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Hackl A, Zed SEDA, Diefenhardt P, Binz-Lotter J, Ehren R, Weber LT. The role of the immune system in idiopathic nephrotic syndrome. Mol Cell Pediatr 2021; 8:18. [PMID: 34792685 PMCID: PMC8600105 DOI: 10.1186/s40348-021-00128-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 11/09/2021] [Indexed: 12/12/2022] Open
Abstract
Idiopathic nephrotic syndrome (INS) in children is characterized by massive proteinuria and hypoalbuminemia and usually responds well to steroids. However, relapses are frequent, which can require multi-drug therapy with deleterious long-term side effects. In the last decades, different hypotheses on molecular mechanisms underlying INS have been proposed and several lines of evidences strongly indicate a crucial role of the immune system in the pathogenesis of non-genetic INS. INS is traditionally considered a T-cell-mediated disorder triggered by a circulating factor, which causes the impairment of the glomerular filtration barrier and subsequent proteinuria. Additionally, the imbalance between Th17/Tregs as well as Th2/Th1 has been implicated in the pathomechanism of INS. Interestingly, B-cells have gained attention, since rituximab, an anti-CD20 antibody demonstrated a good therapeutic response in the treatment of INS. Finally, recent findings indicate that even podocytes can act as antigen-presenting cells under inflammatory stimuli and play a direct role in activating cellular pathways that cause proteinuria. Even though our knowledge on the underlying mechanisms of INS is still incomplete, it became clear that instead of a traditionally implicated cell subset or one particular molecule as a causative factor for INS, a multi-step control system including soluble factors, immune cells, and podocytes is necessary to prevent the occurrence of INS. This present review aims to provide an overview of the current knowledge on this topic, since advances in our understanding of the immunopathogenesis of INS may help drive new tailored therapeutic approaches forward.
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Affiliation(s)
- Agnes Hackl
- Department of Pediatrics, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany. .,Department of Internal Medicine II and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.
| | - Seif El Din Abo Zed
- Department of Pediatrics, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany.,Department of Internal Medicine II and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Paul Diefenhardt
- Department of Internal Medicine II and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Julia Binz-Lotter
- Department of Internal Medicine II and Center for Molecular Medicine Cologne, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Rasmus Ehren
- Department of Pediatrics, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Lutz Thorsten Weber
- Department of Pediatrics, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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Trachtman H, Gipson DS, Somers M, Spino C, Adler S, Holzman L, Kopp JB, Sedor J, Overfield S, Elegbe A, Maldonado M, Greka A. Randomized Clinical Trial Design to Assess Abatacept in Resistant Nephrotic Syndrome. Kidney Int Rep 2017; 3:115-121. [PMID: 29340321 PMCID: PMC5762951 DOI: 10.1016/j.ekir.2017.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction Treatment-resistant nephrotic syndrome is a rare form of glomerular disease that occurs in children and adults. No Food and Drug Administration-approved treatments consistently achieve remission of proteinuria and preservation of kidney function. CD80 (B7-1) can be expressed on injured podocytes, and administration of abatacept (modified CTLA4-Ig based on a natural ligand to CD80) has been associated with sustained normalization of urinary protein excretion and maintenance of glomerular filtration rate in experimental and clinical settings. Methods In this report, we describe the rationale for and design of a randomized, placebo-controlled, clinical trial of abatacept in patients with treatment-resistant nephrotic syndrome caused by focal segmental glomerulosclerosis or minimal change disease. The design is a hybrid of a parallel-group and crossover design (switchover) with the primary objectives assessed in the first period of the study and the secondary objectives assessed using data from both periods. All participants will receive the active agent in 1 of the periods. The duration of treatment will be 4 months per period. Results The primary outcome will be improvement in nephrotic-range proteinuria to subnephrotic range, that is, reduction from baseline to 4 months in urine protein:creatinine ratio ≥ 50% and to a level < 3. The projected sample size is 90 patients, which has 80% power to detect a treatment difference of 28%. Conclusion This study advances efforts to validate CD80 as a therapeutic target for treatment-resistant nephrotic syndrome, and implements a precision medicine-based approach to this serious kidney condition in which the selection of a therapeutic agent is guided by the underlying disease mechanism operating in individual patients.
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Affiliation(s)
- Howard Trachtman
- Division of Nephrology, Department of Pediatrics, New York University Langone Medical Center, New York, New York, USA
| | - Debbie S. Gipson
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Somers
- Division of Nephrology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Sharon Adler
- Division of Nephrology and Hypertension, Harbor-University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Lawrence Holzman
- Department of Medicine, University of Pennsylvania Medical School, Philadelphia, Pennsylvania, USA
| | - Jeffrey B. Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - John Sedor
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | | | | | | | - Anna Greka
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, and Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts, USA
- Correspondence: Anna Greka, Brigham and Women’s Hospital, Harvard Medical School, Harvard Institutes of Medicine, 4 Blackfan Circle, Boston, Massachusetts 02115, USA; or The Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, Massachusetts 02142, USA.Brigham and Women’s HospitalHarvard Medical SchoolHarvard Institutes of Medicine, 4 Blackfan Circle, Boston, Massachusetts 02115, USA; or The Broad Institute of MIT and Harvard415 Main StreetCambridgeMassachusetts 02142USA
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Recent Treatment Advances and New Trials in Adult Nephrotic Syndrome. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7689254. [PMID: 28553650 PMCID: PMC5434278 DOI: 10.1155/2017/7689254] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/12/2017] [Indexed: 12/13/2022]
Abstract
The etiology of nephrotic syndrome is complex and ranges from primary glomerulonephritis to secondary forms. Patients with nephrotic syndrome often need immunosuppressive treatment with its side effects and may progress to end stage renal disease. This review focuses on recent advances in the treatment of primary causes of nephrotic syndrome (idiopathic membranous nephropathy (iMN), minimal change disease (MCD), and focal segmental glomerulosclerosis (FSGS)) since the publication of the KDIGO guidelines in 2012. Current treatment recommendations are mostly based on randomized controlled trials (RCTs) in children, small RCTs, or case series in adults. Recently, only a few new RCTs have been published, such as the Gemritux trial evaluating rituximab treatment versus supportive antiproteinuric and antihypertensive therapy in iMN. Many RCTs are ongoing for iMN, MCD, and FSGS that will provide further information on the effectiveness of different treatment options for the causative disease. In addition to reviewing recent clinical studies, we provide insight into potential new targets for the treatment of nephrotic syndrome from recent basic science publications.
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Kristensen T, Ivarsen P, Povlsen JV. Unsuccessful Treatment with Abatacept in Recurrent Focal Segmental Glomerulosclerosis after Kidney Transplantation. Case Rep Nephrol Dial 2017; 7:1-5. [PMID: 28203563 PMCID: PMC5301131 DOI: 10.1159/000454947] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/02/2016] [Indexed: 01/26/2023] Open
Abstract
Recurrence of focal segmental glomerulosclerosis (FSGS) after renal transplantation occurs in up to 20–50% of FSGS patients and is associated with inferior allograft survival. Treatment of both primary FSGS as well as recurrent FSGS after transplantation with plasma exchange and immunosuppression is often unsuccessful and remains a major challenge as the disease still leads to end-stage renal disease and decreased graft survival. Previous case reports have described patients with recurrent FSGS who were successfully treated with a B7-1 inhibitor (abatacept) inducing partial or complete remission. The rational basis for believing in abatacept as a new therapeutic drug for the treatment of FSGS is the study by Yu et al. [N Engl J Med 2013;369: 2416–2423] showing B7-1 in immunostainings of the podocytes. The authors speculated that B7-1 immunostaining of renal biopsies might identify a subgroup of patients who would benefit from abatacept treatment. We present a case with recurrent FSGS after renal transplantation. The patient was unsuccessfully treated with B7-1 inhibitors. Although the patient was treated with abatacept 10 mg/kg body weight twice, the proteinuria and decreased graft function remained unchanged, and he never reached remission.
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Affiliation(s)
- Tilde Kristensen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Per Ivarsen
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
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