1
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Bonilla M, Efe O, Selvaskandan H, Lerma EV, Wiegley N. A Review of Focal Segmental Glomerulosclerosis Classification With a Focus on Genetic Associations. Kidney Med 2024; 6:100826. [PMID: 38765809 PMCID: PMC11099322 DOI: 10.1016/j.xkme.2024.100826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) defines a distinct histologic pattern observed in kidney tissue that is linked to several distinct underlying causes, all converging on the common factor of podocyte injury. It presents a considerable challenge in terms of classification because of its varied underlying causes and the limited correlation between histopathology and clinical outcomes. Critically, precise nomenclature is key to describe and delineate the pathogenesis, subsequently guiding the selection of suitable and precision therapies. A proposed pathomechanism-based approach has been suggested for FSGS classification. This approach differentiates among primary, secondary, genetic, and undetermined causes, aiming to provide clarity. Genetic FSGS from monogenic mutations can emerge during childhood or adulthood, and it is advisable to conduct genetic testing in cases in which there is a family history of chronic kidney disease, nephrotic syndrome, or resistance to treatment. Genome-wide association studies have identified several genetic risk variants, such as those in apolipoprotein L1 (APOL1), that play a role in the development of FSGS. Currently, no specific treatments have been approved to treat genetic FSGS; however, interventions targeting underlying cofactor deficiencies have shown potential in some cases. Furthermore, encouraging results have emerged from a phase 2 trial investigating inaxaplin, a novel small molecule APOL1 channel inhibitor, in APOL1-associated FSGS.
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Affiliation(s)
- Marco Bonilla
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL
| | - Orhan Efe
- Division of Nephrology, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Haresh Selvaskandan
- IgA Mayer Nephropathy Laboratories, Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Edgar V. Lerma
- Section of Nephrology, University of Illinois at Chicago/Advocate Christ Medical Center, Oak Lawn, IL
| | - Nasim Wiegley
- University of California Davis School of Medicine, Division of Nephrology, Sacramento, CA
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2
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Finn LS. Nephrotic Syndrome Throughout Childhood: Diagnosing Podocytopathies From the Womb to the Dorm. Pediatr Dev Pathol 2024:10935266241242669. [PMID: 38745407 DOI: 10.1177/10935266241242669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
The etiologies of podocyte dysfunction that lead to pediatric nephrotic syndrome (NS) are vast and vary with age at presentation. The discovery of numerous novel genetic podocytopathies and the evolution of diagnostic technologies has transformed the investigation of steroid-resistant NS while simultaneously promoting the replacement of traditional morphology-based disease classifications with a mechanistic approach. Podocytopathies associated with primary and secondary steroid-resistant NS manifest as diffuse mesangial sclerosis, minimal change disease, focal segmental glomerulosclerosis, and collapsing glomerulopathy. Molecular testing, once an ancillary option, has become a vital component of the clinical investigation and when paired with kidney biopsy findings, provides data that can optimize treatment and prognosis. This review focuses on the causes including selected monogenic defects, clinical phenotypes, histopathologic findings, and age-appropriate differential diagnoses of nephrotic syndrome in the pediatric population with an emphasis on podocytopathies.
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Affiliation(s)
- Laura S Finn
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine at The University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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3
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Nayak A, Ettenger R, Wesseling-Perry K. Recurrent disease after pediatric renal transplantation. Pediatr Transplant 2024; 28:e14676. [PMID: 38650536 DOI: 10.1111/petr.14676] [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: 08/15/2023] [Revised: 11/15/2023] [Accepted: 11/30/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND Recurrent disease after kidney transplant remains an important cause of allograft failure, accounting for 7-8% of graft loss and ranking as the fifth most common cause of allograft loss in the pediatric population. Although the pathophysiology of many recurrent diseases is incompletely understood, recent advances in basic science and therapeutics are improving outcomes and changing the course of several of these conditions. METHODS Review of the literature. RESULTS We discuss the diagnosis and management of recurrent disease. CONCLUSION We highlight new insights into the pathophysiology and treatment of post-transplant primary hyperoxaluria, focal segmental glomerulosclerosis, immune complex glomerulonephritis, C3 glomerulopathy, lupus nephritis, atypical hemolytic uremic syndrome, and IgA nephropathy.
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Affiliation(s)
- Anjali Nayak
- Phoenix Children's Hospital and the University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Robert Ettenger
- Mattel Children's Hospital and the University of California at Los Angeles, Los Angeles, California, USA
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4
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Kachmar J, Boyer O, Lipska-Ziętkiewicz B, Morinière V, Gribouval O, Heidet L, Balasz-Chmielewska I, Benetti E, Cloarec S, Csaicsich D, Decramer S, Gellermann J, Guigonis V, Hogan J, Bayazit AK, Melk A, Nigmatullina N, Oh J, Ozaltin F, Ranchin B, Tsimaratos M, Trautmann A, Antignac C, Schaefer F, Dorval G. Steroid-Resistant Nephrotic Syndrome due to NPHS2 Variants Is Not Associated With Posttransplant Recurrence. Kidney Int Rep 2024; 9:973-981. [PMID: 38765578 PMCID: PMC11101709 DOI: 10.1016/j.ekir.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/07/2023] [Accepted: 01/02/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Unlike idiopathic nephrotic syndrome (NS), hereditary podocytopathies are not expected to recur after kidney transplantation. However, some reports of posttransplant recurrence of NS in patients carrying variants in the NPHS2 gene have been described, notably with the p.Arg138Gln variant, which is more prevalent in Europe. The objective of this study was to assess the risk of recurrence after kidney transplantation in a large cohort of patients with biallelic NPHS2 pathogenic variants. Methods Since January 2010, 61 patients identified at Necker-Enfants Malades Hospital and 56 enrolled in the PodoNet Registry with biallelic variants in the NPHS2 gene were transplanted and were compared with 44 transplanted children with steroid-resistant NS (SRNS) without any identified pathogenic variant. Results Of the 117 patients, 23 carried the p.Arg138Gln variant in the homozygous state and 16 in the compound heterozygous state. The other 78 patients carried different variants in the homozygous (n = 44) or compound heterozygous state. Only 1 patient with NPHS2-related SRNS experienced posttransplant recurrence (median follow-up of cohort 8.5 years [2.5-15]). Conversely, 7 of 44 patients (16%) without any identified pathogenic variant recurred within a maximum of 7 days after transplantation (median follow-up 8.9 years [0.6-13.9]). Conclusion In this large cohort, the risk of patients with causative variants in the NPHS2 gene to develop NS recurrence after kidney transplantation was extremely low. This is coherent with the pathophysiology of intrinsic slit-diaphragm disease. These data are reassuring and should be considered when counselling patients, making living kidney donation, whether related or not, a safe choice.
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Affiliation(s)
- Jessica Kachmar
- Laboratoire des Maladies Rénales Héréditaires, Inserm UMR 1163, Imagine Institute for Genetic Diseases, Université Paris Cité, Paris, France
| | - Olivia Boyer
- Laboratoire des Maladies Rénales Héréditaires, Inserm UMR 1163, Imagine Institute for Genetic Diseases, Université Paris Cité, Paris, France
- Service de néphrologie pédiatrique Centre de Référence MARHEA, Hôpital Necker-Enfants Malades, Assistance publique, Hôpitaux de Paris (AP-HP), Paris, France
| | - Beata Lipska-Ziętkiewicz
- Centre for Rare Diseases and Clinical Genetics Unit, Medical University of Gdansk, Gdansk, Poland
| | - Vincent Morinière
- Service de Médecine Génomique des Maladies Rares, Hôpital Necker-Enfants Malades, Assistance publique, Hôpitaux de Paris (AP-HP), Paris, France
| | - Olivier Gribouval
- Laboratoire des Maladies Rénales Héréditaires, Inserm UMR 1163, Imagine Institute for Genetic Diseases, Université Paris Cité, Paris, France
| | - Laurence Heidet
- Laboratoire des Maladies Rénales Héréditaires, Inserm UMR 1163, Imagine Institute for Genetic Diseases, Université Paris Cité, Paris, France
- Service de néphrologie pédiatrique Centre de Référence MARHEA, Hôpital Necker-Enfants Malades, Assistance publique, Hôpitaux de Paris (AP-HP), Paris, France
| | - Irena Balasz-Chmielewska
- Department of Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland
| | - Elisa Benetti
- Pediatric Nephrology Unit, Padua University Hospital, Padua, Italy
| | - Sylvie Cloarec
- Service de Néphrologie-Hémodialyse pédiatrique, Centre de compétence Maladies Rénales Rares, CHRU Tours-Clocheville, Tours, France
| | - Dagmar Csaicsich
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Stéphane Decramer
- Pediatric Nephrology Unit, Toulouse University Hospital; Centre De Référence Des Maladies Rénales Rares du Sud-Ouest, SoRare; INSERM U1048, Institute of Cardiovascular and Metabolic Diseases, Toulouse, France
| | - Jutta Gellermann
- Klinik für Pädiatrie/Nephrologie, Charité Campus Virchox-Klinikum, Berlin, Germany
| | | | - Julien Hogan
- Pediatric Nephrology, Hôpital Universitaire Robert-Debré; Paris Translational Research Center for Organ Transplantation, Inserm UMR-S970, Université Paris Cité, Paris, France
| | | | - Anette Melk
- Children’s Hospital, Hannover Medical School, Hannover, Germany
| | - Nazym Nigmatullina
- National Research Center for Maternal and Child Heatlh, Astana, Kazakhstan
| | - Jun Oh
- Pediatric Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fatih Ozaltin
- Department of Pediatric Nephrology, Hacettepe University, Faculty of Medicine, Sihhiye, Ankara, Türkiye
| | - Bruno Ranchin
- Pediatric Nephrology Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - Michel Tsimaratos
- Faculté de médecine de Marseille, Université de la Méditerranée, Marseille, France
| | - Agnes Trautmann
- Department of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Germany
| | - Corinne Antignac
- Laboratoire des Maladies Rénales Héréditaires, Inserm UMR 1163, Imagine Institute for Genetic Diseases, Université Paris Cité, Paris, France
| | - Franz Schaefer
- Department of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Germany
| | - Guillaume Dorval
- Laboratoire des Maladies Rénales Héréditaires, Inserm UMR 1163, Imagine Institute for Genetic Diseases, Université Paris Cité, Paris, France
- Service de Médecine Génomique des Maladies Rares, Hôpital Necker-Enfants Malades, Assistance publique, Hôpitaux de Paris (AP-HP), Paris, France
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5
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Goodman KN, Puapatanakul P, Barton KT, He M, Miner JH, Gaut JP. A Case of Congenital Nephrotic Syndrome with Crescents Caused by a Novel Compound Heterozygous Pairing of NPHS1 Genetic Variants. Case Rep Nephrol 2024; 2024:5121375. [PMID: 38444459 PMCID: PMC10914425 DOI: 10.1155/2024/5121375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/07/2024] [Accepted: 02/17/2024] [Indexed: 03/07/2024] Open
Abstract
Congenital nephrotic syndrome is an autosomal recessive inherited disorder that manifests as steroid-resistant massive proteinuria in the first three months of life. Defects in the glomerular filtration mechanism are the primary etiology. We present a child who developed severe nephrotic syndrome at two weeks of age and eventually required a bilateral nephrectomy. Genetic testing revealed compound heterozygous variants in NPHS1 including a known pathogenic variant and a missense variant of uncertain significance. Light microscopy revealed crescent formation-an atypical finding in congenital nephrotic syndrome caused by nephrin variants-in addition to focal segmental and global glomerulosclerosis. Electron microscopy showed diffuse podocyte foot process effacement. Confocal and Airyscan immunofluorescence microcopy showed aggregation of nephrin in the podocyte cell body that is not a result of diffuse podocyte foot process effacement as seen in minimal change disease. These findings confirm the novel variant as pathogenic.
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Affiliation(s)
- Kyle N. Goodman
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Pongpratch Puapatanakul
- Division of Nephrology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kevin T. Barton
- Division of Nephrology, Hypertension and Apheresis, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Mai He
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Jeffrey H. Miner
- Division of Nephrology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Joseph P. Gaut
- Department of Pathology and Immunology, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
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6
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Acharya R, Upadhyay K. Early recurrence of focal segmental glomerulosclerosis in a kidney transplant recipient with APOL1 one risk variant. BMJ Case Rep 2023; 16:e254593. [PMID: 37258049 PMCID: PMC10254708 DOI: 10.1136/bcr-2023-254593] [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] [Indexed: 06/02/2023] Open
Abstract
Apolipoprotein 1 (APOL1) risk variants (G1 and G2) are associated with focal segmental glomerulosclerosis (FSGS) in patients of African ancestry. The prevalence of APOL1 two risk variants is lower in Hispanics and very rare in European and Asian populations. APOL1 two risk variants in donor kidneys is associated with recipient kidney graft loss, however the effect of recipient risk variant in the kidney transplant outcome is unclear. Here, we present a late adolescent male with FSGS and end stage renal disease with one APOL1 risk variant (G2) who had immediate recurrence of FSGS in the post-KT period. There was an excellent response to few sessions of plasmapheresis and Rituximab with no further recurrence of FSGS in the 1 year follow-up period. It needs to be seen whether the recipient APOL1 single risk variant causes increased susceptibility to kidney graft loss on a long run via recurrent or de novo pathologies.
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Affiliation(s)
- Ratna Acharya
- Paediatrics, University of Florida, Gainesville, Florida, USA
| | - Kiran Upadhyay
- Paediatrics and Nephrology, University of Florida Health, Gainesville, Florida, USA
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7
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Anderson S. Congenital Nephrotic Syndrome of the Finnish Type in a Dominican Newborn: An Overview and Case Report. Neonatal Netw 2022; 41:83-88. [PMID: 35260424 DOI: 10.1891/11-t-745] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2021] [Indexed: 12/30/2022]
Abstract
Congenital nephrotic syndrome of the Finnish type (CNS-FT) is a rare genetic condition that causes massive proteinuria, hypoproteinemia, hypercholesterolemia, and edema that progresses to end-stage renal disease. Symptoms may manifest in utero as fetal hydrops or during the first few days to months of life. This article shares the case of a Dominican infant who presented with CNS-FT. It provides a comprehensive overview of CNS-FT including the underlying genetic cause, prenatal and postnatal diagnostic testing options, and treatment recommendations. It walks the reader through the diagnostic and initial and longer-term management of this infant and provides patient outcome at 10 months of age.
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8
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Watts AJ, Keller KH, Lerner G, Rosales I, Collins AB, Sekulic M, Waikar SS, Chandraker A, Riella LV, Alexander MP, Troost JP, Chen J, Fermin D, Yee JL, Sampson MG, Beck LH, Henderson JM, Greka A, Rennke HG, Weins A. Discovery of Autoantibodies Targeting Nephrin in Minimal Change Disease Supports a Novel Autoimmune Etiology. J Am Soc Nephrol 2022; 33:238-252. [PMID: 34732507 PMCID: PMC8763186 DOI: 10.1681/asn.2021060794] [Citation(s) in RCA: 103] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 10/10/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Failure of the glomerular filtration barrier, primarily by loss of slit diaphragm architecture, underlies nephrotic syndrome in minimal change disease. The etiology remains unknown. The efficacy of B cell-targeted therapies in some patients, together with the known proteinuric effect of anti-nephrin antibodies in rodent models, prompted us to hypothesize that nephrin autoantibodies may be present in patients with minimal change disease. METHODS We evaluated sera from patients with minimal change disease, enrolled in the Nephrotic Syndrome Study Network (NEPTUNE) cohort and from our own institutions, for circulating nephrin autoantibodies by indirect ELISA and by immunoprecipitation of full-length nephrin from human glomerular extract or a recombinant purified extracellular domain of human nephrin. We also evaluated renal biopsies from our institutions for podocyte-associated punctate IgG colocalizing with nephrin by immunofluorescence. RESULTS In two independent patient cohorts, we identified circulating nephrin autoantibodies during active disease that were significantly reduced or absent during treatment response in a subset of patients with minimal change disease. We correlated the presence of these autoantibodies with podocyte-associated punctate IgG in renal biopsies from our institutions. We also identified a patient with steroid-dependent childhood minimal change disease that progressed to end stage kidney disease; she developed a massive post-transplant recurrence of proteinuria that was associated with high pretransplant circulating nephrin autoantibodies. CONCLUSIONS Our discovery of nephrin autoantibodies in a subset of adults and children with minimal change disease aligns with published animal studies and provides further support for an autoimmune etiology. We propose a new molecular classification of nephrin autoantibody minimal change disease to serve as a framework for instigation of precision therapeutics for these patients.
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Affiliation(s)
- Andrew J.B. Watts
- Department of Pathology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts,Renal Division, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Keith H. Keller
- Department of Pathology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Gabriel Lerner
- Department of Pathology, Boston Medical Center and Boston University, Boston, Massachusetts,Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University, Boston, Massachusetts
| | - Ivy Rosales
- Department of Pathology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - A. Bernard Collins
- Department of Pathology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Miroslav Sekulic
- Department of Pathology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts,Department of Pathology and Cell Biology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Sushrut S. Waikar
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts,Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University, Boston, Massachusetts
| | - Anil Chandraker
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Leonardo V. Riella
- Division of Nephrology, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Mariam P. Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Jonathan P. Troost
- Division of Nephrology, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Junbo Chen
- Department of Pathology, Boston Medical Center and Boston University, Boston, Massachusetts
| | - Damian Fermin
- Division of Medicine, Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Jennifer L. Yee
- Division of Medicine, Department of Pediatrics, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Matthew G. Sampson
- Department of Medicine/Pediatric Nephrology, Boston Children’s Hospital, and Harvard Medical School, Boston, Massachusetts,Kidney Disease Initiative, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Laurence H. Beck
- Section of Nephrology, Department of Medicine, Boston Medical Center and Boston University, Boston, Massachusetts
| | - Joel M. Henderson
- Department of Pathology, Boston Medical Center and Boston University, Boston, Massachusetts
| | - Anna Greka
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts,Kidney Disease Initiative, Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts
| | - Helmut G. Rennke
- Department of Pathology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Astrid Weins
- Department of Pathology, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts,Renal Division, Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
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9
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Uffing A, Hullekes F, Riella LV, Hogan JJ. Recurrent Glomerular Disease after Kidney Transplantation: Diagnostic and Management Dilemmas. Clin J Am Soc Nephrol 2021; 16:1730-1742. [PMID: 34686531 PMCID: PMC8729409 DOI: 10.2215/cjn.00280121] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Recurrent glomerular disease after kidney transplant remains an important cause of allograft failure. Many of the different entities post-transplant still suffer from incomplete knowledge on pathophysiology, and therefore lack targeted and effective therapies. In this review, we focus on specific clinical dilemmas encountered by physicians in managing recurrent glomerular disease by highlighting new insights into the understanding and treatment of post-transplant focal segmental glomerulosclerosis, membranous nephropathy, atypical hemolytic uremic syndrome, C3 glomerulopathy, amyloid light-chain (AL) amyloidosis, and IgA nephropathy.
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Affiliation(s)
- Audrey Uffing
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Nephrology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Hullekes
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V. Riella
- Renal Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts,Department of Surgery, Center for Transplantation Sciences, Massachusetts General Hospital, Boston, Massachusetts
| | - Jonathan J. Hogan
- Division of Renal Electrolyte and Hypertension, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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10
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Boyer O, Schaefer F, Haffner D, Bockenhauer D, Hölttä T, Bérody S, Webb H, Heselden M, Lipska-Zie˛tkiewicz BS, Ozaltin F, Levtchenko E, Vivarelli M. Management of congenital nephrotic syndrome: consensus recommendations of the ERKNet-ESPN Working Group. Nat Rev Nephrol 2021; 17:277-289. [PMID: 33514942 PMCID: PMC8128706 DOI: 10.1038/s41581-020-00384-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 01/30/2023]
Abstract
Congenital nephrotic syndrome (CNS) is a heterogeneous group of disorders characterized by nephrotic-range proteinuria, hypoalbuminaemia and oedema, which manifest in utero or during the first 3 months of life. The main cause of CNS is genetic defects in podocytes; however, it can also be caused, in rare cases, by congenital infections or maternal allo-immune disease. Management of CNS is very challenging because patients are prone to severe complications, such as haemodynamic compromise, infections, thromboses, impaired growth and kidney failure. In this consensus statement, experts from the European Reference Network for Kidney Diseases (ERKNet) and the European Society for Paediatric Nephrology (ESPN) summarize the current evidence and present recommendations for the management of CNS, including the use of renin-angiotensin system inhibitors, diuretics, anticoagulation and infection prophylaxis. Therapeutic management should be adapted to the clinical severity of the condition with the aim of maintaining intravascular euvolaemia and adequate nutrition, while preventing complications and preserving central and peripheral vessels. We do not recommend performing routine early nephrectomies but suggest that they are considered in patients with severe complications despite optimal conservative treatment, and before transplantation in patients with persisting nephrotic syndrome and/or a WT1-dominant pathogenic variant.
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Affiliation(s)
- Olivia Boyer
- grid.412134.10000 0004 0593 9113Department of Pediatric Nephrology, Reference center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France ,grid.508487.60000 0004 7885 7602Laboratory of Hereditary Kidney Diseases, Imagine Institute, INSERM U1163, Paris Descartes University, Paris, France
| | - Franz Schaefer
- grid.7700.00000 0001 2190 4373Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Dieter Haffner
- grid.10423.340000 0000 9529 9877Department of Pediatric Kidney, Liver and Metabolic Diseases, Children’s Hospital, Hannover Medical School, Hannover, Germany ,grid.10423.340000 0000 9529 9877Center for Congenital Kidney Diseases, Center for Rare Diseases, Hannover Medical School, Hannover, Germany
| | - Detlef Bockenhauer
- grid.424537.30000 0004 5902 9895UCL Department of Renal Medicine and Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Tuula Hölttä
- grid.15485.3d0000 0000 9950 5666Department of Pediatric Nephrology and Transplantation, The New Children’s Hospital, HUS Helsinki University Hospital, Helsinki, Finland
| | - Sandra Bérody
- grid.412134.10000 0004 0593 9113Department of Pediatric Nephrology, Reference center for Idiopathic Nephrotic Syndrome in Children and Adults, Imagine Institute, Paris University, Necker Hospital, APHP, Paris, France
| | - Hazel Webb
- grid.424537.30000 0004 5902 9895UCL Department of Renal Medicine and Renal Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Beata S. Lipska-Zie˛tkiewicz
- grid.11451.300000 0001 0531 3426Clinical Genetics Unit, Department of Biology and Medical Genetics, Medical University of Gdańsk, Gdańsk, Poland ,grid.11451.300000 0001 0531 3426Centre for Rare Diseases, Medical University of Gdańsk, Gdańsk, Poland
| | - Fatih Ozaltin
- grid.14442.370000 0001 2342 7339Department of Pediatric Nephrology and Nephrogenetics Laboratory, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Elena Levtchenko
- grid.5596.f0000 0001 0668 7884Division of Pediatric Nephrology, Department of Pediatrics, University Hospitals Leuven; Department of Development & Regeneration, University of Leuven, Leuven, Belgium
| | - Marina Vivarelli
- grid.414125.70000 0001 0727 6809Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
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11
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Cheong HI. Genetic tests in children with steroid-resistant nephrotic syndrome. Kidney Res Clin Pract 2020; 39:7-16. [PMID: 32155690 PMCID: PMC7105627 DOI: 10.23876/j.krcp.20.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/07/2020] [Accepted: 02/19/2020] [Indexed: 11/05/2022] Open
Abstract
Steroid-resistant nephrotic syndrome (SRNS) is a common cause of chronic kidney disease in children, and a considerable number of patients progress to end-stage renal disease. SRNS is a highly heterogeneous disorder, both clinically and genetically, and more than 50 monogenic causes of SRNS, including isolated and syndromic forms, have been identified. Recent large-cohort studies indicate that at least 30% of childhood-onset SRNS cases are genetic. The benefits of definitive molecular diagnosis by genetic testing include the avoidance of unnecessary and potentially harmful diagnostic procedures (e.g., kidney biopsy) and treatment (e.g., steroid and immunosuppressants), detection of rare and potentially treatable mutations (e.g., coenzyme Q10 biosynthesis pathway defect), prediction of prognosis (e.g., posttransplant recurrence), and providing precise genetic counseling. Furthermore, the identification of novel disease-causing genes could provide new insights into the pathogenic mechanisms of SRNS. Therefore, whenever accessible and affordable, genetic testing is recommended for all pediatric patients with SRNS, and should certainly be performed in patients with a higher probability of genetic predisposition based on genotype-phenotype correlation data. The genetic testing approach should be determined for each patient, and clinicians should, therefore, be aware of the advantages and disadvantages of methods currently available, which include Sanger sequencing, gene panel testing, and whole-exome or whole-genome sequencing. Importantly, the need for precise and thorough phenotyping by clinicians, even in the era of genomics, cannot be overemphasized. This review provides an update on recent advances in genetic studies, a suggested approach for the genetic testing of pediatric patients with SRNS.
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Affiliation(s)
- Hae Il Cheong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, Republic of Korea
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12
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Molecular stratification of idiopathic nephrotic syndrome. Nat Rev Nephrol 2019; 15:750-765. [DOI: 10.1038/s41581-019-0217-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2019] [Indexed: 01/03/2023]
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13
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Abstract
Zusammenfassung
Das steroid-resistente nephrotische Syndrom (SRNS) mit dem histomorphologischen Korrelat der fokal-segmentalen Glomerulosklerose (FSGS) stellt eine bedeutende Ursache für eine terminale Niereninsuffizienz im Kindesalter, aber auch bei erwachsenen Patienten dar. Das Erkrankungsspektrum zeichnet sich durch eine große genetische Heterogenität aus, wobei auch nicht genetische Ursachen bei der FSGS beobachtet werden. Die genetische Grundlage des SRNS/FSGS-Komplexes ist v. a. für ältere Kinder/Jugendliche und Erwachsene bisher noch unzureichend verstanden. Die eindeutige Abgrenzung genetischer SRNS/FSGS-Ursachen ist unerlässlich, da sich bereits heute hieraus eine Vielzahl an klinischen Implikationen ergeben. Die Identifikation unbekannter Erkrankungsallele oder Erkrankungsgene kann zudem Erkenntnisse bringen, die ein gänzlich neues Verständnis der Pathomechanismen ermöglichen. Durch umfassende genetische Untersuchungen besteht die Möglichkeit, die ungelöste genetische Basis der Rekurrenz der FSGS-Erkrankung bei bislang Varianten-negativen Patienten zu finden.
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Affiliation(s)
- Julia Hoefele
- Aff1 Institut für Humangenetik Klinikum rechts der Isar, Technische Universität München Trogerstr. 32 81675 München Deutschland
| | - Bodo B. Beck
- Aff2 0000 0000 8852 305X grid.411097.a Institut für Humangenetik Uniklinik Köln Kerpener Str. 34 50937 Köln Deutschland
| | - Lutz T. Weber
- Aff3 0000 0000 8852 305X grid.411097.a Klinik und Poliklinik für Kinder- und Jugendmedizin Uniklinik Köln Kerpener Str. 62 50937 Köln Deutschland
| | - Paul Brinkkötter
- Aff4 0000 0000 8852 305X grid.411097.a Klinik II für Innere Medizin Uniklinik Köln Kerpener Str. 62 50937 Köln Deutschland
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14
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Francis A, Didsbury M, McCarthy H, Kara T. Treatment of recurrent focal segmental glomerulosclerosis post-kidney transplantation in Australian and New Zealand children: A retrospective cohort study. Pediatr Transplant 2018; 22:e13185. [PMID: 29676031 DOI: 10.1111/petr.13185] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2018] [Indexed: 11/27/2022]
Abstract
Disease recurrence affects around a third of renal transplants for children with FSGS and is associated with poor graft outcomes. Unfortunately, there are no large trials guiding treatment for recurrent FSGS. We aimed to describe current therapies and treatment response for recurrent FSGS in 4 centres in Australia and New Zealand. Data were collected on children (age <18 years) with recurrent FSGS (1990-2015). We reviewed patient charts to obtain clinical information. Ethics approval was obtained from the relevant boards. Complete records were available on 24 patients (62% female, 54% Caucasian). Median time to first recurrence was 4 days (IQR 2-5 days). There were 14 separate treatment regimens, involving an average of 2 agents. The most common therapies were plasma exchange (20/24 patients, 83%), cyclosporin (15/24, 63%), and methylprednisolone (9/24, 38%). Full remission was achieved in 15 (63%), partial remission in 2 (8%), and no remission in 7 (29%) patients. Of the patients with no remission, 5 lost their graft to recurrent disease and 1 to concurrent acute vascular rejection. The plethora of different treatment regimens reflects the poor evidence guiding management for recurrent FSGS. More research is needed to improve outcomes.
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Affiliation(s)
- Anna Francis
- Child and Adolescent Renal Services, Lady Cilento Children's Hospital, South Brisbane, Qld, Australia.,Centre for Kidney Research, University of Sydney, Sydney, NSW, Australia
| | - Madeleine Didsbury
- Centre for Kidney Research, University of Sydney, Sydney, NSW, Australia
| | - Hugh McCarthy
- Centre for Kidney Research, University of Sydney, Sydney, NSW, Australia.,Paediatric Nephrology, Sydney Children's Hospitals Network, Sydney, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Tonya Kara
- Centre for Kidney Research, University of Sydney, Sydney, NSW, Australia.,Paediatric Nephrology, Starship Children's Hospital, Auckland, New Zealand
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15
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Noone DG, Iijima K, Parekh R. Idiopathic nephrotic syndrome in children. Lancet 2018; 392:61-74. [PMID: 29910038 DOI: 10.1016/s0140-6736(18)30536-1] [Citation(s) in RCA: 272] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 02/15/2018] [Accepted: 02/23/2018] [Indexed: 12/19/2022]
Abstract
The incidence of idiopathic nephrotic syndrome (NS) is 1·15-16·9 per 100 000 children, varying by ethnicity and region. The cause remains unknown but the pathogenesis of idiopathic NS is thought to involve immune dysregulation, systemic circulating factors, or inherited structural abnormalities of the podocyte. Genetic risk is more commonly described among children with steroid-resistant disease. The mainstay of therapy is prednisone for the vast majority of patients who are steroid responsive; however, the disease can run a frequently relapsing course, necessitating the need for alternative immunosuppressive agents. Infection and venous thromboembolism are the main complications of NS with also increased risk of acute kidney injury. Prognosis in terms of long-term kidney outcome overall is excellent for steroid-responsive disease, and steroid resistance is an important determinant of future risk of chronic or end-stage kidney disease.
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Affiliation(s)
- Damien G Noone
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Rulan Parekh
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada; Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada; Dalla Lana School of Public Health, and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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16
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First Report of Recurrent Nephrotic Syndrome After Kidney Transplantation in a Patient With NUP93 Gene Mutations: A Case Report. Transplant Proc 2018; 50:3954-3956. [PMID: 30577294 DOI: 10.1016/j.transproceed.2018.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/04/2018] [Indexed: 01/09/2023]
Abstract
Mutations in nucleoporin 93 (NUP93) gene have been shown recently to be one of the very rare causes of genetic steroid-resistant nephrotic syndrome (SRNS). Until now, none of the 7 published cases with NUP93-SRNS, experienced recurrence of nephrotic syndrome (NS) after transplantation. Here, we present the first case of recurrent NS in a patient with NUP93-SRNS ever reported. A 3-year-old boy with infantile SRNS was started on chronic peritoneal dialysis because of end-stage renal failure owing to biopsy-proven focal segmental glomerulosclerosis (FSGS). At the age of 6 years, the boy received a renal allograft. The posttransplant period was uncomplicated until 1.7 years after transplantation, when the patient developed nephrotic proteinuria during a respiratory tract infection. Renal graft biopsy showed subtotal fusion of podocytes, which was compatible with an early histopathologic sign of recurrence of FSGS. Immediate treatment with daily plasma exchange (PE) was started at the second day. The proteinuria disappeared completely after the second PE. However, it reappeared after stopping daily PE. It disappeared again after reintroduction of daily PE, therefore PE-dependent recurrent NS was diagnosed and treatment with rituximab was given. After the first dose, proteinuria never reappeared despite stopping PE therapy. Surprisingly, next-generation sequencing revealed compound heterozygous mutations in exons 16 and 18 of the NUP93 gene (c.1772G>T - European founder allele and 1916T>C) and his parents confirmed heterozygous asymptomatic carriers. This is the first case of recurrent NS in a patient with NUP93 gene mutations, suggesting a new pathomechanism possibly involving the nucleoporins.
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17
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Feygina VM, Kotru A, Du C. Abdominal distention and continuous feeding intolerance after intraperitoneal kidney transplant: Answers. Pediatr Nephrol 2018; 33:607-609. [PMID: 28589211 DOI: 10.1007/s00467-017-3708-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 05/11/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Valeriya M Feygina
- Department of Pediatrics, Division of Pediatric Nephrology, Geisinger Medical Center, Danville, PA, 17822, USA.
| | - Anil Kotru
- Department of Transplantation and LiverSurgery, Geisinger Medical Center, Danville, PA, 17822, USA
| | - Christine Du
- Department of Transplantation and LiverSurgery, Geisinger Medical Center, Danville, PA, 17822, USA
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18
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Bérody S, Heidet L, Gribouval O, Harambat J, Niaudet P, Baudouin V, Bacchetta J, Boudaillez B, Dehennault M, de Parscau L, Dunand O, Flodrops H, Fila M, Garnier A, Louillet F, Macher MA, May A, Merieau E, Monceaux F, Pietrement C, Rousset-Rouvière C, Roussey G, Taque S, Tenenbaum J, Ulinski T, Vieux R, Zaloszyc A, Morinière V, Salomon R, Boyer O. Treatment and outcome of congenital nephrotic syndrome. Nephrol Dial Transplant 2018; 34:458-467. [DOI: 10.1093/ndt/gfy015] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/24/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sandra Bérody
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
| | - Laurence Heidet
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
| | | | - Jérome Harambat
- Centre Hospitalier Universitaire de Bordeaux, Néphrologie pédiatrique, Bordeaux, France
| | - Patrick Niaudet
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
| | - Veronique Baudouin
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Hôpital Universitaire Robert Debré, Néphrologie pédiatrique, Paris, France
| | | | | | | | | | - Olivier Dunand
- CHU Felix Guyon, Pédiatrie, Saint-Denis, La Reunion, France
| | | | - Marc Fila
- Centre Hospitalier Regional Universitaire de Montpellier, Néphrologie pédiatrique, Montpellier, France
| | - Arnaud Garnier
- Centre Hospitalier Universitaire de Toulouse, Néphrologie pédiatrique, Toulouse, France
| | | | - Marie-Alice Macher
- Hôpital Universitaire Robert Debré, Néphrologie pédiatrique, Paris, France
| | - Adrien May
- Centre Hospitalier Sud Francilien, Pédiatrie, Corbeil-Essonnes, France
| | | | | | | | | | - Gwenaëlle Roussey
- Centre Hospitalier Universitaire de Nantes, Néphrologie pédiatrique, Nantes, France
| | - Sophie Taque
- Centre Hospitalier Universitaire de Rennes, Pédiatrie, Rennes, France
| | - Julie Tenenbaum
- Centre Hospitalier Regional Universitaire de Montpellier, Néphrologie pédiatrique, Montpellier, France
| | - Tim Ulinski
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Hôpital Armand-Trousseau, Néphrologie pédiatrique, Paris, France
| | - Rachel Vieux
- Centre Hospitalier Universitaire de Nancy, Pédiatrie, Nancy, France
| | | | | | - Rémi Salomon
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
| | - Olivia Boyer
- Hôpital Necker-Enfants malades, Néphrologie pédiatrique, Assistance Publique des Hôpitaux de Paris, Université Paris Descartes-Sorbonne Paris-Cité, Paris, France
- Centre de référence des Maladies Rénales Héréditaires de l'Enfant et de l'Adulte (MARHEA), Centre de référence du syndrome néphrotique idiopathique de l'enfant et de l'adulte, Hôpital Necker-Enfants Malades, Paris, France
- Inserm U1163, Imagine Institute, Paris, France
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19
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Hamasaki Y, Muramatsu M, Hamada R, Ishikura K, Hataya H, Satou H, Honda M, Nakanishi K, Shishido S. Long-term outcome of congenital nephrotic syndrome after kidney transplantation in Japan. Clin Exp Nephrol 2017; 22:719-726. [PMID: 29185126 DOI: 10.1007/s10157-017-1508-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 11/09/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Congenital nephrotic syndrome is difficult to manage, particularly the Finnish type (CNF), with patients experiencing severe edema, sepsis and thrombosis before kidney transplantation. Further, nephrosis and thrombosis remain problematic after transplantation. METHODS Of 22 CNF patients managed at our hospital, 14 who underwent kidney transplantation were retrospectively studied. CNF was diagnosed according to standard criteria. RESULTS The study population consisted of 3 males and 11 females. Mean gestation period was 36 ± 1.4 weeks and mean birth weight was 2442 ± 454 g (mean placenta to body weight ratio: 0.4). All patients started dialysis at 2.4 ± 1.3 years and underwent kidney transplantation at 5.2 ± 2.0 years. The kidneys were donated by the parents (n = 13), and cadaver (n = 2), including overlap. Mean follow-up period after transplantation was 14.3 ± 8.9 years, and mean age at last observation was 19.5 ± 8.5 years. Two patients had recurrent proteinuria after kidney transplantation; one underwent retransplantation following graft failure and eventually required dialysis, while the second had complete remission after intensive immunosuppressive therapy. There were no cases of thrombosis or serious infections. Mean eGFR at the time of last observation was 57.3 ± 16.5 ml/min/1.73 m2, while mean height SD score was - 2.1 ± 0.9 at the time of transplantation and - 1.5 ± 1.5 at last observation. CONCLUSIONS Long-term outcome in these 14 CNF patients showed satisfactory graft survival, improved height SD score, and favorable development. Although recurrent proteinuria after transplant was not predictive, it was associated with graft survival rate.
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Affiliation(s)
- Yuko Hamasaki
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, 6-11-1 Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan. .,Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.
| | - Masaki Muramatsu
- Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Kenji Ishikura
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Hiroshi Hataya
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan.,Department of General Pediatrics, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Hiroyuki Satou
- Department of Urology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Masataka Honda
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Seiichiro Shishido
- Department of Pediatric Nephrology, Toho University Faculty of Medicine, 6-11-1 Omori-Nishi, Ota-Ku, Tokyo, 143-8541, Japan.,Department of Nephrology, Toho University Faculty of Medicine, Tokyo, Japan
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20
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Application of next-generation sequencing technology to diagnosis and treatment of focal segmental glomerulosclerosis. Clin Exp Nephrol 2017; 22:491-500. [PMID: 28752288 PMCID: PMC5956018 DOI: 10.1007/s10157-017-1449-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/06/2017] [Indexed: 12/15/2022]
Abstract
A broad range of genetic and non-genetic factors can lead to kidney injury that manifests as focal segmental glomerulosclerosis (FSGS), which can be classified into primary (idiopathic) and secondary forms. Previous genetic approaches to familial or sporadic cases of FSGS or steroid-resistant nephrotic syndrome identified causal mutations in a subset of genes. Recently, next-generation sequencing (NGS) approaches are becoming a part of a standard assessment in medical genetics. Current knowledge of the comprehensive genomic information is changing the way we think about FSGS and draws attention not only to identification of novel causal genes, but also to potential roles for combinations of mutations in multiple genes, mutations with complex inheritance, and susceptibility genes with variable penetrance carrying relatively minor but significant effects. This review provides an update on recent advances in the genetic analysis of FSGS and highlights the potential as well as the new challenges of NGS for diagnosis and mechanism-based treatment of FSGS.
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21
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Abstract
OBJECTIVE The aim of this work was to analyze the evolution of the 1st renal transplantation in children with nephrotic syndrome in the 1st year of life (NSFL). METHODS In this retrospective study of 15 patients (8 women and 7 men) with NSFL receiving transplants from 1989 to 2013, 9 had NS of Finnish type, 4 diffuse mesangial sclerosis, 1 minimal changes, and 1 collapsing glomerulopathy. We analyzed the clinical and analytic situation at 4 time points: before dialysis, before transplantation, 3 months after transplantation, and long-term evolution. RESULTS Mean follow-up was 72.8 months (range, 1 month to 16.9 years); mean age at diagnosis was 2.21 months (range, 0-8.2 months); mean age at onset of replacement therapy was 22.9 ± 16.4 months (range, 3.8-55.4 months); and mean time on dialysis was 14.9 months (range, 2-44 months). Age at transplantation was 3.1 years (range, 1.8 to 7.7 years), with 6 living-donor transplantations (LDTs) and 9 cadaveric (CDTs). Ten patients required nephrectomy before transplantation (9 bilateral) to control proteinuria after 3.1 ± 3.8 months on dialysis, 1 during transplantation, and 3 after transplantation (2 persistent proteinuria, 1 hypertension). Mean time on dialysis for LDTs was 5.4 ± 2.7 months versus 13.2 ± 6.9 months for CDTs (P < .005). Mean age of cadaveric donors was 6.2 ± 2.4 years and that of living donors 35.5 ± 7.9 years. As complications, there was 1 bleeding from venous anastomosis and 1 urinary leakage after surgery. After 6 ± 5.2 years of evolution, actuarial survival at both 1 and 7 years was 92.9%. One graft was lost owing to acute rejection 1 month after transplantation and 2 others owing to chronic rejection >9 years after transplantation. None had disease recurrence. CONCLUSIONS Short-term complications did not differ from the rest of population if transplantation occurred with standard albumin levels, for which most required pre-transplantation nephrectomy because dialysis failed to reduce proteinuria.
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22
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Ding WY, Koziell A, McCarthy HJ, Bierzynska A, Bhagavatula MK, Dudley JA, Inward CD, Coward RJ, Tizard J, Reid C, Antignac C, Boyer O, Saleem MA. Initial steroid sensitivity in children with steroid-resistant nephrotic syndrome predicts post-transplant recurrence. J Am Soc Nephrol 2014; 25:1342-8. [PMID: 24511128 DOI: 10.1681/asn.2013080852] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Of children with idiopathic nephrotic syndrome, 10%-20% fail to respond to steroids or develop secondary steroid resistance (termed initial steroid sensitivity) and the majority progress to transplantation. Although 30%-50% of these patients suffer disease recurrence after transplantation, with poor long-term outcome, no reliable indicator of recurrence has yet been identified. Notably, the incidence of recurrence after transplantation appears reduced in patients with steroid-resistant nephrotic syndrome (SRNS) due to monogenic disorders. We reviewed 150 transplanted patients with SRNS to identify biomarkers that consistently predict outcome of SRNS after transplantation. In all, 25 children had genetic or familial SRNS and did not experience post-transplant recurrence. We reviewed phenotypic factors, including initial steroid sensitivity, donor type, age, ethnicity, time to ESRD, and time on dialysis, in the remaining 125 children. Of these patients, 57 (45.6%) developed post-transplant recurrence; 26 of 28 (92.9%) patients with initial steroid sensitivity recurred after transplantation, whereas only 26 of 86 (30.2%) patients resistant from the outset recurred (odds ratio, 30; 95% confidence interval, 6.62 to 135.86; P<0.001). We were unable to determine recurrence in two patients (one with initial steroid sensitivity), and nine patients did not receive initial steroids. Our data show that initial steroid sensitivity is highly predictive of post-transplant disease recurrence in this pediatric patient population. Because a pathogenic circulating permeability factor in nephrotic syndrome remains to be confirmed, we propose initial steroid sensitivity as a surrogate marker for post-transplant recurrence.
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Affiliation(s)
- Wen Y Ding
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom; Academic Renal Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Ania Koziell
- Department of Paediatric Nephrology, Evelina Children's Hospital, London, United Kingdom; Department of Experimental Immunobiology, King's College London, Guy's Hospital, London, United Kingdom
| | - Hugh J McCarthy
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom; Academic Renal Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Agnieszka Bierzynska
- Academic Renal Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | | | - Jan A Dudley
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Carol D Inward
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Richard J Coward
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom; Academic Renal Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom
| | - Jane Tizard
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | - Christopher Reid
- Department of Paediatric Nephrology, Evelina Children's Hospital, London, United Kingdom
| | - Corinne Antignac
- Pediatric Nephrology, French Institute of Health and Medical Research Unit 983, Necker Hospital for Sick Children, Paris, France
| | - Olivia Boyer
- Pediatric Nephrology, French Institute of Health and Medical Research Unit 983, Necker Hospital for Sick Children, Paris, France
| | - Moin A Saleem
- Department of Paediatric Nephrology, Bristol Royal Hospital for Children, Bristol, United Kingdom; Academic Renal Unit, University of Bristol, Southmead Hospital, Bristol, United Kingdom;
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23
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Holmberg C, Jalanko H. Congenital nephrotic syndrome and recurrence of proteinuria after renal transplantation. Pediatr Nephrol 2014; 29:2309-17. [PMID: 24682440 PMCID: PMC4212136 DOI: 10.1007/s00467-014-2781-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 01/27/2014] [Accepted: 01/31/2014] [Indexed: 01/16/2023]
Abstract
Renal transplantation (RTx) is the only curative treatment for most cases of congenital and infantile nephrotic syndrome (NS) caused by genetic defects in glomerular podocyte proteins. The outcome of RTx in these children is usually excellent, with no recurrence of nephrotic syndrome. A subgroup of patients with the Finnish type of congenital nephrosis (CNF), shows, however, a clear risk for post-RTx proteinuria. Most of these patients have a homozygous truncating mutation (Fin-major mutation) in the nephrin gene (NPHS1), leading to total absence of the major podocyte protein, nephrin. After RTx, these patients develop anti-nephrin antibodies resulting in nephrotic range proteinuria. Plasma exchange combined with cyclophosphamide and anti-CD20 antibodies has proved to be successful therapy for these episodes. NS recurrence has also occurred in a few patients with mutations in the podocin gene (NPHS2). No anti-podocin antibodies have been detectable, and the pathophysiology of the recurrence remains open. While most of these episodes have resolved, the optimal therapy remains to be determined.
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Affiliation(s)
- Christer Holmberg
- Children's Hospital, University of Helsinki and Helsinki University Central Hospital, PO Box 281, Helsinki, 00290, Finland,
| | - Hannu Jalanko
- Children’s Hospital, University of Helsinki and Helsinki University Central Hospital, PO Box 281, Helsinki, 00290 Finland
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Gbadegesin RA, Winn MP, Smoyer WE. Genetic testing in nephrotic syndrome--challenges and opportunities. Nat Rev Nephrol 2013; 9:179-84. [PMID: 23321566 DOI: 10.1038/nrneph.2012.286] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Monogenic nephrotic syndrome (nephrotic syndrome caused by a single gene defect) is responsible for only a small percentage of cases of nephrotic syndrome, but information from studies of the unique cohort of patients with this form of the disease has dramatically improved our understanding of the disease pathogenesis. The use of genetic testing in the management of children and adults with nephrotic syndrome poses unique challenges for clinicians in terms of who to test and how to use the information obtained from testing in the clinical setting. In our view, not enough data exist at present to justify the routine genetic testing of all patients with nephrotic syndrome. Testing is warranted, however, in patients with congenital nephrotic syndrome (onset at 0-3 months), infantile nephrotic syndrome (onset at 3-12 months), a family history of nephrotic syndrome, and those in whom nephrotic syndrome is associated with other congenital malformations. The family and/or the patient should be given complete and unbiased information on the potential benefits and risks associated with therapy, including the reported outcomes of treatment in patients with similar mutations. Based on the data available in the literature so far, intensive immunosuppressive treatment is probably not indicated in monogenic nephrotic syndrome if complete or partial remission has not been achieved within 6 weeks of starting treatment. We advocate that family members of individuals with genetic forms of nephrotic syndrome undergo routine genetic testing prior to living-related kidney transplantation. Prospective, multicentre studies are needed to more completely determine the burden of disease caused by monogenic nephrotic syndrome, and randomized controlled trials are needed to clarify the presence or absence of clinical responses of monogenic nephrotic syndrome to available therapies.
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Affiliation(s)
- Rasheed A Gbadegesin
- Department of Pediatrics and Center for Human Genetics, Duke University Medical Center, Durham, NC 27710, USA
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Chaudhuri A, Kambham N, Sutherland S, Grimm P, Alexander S, Concepcion W, Sarwal M, Wong C. Rituximab treatment for recurrence of nephrotic syndrome in a pediatric patient after renal transplantation for congenital nephrotic syndrome of Finnish type. Pediatr Transplant 2012; 16:E183-7. [PMID: 21672106 DOI: 10.1111/j.1399-3046.2011.01519.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Congenital nephrotic syndrome (CNS) of the Finnish type due to mutation in the NPHS-1 gene results in massive proteinuria due to structural abnormality in the glomerular slit diaphragm, and is usually refractory to immunosuppressive therapy. Patients eventually require bilateral nephrectomy and renal replacement therapy, with transplantation being the ultimate goal. Post-transplant recurrence of nephrotic syndrome occurs in about 25% of children and is thought to be immune-mediated secondary to antibodies formed against the nephrin protein in renal allograft. Conventional therapy with calcineurin inhibitors (CNI), cyclophosphamide and corticosteroids with or without plasmapheresis often fails to achieve remission resulting in graft loss in 12-16%. There is limited experience with use of rituximab (RTX) in pediatric organ transplant recipients. We report the first case of post-transplant recurrence of nephrotic syndrome in a 4-yr-old child with CNS due to NPHS-1 mutation in whom CNI, corticosteroid and cyclophosphamide therapy was unsuccessful, but who achieved remission after depletion of B cells with RTX, associated with a decrease in the level of anti-nephrin antibodies. The child remains in remission 5 yr following treatment. Our experience suggests that activated B cells may play a pivotal role in the recurrence of nephrosis after renal transplantation in children with CNS.
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Affiliation(s)
- Abanti Chaudhuri
- Department of Pediatrics, Stanford University, Stanford, CA 94305, USA
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Abstract
Congenital nephrotic syndrome (CNS) is a rare kidney disorder characterized by heavy proteinuria, hypoproteinemia, and edema starting soon after birth. The majority of cases are caused by genetic defects in the components of the glomerular filtration barrier, especially nephrin and podocin. CNS may also be a part of a more generalized syndrome or caused by a perinatal infection. Immunosuppressive medication is not helpful in the genetic forms of CNS, and kidney transplantation is the only curative therapy. Before the operation, management of these infants largely depends on the magnitude of proteinuria. In severe cases, daily albumin infusions are required to prevent life-threatening edema. The therapy also includes hypercaloric diet, thyroxin and mineral substitution, prevention of thrombotic episodes, and prompt management of infectious complications. The outcome of CNS patients without major extrarenal manifestations is comparable with other patient groups after kidney transplantation.
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