgAN), but the efficacy and safety remain controversial. The recent STOP-IgAN and TESTING studies have again focused attention on the application of immunosuppressive agents in IgAN. This study investigated the benefits and risks of immunosuppressive agents in IgAN. Methods MEDLINE, EMBASE, the Cochrane Library, and article reference lists were searched for randomized controlled trials (RCTs) comparing immunosuppressive agents with any other non-immunosuppressive agents for treating IgAN. A meta-analysis was performed on the outcomes of proteinuria, creatinine (Cr), estimated glomerular filtration rate (eGFR), and adverse events in patients with IgAN, and trial sequential analyses were also performed for outcomes. Results Twenty-nine RCTs (1957 patients) that met our inclusion criteria were identified. Steroids (weighted mean difference [WMD] –0.70, 95% confidence interval [CI] –1.2 to − 0.20), non-steroidal immunosuppressive agents (NSI) (WMD –0. 43, 95% CI − 0.55 to − 0.31), and combined steroidal and non-steroidal immunosuppressive agents (S&NSI) (WMD –1.46, 95% CI − 2.13 to − 0.79) therapy significantly reduced proteinuria levels compared with the the control group. Steroid treatment significantly reduced the risk of end-stage renal disease (ESRD) (relative risk [RR] 0.39, CI 0.19 to 0.79) compared with the control group. The immunosuppressive therapy group showed significant increases in gastrointestinal, hematological, dermatological, and genitourinary side effects, as well as impaired glucose tolerance or diabetes. Hyperkalemia was more common in the control group. Conclusion Immunosuppressive therapy can significantly reduce proteinuria and ESRD risk in patients with IgAN, but with a concomitant increase in adverse reactions. Therefore, care is required in the application of immunosuppressive agents in IgAN.
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Affiliation(s)
- Zheng Zhang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Yue Yang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Shi-Min Jiang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China.,Graduate School of Peking Union Medical College, Beijing, China
| | - Wen-Ge Li
- Department of Nephrology, China-Japan Friendship 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: 159] [Impact Index Per Article: 31.8] [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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42
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Moran SM, Cattran DC. Recent advances in risk prediction, therapeutics and pathogenesis of IgA nephropathy. Minerva Med 2019; 110:439-449. [PMID: 31142099 DOI: 10.23736/s0026-4806.19.06165-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Immunoglobulin A nephropathy (IgAN) is the world's commonest primary glomerular disease with variable clinical presentation and progression rates that are dependent on clinical-pathologic phenotype and duration of follow-up. Overall 4-40% of patients progress to end-stage kidney disease (ESKD) by 10 years. Treatment decisions remain a challenge due to these variations. The ultimate goal of management is to prevent progression to ESKD and of vital importance is the potential reversible early detection of active glomerular inflammation prior to scarring. IgAN is globally, is the most common biopsy proven glomerulonephritis and a leading cause of ESKD. The Oxford pathological classification was devised by a collaborative pathology and nephrology network to provide an evidence-based scoring system with reproducible independent pathology features of predictive value. Clinical variables that alter prognosis include male sex, increasing age, increased body weight, smoking, Pacific Asian ethnicity, hypertension, proteinuria, and complement deficiency. Excellent conservative therapy is the cornerstone of therapy with tight blood control, renin-angiotensin system inhibition, and statin therapy. The role of immunosuppressive therapy including corticosteroids in IgAN remains open with ongoing clinical trials of low dose oral corticosteroids and enteric coated budesonide. Complement activation contributes to the pathogenic process of IgAN with evidence from genetic, serological, histological and in-vitro studies. This knowledge has translated to clinical trials of investigational agents directly targeting the alternative pathway.
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Affiliation(s)
- Sarah M Moran
- The Toronto Glomerulonephritis Registry and Division of Nephrology, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Trinity Health Kidney Center, Trinity College, Dublin, Ireland
| | - Daniel C Cattran
- The Toronto Glomerulonephritis Registry and Division of Nephrology, University Health Network, Toronto, ON, Canada - .,Department of Medicine, University of Toronto, Toronto, ON, Canada
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Yeo SC, Goh SM, Barratt J. Is immunoglobulin A nephropathy different in different ethnic populations? Nephrology (Carlton) 2019; 24:885-895. [PMID: 30977248 DOI: 10.1111/nep.13592] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2019] [Indexed: 02/06/2023]
Abstract
Immunoglobulin A nephropathy (IgAN) is one of the commonest global patterns of primary glomerulonephritis and remains a leading cause of chronic kidney disease and end-stage renal disease. The sole diagnostic criterion of IgAN remains the presence of dominant mesangial immunoglobulin A deposits on kidney biopsy. Beyond this defining feature, there is significant heterogeneity in the epidemiology, clinical presentation, renal progression and long-term outcomes of IgAN in different ethnic populations. Mirroring this heterogeneity in clinical phenotypes, there is also marked ethnic variation in the extent of histopathological lesions observed on kidney biopsy, which may partly explain the well-documented differences in response to immunomodulatory agents reported in different regions of the world. In parallel, disparities have been identified in genetic association studies and key pathogenic pathways in different ethnic populations. Understanding the basis for these differences in IgAN has important implications for both clinical care and future research. In this review, we will examine the impact of ethnicity on the epidemiology, clinical presentation and outcomes, pathogenesis and genetic associations in IgAN.
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Affiliation(s)
- See Cheng Yeo
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
| | - Su Mein Goh
- Department of Renal Medicine, Tan Tock Seng Hospital, Singapore
| | - Jonathan Barratt
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK.,The John Walls Renal Unit, Leicester General Hospital, Leicester, UK
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45
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Thompson A, Carroll K, A. Inker L, Floege J, Perkovic V, Boyer-Suavet S, W. Major R, I. Schimpf J, Barratt J, Cattran DC, S. Gillespie B, Kausz A, W. Mercer A, Reich HN, H. Rovin B, West M, Nachman PH. Proteinuria Reduction as a Surrogate End Point in Trials of IgA Nephropathy. Clin J Am Soc Nephrol 2019; 14:469-481. [PMID: 30635299 PMCID: PMC6419287 DOI: 10.2215/cjn.08600718] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IgA nephropathy (IgAN) is an important cause of ESKD for which there are no approved therapies. A challenge for evaluating treatments for IgAN is the usual long time course for progression to ESKD. The aim of this Kidney Health Initiative project was to identify surrogate end points that could serve as reliable predictors of a treatment's effect on long-term kidney outcomes in IgAN and be used as a basis for approval. Proteinuria was identified as the most widely recognized and well studied risk factor for progression to ESKD in IgAN. The workgroup performed a critical review of the data on proteinuria reduction as a surrogate end point for a treatment's effect on progression to ESKD in IgAN. Epidemiologic data indicate a strong and consistent relationship between the level and duration of proteinuria and loss of kidney function. Trial-level analyses of data from 13 controlled trials also show an association between treatment effects on percent reduction of proteinuria and treatment effects on a composite of time to doubling of serum creatinine, ESKD, or death. We conclude that data support the use of proteinuria reduction as a reasonably likely surrogate end point for a treatment's effect on progression to ESKD in IgAN. In the United States, reasonably likely surrogate end points can be used as a basis for accelerated approval of therapies intended to treat serious or life-threatening conditions, such as IgAN. The clinical benefit of products approved under this program would need to be verified in a postmarketing confirmatory trial.
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Affiliation(s)
- Aliza Thompson
- Division of Cardiovascular and Renal Products, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | | | | | - Jürgen Floege
- Division of Nephrology, RWTH University of Aachen, Aachen, Germany
| | - Vlado Perkovic
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Sonia Boyer-Suavet
- Service de Néphrologie, Hôpital Pasteur, Centre Hospitalier Universitaire de Nice, Université Nice Sophia-Antipolis, Nice, France; Departments of
| | | | | | - Jonathan Barratt
- Infection, Inflammation and Immunity, University of Leicester, Leicester, UK
| | - Daniel C. Cattran
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Heather N. Reich
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Brad H. Rovin
- The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Melissa West
- American Society of Nephrology, Washington, DC; and
| | - Patrick H. Nachman
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, Minnesota
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46
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Zhang YM, Zhang H. Update on treatment of immunoglobulin A nephropathy. Nephrology (Carlton) 2019; 23 Suppl 4:62-67. [PMID: 30298661 DOI: 10.1111/nep.13453] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2018] [Indexed: 01/04/2023]
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common form of primary glomerulonephritis worldwide and the most common cause of end-stage renal disease in young adults. However, there are still no specific therapies capable of targeting key pathways involved in disease pathogenesis. Recently, many large randomized controlled trials have been reported, such as Supportive Versus Immunosuppressive Therapy for the Treatment of Progressive IgA Nephropathy, Targeted-release Budesonide Versus Placebo in Patients with IgA Nephropathy and Therapeutic Evaluation of Steroids in IgA Nephropathy Global, which are considered to update the 2012 Kidney Disease: Improving Global Outcomes Guideline. More importantly, with a deeper understanding of the roles of mucosal immunity, B-cell activation and complement activation in IgAN, the studies of targeting pathogenic pathways are ongoing. In this review, by systemically searching the clinical trials in IgAN on ClinicalTrials.gov (https://clinicaltrials.gov/), we update the evidence for corticosteroids/immunosuppressive therapy in IgAN and explore the promising targeting pathogenic pathway therapeutic options. With better understanding of pathogenesis of IgAN, emerging therapies will soon become a reality in future.
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Affiliation(s)
- Yue-Miao Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
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47
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Sofue T, Suzuki H, Ueda N, Kushida Y, Minamino T. Post-transplant immunoglobulin A deposition and nephropathy in allografts. Nephrology (Carlton) 2018; 23 Suppl 2:4-9. [PMID: 29968406 DOI: 10.1111/nep.13281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2018] [Indexed: 12/16/2022]
Abstract
Post-transplant immunoglobulin A (IgA) nephropathy (IgAN) in the allograft is the major cause of allograft loss. Using a protocol biopsy, latent mesangial IgA deposition (IgAD) can be detected in the allograft. Latent IgAD is distinguished from IgAN by the absence of urinary abnormalities, although IgA is observed in the mesangium. However, the pathophysiology and most appropriate treatment strategy for latent mesangial IgAD in the allograft remain to be fully determined. Importantly, it is unknown whether all cases of post-transplant asymptomatic IgAD progress to symptomatic IgAN; indeed, IgA deposits disappear in some cases. The differences in allograft prognosis between asymptomatic IgAD and IgAN have also not been determined. Non-invasive methods of diagnosis of IgAD in the allograft using serological and pathological biomarkers are being developed. Possible serum biomarkers include serum galactose-deficient IgA1 (Gd-IgA1), Gd-IgA1-specific IgG and Gd-IgA1-specific IgA, and its immune complexes. Immunofluorescence analysis using Gd-IgA1 monoclonal antibody may provide a pathological biomarker. These serological and pathological biomarkers may be suitable for the characterization of the stage of IgAD. However, there is insufficient information regarding whether serological and pathological biomarkers can predict the progression of asymptomatic IgAD to symptomatic IgAN. We propose that the pathogenesis of IgAN can be defined through the clinical study of IgAD in the allograft using protocol biopsies conducted by nephrologists involved in clinical kidney transplantation.
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Affiliation(s)
- Tadashi Sofue
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hitoshi Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Nobufumi Ueda
- Department of Urology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yoshio Kushida
- Department of Diagnostic Pathology, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tetsuo Minamino
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
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49
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Zheng JN, Bi TD, Zhu LB, Liu LL. Efficacy and safety of mycophenolate mofetil for IgA nephropathy: An updated meta-analysis of randomized controlled trials. Exp Ther Med 2018; 16:1882-1890. [PMID: 30186414 PMCID: PMC6122311 DOI: 10.3892/etm.2018.6418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 05/11/2018] [Indexed: 12/15/2022] Open
Abstract
The efficacy and safety of mycophenolate mofetil (MMF) for immunoglobulin A nephropathy (IgAN) remains debatable. Therefore, the present meta-analysis was conducted with randomized controlled trials (RCTs). PubMed/MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials were analyzed to identify eligible trials. The pooled risk ratio (RR) with 95% confidence interval (CI) was estimated for all the dichotomous outcome measures. A total of eight RCTs with nine publications (n=510 patients) were included. No significant difference was noted between therapeutic regimens with and without MMF for renal remission and end stage renal disease (ESRD) of patients with IgAN (seven trials; RR, 1.250; 95% CI, 0.993–1.574; P=0.057; and four trials; RR, 0.728; 95% CI, 0.164–3.236; P=0.676). To further define the effects of MMF for renal remission, subgroup analysis was performed, demonstrating that MMF was significantly more effective compared with the placebo (three trials; RR, 2.152; 95% CI, 1.198–3.867; P=0.010), although the immunosuppressive regimens with MMF had no significantly different effects compared with those without MMF (four trials; RR, 1.140; 95% CI, 0.955–1.361; P=0.146), indicating that MMF was superior to placebo and had a similar efficacy to other immunosuppressants for renal remission. In addition, subgroup analysis for ESRD revealed no significant differences between MMF and placebo and between the immunosuppressive regimens with and without MMF (three trials; RR, 0.957; 95% CI, 0.160–5.726; P=0.962; and one trial; RR, 0.205; 95% CI, 0.010–4.200; P=0.303). Furthermore, there were no significant differences between the therapeutic regimens with and without MMF in terms of the risk of adverse events. The present meta-analysis demonstrated that MMF was more effective compared with the placebo, may have similar efficacy to other immunosuppressants in terms of inducing renal remission of IgAN and may not increase the risk of adverse events. The long-term effects of MMF on the prognosis of patients with IgAN require verification in further studies.
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Affiliation(s)
- Jian-Nan Zheng
- Department of Nephrology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Tong-Dan Bi
- Department of Nephrology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Lin-Bo Zhu
- Department of Nephrology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
| | - Lin-Lin Liu
- Department of Nephrology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning 110001, P.R. China
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50
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Feehally J. Immunosuppression in IgA Nephropathy: Guideline Medicine Versus Personalized Medicine. Semin Nephrol 2018; 37:464-477. [PMID: 28863793 DOI: 10.1016/j.semnephrol.2017.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The role of immunosuppression in IgAN remains controversial despite a growing evidence base of randomized controlled trials (RCTs). In IgAN with nephrotic syndrome the role for corticosteroids is limited to cases with minimal change on light microscopy. In crescentic IgAN, the use of immunosuppression is supported only by anecdotal data, and outcome may be poor especially when glomerular filtration rate is impaired severely at presentation or there are pathologic features of chronic injury. In slowly progressive IgAN, prediction of outcome now is based both on clinical and pathologic features. Most RCTs have studied patients with urine protein levels greater than 1 g/24 h and only a minority have enrolled patients with a glomerular filtration rate less than 60 mL/min. The Supportive versus immunosuppressive Therapy of Progressive IgA nephropathy (STOP) IgAN study emphasized the efficacy of supportive therapy (including blood pressure control and renin-angiotensin system blockade) in decreasing proteinuria to less than the usually accepted threshold for the use of corticosteroids. Earlier RCTs of corticosteroids usually did not deploy supportive therapy optimally. The recent Therapeutic Evaluation of STeroids in IgA Nephropathy Global (TESTING) study closed prematurely because of excess toxicity, but the high dose of corticosteroids seemed to provide benefit. Guidelines provide valuable information about the quality and limitations of available evidence that needs to be personalized in application to the individual patient's medical and nonmedical circumstances to ensure wise clinical decision making.
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Affiliation(s)
- John Feehally
- Department of Infection, Inflammation and Immunology, University of Leicester, Leicester, UK.
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