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Elahi T, Ahmed S, Ahmed E, Mubarak M. Clinicopathological characteristics and outcomes of adult patients with idiopathic membranoproliferative glomerulonephritis according to an immunofluorescence-based classification. J Nephrol 2024:10.1007/s40620-024-02083-7. [PMID: 39400860 DOI: 10.1007/s40620-024-02083-7] [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: 02/09/2024] [Accepted: 08/16/2024] [Indexed: 10/15/2024]
Abstract
BACKGROUND The classification of membranoproliferative glomerulonephritis (MPGN) into immune complex-mediated MPGN and complement-mediated MPGN on immunofluorescence has provided insights into two distinct disease processes. There are limited data available on renal outcomes of MPGN from developing countries. METHODS A retrospective analysis was conducted on biopsy-proven MPGN cases diagnosed between 1998 and 2018 at the Sindh Institute of Urology and Transplantation (SIUT). Secondary causes were excluded. Patients were reclassified as immune complex-mediated-MPGN and complement-mediated-MPGN based on immunofluorescence results. The clinicopathological findings and outcomes of the two groups were compared. RESULTS In total, 213 patients with idiopathic MPGN were identified. Among these, 163 (76.5%) were reclassified as immune complex-mediated-MPGN and 50 (23.4%) as complement-mediated-MPGN. No significant differences were found between the two groups regarding age, gender, clinical characteristics, biopsy indications, biopsy findings, and renal function at presentation. Overall, 63 subjects (38.7%) with immune complex-mediated-MPGN and 27 (54%) with complement-mediated-MPGN received immunosuppressive agents (p = 0.08). Complete and partial remission rates were higher in immune complex-mediated-MPGN than in complement-mediated-MPGN (76% vs 58%, p < 0.05). At two years, median estimated glomerualr filtration rate (eGFR) tended to be higher in patients with immune complex-mediated-MPGN 91.2 (45.4-113.7) vs 83.45(34.6-102.50) ml/min/1.73 m2, p = 0.22) with significantly better renal survival (76% vs 58%, p = 0.03). Comparatively, more patients progressed to end-stage kidney disease (ESKD) in the complement-mediated-MPGN group (32% vs 19.6%, p = 0.06), with increased overall mortality (5 (10%) vs 7 (4.3%), p = 0.12). CONCLUSION The clinicopathological features at presentation of complement-mediated-MPGN are similar to those of immune complex-mediated-MPGN. However, it is less frequent and overall prognosis is less favorable.
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Affiliation(s)
- Tabassum Elahi
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Chand Bibi Road Near Civil Hospital Karachi, Karachi, 74200, Pakistan.
| | - Saima Ahmed
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Chand Bibi Road Near Civil Hospital Karachi, Karachi, 74200, Pakistan
| | - Ejaz Ahmed
- Department of Nephrology, Sindh Institute of Urology and Transplantation, Chand Bibi Road Near Civil Hospital Karachi, Karachi, 74200, Pakistan
| | - Muhammed Mubarak
- Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
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Kanzaki M, Kurahashi M, Watanabe K, Nishikawa M, Fukuoka K, Shimada N, Mizuno M, Asano K. Successfully treated C3 glomerulopathy in which protein and genetic analyses were useful for diagnosis. CEN Case Rep 2024:10.1007/s13730-024-00928-5. [PMID: 39264532 DOI: 10.1007/s13730-024-00928-5] [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: 06/12/2024] [Accepted: 09/02/2024] [Indexed: 09/13/2024] Open
Abstract
C3 glomerulopathy is a rare disease that results in nephritis due to complement dysregulation and is characterized by C3 deposition in the glomerulus. Dysregulation of the alternative pathway underlies the pathogenesis, but activation of the terminal pathway is also common. The disease is often caused by acquired rather than genetic factors, i.e., autoantibodies against C3 or C5 converting enzyme (convertase) and other complement-related proteins. We report a case of C3 glomerulopathy diagnosed by renal biopsy that responded well to corticosteroids and went into complete remission within two months. Analysis of complements and complement-related proteins revealed a low level of C3 and a high level of soluble terminal pathway protein complex (sC5b-9). Under genetic analysis about complement-related genes, no pathogenic variant was observed. Based on these findings, we diagnosed this patient with C3 glomerulopathy with autoantibodies. Corticosteroids had a marked effect, which also supports this speculation. Analyses of complements and complement-related proteins, and genetic variants may be useful in understanding the pathogenesis of C3 glomerulopathy and in selecting treatment options.
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Affiliation(s)
- Motoko Kanzaki
- Department of Nephrology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan.
| | - Motoyasu Kurahashi
- Department of Nephrology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
| | - Kentaro Watanabe
- Department of Nephrology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
| | - Mana Nishikawa
- Department of Nephrology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
| | - Kosuke Fukuoka
- Department of Nephrology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
| | - Noriaki Shimada
- Department of Nephrology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
| | - Masashi Mizuno
- Department of Renal Replacement Therapy, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Syowa-Ku, Nagoya, 466-8550, Japan
| | - Kenichiro Asano
- Department of Nephrology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Japan
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Ueda C, Horinouchi T, Inoki Y, Ichikawa Y, Tanaka Y, Kitakado H, Kondo A, Sakakibara N, Nagano C, Yamamura T, Fujimura J, Kamiyoshi N, Ishimori S, Ninchoji T, Kaito H, Shima Y, Iijima K, Nozu K, Yoshikawa N. Clinical characteristics and outcomes of immune-complex membranoproliferative glomerulonephritis and C3 glomerulopathy in Japanese children. Pediatr Nephrol 2024; 39:2679-2689. [PMID: 38662234 PMCID: PMC11272671 DOI: 10.1007/s00467-024-06377-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/29/2024] [Accepted: 04/01/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Membranoproliferative glomerulonephritis (MPGN) can be divided into immune-complex MPGN (IC-MPGN) and C3 glomerulopathy (C3G), which includes dense deposit disease (DDD) and C3 glomerulonephritis (C3GN). These conditions result from abnormalities in different complement pathways and may lead to different prognoses. However, there are limited studies describing the respective clinical courses. METHODS In this study, Japanese pediatric patients diagnosed with MPGN based on kidney biopsies conducted between February 2002 and December 2022 were reclassified as having IC-MPGN or C3G (DDD or C3GN). We retrospectively analyzed the clinical characteristics and outcomes of these patients. RESULTS Out of 25 patients with MPGN, three (12.0%) were diagnosed with DDD, 20 (80.0%) with C3GN, and two (8.0%) with IC-MPGN. There were 13 (65.0%) patients and one (33.3%) patient in remission after treatment for C3GN and DDD, respectively, and no patients with IC-MPGN achieved remission. The median follow-up period was 5.3 (2.5-8.9) years, and none of the patients in either group progressed to an estimated glomerular filtration rate < 15 ml/min/1.73 m2. Patients with C3GN presenting mild to moderate proteinuria (n = 8) received a renin-angiotensin system inhibitor (RAS-I) alone, and these patients exhibited a significant decrease in the urinary protein creatinine ratio and a notable increase in serum C3 levels at the last follow-up. CONCLUSIONS Most patients with MPGN were diagnosed with C3GN. The remission rate for C3GN was high, and no patients developed kidney failure during the approximately 5-year follow-up. Additionally, patients with C3GN with mild to moderate proteinuria had good outcomes with RAS-I alone, but continued vigilance is necessary to determine long-term prognosis.
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Affiliation(s)
- Chika Ueda
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan.
| | - Yuta Inoki
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Yuta Ichikawa
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Yu Tanaka
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Hideaki Kitakado
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Atsushi Kondo
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Nana Sakakibara
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - China Nagano
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Junya Fujimura
- Department of Pediatrics, Kakogawa Central City Hospital, 439 Honmachi, Kakogawa-Cho, Kakogawa, 675-8611, Japan
| | - Naohiro Kamiyoshi
- Department of Pediatrics, Japanese Red Cross Society Himeji Hospital, 1-12-1 Shimoteno, Himeji, 670-8540, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe‑cho, Takatsuki, 569-1192, Japan
| | - Takeshi Ninchoji
- Department of Pediatrics, Harima-Himeji General Medical Center, 3-264 Kamiyacho, Himeji, 670-8560, Japan
| | - Hiroshi Kaito
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojima-Minamimachi, Chuo-Ku, Kobe, 650-0047, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, 811-1 Kimiidera, Wakayama, 641-8509, Japan
| | - Kazumoto Iijima
- Hyogo Prefectural Kobe Children's Hospital, 1-6-7, Minatojima-Minamimachi, Chuo-Ku, Kobe, 650-0047, Japan
- Department of Advanced Pediatric Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Norishige Yoshikawa
- Clinical Research Center, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, 569-1192, Japan
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Balestra E, Barbi E, Ceconi V, Di Maso V, Conversano E, Pennesi M. Pioglitazone, a PPAR-y agonist, as one of the new therapeutic candidates for C3 glomerulopathy. Pediatr Nephrol 2024; 39:309-314. [PMID: 37493956 PMCID: PMC10673980 DOI: 10.1007/s00467-023-06088-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND C3-glomerulopathy (C3G) is a rare pediatric kidney disease characterised by dysregulation of the alternative complement pathway, with glomerular deposition of C3. C3G may often present as a steroid-resistant nephrotic syndrome (SRNS), and there is no established effective therapy: the usual treatment involves corticosteroids and immunosuppressive drugs. Pioglitazone, a PPAR-γ agonist with a protective action on podocytes, was reported in a few cases as helpful in reducing proteinuria when combined with steroids. CASE-DIAGNOSIS/TREATMENT We report the case of a 13-year-old girl with silent past medical history who presented with SRNS. A kidney biopsy showed findings indicative of C3G. A low sodium diet and angiotensin-converting enzyme inhibitor were started; immunosuppressive treatment with mycophenolate mofetil (MMF) was administered due to the cortico-resistance. Because of poor response to the immunosuppressant, a trial with eculizumab was attempted without significant response and persistence of proteinuria in the nephrotic range. A further therapeutic trial was performed with tacrolimus with no disease remission. Due to a severe deterioration in her condition, the girl was hospitalized and treated with high-dose steroid bolus. A daily dose of oral prednisone and MMF were re-started without benefit with persistent levels of nephrotic range proteinuria. The administration of pioglitazone consistently lowered proteinuria levels for the first time since the onset of the disease, with a maintenance of the effect and normalization (< 0.15 g/24 h) at the 10-month follow-up. CONCLUSIONS In this patient affected by C3G, pioglitazone proved effective in reducing proteinuria levels.
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Affiliation(s)
- Elia Balestra
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy.
| | - Egidio Barbi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
- Paediatric Department, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy
| | - Viola Ceconi
- Department of Medicine, Surgery, and Health Sciences, University of Trieste, Trieste, Italy
| | - Vittorio Di Maso
- Department of Nephrology, Cattinara Hospital, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), Trieste, Italy
| | - Ester Conversano
- Paediatric Department, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy
| | - Marco Pennesi
- Paediatric Department, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy
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Nakagawa N, Kimura T, Sakate R, Isaka Y, Narita I. Demographics and treatment of patients with primary membranoproliferative glomerulonephritis in Japan using a national registry of clinical personal records. Clin Exp Nephrol 2023; 27:928-935. [PMID: 37515698 PMCID: PMC10581954 DOI: 10.1007/s10157-023-02387-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 07/18/2023] [Indexed: 07/31/2023]
Abstract
BACKGROUND Membranoproliferative glomerulonephritis (MPGN) is a rare glomerular injury that causes nephrotic syndrome and end-stage kidney disease. The nationwide demographics and treatment of Japanese patients with primary MPGN have not yet been reported. METHODS We collected clinical personal records of patients with primary MPGN between 2015 and 2018 from the national registry organized by the Japanese Ministry of Health, Labour, and Welfare and investigated the characteristics of primary MPGN throughout Japan. RESULTS Of 258 patients with primary MPGN, 199 and 59 showed nephrotic and non-nephrotic syndrome, respectively. The median age at onset was higher in patients with nephrotic syndrome than in those with non-nephrotic syndrome (45 [24-63] vs. 35 [14-53] years, respectively; P = 0.010). The use of oral prednisolone was significantly higher in patients with nephrotic syndrome than in those with non-nephrotic syndrome (73.9% vs. 59.3%, respectively; P = 0.032). When patients were divided into three age groups: adolescent and young adult group (≤ 39 years; n = 80), middle adult group (40-64 years; n = 111), and older adult group (≥ 65 years; n = 67), the use of oral prednisolone, cyclosporine, and mizoribine was significantly higher in the adolescent and young adult group than in the middle adult group. The mean dosage of oral prednisolone and mizoribine showed no differences among the three age groups. CONCLUSION The national registry of clinical personal records of primary MPGN could provide an informative insight into the characteristics, clinical features, and treatment approaches for patients with primary MPGN in Japan.
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Affiliation(s)
- Naoki Nakagawa
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University, 2-1-1-1 Midorigaoka-Higashi, Asahikawa, Japan.
| | - Tomonori Kimura
- Reverse Translational Research Project, Center for Rare Disease Research, National Institutes of Biomedical Innovation, Health and Nutrition (NIBIOHN), Ibaraki, Japan
- Laboratory of Rare Disease Resource Library, Center for Rare Disease Research, National Institutes of Biomedical Innovation, Health and Nutrition (NIBIOHN), Ibaraki, Japan
| | - Ryuichi Sakate
- Reverse Translational Research Project, Center for Rare Disease Research, National Institutes of Biomedical Innovation, Health and Nutrition (NIBIOHN), Ibaraki, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Long-term follow-up including extensive complement analysis of a pediatric C3 glomerulopathy cohort. Pediatr Nephrol 2022; 37:601-612. [PMID: 34476601 PMCID: PMC8921070 DOI: 10.1007/s00467-021-05221-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/06/2021] [Accepted: 07/06/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND C3 glomerulopathy (C3G) is a rare kidney disorder characterized by predominant glomerular depositions of complement C3. C3G can be subdivided into dense deposit disease (DDD) and C3 glomerulonephritis (C3GN). This study describes the long-term follow-up with extensive complement analysis of 29 Dutch children with C3G. METHODS Twenty-nine C3G patients (19 DDD, 10 C3GN) diagnosed between 1992 and 2014 were included. Clinical and laboratory findings were collected at presentation and during follow-up. Specialized assays were used to detect rare variants in complement genes and measure complement-directed autoantibodies and biomarkers in blood. RESULTS DDD patients presented with lower estimated glomerular filtration rate (eGFR). C3 nephritic factors (C3NeFs) were detected in 20 patients and remained detectable over time despite immunosuppressive treatment. At presentation, low serum C3 levels were detected in 84% of all patients. During follow-up, in about 50% of patients, all of them C3NeF-positive, C3 levels remained low. Linear mixed model analysis showed that C3GN patients had higher soluble C5b-9 (sC5b-9) and lower properdin levels compared to DDD patients. With a median follow-up of 52 months, an overall benign outcome was observed with only six patients with eGFR below 90 ml/min/1.73 m2 at last follow-up. CONCLUSIONS We extensively described clinical and laboratory findings including complement features of an exclusively pediatric C3G cohort. Outcome was relatively benign, persistent low C3 correlated with C3NeF presence, and C3GN was associated with higher sC5b-9 and lower properdin levels. Prospective studies are needed to further elucidate the pathogenic mechanisms underlying C3G and guide personalized medicine with complement therapeutics.
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7
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Xu L, Wei F, Feng J, Liu J, Liu J, Tang X, Fang X, Chen J, Zhai Y, Liu H, Sun L, Qian Y, Wu B, Wang H, Shen Q, Rao J, Xu H. Characteristics and outcomes of glomerulonephritis with membranoproliferative pattern in children. Transl Pediatr 2021; 10:2985-2996. [PMID: 34976764 PMCID: PMC8649586 DOI: 10.21037/tp-21-286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/16/2021] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Membranoproliferative glomerulonephritis (MPGN) is a rare histopathologic pattern of glomerular injury with limited studies in pediatric patients. Characteristics and outcomes of children with MPGN have also remained to be further explored. METHODS We retrospectively reviewed the clinicopathological features, genetic findings, treatments and outcomes in 17 pediatric patients pathologically diagnosed with MPGN from 2007 to 2020 in the Children's National Medical Center in China. RESULTS Median age at disease onset was 9.9 years (IQR, 5.6-11.9 years). Most of the patients (12/17) had nephrotic range of proteinuria, and nephritic-nephrotic syndrome was the most common clinical presentation (35.2%). Secondary causes were identified in eight patients including hepatitis B virus (HBV) infection (n=4), methylmalonic acidemia (MMA, n=2), rheumatoid arthritis (RA, n=1) and Aymé-Gripp Syndrome (n=1). The nine patients with primary MPGN were further identified as immune-complex mediated MPGN (n=8), and unclassifiable MPGN (U-MGPN, n=1). Genetic analyses identified pathogenic variants of MMACHC gene in two cases of MMA and established the diagnosis for Aymé-Gripp syndrome in one case with a de novo variant of MAF gene. Comparing study between the complete or partial remission group (n=8) and non-response group (n=9) showed a significant difference in the timing of renal biopsy (P<0.05). Normal renal function was preserved in ten patients at the last follow-up. Two patients developed into end-stage renal disease (ESRD). CONCLUSIONS Children with MPGN pattern present heterogenous clinical features. Genetic detection helps to explore underlying causes of MPGN. Early identification of the primary or secondary causes of MPGN in children is vital.
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Affiliation(s)
- Linan Xu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.,Shanghai Kidney Development and Pediatric Kidney Disease Research Center, Shanghai, China.,Shanghai Key Lab of Birth Defect, Children's Hospital of Fudan University, Shanghai, China
| | - Fengfang Wei
- Affiliated Hospital of Putian University, Fujian, China
| | - Jiayan Feng
- Department of Pathology, Children's Hospital of Fudan University, Shanghai, China
| | - Jiaojiao Liu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.,Shanghai Kidney Development and Pediatric Kidney Disease Research Center, Shanghai, China.,Shanghai Key Lab of Birth Defect, Children's Hospital of Fudan University, Shanghai, China
| | - Jialu Liu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.,Shanghai Kidney Development and Pediatric Kidney Disease Research Center, Shanghai, China.,Shanghai Key Lab of Birth Defect, Children's Hospital of Fudan University, Shanghai, China
| | - Xiaoshan Tang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.,Shanghai Kidney Development and Pediatric Kidney Disease Research Center, Shanghai, China.,Shanghai Key Lab of Birth Defect, Children's Hospital of Fudan University, Shanghai, China
| | - Xiaoyan Fang
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.,Shanghai Kidney Development and Pediatric Kidney Disease Research Center, Shanghai, China.,Shanghai Key Lab of Birth Defect, Children's Hospital of Fudan University, Shanghai, China
| | - Jing Chen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.,Shanghai Kidney Development and Pediatric Kidney Disease Research Center, Shanghai, China.,Shanghai Key Lab of Birth Defect, Children's Hospital of Fudan University, Shanghai, China
| | - Yihui Zhai
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.,Shanghai Kidney Development and Pediatric Kidney Disease Research Center, Shanghai, China.,Shanghai Key Lab of Birth Defect, Children's Hospital of Fudan University, Shanghai, China
| | - Haimei Liu
- Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Li Sun
- Department of Rheumatology, Children's Hospital of Fudan University, Shanghai, China
| | - Yanyan Qian
- Clinical Genetic Center, Children's Hospital of Fudan University, Shanghai, China
| | - Bingbing Wu
- Clinical Genetic Center, Children's Hospital of Fudan University, Shanghai, China
| | - Huijun Wang
- Clinical Genetic Center, Children's Hospital of Fudan University, Shanghai, China
| | - Qian Shen
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.,Shanghai Kidney Development and Pediatric Kidney Disease Research Center, Shanghai, China.,Shanghai Key Lab of Birth Defect, Children's Hospital of Fudan University, Shanghai, China
| | - Jia Rao
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.,Shanghai Kidney Development and Pediatric Kidney Disease Research Center, Shanghai, China.,Shanghai Key Lab of Birth Defect, Children's Hospital of Fudan University, Shanghai, China
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China.,Shanghai Kidney Development and Pediatric Kidney Disease Research Center, Shanghai, China.,Shanghai Key Lab of Birth Defect, Children's Hospital of Fudan University, Shanghai, China
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8
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Nakagawa N, Mizuno M, Kato S, Maruyama S, Sato H, Nakaya I, Sugiyama H, Fujimoto S, Miura K, Matsumura C, Gotoh Y, Suzuki H, Kuroki A, Yoshino A, Nakatani S, Hiromura K, Yamamoto R, Yokoyama H, Narita I, Isaka Y. Demographic, clinical characteristics and treatment outcomes of immune-complex membranoproliferative glomerulonephritis and C3 glomerulonephritis in Japan: A retrospective analysis of data from the Japan Renal Biopsy Registry. PLoS One 2021; 16:e0257397. [PMID: 34520493 PMCID: PMC8439563 DOI: 10.1371/journal.pone.0257397] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 09/01/2021] [Indexed: 12/14/2022] Open
Abstract
The reclassification of membranoproliferative glomerulonephritis (MPGN) into immune-complex MPGN (IC-MPGN) and C3 glomerulopathy (C3G) based on immunofluorescence findings in kidney biopsies has provided insights into these two distinct diseases. C3G is further classified into dense deposit disease and C3 glomerulonephritis (C3GN) based on electron micrographic findings. Although these diseases have poor outcomes, limited Japanese literature confined to small, single-center cohorts exist on these diseases. We retrospectively analyzed 81 patients with MPGN type I and III from 15 hospitals in the Japan Renal Biopsy Registry to compare demographic, clinical characteristics and treatment outcomes of patients with IC-MPGN to those with C3GN. Of the 81 patients reviewed by immunofluorescence findings in kidney biopsies, 67 patients had IC-MPGN and 14 patients had C3GN. Age at diagnosis and systolic and diastolic pressure were higher and proteinuria and impaired renal function were significantly more prevalent in patients with IC-MPGN than those with C3GN. About 80% of the patients in both groups were treated with immunosuppressive therapy. At last follow-up (median 4.8 years), complete remission rate of proteinuria was significantly higher in patients with C3GN (64.3%) than in those with IC-MPGN (29.9%; P = 0.015). The renal survival rate was lower in patients with IC-MPGN when compared to C3GN (73.1% vs. 100%; log-rank, P = 0.031). Systolic blood pressure and renal function at baseline were independent predictors of progression to end-stage kidney disease. The overall prognosis of patients with C3GN is more favorable than for patients with IC-MPGN.
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Affiliation(s)
- Naoki Nakagawa
- Division of Cardiology, Nephrology, Pulmonology and Neurology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan
- * E-mail:
| | - Masashi Mizuno
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
- Renal Replacement Therapy, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Sawako Kato
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroshi Sato
- Clinical Pharmacology and Therapeutics, Tohoku University, Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Izaya Nakaya
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Hitoshi Sugiyama
- Department of Human Resource Development of Dialysis Therapy for Kidney Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shouichi Fujimoto
- Faculty of Medicine, Department of Hemovascular Medicine and Artificial Organs, University of Miyazaki, Miyazaki, Japan
| | - Kenichiro Miura
- Department of Pediatric Nephrology, Tokyo Women’s Medical University, Tokyo, Japan
| | - Chieko Matsumura
- Department of Pediatrics, National Hospital Organization Chibahigashi National Hospital, Chiba, Japan
| | - Yoshimitsu Gotoh
- Department of Pediatric Nephrology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Nagoya, Japan
| | - Hitoshi Suzuki
- Faculty of Medicine, Department of Nephrology, Juntendo University, Tokyo, Japan
| | - Aki Kuroki
- Division of Nephrology, Department of Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Atsunori Yoshino
- Department of Nephrology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Shinya Nakatani
- Department of Metabolism, Endocrinology and Molecular Medicine, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Keiju Hiromura
- Department of Nephrology and Rheumatology, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Ryohei Yamamoto
- Health and Counseling Center, Osaka University, Toyonaka, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, Uchinada, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
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9
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Therapy and outcomes of C3 glomerulopathy and immune-complex membranoproliferative glomerulonephritis. Pediatr Nephrol 2021; 36:591-600. [PMID: 32886193 DOI: 10.1007/s00467-020-04736-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/13/2020] [Accepted: 07/31/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Data on therapy and outcome of dense deposit disease (DDD), C3 glomerulonephritis (C3GN), and immune-complex MPGN (IC-MPGN) in children are limited. METHODS In this retrospective single-center study from 2007 to 2019, kidney biopsies were reviewed to include patients aged <18-years with C3 glomerulopathy and IC-MPGN. Initial immunosuppression comprised prednisolone, mycophenolate mofetil (n = 51), tacrolimus (n = 11), and/or IV cyclophosphamide (n = 20). Clinicopathological features, response to therapy, and adverse outcome (eGFRcr < 15 mL/min/1.73 m2 or death) were evaluated. RESULTS A total of 92 patients were classified as DDD (n = 48, 52.2%), C3GN (n = 26, 28.3%), and IC-MPGN (n = 18, 19.6%) by immunohistochemistry and electron microscopy; 8 patients with DDD were misclassified as IC-MPGN on immunofluorescence. At last follow-up (median 4.3 years), complete or partial remission occurred in 28.5, 36.1, and 16.7% patients with DDD, C3GN, and IC-MPGN, respectively. Serum albumin at onset < 2.5 g/dL (HR = 0.29, P = 0.005) and persistently low serum C3 (HR = 0.34, P = 0.02) were associated with lack of remission. The 5-year kidney survival was 62.6, 85.5, and 88.5% in patients with DDD, C3GN, and IC-MPGN, respectively (log-rank, P = 0.006). Presentation as rapidly progressive GN (HR = 11.2, P < 0.001), age > 10 years at onset (HR = 4.0, P = 0.004), and DDD (HR = 4.2, P = 0.02) were independently associated with adverse outcome; achieving remission was protective (HR = 0.04; P < 0.001). CONCLUSION Outcome in patients with C3 glomerulopathy and IC-MPGN was unsatisfactory, and only a small proportion of patients achieved complete or partial remission. Patients with DDD were more likely to present with rapidly progressive GN and were at higher risk of adverse outcomes, including kidney failure.
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10
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Kirpalani A, Jawa N, Smoyer WE, Licht C. Long-Term Outcomes of C3 Glomerulopathy and Immune-Complex Membranoproliferative Glomerulonephritis in Children. Kidney Int Rep 2020; 5:2313-2324. [PMID: 33305125 PMCID: PMC7710848 DOI: 10.1016/j.ekir.2020.09.019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/15/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction The reclassification of membranoproliferative glomerulonephritis (MPGN) into immune-complex MPGN (IC-MPGN) and C3 glomerulopathy (C3G) has provided insights into 2 distinct diseases. Although outcomes in adults are poor in both diseases, the pediatric literature is scarce and limited to small, single-center cohorts. Methods We conducted a retrospective analysis of 165 pediatric patients across 17 hospitals to compare outcomes between children with IC-MPGN and C3G. Results Forty-two percent of patients initially diagnosed with MPGN were reclassified as C3G after a review of renal biopsy reports. There was a trend toward higher serum creatinine levels in patients with C3G compared with IC-MPGN both at diagnosis (mean 168.9 [range 45.4–292.4] vs. 93.7 [range 70.7–116.6] μmol/l, P = 0.25) and after a mean follow-up time of 4 years (mean 145.0 (range −8.1 to 298.1) vs 99.1 (range 46.3–151.9) μmol/l, P = 0.47), although the estimated glomerular filtration rate (eGFR) was not significantly different. Steroid treatment was associated with a significant improvement in eGFR versus no steroids in C3G (mean +43.0 (range 12.9–73.0) vs. −3.0 (range −23.1 to 17.2) ml/min per 1.73 m2, P = 0.02) but not in IC-MPGN. Overall kidney function was preserved in both groups although hypertension remained prevalent in 42.5% of the cohort at the last follow-up, and the urine protein/creatinine ratio remained elevated (mean 253.8 [range 91.9–415.7] mg/mmol). Conclusion This large pediatric IC-MPGN/C3G cohort revealed nearly half of the patients were misclassified, and there may be a trend toward worse renal prognosis in C3G although they may have greater steroid responsiveness. The overall prognosis appears to be more favorable than in adults; however, persistent hypertension and proteinuria suggest suboptimal disease control.
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Affiliation(s)
- Amrit Kirpalani
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Natasha Jawa
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - William E Smoyer
- The Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
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11
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Treatment of C3 Glomerulopathy in Adult Kidney Transplant Recipients: A Systematic Review. Med Sci (Basel) 2020; 8:medsci8040044. [PMID: 33096866 PMCID: PMC7712822 DOI: 10.3390/medsci8040044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/09/2020] [Accepted: 10/19/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND C3 glomerulopathy (C3G), a rare glomerular disease mediated by alternative complement pathway dysregulation, is associated with a high rate of recurrence and graft loss after kidney transplantation (KTx). We aimed to assess the efficacy of different treatments for C3G recurrence after KTx. METHODS Databases (MEDLINE, EMBASE, and Cochrane Database) were searched from inception through 3 May, 2019. Studies were included that reported outcomes of adult KTx recipients with C3G. Effect estimates from individual studies were combined using the random-effects, generic inverse variance method of DerSimonian and Laird., The protocol for this meta-analysis is registered with PROSPERO (no. CRD42019125718). RESULTS Twelve studies (7 cohort studies and 5 case series) consisting of 122 KTx patients with C3G (73 C3 glomerulonephritis (C3GN) and 49 dense deposit disease (DDD)) were included. The pooled estimated rates of allograft loss among KTx patients with C3G were 33% (95% CI: 12-57%) after eculizumab, 42% (95% CI: 2-89%) after therapeutic plasma exchange (TPE), and 81% (95% CI: 50-100%) after rituximab. Subgroup analysis based on type of C3G was performed. Pooled estimated rates of allograft loss in C3GN KTx patients were 22% (95% CI: 5-46%) after eculizumab, 56% (95% CI: 6-100%) after TPE, and 70% (95% CI: 24-100%) after rituximab. Pooled estimated rates of allograft loss in DDD KTx patients were 53% (95% CI: 0-100%) after eculizumab. Data on allograft loss in DDD after TPE (1 case series, 0/2 (0%) allograft loss at 6 months) and rituximab (1 cohort, 3/3 (100%) allograft loss) were limited. Among 66 patients (38 C3GN, 28 DDD) who received no treatment (due to stable allograft function at presentation and/or clinical judgment of physicians), pooled estimated rates of allograft loss were 32% (95% CI: 7-64%) and 53% (95% CI: 28-77%) for C3GN and DDD, respectively. Among treated C3G patients, data on soluble membrane attack complex of complement (sMAC) were limited to patients treated with eculizumab (N = 7). 80% of patients with elevated sMAC before eculizumab responded to treatment. In addition, all patients who responded to eculizumab had normal sMAC levels after post-eculizumab. CONCLUSIONS Our study suggests that the lowest incidence of allograft loss (33%) among KTX patients with C3G are those treated with eculizumab. Among those who received no treatment for C3G due to stable allograft function, there is a high incidence of allograft loss of 32% in C3GN and 53% in DDD. sMAC level may help to select good responders to eculizumab.
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12
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Drake KA, Ellington N, Gattineni J, Torrealba JR, Hendricks AR. Clinicopathological features of C3 glomerulopathy in children: a single-center experience. Pediatr Nephrol 2020; 35:153-162. [PMID: 31667615 DOI: 10.1007/s00467-019-04388-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 09/04/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND C3 glomerulopathy (C3G) is defined by dominant glomerular deposition of C3 and minimal or no immunoglobulin, with two subtypes-dense deposit disease (DDD) and C3 glomerulonephritis (C3GN)-distinguished by features on electron microscopy (EM). Given that this rare disease has generally unfavorable yet highly variable outcomes, we sought out to review the histopathology, complement/genetic studies, and renal outcomes of pediatric patients with C3G at our institution. METHODS All native kidney biopsies performed in a single pediatric hospital over a 10-year period were reviewed for features of C3G. Of 589 biopsy reports, we identified 9 patients fulfilling the diagnostic criteria for C3G and retrospectively reviewed their clinical chart and renal biopsy findings. RESULTS We identified 4 patients with DDD, 4 with C3GN, and 1 indeterminate case, with features of both C3GN and DDD. Five patients were positive for one or more nephritic factors (C3NeF, C4NeF, C5NeF) with 1 patient additionally positive for complement factor H (CFH) autoantibody. Genetic testing done in 5 of the 9 patients failed to identify any causative mutations. Three patients showed progressive renal dysfunction over a mean follow-up period of 33 months. CONCLUSIONS Complement and genetic studies are now routinely recommended for patients with a histopathological diagnosis of C3G. Careful interpretation of these studies and their prognostic and therapeutic implications in conjunction with biopsy findings is needed to further understand the pathophysiology of this rare disease in children.
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Affiliation(s)
- Keri A Drake
- Division of Pediatric Nephrology, UT Southwestern Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA
| | - Natalie Ellington
- Department of Pathology, UT Southwestern Medical Center, 6210 Harry Hines Blvd, Dallas, TX, 75390-9234, USA
| | - Jyothsna Gattineni
- Division of Pediatric Nephrology, UT Southwestern Medical Center, 1935 Medical District Drive, Dallas, TX, 75235, USA
| | - Jose R Torrealba
- Department of Pathology, UT Southwestern Medical Center, 6210 Harry Hines Blvd, Dallas, TX, 75390-9234, USA
| | - Allen R Hendricks
- Department of Pathology, UT Southwestern Medical Center, 5959 Harry Hines Blvd., Suite HP3-378, Dallas, TX, 75390-9234, USA.
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13
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Abstract
Nephrotic syndrome is characterized by edema, proteinuria, hypoalbuminemia, and hyperlipidemia. Minimal change disease, the most common cause in childhood, generally responds to corticosteroids, although most patients experience disease relapses. Focal segmental glomerulosclerosis is usually resistant to corticosteroids and carries a significant risk of kidney failure, necessitating renal transplantation. Nephrotic syndrome may also be secondary to gene mutations and systemic diseases such as lupus. Clinical evaluation involves distinguishing primary and secondary causes and monitoring for disease complications, including blood clots and serious infections such as spontaneous bacterial peritonitis. Immunosuppressive medications are used to prevent relapses and treat corticosteroid-resistant disease.
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Affiliation(s)
- Chia-Shi Wang
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322-1015, USA.
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, 2015 Uppergate Drive Northeast, Atlanta, GA 30322-1015, USA
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14
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Hosoya M, Kawasaki Y, Maeda R, Sato M, Suyama K, Hashimoto K, Hosoya M. Predictive factors for poor outcome in pediatric C3 glomerulonephritis. Fukushima J Med Sci 2018; 64:142-150. [PMID: 30369521 DOI: 10.5387/fms.2018-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND To clarify the predictive factors for poor outcome in pediatric C3 glomerulonephritis (C3GN), we retrospectively evaluated the relationship between the clinico-pathological findings and prognosis in cases of pediatric C3GN. METHODS We enrolled 18 patients diagnosed with C3GN. These patients were divided into two groups, four patients in the end-stage renal disease (ESRD) group and 14 patients in non-ESRD group, based on clinical status at the last examination. Patients in the non-ESRD group were further divided into Subgroup A, consisting of 6 treatment responders, and Subgroup B, consisting of 8 non- responders. The clinical and laboratory findings, as well as the histological findings were investigated for each group. RESULTS The frequency of nephrotic syndrome at onset in the ESRD group was higher than that in the non-ESRD group. Before treatment and at 2 years after treatment, urinary protein excretion levels and serum creatinine levels in the ESRD group were higher than those in the non-ESRD group. The mean serum C3 and CH50 levels at 2 years after treatment in the ESRD group were lower than those in the non-ESRD group. The degree of renal injury, level of mesangial deposits and degree of alpha SMA staining at the time of the first renal biopsy in the ESRD group were all higher than those in the non-ESRD group. CONCLUSIONS Our results suggest that the severity of C3GN at onset and persistent complements activity are associated with poor prognosis in C3GN.
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Affiliation(s)
- Mamiko Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Yukihiko Kawasaki
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Ryo Maeda
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Masatoki Sato
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Kazuhide Suyama
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Koichi Hashimoto
- Department of Pediatrics, Fukushima Medical University School of Medicine
| | - Mitsuaki Hosoya
- Department of Pediatrics, Fukushima Medical University School of Medicine
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15
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Holle J, Berenberg-Goßler L, Wu K, Beringer O, Kropp F, Müller D, Thumfart J. Outcome of membranoproliferative glomerulonephritis and C3-glomerulopathy in children and adolescents. Pediatr Nephrol 2018; 33:2289-2298. [PMID: 30238151 DOI: 10.1007/s00467-018-4034-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 06/22/2018] [Accepted: 07/23/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Membranoproliferative glomerulonephritis (MPGN) is a rare cause of glomerulopathy in children. Recently, a new classification based on immunohistological features has been established. Infections and anomalies in complement-regulating genes, leading to alternative complement pathway activation, are suspected to trigger the disease. Nevertheless, little is known about optimal treatment and outcome in children with immune-complex-MPGN (IC-MPGN) and C3-glomerulopathy (C3G). METHODS The method used is retrospective analysis of clinical, histological, and genetic characteristics of 14 pediatric patients with MPGN in two medical centers. RESULTS Mean age of the patients was 10.6 ± 4.5 years. Patients were grouped into C3G (n = 6) and IC-MPGN (n = 8). One patient showed a likely pathogenic variant in the CFHR5 gene. All 10 patients had risk polymorphisms in complement-regulating genes. Most patients were treated with ACE inhibition, steroids, and mycophenolate mofetil. Three patients with C3G received eculizumab. Median follow-up was 2.3 years. After 1 year of disease, three patients (two C3G, one IC-MPGN) reached complete, five patients partial (three IC-MPGN, two C3G), and five patients no remission (four IC-MPGN, one C3G). One patient progressed to end-stage renal disease (ESRD) 6 years after disease onset. CONCLUSIONS IC-MPGN and C3G are rare disorders in children. Most patients have signs of complement activation associated with risk polymorphisms or likely pathogenic variants in complement-regulating genes. Steroids and mycophenolate mofetil seem to be effective and for some patients, eculizumab might be a treatment option. Outcome is heterogeneous and precise differentiation between IC-MPGN and C3G is still pending.
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Affiliation(s)
- Johannes Holle
- Department of Pediatric Pulmonology, Immunology and Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Lena Berenberg-Goßler
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Kaiyin Wu
- Department of Pathology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Ortraud Beringer
- Department of Pediatrics and Adolescent Medicine, Pediatric Nephrology, Ulm University Medical Center, Ulm, Germany
| | - Florian Kropp
- Department of Pediatrics and Adolescent Medicine, Pediatric Nephrology, Ulm University Medical Center, Ulm, Germany
| | - Dominik Müller
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Julia Thumfart
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité - Universitätsmedizin Berlin, Berlin, Germany
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16
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Regunathan-Shenk R, Avasare RS, Ahn W, Canetta PA, Cohen DJ, Appel GB, Bomback AS. Kidney Transplantation in C3 Glomerulopathy: A Case Series. Am J Kidney Dis 2018; 73:316-323. [PMID: 30413277 DOI: 10.1053/j.ajkd.2018.09.002] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 09/03/2018] [Indexed: 02/08/2023]
Abstract
RATIONALE & OBJECTIVE C3 glomerulopathy (C3G), a form of glomerulonephritis associated with dysregulation of the alternative complement pathway, occurs either as dense deposit disease (DDD) or C3 glomerulonephritis (C3GN). Few studies have reported outcomes of patients with C3G after transplantation since its formal classification and the advent of complement-targeting therapies such as eculizumab. STUDY DESIGN Case series of C3G. SETTING & PARTICIPANTS We reviewed laboratory testing, native and allograft biopsy reports, and clinical charts of the 19 patients (12, C3GN; and 7, DDD) from our C3G registry who underwent transplantation between 1999 and 2016. RESULTS During a median follow-up of 76 months, 16 patients had recurrent disease (10 of 12, C3GN; and 6 of 7, DDD), with median time to recurrence of 14 months in C3GN versus 15 months in DDD. Graft failure was more frequent in patients with DDD (6 of 7) than in patients with C3GN (3 of 12), occurred at a median time of 42 months posttransplantation, and was attributed to recurrent disease in half the failures. A rare genetic variant or autoantibody associated with alternative complement pathway abnormalities was detected in 9 of 10 screened patients. Treatment of 7 patients (8 allografts) with eculizumab was associated with variable clinical outcomes. LIMITATIONS Incomplete testing for complement pathway abnormalities and genetic defects, incomplete records of HLA antigen matching, lack of centralized biopsy review, and limited sample size. CONCLUSIONS In a case series of C3G transplant recipients, the proportion of disease recurrence was high in both C3GN and DDD, although graft loss appeared to occur more frequently in DDD. In a small subset of study patients, eculizumab therapy was not consistently followed by salutary outcomes.
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Affiliation(s)
- Renu Regunathan-Shenk
- Division of Kidney Disease and Hypertension, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Rupali S Avasare
- Division of Nephrology and Hypertension, Department of Medicine, Oregon Health and Science University, Portland, OR
| | - Wooin Ahn
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Pietro A Canetta
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - David J Cohen
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Gerald B Appel
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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17
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Bomback AS, Santoriello D, Avasare RS, Regunathan-Shenk R, Canetta PA, Ahn W, Radhakrishnan J, Marasa M, Rosenstiel PE, Herlitz LC, Markowitz GS, D'Agati VD, Appel GB. C3 glomerulonephritis and dense deposit disease share a similar disease course in a large United States cohort of patients with C3 glomerulopathy. Kidney Int 2018; 93:977-985. [PMID: 29310824 DOI: 10.1016/j.kint.2017.10.022] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/05/2017] [Accepted: 10/20/2017] [Indexed: 11/16/2022]
Abstract
C3 glomerulonephritis (C3GN) and dense deposit disease comprise the two classes of C3 glomerulopathy. Studies from Europe and Asia have aided our understanding of this recently defined disorder, but whether these data apply to a diverse United States patient population remains unclear. We, therefore, reviewed clinical and histopathological data, including generation of a C3 Glomerulopathy Histologic Index to score biopsy activity and chronicity, to determine predictors of progression to end-stage renal disease (ESRD) and advanced chronic kidney disease (CKD) in 111 patients (approximately 35% non-white) with C3 glomerulopathy: 87 with C3GN and 24 with dense deposit disease. Complement-associated gene variants and autoantibodies were detected in 24% and 35% of screened patients, respectively. Our C3 Glomerulopathy Histologic Index denoted higher activity in patients with C3GN and higher chronicity in patients with dense deposit disease. Over an average of 72 months of follow-up, remission occurred in 38% of patients with C3GN and 25% of patients with dense deposit disease. Progression to late-stage CKD and ESRD was common, with no differences between C3GN (39%) and dense deposit disease (42%). In multivariable models, the strongest predictors for progression were estimated glomerular filtration rate at diagnosis (clinical variables model) and tubular atrophy/interstitial fibrosis (histopathology variables model). Using our C3 Glomerulopathy Histologic Index, both total activity and total chronicity scores emerged as the strongest predictors of progression. Thus, in a large, diverse American cohort of patients with C3 glomerulopathy, there is a high rate of progression to CKD and ESRD with no differences between C3GN and dense deposit disease.
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Affiliation(s)
- Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA.
| | - Dominick Santoriello
- Department of Pathology and Cell Biology, Division of Renal Pathology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Rupali S Avasare
- Department of Medicine, Division of Nephrology, Oregon Health and Science University, Portland, Oregon, USA
| | - Renu Regunathan-Shenk
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Pietro A Canetta
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Wooin Ahn
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Jai Radhakrishnan
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Maddalena Marasa
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Paul E Rosenstiel
- Department of Pathology and Cell Biology, Division of Renal Pathology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Leal C Herlitz
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Division of Renal Pathology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Division of Renal Pathology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Gerald B Appel
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Bouatou Y, Kers J, Chevalier-Florquin MSN, Claessen N, Nguyen TQ, Damman J, Proença H, Roelofs JJTH, Florquin S. Diagnostic accuracy of immunofluorescence versus immunoperoxidase staining to distinguish immune complex-mediated glomerulonephritis and C3 dominant glomerulopathy. Histopathology 2017; 72:601-608. [PMID: 28881045 DOI: 10.1111/his.13385] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 09/03/2017] [Indexed: 11/29/2022]
Abstract
AIMS The technique used for classification of membranoproliferative glomerulonephritis (MPGN) has been changed from an electron microscopy-based to an immunofluorescence (IF)-based semiquantitative technique with immunoperoxidase (IP) staining as a backup option when IF is not possible. Since data on that matter is lacking, our aims were to study the interobserver variability, the correlation and the reclassification of MPGN based on these two techniques. METHODS AND RESULTS We retrospectively analysed cases of type 1 MPGN. We repeated IF staining and performed IP staining for IgG, kappa, lambda, C3c and C4d in 35 renal biopsies, among which 19 biopsies had matched IP and IF samples. We observed substantial to near-perfect agreement among the seven observers for both IF and IP (W coefficients from 0.66 for IF lambda to 0.89 for IF C4d). Of the 19 cases with matched IP and IF samples, five (26%) turned out to have different diagnoses on IF and on IP. Also, the ability of C4d to discriminate immune complex-mediated glomerulonephritis (ICGN) from C3 glomerulopathy (C3G) was poor, with areas under the curve of 0.44 [95% confidence interval (CI) 0.24-0.63] and 0.66 (95% CI 0.50-0.81) for the receiver operating characteristic curves of IF and IP respectively. Limitations include the fact that no clinical data regarding complement activation were available. CONCLUSION The diagnosis of ICGN versus C3GN depends on the immunochemical technique used. Also, the use of C4d failed to discriminate ICGN from C3G in our study. Further validation studies are required to avoid misdiagnosis based on kidney biopsy.
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Affiliation(s)
- Yassine Bouatou
- Department of Pathology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.,Division of Nephrology, Geneva University Hospitals, Geneva, Switzerland
| | - Jesper Kers
- Department of Pathology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Nike Claessen
- Department of Pathology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Tri Q Nguyen
- Department of Pathology, University Medical Centre Utrecht, University of Utrecht, Utrecht, The Netherlands
| | - Jeffrey Damman
- Department of Pathology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Henrique Proença
- Department of Pathology, Hospital do Rim e Hipertensão, São Paulo, Brazil
| | - Joris J T H Roelofs
- Department of Pathology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sandrine Florquin
- Department of Pathology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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Lebreton C, Bacchetta J, Dijoud F, Bessenay L, Fremeaux-Bacchi V, Sellier-Leclerc AL. C3 glomerulopathy and eculizumab: a report on four paediatric cases. Pediatr Nephrol 2017; 32:1023-1028. [PMID: 28236143 DOI: 10.1007/s00467-017-3619-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 11/18/2016] [Accepted: 12/06/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Eculizumab may be used to treat C3-glomerulopathy (C3G), a rare but severe glomerular disease. DIAGNOSIS AND TREATMENT Patients 1, 2 and 3 were diagnosed with nephritic syndrome with alternative complement pathway activation (low C3, C3Nef-positive) and C3G at the age of 9, 13 and 12 years, respectively. Treatment with eculizumab normalized proteinuria within 1, 2 and 7 months, respectively. Proteinuria relapsed when eculizumab was withdrawn, but the re-introduction of eculizumab normalized proteinuria. Patient 4 was diagnosed with C3G at 9 years of age, with progression to end-stage renal disease within 2 years, followed by a first renal transplantation (R-Tx) with early disease recurrence and graft loss within 39 months. After a second R-Tx, she rapidly presented with biological and histological recurrence: therapy with eculizumab was started, with no effect on proteinuria after 5 months, in a complex clinical setting (i.e. association of C3G recurrence, humoral rejection and BK nephritis). Eculizumab was withdrawn due to multiple viral reactivations, but the re-introduction of the drug a few months later enabled a moderate decrease in proteinuria. CONCLUSION These cases illustrate the efficacy of eculizumab, at least on native kidneys, in paediatric C3G. However, larger international studies are warranted to confirm the benefit and safety of eculizumab therapy.
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Affiliation(s)
- Célia Lebreton
- Service de Néphrologie Rhumatologie Dermatologie Pédiatriques, Centre de Référence des Maladies Rénales Rares Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69677, Bron, France
| | - Justine Bacchetta
- Service de Néphrologie Rhumatologie Dermatologie Pédiatriques, Centre de Référence des Maladies Rénales Rares Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69677, Bron, France.,Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France
| | - Frédérique Dijoud
- Faculté de Médecine Lyon Est, Université Lyon 1, Lyon, France.,Laboratoire d'Anatomopathologie, Groupe Hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Lucie Bessenay
- Service de Pédiatrie, CHU Clermont Ferrand, Clermont Ferrand, France
| | - Véronique Fremeaux-Bacchi
- Laboratoire d'Immunologie, Hôpital Georges Pompidou, Assistance publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Anne Laure Sellier-Leclerc
- Service de Néphrologie Rhumatologie Dermatologie Pédiatriques, Centre de Référence des Maladies Rénales Rares Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 boulevard Pinel, 69677, Bron, France.
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Differences in clinical findings, pathology, and outcomes between C3 glomerulonephritis and membranoproliferative glomerulonephritis. Pediatr Nephrol 2016; 31:1091-9. [PMID: 26846787 DOI: 10.1007/s00467-015-3307-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 12/21/2015] [Accepted: 12/21/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND To clarify the clinical manifestations of pediatric complement component C3 glomerulonephritis (C3GN), we retrospectively evaluated differences in the clinicopathological findings and prognosis between C3GN and immune-complex-mediated membranoproliferative glomerulonephritis (IC-MPGN). METHODS Thirty-seven patients diagnosed with "idiopathic MPGN" were enrolled in this retrospective study. The patients were divided into two groups, with Group 1 consisting of 19 patients diagnosed with IC-MPGN and Group 2 consisting of 18 patients diagnosed with C3GN. The clinical findings and the prognosis were investigated for both groups. RESULTS Thirteen patients in Group 2 were identified by mandatory annual school screening for urinary abnormalities. The incidence of macro-hematuria and the frequency of low serum C4 values were lower in Group 2 patients than in Group 1 patients. At the time of the second renal biopsy, urinary protein excretion, incidence of hematuria, frequency of low serum C3 values, and scores for mesangial proliferation, glomerular sclerosis, and interstitial fibrosis were higher in Group 2 patients than in Group 1 patients. At the most recent follow-up examination, the number of patients categorized as non-responding or with end-stage renal disease was higher in Group 2 patients than in Group 1 patients. CONCLUSIONS Our results suggest that the treatment response and prognosis of patients with C3GN are worse than those of patients with IC-mediated MPGN. Therefore, in the clinical context regarding treatment options and prognosis, it may be useful to classify idiopathic MPGN as C3GN or IC-MPGN. In addition, long-term follow-up of C3GN is necessary.
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