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Zare Moghaddam M, Mousavi MJ, Ghotloo S. Stem cell-based therapy for systemic lupus erythematous. J Transl Autoimmun 2024; 8:100241. [PMID: 38737817 PMCID: PMC11087996 DOI: 10.1016/j.jtauto.2024.100241] [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: 01/11/2024] [Revised: 04/08/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024] Open
Abstract
Systemic lupus erythematosus (SLE), an autoimmune disease, is among the most prevalent rheumatic autoimmune disorders. It affects autologous connective tissues caused by the breakdown of self-tolerance mechanisms. During the last two decades, stem cell therapy has been increasingly considered as a therapeutic option in various diseases, including parkinson's disease, alzheimer, stroke, spinal cord injury, multiple sclerosis, inflammatory bowel disease, liver disease, diabete, heart disease, bone disease, renal disease, respiratory diseases, and hematological abnormalities such as anemia. This is due to the unique properties of stem cells that divide and differentiate to the specialized cells in the damaged tissues. Moreover, they impose immunomodulatory properties affecting the diseases caused by immunological abnormalities such as rheumatic autoimmune disorders. In the present manuscript, efficacy of stem cell therapy with two main types of stem cells, including mesenchymal stem cell (MSC), and hematopoietic stem cells (HSC) in animal models or human patients of SLE, has been reviewed. Taken together, MSC and HSC therapies improved the disease activity, and severity in kidney, lung, liver, and bone (improvement in the clinical manifestation). In addition, a change in the immunological parameters occurred (improvement in immunological parameters). The level of autoantibodies, including antinuclear antibody (ANA), and anti-double-stranded deoxyribonucleic acid antibodies (dsDNA Abs) reduced. A conversion of Th1/Th2 ratio (in favor of Th2), and Th17/Treg (in favor of Treg) was also detected. In spite of many advantages of MSC and HSC transplantations, including efficacy, safety, and increased survival rate of SLE patients, some complications, including recurrence of the disease, occurrence of infections, and secondary autoimmune diseases (SAD) were observed after transplantation that should be addressed in the next studies.
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Affiliation(s)
- Maryam Zare Moghaddam
- Department of Immunology, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Javad Mousavi
- Department of Hematology, Faculty of Allied Medicine, Bushehr University of Medical Sciences, Bushehr, Iran
| | - Somayeh Ghotloo
- Autoimmune Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
- Department of Clinical Laboratory Sciences, School of Allied Medical Sciences, Kashan University of Medical Sciences, Kashan, Iran
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Rodriguez-Ramirez S, Wiegley N, Mejia-Vilet JM. Kidney Biopsy in Management of Lupus Nephritis: A Case-Based Narrative Review. Kidney Med 2024; 6:100772. [PMID: 38317756 PMCID: PMC10840121 DOI: 10.1016/j.xkme.2023.100772] [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: 02/07/2024] Open
Abstract
Kidney involvement in patients with lupus highly increases morbidity and mortality. In recent years, several reports have emphasized the dissociation between clinical and histological findings and highlighted the role of kidney biopsy as an instrument for diagnosis and follow-up of lupus nephritis. The kidney biopsy at initial diagnosis allows an early diagnosis, assessment of activity and chronicity, and detection of nonimmune complex nephritis. A kidney biopsy repeated months after treatment aids in the detection of persistent histological inflammation, which has been linked to the occurrence of future kidney relapses. A kidney biopsy at a relapse detects histological changes including chronic scarring. Finally, a kidney biopsy in patients with a clinical response undergoing maintenance immunosuppression may aid therapy tapering and/or suspension. The evidence supporting the use of a kidney biopsy in different scenarios across the course of lupus nephritis is heterogeneous, with most reports assessing the value for the diagnosis of a first or relapsing flare. In contrast, less evidence suggests additional therapeutic-modifying information derived from repeat posttreatment biopsies and biopsies to evaluate treatment tapering or suspension. In this clinical case-based review, we examine the role of kidney biopsy as a tool to improve clinical outcomes of patients with lupus nephritis.
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Affiliation(s)
- Sonia Rodriguez-Ramirez
- Division of Nephrology, University Health Network, Toronto, Ontario, Canada
- Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Nasim Wiegley
- University of California, Davis School of Medicine, Division of Nephrology, Sacramento, California, United States
| | - Juan Manuel Mejia-Vilet
- Department of Nephrology and Mineral Metabolism. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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3
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Ye J, Croom N, Troxell ML, Kambham N, Zuckerman JE, Andeen N, Dall’Era M, Hsu R, Walavalkar V, Laszik ZG, Urisman A. Non-Full House Membranous Lupus Nephritis Represents a Clinically Distinct Subset. KIDNEY360 2023; 4:935-942. [PMID: 37257088 PMCID: PMC10371271 DOI: 10.34067/kid.0000000000000161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/21/2023] [Indexed: 06/02/2023]
Abstract
Key Points Non-full house (NFH) membranous lupus nephritis (MLN) is a minor subset of all MLN cases. Patients with NFH MLN tend to be older when diagnosed with systemic lupus erythematosus, undergo first renal biopsy at an older age, and have fewer extrarenal systemic manifestations. Lower load of C3 glomerular deposits seen in NFH MLN biopsies suggests attenuation of complement-mediated injury, which may have wider systemic implications. Background Renal involvement in systemic lupus erythematosus (SLE) is a key predictor of morbidity and mortality. Immunofluorescence (IF) staining of glomeruli is typically positive for IgG, IgA, IgM, C3, and C1q—the full house (FH) pattern. However, a subset of patients with membranous lupus nephritis (MLN) have a Non-FH (NFH) IF pattern more typical of idiopathic membranous nephropathy. Methods From a multi-institutional cohort of 113 MLN cases, we identified 29 NFH MLN biopsies. NFH MLN was defined by IF criteria: ≥1+ glomerular capillary loop IgG staining and<1+ IgA, IgM, and C1q. FH MLN was defined as ≥1+ staining for all five antibodies. Intermediate (Int) cases did not meet criteria for FH or NFH. We compared the pathological and clinical characteristics and outcomes among patients with FH, NFH, and Int IF patterns on kidney biopsy. Results NFH MLN represents a subset of MLN biopsies (13.4%). Compared with patients with FH MLN, patients with NFH MLN were older at SLE diagnosis (29 versus 22.5 years), had a longer time to initial kidney biopsy (8 versus 3.16 years), and had fewer SLE manifestations (2.5 versus 3.36 involved systems). NFH MLN biopsies showed lower C3 IF intensity (1.16+ versus 2.38+). Int biopsies had findings intermediate between those of NFH and FH groups. Conclusions NFH IF pattern defines a small subset of MLN biopsies and appears to be associated with milder clinical manifestations and slower disease progression. Less robust C3 deposition in NFH MLN may suggest a pathophysiology distinct from that of FH MLN.
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Affiliation(s)
- Julia Ye
- Department of Pathology, University of California, San Francisco, San Francisco, California
| | - Nicole Croom
- Department of Pathology, University of California, San Francisco, San Francisco, California
| | - Megan L. Troxell
- Department of Pathology, Stanford University, Palo Alto, California
| | - Neeraja Kambham
- Department of Pathology, Stanford University, Palo Alto, California
| | - Jonathan E. Zuckerman
- Department of Pathology, University of California, Los Angeles, Los Angeles, California
| | - Nicole Andeen
- Department of Pathology, Oregon Health and Science University, Portland, Oregon
| | - Maria Dall’Era
- Division of Rheumatology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Raymond Hsu
- Division of Nephrology, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Vighnesh Walavalkar
- Department of Pathology, University of California, San Francisco, San Francisco, California
| | - Zoltan G. Laszik
- Department of Pathology, University of California, San Francisco, San Francisco, California
| | - Anatoly Urisman
- Department of Pathology, University of California, San Francisco, San Francisco, California
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Moroni G, Porata G, Raffiotta F, Frontini G, Calatroni M, Reggiani F, Banfi G, Ponticelli C. Predictors of increase in chronicity index and of kidney function impairment at repeat biopsy in lupus nephritis. Lupus Sci Med 2022; 9:9/1/e000721. [PMID: 35973744 PMCID: PMC9386217 DOI: 10.1136/lupus-2022-000721] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/30/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Based on available data, the histological predictors of long-term outcome of lupus nephritis (LN) are not clearly defined. Aims of this retrospective study were: (i) to evaluate the change of chronicity index from the first to second kidney biopsy and to find the predictors of chronicity index increase and (ii) to detect the clinical/histological features at first and at second kidney biopsy associated with long-term kidney function impairment. METHODS Among 203 biopsy proven LN subjects, 61 repeated kidney biopsy 49 months after the first biopsy. The reasons for repeated biopsy were: nephritic flares in 25 (41%), proteinuric flares in 21 (36%) of patients and protocol biopsy in 14 (23%) of cases. RESULTS During 23-year follow-up, 25 patients presented a decrease in glomerular filtration rate (eGFR) ≥30%. At repeat biopsy, chronicity index increased in 44 participants (72%) and did not increase in 17 (28%). Nephritic syndrome and serum creatinine >1.6 mg/dL at presentation correlated with chronicity index increase (p=0.031, 0.027, respectively), cyclophosphamide therapy tended to protect against chronicity index increase (p=0.059). Kidney flares occurred in 53.6% of patients with vs 23.5% of those without chronicity index increase (p=0.035). Chronicity index increases of 3.5 points in patients with kidney flares vs 2 in those without flares (p=0.001). At second, but not at first kidney biopsy, two different models predicted eGFR decrease at multivariate analysis. The first included activity index >3 (OR: 3.230; p=0.013) and chronicity index >4 (OR: 2.905; p=0.010), and the second model included moderate/severe cellular/fibrocellular crescents (OR: 4.207; p=0.010) and interstitial fibrosis (OR: 2.525; p=0.025). CONCLUSION At second biopsy, chronicity index increased in 3/4 of participants. Its increase was predicted by kidney dysfunction at presentation and occurrence of LN flares. Kidney function impairment was predicted by both activity and chronicity index and by some of their components at repeated biopsy, but not at first biopsy.
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Affiliation(s)
- Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy .,Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Giulia Porata
- U.O. Nefrologia e Dialisi, ASST Santi Paolo e Carlo, Milano, Italy
| | | | - Giulia Frontini
- Nefrologia, Dialisi e Trapianto di Rene, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marta Calatroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco Reggiani
- Department of Biomedical Sciences, Humanitas University, Milan, Italy.,Nephrology and Dialysis Division, IRCCS Humanitas Research Hospital, Rozzano, Italy
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Zhou X, Zhang Y, Wang N. Systematic identification of key extracellular proteins as the potential biomarkers in lupus nephritis. Front Immunol 2022; 13:915784. [PMID: 35967373 PMCID: PMC9366080 DOI: 10.3389/fimmu.2022.915784] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/01/2022] [Indexed: 11/21/2022] Open
Abstract
Background Lupus nephritis (LN) is the most common and severe clinical manifestation of systemic lupus erythematosus (SLE) with considerable morbidity/mortality and limited treatment options. Since kidney biopsy is a relative hysteretic indicator, it is indispensable to investigate potential biomarkers for early diagnosis and predicting clinical outcomes of LN patients. Extracellular proteins may become the promising biomarkers by the secretion into body fluid. Our study linked extracellular proteins with lupus nephritis to identify the emerging biomarkers. Methods The expression profiling data were acquired from the Gene Expression Omnibus (GEO) database. Meanwhile, the two gene lists encoding extracellular proteins were collected from the Human Protein Atlas (HPA) and UniProt database. Subsequently, the extracellular protein-differentially expressed genes (EP-DEGs) were screened out, and the key EP-DEGs were determined by MCODE, MCC, and Degree methods via the protein–protein interaction (PPI) network. The expression level, immune characteristics, and diagnostic value of these candidate biomarkers were investigated. Finally, the Nephroseq V5 tool was applied to evaluate the clinical significance of the key EP-DEGs. Results A total of 164 DEGs were acquired by comparing LN samples with healthy controls based on GSE32591 datasets. Then, 38 EP-DEGs were screened out through the intersection between DEGs and extracellular protein gene lists. Function enrichment analysis indicated that these EP-DEGs might participate in immune response and constitute the extracellular matrix. Four key EP-DEGs (LUM, TGFBI, COL1A2, and POSTN) were eventually identified as candidate biomarkers, and they were all overexpressed in LN samples. Except that LUM expression was negatively correlated with most of the immune regulatory genes, there was a positive correlation between the remaining three biomarkers and the immune regulatory genes. In addition, these biomarkers had high diagnostic value, especially the AUC value of the LUM–TGFBI combination which reached almost 1 (AUC = 0.973), demonstrating high accuracy in distinguishing LN from controls. Finally, we found a meaningful correlation of these biomarkers with sex, WHO class, and renal function such as glomerular filtration rate (GFR), serum creatinine level, and proteinuria. Conclusion In summary, our study comprehensively identified four key EP-DEGs exerting a vital role in LN diagnosis and pathogenesis and serving as promising therapeutic targets.
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Affiliation(s)
- Xue Zhou
- Department of Nephrology, Tianjin Haihe Hospital, Tianjin, China
- Haihe Hospital, Tianjin University, Tianjin, China
- Haihe Clinical School, Tianjin Medical University, Tianjin, China
| | - Yuefeng Zhang
- Department of Nephrology, Tianjin Haihe Hospital, Tianjin, China
- Haihe Hospital, Tianjin University, Tianjin, China
- Haihe Clinical School, Tianjin Medical University, Tianjin, China
| | - Ning Wang
- Medical Department, The Third Central Hospital of Tianjin, Tianjin, China
- *Correspondence: Ning Wang,
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Fava A, Rao DA, Mohan C, Zhang T, Rosenberg A, Fenaroli P, Belmont HM, Izmirly P, Clancy R, Monroy Trujillo J, Fine D, Arazi A, Berthier CC, Davidson A, James JA, Diamond B, Hacohen N, Wofsy D, Raychaudhuri S, Apruzzese W, Buyon J, Petri M. Urine Proteomics and Renal Single Cell Transcriptomics Implicate IL-16 in Lupus Nephritis. Arthritis Rheumatol 2021; 74:829-839. [PMID: 34783463 PMCID: PMC9050800 DOI: 10.1002/art.42023] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 10/13/2021] [Accepted: 11/09/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Current treatments are effective only in 30% of lupus nephritis patients emphasizing the need for novel therapeutic strategies. To develop mechanistic hypotheses and explore novel biomarkers, we analyzed the longitudinal urinary proteomic profiles in patients with lupus nephritis undergoing treatment. METHODS We quantified 1,000 urinary proteins in 30 patients with lupus nephritis at the time of the diagnostic renal biopsy and after 3, 6, and 12 months. The proteins and molecular pathways detected in the urine proteome were then analyzed with respect to baseline clinical features and longitudinal trajectories. The intrarenal expression of candidate biomarkers was evaluated using single cell transcriptomics of renal biopsies from lupus nephritis patients. RESULTS Our analysis revealed multiple biological pathways including chemotaxis, neutrophil activation, platelet degranulation, and extracellular matrix organization that could be noninvasively quantified and monitored in the urine. We identified 237 urinary biomarkers associated with lupus nephritis as compared to controls without SLE. IL-16, CD163, and TGF-β mirrored intrarenal nephritis activity. Response to treatment was paralleled by a reduction of urinary IL-16, a CD4 ligand with proinflammatory and chemotactic properties. Single cell RNA sequencing independently demonstrated that IL16 is the second most expressed cytokine by most infiltrating immune cells in lupus nephritis kidneys. IL-16 producing cells were found at key sites of kidney injury. CONCLUSION Urine proteomics may profoundly change the diagnosis and management of lupus nephritis by noninvasively monitor active intrarenal biological pathways. These findings implicate IL-16 in lupus nephritis pathogenesis designating it as a potentially treatable target and biomarker.
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Affiliation(s)
- Andrea Fava
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
| | - Deepak A Rao
- Division of Rheumatology, Immunology, Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Avi Rosenberg
- Division of Renal Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Paride Fenaroli
- Division of Renal Pathology, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine and Surgery, Nephrology Unit, Parma University Hospital, Parma, Italy
| | | | - Peter Izmirly
- New York University School of Medicine, New York, New York, USA
| | - Robert Clancy
- New York University School of Medicine, New York, New York, USA
| | | | - Derek Fine
- Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - Arnon Arazi
- Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | | | | | - Judith A James
- Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Betty Diamond
- Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | | | - David Wofsy
- University of California San Francisco, San Francisco, CA, USA
| | - Soumya Raychaudhuri
- Division of Rheumatology, Immunology, Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Center for Data Sciences, Brigham and Women's Hospital, Boston, MA, 02115, USA.,Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA, USA.,Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, The University of Manchester, Oxford Road, Manchester, UK
| | - William Apruzzese
- Division of Rheumatology, Immunology, Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Jill Buyon
- New York University School of Medicine, New York, New York, USA
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, USA
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Fava A, Fenaroli P, Rosenberg A, Bagnasco S, Li J, Monroy-Trujillo J, Fine D, Atta MG, Petri M. History of Proliferative Glomerulonephritis Predicts End Stage Kidney Disease in Pure Membranous Lupus Nephritis. Rheumatology (Oxford) 2021; 61:2483-2493. [PMID: 34664621 DOI: 10.1093/rheumatology/keab775] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 10/08/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Pure membranous (class V) lupus nephritis (LN) is considered a less aggressive phenotype, but tissue fibrosis and chronic kidney disease may still develop. This study aimed to elucidate the prognostic value of a history of class switch in pure membranous LN. METHODS We included LN patients with at least two clinically indicated kidney biopsies. New onset of end stage kidney disease (ESKD) was defined as estimated glomerular filtration rate < 15 ml/min/1.73m2, initiation of dialysis, or kidney transplantation. RESULTS Among 220 patients (542 biopsies), 199 (90%) were female, and 118 (54%) were African American, 59 (27%) Caucasian, with median age of 28 years at the first kidney biopsy. Patients with pure class V in a first biopsy converted to proliferative LN in 41% of cases. Pure class V in a repeat biopsy was preceded by proliferative LN in 52%. Trajectory analysis of up to 4 repeat biopsies revealed that ISN class switch may happen at any time, even after multiple biopsies with the same class. New onset ESKD was observed within 2 years in 5/56 (9%) patients with pure class V in a repeat biopsy. All 5 patients had proliferative LN in the first biopsy (log rank p= 0.024). CONCLUSIONS The conversion from proliferative to membranous (and vice-versa) is frequent in SLE. It can occur at any time in the course of disease, limiting the prognostic value of the first biopsy. Evidence of prior proliferative LN is key as it is associated with higher risk of ESKD in non-proliferative LN.
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Affiliation(s)
- Andrea Fava
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paride Fenaroli
- Division of Nephrology, University Hospital, Parma, Italy.,Division of Renal Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Avi Rosenberg
- Division of Renal Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Serena Bagnasco
- Division of Renal Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - Jessica Li
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Derek Fine
- Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - Mohamed G Atta
- Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Hsieh TY, Lin YC, Hung WT, Chen YM, Wen MC, Chen HH, Lin WY, Hsieh CW, Lin CT, Lai KL, Tang KT, Tseng CW, Huang WN, Chen YH, Tsai SC, Wu YD. Change of Renal Gallium Uptake Correlated with Change of Inflammation Activity in Renal Pathology in Lupus Nephritis Patients. J Clin Med 2021; 10:jcm10204654. [PMID: 34682781 PMCID: PMC8541120 DOI: 10.3390/jcm10204654] [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: 08/14/2021] [Revised: 10/04/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022] Open
Abstract
Background: Lupus nephritis (LN) often lead to end-stage renal disease in systemic lupus erythematosus patients. This study aimed to investigate the clinical application of renal gallium-67 scans for determining renal histological parameters in LN patients. Methods: Between 2006 and 2018, 237 biopsy-proven and 35 repeat biopsies LN patients who underwent renal gallium scans before or after biopsy were included for analysis. The classification and scoring of LN were assessed according to the International Society of Nephrology/Renal Pathology Society. A delayed 48-h gallium scan was performed and interpreted by semiquantitative methods using left kidney/spine (K/S) ratio. The renal histological results were compared with gallium uptake. Results: Out of 237 participants, 180 (76%) had proliferative LN. Baseline gallium left K/S ratio was significantly higher in class IV LN as compared to class III (median (interquartile range, IQR): 1.16 (1.0–1.3), 0.95 (0.9–1.1), respectively, p < 0.001). Furthermore, changes in gallium uptake between two biopsies were positively correlated with changes activity index (r = 0.357, p = 0.035), endocapillary hypercellularity (r = 0.385, p = 0.032), and neutrophils infiltration (r = 0.390, p = 0.030) in renal pathology. Conclusions: Renal gallium uptake is associated with active inflammation in LN. Changes in renal gallium uptake positively correlated with changes in activity index in renal pathology.
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Affiliation(s)
- Tsu-Yi Hsieh
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Education, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Yi-Ching Lin
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (Y.-C.L.); (W.-Y.L.)
- Department of Public Health, China Medical University, Taichung 40447, Taiwan
| | - Wei-Ting Hung
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Education, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Yi-Ming Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
- Faculty of Medicine, National Yang-Ming University, Taipei 11221, Taiwan
| | - Mei-Chin Wen
- Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan;
| | - Hsin-Hua Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Wan-Yu Lin
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (Y.-C.L.); (W.-Y.L.)
| | - Chia-Wei Hsieh
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Institute of Biomedical Science and Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 402, Taiwan
| | - Ching-Tsai Lin
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
| | - Kuo-Tung Tang
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
| | - Chih-Wei Tseng
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
| | - Wen-Nan Huang
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Yi-Hsing Chen
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Department of Medical Research, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Shih-Chuan Tsai
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (Y.-C.L.); (W.-Y.L.)
- Department of Medical Imaging and Radiological Sciences, Central Taiwan University of Science and Technology, Taichung 406053, Taiwan
- Correspondence: (S.-C.T.); (Y.-D.W.)
| | - Yi-Da Wu
- Division of Allergy, Immunology and Rheumatology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (T.-Y.H.); (W.-T.H.); (Y.-M.C.); (H.-H.C.); (C.-W.H.); (C.-T.L.); (K.-L.L.); (K.-T.T.); (C.-W.T.); (W.-N.H.); (Y.-H.C.)
- Correspondence: (S.-C.T.); (Y.-D.W.)
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9
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Das U, Patel R, Guditi S, Taduri G. Correlation between the clinical remission and histological remission in repeat biopsy findings of quiescent proliferative lupus nephritis. Lupus 2021; 30:876-883. [PMID: 33611965 DOI: 10.1177/0961203321995251] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The optimal duration of maintenance therapy is controversial in proliferative lupus nephritis (LN). Discordance between clinical parameters of renal remission and histological findings has made repeat biopsy a compulsory tool to confirm the histological remission (HR), but the timing is debatable. Aim of this study was to find the correlation of sustained complete clinical remission (CR) in sever lupus nephritis with histological findings on repeat kidney biopsy and appropriate duration of treatment in maintenance phase after achieving complete clinical remission. METHODS Repeated kidney biopsy (biopsy 2) was performed on patients of biopsy proven (biopsy 1) proliferative LN who had been in CR for at least 2-years. The clinical and histologic findings of these groups (biopsy 1 and biopsy 2) were compared. Total 29 patients were included for the final analysis. Group 2 was further divided as per the duration of sustained CR (>48 months & <48 months). Regression analysis were used to find predictors of the HR. RESULTS Average time taken to achieve CR was 9(range 2-24) months. Average duration of follow up and maintenance therapy was 68 ± 17.8 and 62.5 ± 14.2 months respectively. In the repeat kidney biopsy, HR was observed in 93.1% patients. Immunofluorescence study (IF) was normal in 72% of the patients. Normal light microscopy (LM) findings were observed in 58% patients. Transformation from proliferative to nonproliferative LN was noted in 82% cases. Other than the duration of CR on maintenance therapy and blood pressure, rest of the variables failed to predict HR. In sustained remission for more than 48-months group, 100% patients achieved HR whereas only 84% in 24-48-months group. CONCLUSION Sustained CR on maintenance immunosuppressive therapy for more than 48-months duration predicts HR in repeat kidney biopsy findings in quiescent proliferative LN. Hence the minimum duration of maintenance therapy in proliferative LN should be at least for another 48 months after achieving CR.
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Affiliation(s)
- Uttara Das
- Department of Nephrology, Nizam"s Institute of Medical Sciences, Hyderabad, India
| | - Ravi Patel
- Department of Nephrology, Nizam"s Institute of Medical Sciences, Hyderabad, India
| | - Swarnalatha Guditi
- Department of Nephrology, Nizam"s Institute of Medical Sciences, Hyderabad, India
| | - Gangadhar Taduri
- Department of Nephrology, Nizam"s Institute of Medical Sciences, Hyderabad, India
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10
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Fava A, Buyon J, Mohan C, Zhang T, Belmont HM, Izmirly P, Clancy R, Trujillo JM, Fine D, Zhang Y, Magder L, Rao DA, Arazi A, Berthier CC, Davidson A, Diamond B, Hacohen N, Wofsy D, Apruzzese W, Raychaudhuri S, Petri M. Integrated urine proteomics and renal single-cell genomics identify an IFN-γ response gradient in lupus nephritis. JCI Insight 2020; 5:138345. [PMID: 32396533 PMCID: PMC7406291 DOI: 10.1172/jci.insight.138345] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 05/06/2020] [Indexed: 12/13/2022] Open
Abstract
Lupus nephritis, one of the most serious manifestations of systemic lupus erythematosus (SLE), has a heterogeneous clinical and pathological presentation. For example, proliferative nephritis identifies a more aggressive disease class that requires immunosuppression. However, the current classification system relies on the static appearance of histopathological morphology, which does not capture differences in the inflammatory response. Therefore, a biomarker grounded in the disease biology is needed in order to understand the molecular heterogeneity of lupus nephritis and identify immunologic mechanism and pathways. Here, we analyzed the patterns of 1000 urine protein biomarkers in 30 patients with active lupus nephritis. We found that patients stratify over a chemokine gradient inducible by IFN-γ. Higher values identified patients with proliferative lupus nephritis. After integrating the urine proteomics with the single-cell transcriptomics of kidney biopsies, we observed that the urinary chemokines defining the gradient were predominantly produced by infiltrating CD8+ T cells, along with natural killer and myeloid cells. The urine chemokine gradient significantly correlated with the number of kidney-infiltrating CD8+ cells. These findings suggest that urine proteomics can capture the complex biology of the kidney in lupus nephritis. Patient-specific pathways could be noninvasively tracked in the urine in real time, enabling diagnosis and personalized treatment.
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Affiliation(s)
- Andrea Fava
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jill Buyon
- New York University School of Medicine, New York, New York, USA
| | | | - Ting Zhang
- University of Houston, Houston, Texas, USA
| | | | - Peter Izmirly
- New York University School of Medicine, New York, New York, USA
| | - Robert Clancy
- New York University School of Medicine, New York, New York, USA
| | | | - Derek Fine
- Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yuji Zhang
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland, USA
- University of Maryland Marlene and Stewart Greenebaum Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Laurence Magder
- Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland, USA
| | - Deepak A. Rao
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Arnon Arazi
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Celine C. Berthier
- Internal Medicine, Department of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Anne Davidson
- Center for Autoimmune and Musculoskeletal Diseases, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Betty Diamond
- Center for Autoimmune and Musculoskeletal Diseases, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Nir Hacohen
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - David Wofsy
- Division of Rheumatology, UCSF, San Francisco, California, USA
| | - William Apruzzese
- Division of Rheumatology, Inflammation and Immunity, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Soumya Raychaudhuri
- Center for Data Sciences and
- Division of Rheumatology and Genetics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Biomedical Informatics, Harvard Medical School, Boston, Massachusetts, USA
- Program in Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Centre for Genetics and Genomics Versus Arthritis, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
| | - Michelle Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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11
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Saleh M, Eltoraby EE, Tharwat S, Nassar MK. Clinical and histopathological features and short-term outcomes of lupus nephritis: a prospective study of 100 Egyptian patients. Lupus 2020; 29:993-1001. [PMID: 32493152 DOI: 10.1177/0961203320928424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The short-term outcomes of lupus nephritis (LN) are variable and unpredictable among individuals. We aimed to evaluate the clinical and histopathological features and short-term renal outcomes in LN patients. METHODS This was a prospective cohort study carried out at nephrology and rheumatology units in Egypt between 2018 and 2019. A total of 100 patients with biopsy-proven LN were studied. Patients were evaluated for response after six months. RESULTS The female-to-male ratio was 8.1:1. About 70% of patients were hypertensive at disease onset, with rates for classes I, II, III, IV, V and VI LN being 1%, 7%, 20%, 53%, 14% and 6%, respectively. Among the immunosuppressive drugs used for induction, mycophenolate mofetil (MMF) represented the most commonly used (44%) followed by cyclophosphamide (CYC; 37%). After six months of follow-up, about two thirds of patients achieved remission. There was no significant difference in remission rate between MMF and CYC. On multivariate analysis, serum creatinine (SCr) at presentation was the most significant predictor of renal recovery. According to the receiver operating characteristic curve, the cut-off value of SCr was 1.6 mg/dL, with a sensitivity of 76% and specificity of 71% predicting renal recovery. Repeat renal biopsy was needed in 10 patients; class and treatment strategy changed in 40% and 70% of them, respectively. CONCLUSION Our findings in Egyptian LN patients compare favourably with most studies.
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Affiliation(s)
- Mohammed Saleh
- Nephrology unit, Internal Medicine Department, The Ministry of Health and Population of Egypt, Egypt
| | - Ehab E Eltoraby
- Rheumatology and Immunology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, Egypt
| | - Samar Tharwat
- Rheumatology and Immunology Unit, Internal Medicine Department, Faculty of Medicine, Mansoura University, Egypt
| | - Mohammed Kamal Nassar
- Mansoura Nephrology and Dialysis Unit (MNDU), Internal Medicine Department, Faculty of Medicine, Mansoura University, Egypt
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12
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Gupta KL, Bharati J, Anakutti H, Pattanashetti N, Rathi M, Ramachandran R, Nada R. Contribution of Clinically Indicated Repeat Renal Biopsy in Indian Patients with Lupus Nephritis. Indian J Nephrol 2020; 30:377-381. [PMID: 33840956 PMCID: PMC8023033 DOI: 10.4103/ijn.ijn_166_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 09/05/2019] [Accepted: 09/16/2019] [Indexed: 11/30/2022] Open
Abstract
Background: Repeat renal biopsy is usually done for lupus nephritis (LN) flare or resistant disease. We analyzed the changes between first and repeat biopsy and the contribution of repeat biopsy on renal outcome in LN patients. Methods: This was a retrospective study carried out at a tertiary care center in India. Sixty-two LN patients who underwent repeat biopsy for clinical indications, between January 2012 to December 2016, were included. Clinical and histological parameters at first and second biopsies were compared. Logistic regression analysis was done to determine parameters on repeat biopsy predicting response at last visit. Results: Repeat biopsy was done for relapse in 56% and for resistant disease in 44% patients. Seven (13.7%) out of 51 patients with baseline proliferative histology converted to non-proliferative lesion on second biopsy, while 2 (18.2%) out of 11 with baseline non-proliferative lesion converted to proliferative lesion on second biopsy. On repeat biopsy, the presence of endocapillary proliferation decreased, whereas glomerulosclerosis, interstitial fibrosis/tubular atrophy (IFTA), and glomerular basement membrane thickening increased. At the last visit (median follow-up of 38.6 months after first biopsy and 13.8 months after second biopsy), 79% of patients were in remission and 6.5% needed renal replacement therapy. The presence of IFTA >30% and thrombotic microangiopathy (TMA) on second biopsy independently predicted response at last visit. Conclusion: In Indian patients with LN, chronicity markers and superimposed membranous pattern increased on repeat biopsy done for clinical indications. The presence of IFTA and TMA on second biopsy predicted response at last visit.
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Affiliation(s)
| | | | | | | | - Manish Rathi
- Department of Nephrology, PGIMER, Chandigarh, India
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13
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Ayoub I, Cassol C, Almaani S, Rovin B, Parikh SV. The Kidney Biopsy in Systemic Lupus Erythematosus: A View of the Past and a Vision of the Future. Adv Chronic Kidney Dis 2019; 26:360-368. [PMID: 31733720 DOI: 10.1053/j.ackd.2019.08.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/22/2019] [Accepted: 08/20/2019] [Indexed: 12/12/2022]
Abstract
The kidney biopsy advanced our understanding of kidney disease in systemic lupus erythematosus. It allowed for better recognition and classification of lupus nephritis (LN). Several LN classifications have been devised in an effort to inform treatment decision and predict prognosis, and these are being further updated. In this review, we will examine the role of diagnostic as well as repeat kidney biopsy in the management of LN, including the potential role of molecular interrogation as a step forward beyond conventional histology to guide the discovery of novel biomarkers and a precision medicine approach to the management of LN.
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14
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Almaani S, Parikh SV. Membranous Lupus Nephritis: A Clinical Review. Adv Chronic Kidney Dis 2019; 26:393-403. [PMID: 31733724 DOI: 10.1053/j.ackd.2019.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 07/01/2019] [Accepted: 08/19/2019] [Indexed: 01/09/2023]
Abstract
Membranous lupus nephritis (MLN) (Class V lupus nephritis [LN]) is a distinct form of LN defined by the presence of subepithelial immune complex deposits seen on kidney biopsy. MLN is often associated with the nephrotic syndrome. The histology of MLN closely resembles that of idiopathic (primary) membranous nephropathy (pMN). However, MLN typically has abundant mesangial deposits that are absent in primary membranous nephropathy. The clinical presentation, management, and prognosis of MLN differ from that of the proliferative forms of LN (Class III, IV, or Mixed III/IV + V). Although immunosuppressive therapy is often warranted in MLN, the optimal treatment regimen remains unclear. Here we describe the clinical presentation, histologic features, and natural history of MLN. We also review the role of supportive treatment and discuss when to deploy immunosuppressive management in MLN.
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15
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Pakozdi A, Pyne D, Sheaff M, Rajakariar R. Utility of a repeat renal biopsy in lupus nephritis: a single centre experience. Nephrol Dial Transplant 2019; 33:507-513. [PMID: 28444337 DOI: 10.1093/ndt/gfx019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 01/24/2017] [Indexed: 11/15/2022] Open
Abstract
Background The role of repeat renal biopsy in lupus nephritis (LN) to guide treatment or predict prognosis has been controversial. We assessed glomerular and tubulointerstitial histological characteristics of serial renal biopsies, correlations with clinical variables and the impact on subsequent management. Methods Out of a large single-centre cohort of 270 biopsy-proven LN patients, 66 (24%) had serial biopsies. LN classes based on glomerular pathology were defined according to the International Society of Nephrology/Renal Pathology Society 2003 classification, while tubulointerstitial pathologies were evaluated using the revised Austin's semi-quantitative scoring system. Results LN class transitions from proliferative (III and IV) to non-proliferative classes (II and V) were uncommon (n = 4, 7.7%), while non-proliferatives frequently switched to proliferative classes (n = 12, 63.2%) and were more likely to receive increased immunosuppression (P = 0.040). Biochemical or serological variables could not predict these histopathological transitions. Tubulointerstitial score (mean ± standard deviation) progressed from 2.69 ± 2.03 on reference to 3.78 ± 2.03 on repeat biopsy (P = 0.001). Serum creatinine levels correlated with the degree of tubular atrophy on both reference (r = 0.33, P = 0.048) and repeat biopsy (r = 0.56, P < 0.001), and with interstitial scarring (r = 0.60, P < 0.001) on repeat biopsy. Greater interstitial inflammation on reference biopsy was associated with advanced interstitial scarring on repeat biopsies (r = 0.385, P = 0.009). Conclusions Repeat renal biopsy is an important tool to guide management, in particular in those with initial class II or V who flare. Although class transitions cannot be predicted by clinical parameters, serum creatinine level correlates with the degree of tubulointerstitial damage.
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Affiliation(s)
- Angela Pakozdi
- Department of Rheumatology, Barts Health NHS Trust, London, UK
| | - Debasish Pyne
- Department of Rheumatology, Barts Health NHS Trust, London, UK
| | - Michael Sheaff
- Department of Histopathology, Barts Health NHS Trust, London, UK
| | - Ravindra Rajakariar
- Department of Nephrology, Barts Health NHS Trust, Whitechapel Road, London, UK
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16
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Smith EMD, Eleuteri A, Goilav B, Lewandowski L, Phuti A, Rubinstein T, Wahezi D, Jones CA, Marks SD, Corkhill R, Pilkington C, Tullus K, Putterman C, Scott C, Fisher AC, Beresford MW. A Markov Multi-State model of lupus nephritis urine biomarker panel dynamics in children: Predicting changes in disease activity. Clin Immunol 2018; 198:71-78. [PMID: 30391651 DOI: 10.1016/j.clim.2018.10.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 09/28/2018] [Accepted: 10/31/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND A urine 'biomarker panel' comprising alpha-1-acid-glycoprotein, ceruloplasmin, transferrin and lipocalin-like-prostaglandin-D synthase performs to an 'excellent' level for lupus nephritis identification in children cross-sectionally. The aim of this study was to assess if this biomarker panel predicts lupus nephritis flare/remission longitudinally. METHODS The novel urinary biomarker panel was quantified by enzyme linked immunoabsorbant assay in participants of the United Kingdom Juvenile Systemic Lupus Erythematosus (UK JSLE) Cohort Study, the Einstein Lupus Cohort, and the South African Paediatric Lupus Cohort. Monocyte chemoattractant protein-1 and vascular cell adhesion molecule-1 were also quantified in view of evidence from other longitudinal studies. Serial urine samples were collected during routine care with detailed clinical and demographic data. A Markov Multi-State model of state transitions was fitted, with predictive clinical/biomarker factors assessed by a corrected Akaike Information Criterion (AICc) score (the better the model, the lower the AICc score). RESULTS The study included 184 longitudinal observations from 80 patients. The homogeneous multi-state Markov model of lupus nephritis activity AICc score was 147.85. Alpha-1-acid-glycoprotein and ceruloplasmin were identified to be the best predictive factors, reducing the AICc score to 139.81 and 141.40 respectively. Ceruloplasmin was associated with the active-to-inactive transition (hazard ratio 0.60 (95% confidence interval [0.39, 0.93])), and alpha-1-acid-glycoprotein with the inactive-to-active transition (hazard ratio 1.49 (95% confidence interval [1.10, 2.02])). Inputting individual alpha-1-acid-glycoprotein/ceruloplasmin values provides 3, 6 and 12 months probabilities of state transition. CONCLUSIONS Alpha-1-acid-glycoprotein was predictive of active lupus nephritis flare, whereas ceruloplasmin was predictive of remission. The Markov state-space model warrants testing in a prospective clinical trial of lupus nephritis biomarker led monitoring.
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Affiliation(s)
- E M D Smith
- Department of Women's & Children's Health, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - A Eleuteri
- Medical Physics and Clinical Engineering, and Department of Physics, University of Liverpool, Liverpool, UK.
| | - B Goilav
- Department of Paediatric Nephrology, Albert Einstein College of Medicine, New York, USA.
| | | | - A Phuti
- Paediatric Rheumatology, University of Cape Town, Cape Town, South Africa.
| | - T Rubinstein
- Department of Paediatric Rheumatology, Albert Einstein College of Medicine, New York, USA.
| | - D Wahezi
- Department of Paediatric Rheumatology, Albert Einstein College of Medicine, New York, USA.
| | - C A Jones
- Department of Paediatric Nephrology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
| | - S D Marks
- Paediatric Nephrology, Great Ormond Street Hospital, London, UK.
| | - R Corkhill
- Department of Women's & Children's Health, University of Liverpool, Liverpool, UK.
| | - C Pilkington
- Paediatric Rheumatology, Great Ormond Street Hospital, London, UK.
| | - K Tullus
- Paediatric Nephrology, Great Ormond Street Hospital, London, UK.
| | - C Putterman
- Department of Rheumatology, Albert Einstein College of Medicine, New York, USA.
| | - C Scott
- Paediatric Rheumatology, University of Cape Town, Cape Town, South Africa.
| | - A C Fisher
- Medical Physics and Clinical Engineering, and Department of Physics, University of Liverpool, Liverpool, UK.
| | - M W Beresford
- Department of Women's & Children's Health, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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17
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Smith EMD, Lewandowski LB, Jorgensen AL, Phuti A, Nourse P, Scott C, Beresford MW. Growing international evidence for urinary biomarker panels identifying lupus nephritis in children - verification within the South African Paediatric Lupus Cohort. Lupus 2018; 27:2190-2199. [PMID: 30348048 DOI: 10.1177/0961203318808376] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND A urinary biomarker panel including alpha-1-acid-glycoprotein (AGP), lipocalin-like-prostaglandin-D-synthase (LPGDS), transferrin and ceruloplasmin demonstrates an 'excellent' ability for identifying active lupus nephritis in UK/US children. This study aimed to assess whether this panel identifies active lupus nephritis within the South African Paediatric Lupus Cohort. METHODS Juvenile-onset-systemic lupus erythematosus (JSLE) patients aged < 19 years at diagnosis and healthy controls were recruited. Patients were categorized as having active lupus nephritis (renal BILAG score; A/B and previous histological confirmation) or inactive lupus nephritis (renal BILAG score: D/E). Urinary biomarkers were quantified by ELISA. Mann-Whitney U-test compared biomarker levels between groups. Binary logistic regression and receiver operating curve analysis assessed biomarker combinations. RESULTS Twenty-three juvenile-onset-systemic lupus erythematosus patients were recruited with a median age of 13.5 years (interquartile range (IQR) 12.7-14.9) and disease duration of 2.6 years (IQR 1.8-4.0). Eighteen healthy controls had a median age of 11.0 years (IQR 10.0-12.0). AGP, LPGDS, transferrin, ceruloplasmin and VCAM-1 were significantly higher in active than in inactive lupus nephritis patients (corrected p-values, all pc < 0.05), with no difference between inactive lupus nephritis patients and healthy controls (all pc = 1.0). The optimal biomarker combination included AGP, ceruloplasmin, LPGDS and transferrin (area under the curve = 1.0). CONCLUSIONS A urinary biomarker panel comprising AGP, ceruloplasmin, LPGDS and transferrin previously validated within UK/US cohorts also performed excellently within a racially distinct South African cohort which displayed more severe lupus nephritis.
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Affiliation(s)
- E M D Smith
- 1 Department of Women's & Children's Health, University of Liverpool, UK.,2 Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - L B Lewandowski
- 3 Intramural Research Program, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, USA
| | - A L Jorgensen
- 4 Department of Biostatistics, University of Liverpool, UK
| | - A Phuti
- 5 Paediatric Rheumatology, University of Cape Town, South Africa
| | - P Nourse
- 6 Paediatric Nephrology, University of Cape Town, South Africa
| | - C Scott
- 5 Paediatric Rheumatology, University of Cape Town, South Africa
| | - M W Beresford
- 1 Department of Women's & Children's Health, University of Liverpool, UK.,2 Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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18
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Abstract
Most of the attention paid to lupus nephritis, in the medical literature and in clinical trials, has primarily focused on proliferative forms of lupus nephritis (class III and IV lesions), but with lower thresholds to biopsy and rebiopsy patients with lupus, clinicians are encountering more cases with purely mesangial disease (class I and II) or membranous nephropathy patterns (class V). These lesions often will be associated with milder disease courses but still require dedicated follow-up by a nephrologist and focused therapeutic strategies that, at times, will include immunosuppression.
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Affiliation(s)
- Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University College of Physicians and Surgeons, 622 West 168th Street, PH 4-124, New York, NY 10032, USA.
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19
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Wu CY, Yang HY, Chien HP, Tseng MH, Huang JL. Urinary clusterin-a novel urinary biomarker associated with pediatric lupus renal histopathologic features and renal survival. Pediatr Nephrol 2018; 33:1189-1198. [PMID: 29511890 DOI: 10.1007/s00467-018-3924-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Lupus nephritis (LN) is a major risk factor for systemic lupus erythematous (SLE)-related morbidity and mortality. With the aim of bypassing renal biopsy, we analyzed urinary biomarkers for their ability to predict renal histopathologic features and end-stage kidney disease (ESKD). METHODS Urinary albumin, ß2-microglobulin (B2M), cystatin C, kidney injury molecule-1 (KIM-1), monocyte chemoattractant protein 1 (MCP-1), clusterin, calbindin, interleukin-18 (IL-18), neutrophil gelatinase-associated lipocalin (NGAL), trefoil factor 3 (TFF3), osteopontin, and glutathione S-transferase π (GST-π) levels were measured at time of renal biopsy. Renal histopathologies were carefully reviewed. RESULTS Urine from 60 pediatric SLE cases with LN, 29 without and 22 healthy controls were collected. Median age at SLE diagnosis was 12.92 years (range = 4.27-17.30 years) and 10 cases progressed to ESKD during a period of 4.12 ± 2.17 years. Urinary albumin and clusterin were significantly elevated (p = 0.035 and 0.048, respectively) in patients with tubulointerstitial renal lesions. Urinary clusterin among all urinary markers, performed best at predicting ESKD with cutoff of 0.61 × 10-4 (AUC = 0.804; p = 0.002). Interestingly, elevation of urinary clusterin likely resulted from local over-expression in tubulointerstitial tissue since the level of serum clusterin was not concomitantly higher (p = 0.424). CONCLUSION Urinary biomarkers are emerging as non-invasive indicators for lupus-related renal histopathology and renal outcome prediction in pediatric SLE patients. Urinary clusterin, a newly identified biomarker, is an indicator that shows an association with tubulointerstitial renal lesions and demonstrates the best ability to predict ESKD.
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Affiliation(s)
- Chao-Yi Wu
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital Linko branch, Taoyuan, Taiwan.,Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Huang-Yu Yang
- Chang Gung University, College of Medicine, Taoyuan, Taiwan.,Department of Nephrology, Chang Gung Memorial Hospital Linko branch, Taoyuan, Taiwan
| | - Hui-Ping Chien
- Chang Gung University, College of Medicine, Taoyuan, Taiwan.,Department of Pathology, Chang Gung Memorial Hospital Linko branch, Taoyuan, Taiwan
| | - Min-Hua Tseng
- Chang Gung University, College of Medicine, Taoyuan, Taiwan.,Division of Pediatric Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital Linko branch, Taoyuan, Taiwan
| | - Jing-Long Huang
- Division of Allergy, Asthma, and Rheumatology, Department of Pediatrics, Chang Gung Memorial Hospital Linko branch, Taoyuan, Taiwan. .,Chang Gung University, College of Medicine, Taoyuan, Taiwan.
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20
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Smith EMD, Yin P, Jorgensen AL, Beresford MW. Clinical predictors of proteinuric remission following an LN flare - evidence from the UK JSLE cohort study. Pediatr Rheumatol Online J 2018; 16:14. [PMID: 29467038 PMCID: PMC5822554 DOI: 10.1186/s12969-018-0230-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 02/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Proteinuria is a well-known risk factor for progression of renal dysfunction in a variety of chronic kidney diseases. In adult-onset Systemic Lupus Erytematosus (SLE) patients with lupus nephritis (LN), proteinuria takes a significant period of time to normalise, with proteinuric remission being associated with improved renal survival and reductions in mortality. The length of time required to attain proteinuric remission has not previously been investigated in Juvenile-onset SLE (JSLE). The aim of this study was to elucidate when proteinuric remission occurs, and whether clinical/demographic factors at LN onset bear influence on the time to proteinuric remission. METHODS Participants of the UK JSLE Cohort Study and Repository were included if they had active LN (renal biopsy and/or renal British Isles Lupus Assessment Grade (BILAG) score defined active LN) and proteinuria. Univariate Cox proportional hazard regression modelling was used to explore factors associated with time to proteinuric recovery. Covariates with p-value < 0.2 were included in a multivariable Cox regression model, and backward stepwise variable selection applied. RESULT 64/350 (18%) of UK JSLE Cohort Study patients fulfilled the study inclusion criteria. 25 (39%) achieved proteinuric remission within a median of 17 months (min 2.4, max 78). Within a multivariate Cox proportional hazard regression model, age at time of LN flare (p = 0.007, HR 1.384, CI 1.095-1.750), eGFR (p = 0.035, HR 1.016, CI 1.001-1.030) and haematological involvement (p = 0.016, HR 0.324, CI 0.129-0.812) at the time of LN onset were found to be significantly associated with time to proteinuric recovery. CONCLUSIONS A significant proportion of children with LN have on-going proteinuria approximately two years after their initial flare. Poor prognostic factors all at time of LN onset include younger age, low eGFR, and concomitant haematological involvement.
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Affiliation(s)
- Eve M. D. Smith
- 0000 0004 1936 8470grid.10025.36Department of Women’s & Children’s Health, University of Liverpool, Institute In The Park, Alder Hey Children’s Hospital, East Prescott Road, Liverpool, L14 5AB UK ,0000 0004 0421 1374grid.417858.7Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Peng Yin
- 0000 0001 0483 7922grid.458489.cResearch Center for Biomedical Information Technology, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Andrea L. Jorgensen
- 0000 0004 1936 8470grid.10025.36Department of Biostatistics, Block F, Waterhouse Building, University of Liverpool, Liverpool, UK
| | - Michael W. Beresford
- 0000 0004 1936 8470grid.10025.36Department of Women’s & Children’s Health, University of Liverpool, Institute In The Park, Alder Hey Children’s Hospital, East Prescott Road, Liverpool, L14 5AB UK ,0000 0004 0421 1374grid.417858.7Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
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21
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Shi H, Jia J, Li D, Wei L, Shang W, Zheng Z. Blood oxygen level dependent magnetic resonance imaging for detecting pathological patterns in lupus nephritis patients: a preliminary study using a decision tree model. BMC Nephrol 2018; 19:33. [PMID: 29426280 PMCID: PMC5806290 DOI: 10.1186/s12882-017-0787-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 12/11/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Precise renal histopathological diagnosis will guide therapy strategy in patients with lupus nephritis. Blood oxygen level dependent (BOLD) magnetic resonance imaging (MRI) has been applicable noninvasive technique in renal disease. This current study was performed to explore whether BOLD MRI could contribute to diagnose renal pathological pattern. METHODS Adult patients with lupus nephritis renal pathological diagnosis were recruited for this study. Renal biopsy tissues were assessed based on the lupus nephritis ISN/RPS 2003 classification. The Blood oxygen level dependent magnetic resonance imaging (BOLD-MRI) was used to obtain functional magnetic resonance parameter, R2* values. Several functions of R2* values were calculated and used to construct algorithmic models for renal pathological patterns. In addition, the algorithmic models were compared as to their diagnostic capability. RESULTS Both Histopathology and BOLD MRI were used to examine a total of twelve patients. Renal pathological patterns included five classes III (including 3 as class III + V) and seven classes IV (including 4 as class IV + V). Three algorithmic models, including decision tree, line discriminant, and logistic regression, were constructed to distinguish the renal pathological pattern of class III and class IV. The sensitivity of the decision tree model was better than that of the line discriminant model (71.87% vs 59.48%, P < 0.001) and inferior to that of the Logistic regression model (71.87% vs 78.71%, P < 0.001). The specificity of decision tree model was equivalent to that of the line discriminant model (63.87% vs 63.73%, P = 0.939) and higher than that of the logistic regression model (63.87% vs 38.0%, P < 0.001). The Area under the ROC curve (AUROCC) of the decision tree model was greater than that of the line discriminant model (0.765 vs 0.629, P < 0.001) and logistic regression model (0.765 vs 0.662, P < 0.001). CONCLUSIONS BOLD MRI is a useful non-invasive imaging technique for the evaluation of lupus nephritis. Decision tree models constructed using functions of R2* values may facilitate the prediction of renal pathological patterns.
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Affiliation(s)
- Huilan Shi
- Department of Radiology, Tianjin Medical University General Hospital, No.154, Anshan Road, Heping District, Tianjin, People's Republic of China
| | - Junya Jia
- Department of Nephrology, Tianjin Medical University General Hospital, No.154, Anshan Road, Heping District, Tianjin, People's Republic of China
| | - Dong Li
- Department of Nephrology, Tianjin Medical University General Hospital, No.154, Anshan Road, Heping District, Tianjin, People's Republic of China
| | - Li Wei
- Department of Nephrology, Tianjin Medical University General Hospital, No.154, Anshan Road, Heping District, Tianjin, People's Republic of China
| | - Wenya Shang
- Department of Nephrology, Tianjin Medical University General Hospital, No.154, Anshan Road, Heping District, Tianjin, People's Republic of China
| | - Zhenfeng Zheng
- Department of Nephrology, Tianjin Medical University General Hospital, No.154, Anshan Road, Heping District, Tianjin, People's Republic of China.
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22
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Bennett MR, Ma Q, Ying J, Devarajan P, Brunner H. Effects of age and gender on reference levels of biomarkers comprising the pediatric Renal Activity Index for Lupus Nephritis (p-RAIL). Pediatr Rheumatol Online J 2017; 15:74. [PMID: 29029629 PMCID: PMC5640910 DOI: 10.1186/s12969-017-0202-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/05/2017] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disease that disproportionately effects women and children of minorities. Renal involvement (lupus nephritis, or LN) occurs in up to 80% of children with SLE and is a major determinant of poor prognosis. We have developed a non-invasive pediatric Renal Activity Index for Lupus (p-RAIL) that consists of laboratory measures that reflect histologic LN activity. These markers are neutrophil gelatinase associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), monocyte chemotactic protein (MCP-1), adiponectin (APN), ceruloplasmin (CP) and hemopexin (HPX). A major gap in the knowledge base and a barrier to clinical utility is how these markers behave in healthy children. We set out to establish a reference range for the p-RAIL markers in a population of healthy children, and to determine if levels of these markers fluctuate with age or gender. METHODS Urine was collected from 368 healthy children presenting to Cincinnati Children's primary care clinic for well child visits and assayed for NGAL, KIM-1, MCP-1, APN, CP and HPX using commercially available kits or assay materials. RESULTS Specimens were grouped by age (0-5 years (n = 94); 5-10 (n = 89); 10-15 (n = 93); 15-20 (n = 91)) and gender (M = 184, F = 184). For age and gender comparisons, values were log transformed prior to analysis. The medians (minimums, maximums) of each marker in the combined population were as follows: NGAL 6.65 (0.004, 391.52) ng/ml, KIM-1416.84 (6.22, 2512.43) pg/ml, MCP-1209.36 (9.49, 2237.06) pg/ml, APN 8.05 (0.07, 124.50) ng/ml, CP 465.15 (8.02, 7827.00) ng/ml, HPX 588.70 (6.85, 17,658.40)ng/ml. All p-RAIL biomarkers but adiponectin had weak but significant positive correlations with age, with NGAL being the strongest (r = 0.33, p < 0.001). For gender comparisons, NGAL, CP and HPX were elevated in females vs males (86%, p < 0.0001; 3%, p = 0.007, and 5%, p = 0.0005 elevation of the log transformed mean, respectively). CONCLUSIONS We have established a reference range for the p-RAIL biomarkers and have highlighted age and gender differences. This information is essential for rational interpretation of studies and clinical trials utilizing the p-RAIL algorithm.
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Affiliation(s)
- Michael R. Bennett
- 0000 0000 9025 8099grid.239573.9Division Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Qing Ma
- 0000 0000 9025 8099grid.239573.9Division Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Jun Ying
- 0000 0001 2179 9593grid.24827.3bEnvironmental Health, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Prasad Devarajan
- 0000 0000 9025 8099grid.239573.9Division Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Hermine Brunner
- 0000 0000 9025 8099grid.239573.9Rheumatology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
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23
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Tannor EK, Bates WD, Moosa MR. The clinical relevance of repeat renal biopsies in the management of lupus nephritis: a South African experience. Lupus 2017; 27:525-535. [PMID: 28820361 DOI: 10.1177/0961203317726864] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Purpose Clinically, repeat renal biopsies (RRBs) have been performed in lupus nephritis to identify changes in class, plan treatment and assist in prognostication. We set out to compare the histopathological features and outcomes of disease flare and protocol biopsy patients. Methods A retrospective descriptive study was conducted on repeat biopsies performed between January 1984 and December 2015 in lupus nephritis patients. Disease flares and protocol biopsies were compared. Results Of 614 systemic lupus erythematosus (SLE) renal biopsies, 127 (20.7%) RRBs were identified. Disease flare patients accounted for 96 (75.6%) and protocol biopsies for 31 (24.4%) of RRBs. Seventy (72.9%) disease flare patients retained their original class on repeat biopsy. When categorised as proliferative and non-proliferative histology, 83 (87.4%) of the disease flare biopsy patients remained histologically unchanged. Treatment remained unchanged in 57 (60.0%) patients following RRBs for disease flares. Response to immunosuppression in disease flare patients was poorer. Non-response was associated with increased chronicity index (OR = 1.33; 95% CI 1.01-1.76; p = 0.045). Thirty-three (36.3%) disease flare patients developed end-stage kidney disease (ESKD) in one year as compared to one (3.6%) protocol biopsy patient ( p = 0.003). ESKD in disease flare patients was associated with non-response to treatment (OR = 24.6; 95% CI 2.7-219.3; p = 0.004) on multivariate analysis. One-year mortality was 30.0% in the disease flare patients and 3.5% in protocol biopsy patients ( p = 0.018). Conclusion Repeat biopsies in disease flare patients infrequently led to histological class changes, failed to lead to change of treatment in the majority of patients, and were associated with poorer outcomes.
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Affiliation(s)
- E K Tannor
- 1 Division of Nephrology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa.,2 Renal Unit, Department of Medicine, 259295 Komfo Anokye Teaching Hospital , Kumasi, Ghana
| | - W D Bates
- 3 Division of Anatomical Pathology, Stellenbosch University, Tygerberg Academic Hospital and National Health Laboratory Service (NHLS), Cape Town, South Africa
| | - M R Moosa
- 1 Division of Nephrology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
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24
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Narváez J, Ricse M, Gomà M, Mitjavila F, Fulladosa X, Capdevila O, Torras J, Juanola X, Pujol-Farriols R, Nolla JM. The value of repeat biopsy in lupus nephritis flares. Medicine (Baltimore) 2017; 96:e7099. [PMID: 28614228 PMCID: PMC5478313 DOI: 10.1097/md.0000000000007099] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Whether a repeat renal biopsy is helpful during lupus nephritis (LN) flares remains debatable. In order to analyze the clinical utility of repeat renal biopsy in this complex situation, we retrospectively reviewed our series of 54 LN patients who had one or more repeat biopsies performed only on clinical indications. Additionally, we reviewed 686 well-documented similar cases previously reported (PubMed 1990-2015).The analysis of all patients reviewed showed that histological transformations are common during a LN flare, ranging from 40% to 76% of cases. However, the prevalence of transformations and the clinical value of repeat biopsy vary when they are analyzed according to proliferative or nonproliferative lesions.The great majority of patients with class II (78% in our series and 77.5% in the literature review) progressed to a higher grade of nephritis (classes III, IV, or V), resulting in worse renal prognosis. The frequency of pathological conversion in class V is lower (33% and 43%, respectively) but equally clinically relevant, since almost all cases switched to a proliferative class. Therefore, repeat biopsy is highly advisable in patients with nonproliferative LN at baseline biopsy, because these patients have a reasonable likelihood of switch to a proliferative LN that may require more aggressive immunosuppression.In contrast, the majority of patients (82% and 73%) with proliferative classes in the reference biopsy (III, IV or mixed III/IV + V), remained into proliferative classes on repeat biopsy. Although rebiopsy in this group does not seem as necessary, it is still advisable since it will allow us to identify the 18% to 20% of patients that switch to a nonproliferative class. In addition, consistent with the reported clinical experience, repeat biopsy might also be helpful to identify selected cases with clear progression of proliferative lesions despite the initial treatment, for whom it is advisable to intensify inmunosuppression. Thus, our experience and the literature data support that repeat biopsy also brings more advantges than threats in this group.The results of the repeat biopsy led to a change in the immunosuppresive treatment in more than half of the patients on average, intensifying it in the majority of the cases, but also reducing it in 5% to 30%.
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Affiliation(s)
| | | | | | | | - Xavier Fulladosa
- Department of Nephrology, Unitat Funcional de Malalties Autoinmunes Sistèmiques (UFMAS), Hospital Universitari de Bellvitge—IDIBELL, Barcelona, Spain
| | | | - Joan Torras
- Department of Nephrology, Unitat Funcional de Malalties Autoinmunes Sistèmiques (UFMAS), Hospital Universitari de Bellvitge—IDIBELL, Barcelona, Spain
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25
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Abstract
SLE is a chronic inflammatory disease that affects the kidneys in about 50% of patients. Lupus nephritis is a major risk factor for overall morbidity and mortality in SLE, and despite potent anti-inflammatory and immunosuppressive therapies still ends in CKD or ESRD for too many patients. This review highlights recent updates in our understanding of disease epidemiology, genetics, pathogenesis, and treatment in an effort to establish a framework for lupus nephritis management that is patient-specific and oriented toward maintaining long-term kidney function in patients with lupus.
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Affiliation(s)
- Salem Almaani
- Department of Internal Medicine, The Ohio State Wexner Medical Center, Columbus, Ohio
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26
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Noto R, Kamiura N, Ono Y, Tabata S, Hara S, Yokoi H, Yoshimoto A, Yanagita M. Successful treatment with bortezomib and dexamethasone for proliferative glomerulonephritis with monoclonal IgG deposits in multiple myeloma: a case report. BMC Nephrol 2017; 18:127. [PMID: 28385149 PMCID: PMC5382661 DOI: 10.1186/s12882-017-0524-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 03/23/2017] [Indexed: 02/07/2023] Open
Abstract
Background Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) is a form of renal involvement by monoclonal IgG deposits that was found in mesangial, subendothelial or subepithelial regions. The distribution of glomerular deposits was completely different from that in monoclonal immunoglobulin deposition disease. PGNMID is reported to be rarely associated with a hematological malignancy. Previously, only five cases of PGNMID with multiple myeloma have been reported. However, the pathogenic relationship between PGNMID and multiple myeloma was unclear because a detailed description was not provided. We report that a patient with PGNMID associated with multiple myeloma was treated with bortezomib and dexamethasone and underwent the second renal biopsy after treatment, showing that chemotherapy was effective for PGNMID clinically and pathologically. Case presentation A 75-year-old man presented with progressive leg edema, had nephrotic range proteinuria, hypoalbuminemia, moderate renal failure, and occult blood in his urine. Electrophoresis results showed serum and urinary monoclonal spikes of IgGκ type immunoglobulin. A renal biopsy specimen showed lobular mesangial proliferation with mesangiolysis, glomerular micro-aneurysm, and endocapillary hypercellularity. Immunofluorescence results revealed strong granular capillary and mesangial staining for IgG1, C3 and κ light chain in glomeruli without tubular deposits of any immunoglobulin. Electron microscopy also showed dense granular deposits in subendothelial and mesangial areas. PGNMID associated with multiple myeloma (IgGκ type) was diagnosed on the basis of a subsequent bone marrow examination. Bortezomib and dexamethasone therapy significantly reduced proteinuria and elevated serum albumin level. Eight months later, the second renal biopsy showed no active lesions and that the IgG1 and κ light chain deposits had drastically disappeared. Conclusions This is the first case of PGNMID with multiple myeloma successfully treated with bortezomib and dexamethasone in which comparative renal biopsies were performed before and after treatment. Our findings suggest the pathogenesis of PGNMID and therapeutic options for PGNMID.
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Affiliation(s)
- Rio Noto
- Department of Clinical Nephrology, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminamimachi, Chuo-ku, Kobe-city, Hyogo, 650-0047, Japan
| | - Nozomu Kamiura
- Department of Clinical Nephrology, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminamimachi, Chuo-ku, Kobe-city, Hyogo, 650-0047, Japan
| | - Yuichiro Ono
- Department of Clinical Hematology, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Sumie Tabata
- Department of Clinical Hematology, Kobe City Medical Center General Hospital, Hyogo, Japan
| | - Shigeo Hara
- Department of Diagnostic Pathology, Kobe University Hospital, Hyogo, Japan
| | - Hideki Yokoi
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Akihiro Yoshimoto
- Department of Clinical Nephrology, Kobe City Medical Center General Hospital, 2-1-1, Minatojimaminamimachi, Chuo-ku, Kobe-city, Hyogo, 650-0047, Japan.
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
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27
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Kajawo S, Botha FCJ, Okpechi IG. Clinico-pathological features of repeat renal biopsies in patients with lupus nephritis at Groote Schuur Hospital, Cape Town. Lupus 2017; 26:1339-1346. [DOI: 10.1177/0961203317695466] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Repeat renal biopsies in patients with lupus nephritis are usually done to guide treatment or to establish disease chronicity. Their value is not clear from available literature. There are also no available data in Africa to guide clinicians. Methods This was a retrospective study of patients undergoing a repeat renal biopsy between January 2003 and December 2014 from a single centre in Cape Town, South Africa. Relevant demographic, clinical and histological records of patients with repeat renal biopsies were documented. Comparison of data from first and second renal biopsy was performed. Results Forty-four patients had at least two biopsies done during the study period. Most patients were females (81.8%). The mean biopsy interval was 2.8 ± 1.8 (range 0.38–9.4) years. Proteinuria was the main indication for the repeat biopsy (36.1%). The glomerular filtration rate and proteinuria worsened between the two biopsies ( p = 0.001 and 0.019, respectively) suggesting disease progression. Most patients (65.4%) with a non-proliferative class of lupus nephritis at first biopsy progressed into a proliferative class, whereas patients with initial proliferative lupus nephritis at first biopsy (77.8%) remained as proliferative at repeat biopsy. Treatment was changed in 85% of patients at second biopsy. Conclusion Repeat renal biopsies in patients with lupus nephritis presents a useful means of assessing disease progression and provides guidance regarding modification of treatment. More studies are, however, required to evaluate the value of repeat biopsies and perhaps the need for protocol renal biopsies in patients with lupus nephritis.
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Affiliation(s)
- S Kajawo
- Division of Nephrology and Hypertension, University of Cape Town, South Africa
- Division of Clinical Practice and Patient Care, National University of Science and Technology, Bulawayo, Zimbabwe
| | - F C J Botha
- Division of Anatomical Pathology, University of Cape Town; and National Health Laboratory Service, Groote Schuur Hospital, Cape Town, South Africa
| | - I G Okpechi
- Division of Nephrology and Hypertension, University of Cape Town, South Africa
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28
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Abstract
Since its incorporation into clinical practice in the 1950s, the percutaneous kidney biopsy has played an important role in advancing our understanding of lupus nephritis (LN). The biopsy findings have been used to classify and subgroup LN in order to obtain an accurate diagnosis and also to inform treatment decisions and predict prognosis. Several classifications schemes have been applied clinically however despite this evolution in histopathologic classification, our ability to predict treatment response and determine prognosis remains limited. In this review we will examine the evolving role of the kidney biopsy in the management of LN, including the potentially larger role the biopsy could play in the future.
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Affiliation(s)
- Samir V Parikh
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anthony Alvarado
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ana Malvar
- Nephrology Unit, Hospital Fernandez, Buenos Aires, Argentina
| | - Brad H Rovin
- Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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29
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Smith EMD, Beresford MW. Urinary biomarkers in childhood lupus nephritis. Clin Immunol 2016; 185:21-31. [PMID: 27373868 DOI: 10.1016/j.clim.2016.06.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 06/26/2016] [Accepted: 06/27/2016] [Indexed: 12/12/2022]
Abstract
Juvenile-onset systemic lupus erythematosus (JSLE) is a rare, severe multisystem autoimmune disease affecting the kidney (Lupus Nephritis, LN) in up to 80% of children. LN is more severe in children than adults, with potential for irreversible kidney damage requiring dialysis or transplant. Renal biopsy is currently the gold standard for diagnosing and monitoring LN, however, it is invasive and associated with complications. Urine biomarkers have been shown to be better than serum biomarkers in differentiating renal disease from other organ manifestations. Over the past decade, there have been an increasing number of studies investigating specific candidate biomarkers implicated in the pathogenesis of LN or screening for urinary biomarkers using hypothesis free methods. In this review, developments in urine biomarkers for LN will be reviewed, highlighting those that are of relevance to children and have gone through validation in independent international patient cohorts, bringing them close to clinical translation.
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Affiliation(s)
- Eve M D Smith
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Institute in the Park, Alder Hey Children's NHS Foundation Trust Hospital, East Prescott Road, Liverpool L14 5AB, UK.
| | - Michael W Beresford
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Institute in the Park, Alder Hey Children's NHS Foundation Trust Hospital, East Prescott Road, Liverpool L14 5AB, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust in the Park, East Prescott Road, Liverpool, L14 5AB, Liverpool, UK.
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30
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Moroni G, Depetri F, Ponticelli C. Lupus nephritis: When and how often to biopsy and what does it mean? J Autoimmun 2016; 74:27-40. [PMID: 27349351 DOI: 10.1016/j.jaut.2016.06.006] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 01/30/2023]
Abstract
Renal disease is a frequent complication of SLE which can lead to significant illness and even death. Today, a baseline renal biopsy is highly recommended for all subjects with evidence of lupus nephritis. Biopsy allows the clinician to recognize and classify different forms of autoimmune lupus glomerulonephritis, and to detect other glomerular diseases with variable pathogenesis which are not directly related to autoimmune reactivity, such as lupus podocytopathy. Moreover, not only glomerular diseases, but other severe forms of renal involvement, such as tubulo-interstitial nephritis or thrombotic microangiopathy may be detected by biopsy in lupus patients. Thus, an accurate definition of the nature and severity of renal involvement is mandatory to assess the possible risk of progression and to establish an appropriate treatment. The indications to repeat biopsy are more controversial. Some physicians recommend protocol biopsies to recognize the possible transformation from one class to another one, or to identify silent progression of renal disease, others feel that good clinical monitoring is sufficient to assess prognosis and to make therapeutic decisions. At any rate, although any decision should always be taken by considering the clinical conditions of the patient, there are no doubts that repeat renal biopsy may represent a useful tool in difficult cases to evaluate the response to therapy, to modulate the intensity of treatment, and to predict the long-term renal outcome both in quiescent lupus and in flares of activity.
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Affiliation(s)
- Gabriella Moroni
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milano, Italy.
| | - Federica Depetri
- Nephrology and Dialysis Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Della Commenda 15, 20122, Milano, Italy.
| | - Claudio Ponticelli
- Nephrology and Dialysis Unit, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, Milano, Italy.
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31
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Schober FP, Pendergraft WF. Dialogue: A blissful future for lupus nephritis: harnessing repeat kidney biopsies to identify meaningful biomarkers of disease. Lupus Sci Med 2015; 2:e000083. [PMID: 25866670 PMCID: PMC4386462 DOI: 10.1136/lupus-2015-000083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 03/05/2015] [Indexed: 01/20/2023]
Affiliation(s)
- Fernanda Payan Schober
- Division of Nephrology, Department of Medicine , University of North Carolina (UNC) Kidney Center , Chapel Hill, North Carolina , USA
| | - William F Pendergraft
- Division of Nephrology, Department of Medicine , University of North Carolina (UNC) Kidney Center , Chapel Hill, North Carolina , USA ; The Broad Institute of Harvard and MIT , Cambridge, Massachusetts , USA
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Varalaxmi B, Sandeep P, Sridhar AVSSN, Raveendra P, Kishore CK, Ram R, Kumar VS. Renal infarction due to lupus vasculopathy. Lupus 2015; 24:985-9. [PMID: 25661836 DOI: 10.1177/0961203315570684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 01/07/2015] [Indexed: 11/15/2022]
Abstract
In the ISN/RPS 2003 classification of lupus nephritis (LN) renal vascular lesions are not mentioned. We present a patient with postpartum lupus vasculopathy. The renal biopsy in our patient showed concentric intimal thickening with narrowed lumen. No inflammatory changes were found. It also revealed immunoglobulin and complement deposition on the wall of the arteriole. These changes indicate lupus vasculopathy. The glomeruli revealed diffuse proliferative glomerulonephritis, with wire loops and cellular crescent in one glomerulus. The patient showed improvement with immunosuppression.
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Affiliation(s)
| | | | | | | | | | - R Ram
- Nephrology, SVIMS, Tirupati, India
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Buyon J, van Vollenhoven R. Lupus Science and Medicine: the Editors present highlights for the bedside and for the bench in the inaugural issue. Lupus Sci Med 2014; 1:e000033. [PMID: 25379193 PMCID: PMC4213829 DOI: 10.1136/lupus-2014-000033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2014] [Indexed: 11/25/2022]
Affiliation(s)
- Jill Buyon
- NYU Langone Medical Center , New York, New York , USA
| | - Ronald van Vollenhoven
- Professor & Head of Unit for Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institute Stockholm, Sweden
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