1
|
Guo Q, Qiao P, Wang J, Zhao L, Guo Z, Li X, Fan X, Yu C, Zhang L. Investigating the value of urinary biomarkers in relation to lupus nephritis histopathology: present insights and future prospects. Front Pharmacol 2024; 15:1421657. [PMID: 39104393 PMCID: PMC11298450 DOI: 10.3389/fphar.2024.1421657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 07/02/2024] [Indexed: 08/07/2024] Open
Abstract
Lupus nephritis (LN), a leading cause of death in Systemic Lupus Erythematosus (SLE) patients, presents significant diagnostic and prognostic challenges. Although renal pathology offers critical insights regarding the diagnosis, classification, and therapy for LN, its clinical utility is constrained by the invasive nature and limited reproducibility of renal biopsies. Moreover, the continuous monitoring of renal pathological changes through repeated biopsies is impractical. Consequently, there is a growing interest in exploring urine as a non-invasive, easily accessible, and dynamic "liquid biopsy" alternative to guide clinical management. This paper examines novel urinary biomarkers from a renal pathology perspective, encompassing cellular components, cytokines, adhesion molecules, auto-antibodies, soluble leukocyte markers, light chain fragments, proteins, small-molecule peptides, metabolomics, urinary exosomes, and ribonucleic acids. We also discuss the application of combined models comprising multiple biomarkers in assessing lupus activity. These innovative biomarkers and models offer insights into LN disease activity, acute and chronic renal indices, fibrosis, thrombotic microangiopathy, podocyte injury, and other pathological changes, potentially improving the diagnosis, management, and prognosis of LN. These urinary biomarkers or combined models may serve as viable alternatives to traditional renal pathology, potentially revolutionizing the method for future LN diagnosis and observation.
Collapse
Affiliation(s)
- Qianyu Guo
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Rheumatology, Shanxi Bethune Hospital, Taiyuan, China
| | - Pengyan Qiao
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Rheumatology, Shanxi Bethune Hospital, Taiyuan, China
| | - Juanjuan Wang
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Stem Cell Translational Laboratory, Shanxi Bethune Hospital, Taiyuan, China
| | - Li Zhao
- School of Pharmacy, Shanxi Medical University, Taiyuan, China
| | - Zhiying Guo
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Rheumatology, Shanxi Bethune Hospital, Taiyuan, China
| | - Xiaochen Li
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Rheumatology, Shanxi Bethune Hospital, Taiyuan, China
| | - Xiuying Fan
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Office of Drug Clinical Trial Institution, Taiyuan, China
| | - Chong Yu
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Rheumatology, Shanxi Bethune Hospital, Taiyuan, China
| | - Liyun Zhang
- Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Third Hospital of Shanxi Medical University, Taiyuan, China
- Department of Rheumatology, Shanxi Bethune Hospital, Taiyuan, China
- Stem Cell Translational Laboratory, Shanxi Bethune Hospital, Taiyuan, China
- Office of Drug Clinical Trial Institution, Taiyuan, China
| |
Collapse
|
2
|
Omer MH, Shafqat A, Ahmad O, Nadri J, AlKattan K, Yaqinuddin A. Urinary Biomarkers for Lupus Nephritis: A Systems Biology Approach. J Clin Med 2024; 13:2339. [PMID: 38673612 PMCID: PMC11051403 DOI: 10.3390/jcm13082339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Systemic lupus erythematosus (SLE) is the prototypical systemic autoimmune disorder. Kidney involvement, termed lupus nephritis (LN), is seen in 40-60% of patients with systemic lupus erythematosus (SLE). After the diagnosis, serial measurement of proteinuria is the most common method of monitoring treatment response and progression. However, present treatments for LN-corticosteroids and immunosuppressants-target inflammation, not proteinuria. Furthermore, subclinical renal inflammation can persist despite improving proteinuria. Serial kidney biopsies-the gold standard for disease monitoring-are also not feasible due to their inherent risk of complications. Biomarkers that reflect the underlying renal inflammatory process and better predict LN progression and treatment response are urgently needed. Urinary biomarkers are particularly relevant as they can be measured non-invasively and may better reflect the compartmentalized renal response in LN, unlike serum studies that are non-specific to the kidney. The past decade has overseen a boom in applying cutting-edge technologies to dissect the pathogenesis of diseases at the molecular and cellular levels. Using these technologies in LN is beginning to reveal novel disease biomarkers and therapeutic targets for LN, potentially improving patient outcomes if successfully translated to clinical practice.
Collapse
Affiliation(s)
- Mohamed H. Omer
- School of Medicine, Cardiff University, Cardiff CF14 4YS, UK;
| | - Areez Shafqat
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (O.A.); (J.N.); (K.A.); (A.Y.)
| | - Omar Ahmad
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (O.A.); (J.N.); (K.A.); (A.Y.)
| | - Juzer Nadri
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (O.A.); (J.N.); (K.A.); (A.Y.)
| | - Khaled AlKattan
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (O.A.); (J.N.); (K.A.); (A.Y.)
| | - Ahmed Yaqinuddin
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (O.A.); (J.N.); (K.A.); (A.Y.)
| |
Collapse
|
3
|
Guo Z, Guo Q, Li X, Gao X, Zhang L, Xu K. Urinary biomarkers associated with podocyte injury in lupus nephritis. Front Pharmacol 2024; 15:1324540. [PMID: 38313309 PMCID: PMC10834635 DOI: 10.3389/fphar.2024.1324540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/10/2024] [Indexed: 02/06/2024] Open
Abstract
The most prevalent and devastating form of organ damage in systemic lupus erythematosus (SLE) is lupus nephritis (LN). LN is characterized by glomerular injury, inflammation, cell proliferation, and necrosis, leading to podocyte injury and tubular epithelial cell damage. Assays for urine biomarkers have demonstrated significant promise in the early detection of LN, evaluation of disease activity, and tracking of reaction to therapy. This is because they are non-invasive, allow for frequent monitoring and easy self-collection, transport and storage. Podocyte injury is believed to be a essential factor in LN. The extent and type of podocyte injury could be connected to the severity of proteinuria, making podocyte-derived cellular debris and injury-related urinary proteins potential markers for the diagnosis and monitoring of LN. This article focuses on studies examining urinary biomarkers associated with podocyte injury in LN, offering fresh perspectives on the application of biomarkers in the early detection and management of LN.
Collapse
Affiliation(s)
| | | | | | | | | | - Ke Xu
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, China
| |
Collapse
|
4
|
Stone HK, Huang B, Chen C, Ma Q, Bennett MR, Devarajan P. External Validation of a Urinary Biomarker Risk Score for the Prediction of Steroid Responsiveness in Adults With Nephrotic Syndrome. Kidney Int Rep 2023; 8:2458-2468. [PMID: 38025209 PMCID: PMC10658279 DOI: 10.1016/j.ekir.2023.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction In idiopathic nephrotic syndrome, response to corticosteroids remains the best indicator of prognosis. Noninvasive markers to predict a patient's response to steroids would allow improved prognostication and a more personalized approach to management. We have previously derived a urinary biomarker risk score which can differentiate steroid sensitive nephrotic syndrome (SSNS) from steroid resistant nephrotic syndrome (SRNS) in children. The goal of this study was to validate this previously derived biomarker risk score in a cohort of steroid-naïve adult patients, to determine whether the panel could be used to predict steroid responsiveness at the time of initial diagnosis. Methods In this external validation study, clinical data, and urinary specimens (obtained before initiation of steroid treatment) from adult patients were used in the Nephrotic Syndrome Study Network (NEPTUNE) cohort. A panel of 5 previously identified and validated urinary biomarkers, including neutrophil gelatinase-associated lipocalin (NGAL), vitamin D binding protein (VDBP), Fetuin-A (FetA), Transthyretin (TTR), and alpha-1 acid glycoprotein 2 (AGP2) was measured. A summary risk score for steroid resistance was calculated based on biomarker concentrations. Receiver operating characteristic curves were created for each log-transformed biomarker concentration and for the individual and combined biomarker risk score. Results The urine biomarker risk score predicted development of steroid resistance, with optimal sensitivity and specificity of 0.74, and area under the receiver operating characteristic curve (AUC) of 0.79 using both absolute and creatinine-corrected concentrations. Conclusion This study validates the previously derived urinary biomarker risk score to predict steroid resistance in adult patients with nephrotic syndrome at initial diagnosis.
Collapse
Affiliation(s)
- Hillarey K. Stone
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Bin Huang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Chen Chen
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Qing Ma
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Michael R. Bennett
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
5
|
Cody EM, Wenderfer SE, Sullivan KE, Kim AHJ, Figg W, Ghumman H, Qiu T, Huang B, Devarajan P, Brunner HI. Urine biomarker score captures response to induction therapy with lupus nephritis. Pediatr Nephrol 2023; 38:2679-2688. [PMID: 36715772 PMCID: PMC10393841 DOI: 10.1007/s00467-023-05888-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Renal Activity Index for Lupus (RAIL) consists of urine protein assessment of neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, monocyte chemotactic protein 1, adiponectin, hemopexin, and ceruloplasmin, which non-invasively identifies lupus nephritis (LN). We aimed to delineate RAIL scores with inactive versus active LN and changes over time with response to LN induction therapy. METHODS There were 128 pediatric patients with systemic lupus erythematosus (SLE) and age-matched healthy controls recruited in a prospective case control study, with kidney biopsy confirmation of LN. Laboratory and clinical information was recorded and urine collected at diagnosis and end of induction and during maintenance therapy. Response to therapy was assessed by repeat kidney biopsy or laboratory parameters. Urine was assayed for RAIL biomarkers and the RAIL score calculated. RESULTS Pediatric RAIL (pRAIL) scores from 128 children and young adults with SLE (with/without LN: 70/38) including 25 during LN induction therapy, differentiated clinically active LN from inactive LN or without LN, and controls (all p < 0.0017). pRAIL scores significantly decreased with complete LN remission by 1.07 ± 1.7 (p = 0.03). CONCLUSIONS The RAIL biomarkers differentiate LN patients based on activity of kidney disease, with decreases of ≥ 1 in pRAIL scores indicating complete response to induction therapy. Significantly lower RAIL scores in healthy controls and in SLE patients without known LN raise the possibility of subclinical kidney disease. A higher resolution version of the Graphical abstract is available as Supplementary information.
Collapse
Affiliation(s)
- Ellen M Cody
- Division of Nephrology, Hypertension and Pheresis, Department of Pediatrics, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, Campus, Box 8116, St. Louis, MO, 63110, USA.
| | - Scott E Wenderfer
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Nephrology, B.C. Children's Hospital, Vancouver, BC, Canada
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alfred H J Kim
- Division of Rheumatology, Department of Medicine, Washington University School of Medicine, St Louis, MO, USA
| | - Wesley Figg
- Medical School, Baylor College of Medicine, Houston, TX, USA
| | - Harneet Ghumman
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Tingting Qiu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Hermine I Brunner
- Department of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
6
|
Zhang P, Yang X, Fang X, Xu C, Gao C, Xia Z. Anti-C1q antibodies in lupus nephritis children with glomerular microthrombosis. Nephrology (Carlton) 2023. [PMID: 37485575 DOI: 10.1111/nep.14194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 05/22/2023] [Accepted: 05/31/2023] [Indexed: 07/25/2023]
Abstract
AIM Glomerular microthrombosis (GMT) was a common vascular lesion in patients with lupus nephritis (LN). The objective of this study was to investigate the relationship between serum anti-beta2-glycoprotein I antibodies (a-β2GP1) and anti-complement 1q antibodies (a-C1q) antibodies and to investigate the possible mechanism of GMT in children with LN. METHODS The subjects were 191 children with LN diagnosed by renal biopsy in our hospital from January 2017 to January 2020. The patients were divided into GMT group and non-GMT group. The clinical manifestations, laboratory tests, renal pathology, prognosis of the two groups and the relationship between a-β2GP1 and a-C1q antibodies were observed. RESULTS In 191 children with LN, 52 cases (27.23%) presented with GMT. The value of C3, haemoglobin (Hb), estimate glomerular filtration rate (eGFR) and anticardiolipin antibody (ACA) in GMT group were lower than that of non-GMT group (p < .05, p < .01). The value of serum creatinine (Scr), 24 h proteinuria (PRO), urine red blood cells (RBC), N-acetyl-β-d-glucosidase (NAG) and retinol-binding protein (RBP), a-C1q, a-β2GP1, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) and renal histopathological activity index (AI) score in GMT group were higher than that of non-GMT group (p < .05, p < .01). The positive proportions of serum a-C1q and a-β2GP1 in GMT group were higher than those in non-GMT group (p < .05). According to Spearman correlation analysis, a-C1q was positively correlated with AI score, SLEDAI, a-β2GP1, GMT, LN-III and LN-IV. Hb, eGFR and a-C1q Ab were associated with the formation of GMT in children with LN. The complete proteinuria remission and renal survival in GMT group were significantly lower than those in non-GMT group (p < .05, p < .01). CONCLUSION LN children with GMT had more severe clinical manifestations and renal pathologic damages, and poor outcome. Serum a-C1q level was positively correlated with a-β2GP1, and a-β2GP1 may be involved in the formation of GMT in children with LN, which might involve in the activation of complement classical pathway.
Collapse
Affiliation(s)
- Pei Zhang
- Department of Paediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, People's Republic of China
| | - Xiao Yang
- Department of Paediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, People's Republic of China
| | - Xiang Fang
- Department of Paediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, People's Republic of China
| | - Chao Xu
- Department of Paediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, People's Republic of China
| | - Chunlin Gao
- Department of Paediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, People's Republic of China
| | - Zhengkun Xia
- Department of Paediatrics, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, People's Republic of China
| |
Collapse
|
7
|
Akhgar A, Sinibaldi D, Zeng L, Farris AB, Cobb J, Battle M, Chain D, Cann JA, Illei GG, Lim SS, White WI. Urinary markers differentially associate with kidney inflammatory activity and chronicity measures in patients with lupus nephritis. Lupus Sci Med 2023; 10:10/1/e000747. [PMID: 36717181 PMCID: PMC9887703 DOI: 10.1136/lupus-2022-000747] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 01/04/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Lupus nephritis (LN) is diagnosed by biopsy, but longitudinal monitoring assessment methods are needed. Here, in this preliminary and hypothesis-generating study, we evaluate the potential for using urine proteomics as a non-invasive method to monitor disease activity and damage. Urinary biomarkers were identified and used to develop two novel algorithms that were used to predict LN activity and chronicity. METHODS Baseline urine samples were collected for four cohorts (healthy donors (HDs, n=18), LN (n=42), SLE (n=17) or non-LN kidney disease biopsy control (n=9)), and over 1 year for patients with LN (n=42). Baseline kidney biopsies were available for the LN (n=46) and biopsy control groups (n=9). High-throughput proteomics platforms were used to identify urinary analytes ≥1.5 SD from HD means, which were subjected to stepwise, univariate and multivariate logistic regression modelling to develop predictive algorithms for National Institutes of Health Activity Index (NIH-AI)/National Institutes of Health Chronicity Index (NIH-CI) scores. Kidney biopsies were analysed for macrophage and neutrophil markers using immunohistochemistry (IHC). RESULTS In total, 112 urine analytes were identified from LN, SLE and biopsy control patients as both quantifiable and overexpressed compared with HDs. Regression analysis identified proteins associated with the NIH-AI (n=30) and NIH-CI (n=26), with four analytes common to both groups, demonstrating a difference in the mechanisms associated with NIH-AI and NIH-CI. Pathway analysis of the NIH-AI and NIH-CI analytes identified granulocyte-associated and macrophage-associated pathways, and the presence of these cells was confirmed by IHC in kidney biopsies. Four markers each for the NIH-AI and NIH-CI were identified and used in the predictive algorithms. The NIH-AI algorithm sensitivity and specificity were both 93% with a false-positive rate (FPR) of 7%. The NIH-CI algorithm sensitivity was 88%, specificity 96% and FPR 4%. The accuracy for both models was 93%. CONCLUSIONS Longitudinal predictions suggested that patients with baseline NIH-AI scores of ≥8 were most sensitive to improvement over 6-12 months. Viable approaches such as this may enable the use of urine samples to monitor LN over time.
Collapse
Affiliation(s)
- Ahmad Akhgar
- Clinical Pharmacology and Safety Sciences R&D, AstraZeneca US, Gaithersburg, Maryland, USA
| | - Dominic Sinibaldi
- Applied Analytics and AI, BioPharmaceuticals R&D, AstraZeneca US, Gaithersburg, Maryland, USA
| | - Lingmin Zeng
- Late Oncology Biometrics, AstraZeneca US, Gaithersburg, Maryland, USA
| | - Alton B Farris
- Department of Pathology and Laboratory Medicine, Emory University Hospital, Atlanta, Georgia, USA
| | - Jason Cobb
- Department of Medicine, Renal Medicine Division, Emory University, Atlanta, Georgia, USA
| | - Monica Battle
- Department of Rheumatology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - David Chain
- Clinical Proteomics, Translational Medicine, Early Oncology, AstraZeneca US, Gaithersburg, Maryland, USA
| | - Jennifer A Cann
- Clinical Pharmacology and Safety Sciences R&D, AstraZeneca US, Gaithersburg, Maryland, USA
| | - Gábor G Illei
- Clinical Development, Viela Bio, Gaithersburg, Maryland, USA
| | - S Sam Lim
- Department of Medicine, Division of Rheumatology, Emory University, Atlanta, Georgia, USA
| | - Wendy I White
- Clinical Pharmacology and Quantitative Pharmacology, Clinical Pharmacology & Safety Sciences, BioPharmaceuticals R&D, AstraZeneca US, Gaithersburg, Maryland, USA
| |
Collapse
|
8
|
Costa-Reis P, Maurer K, Petri MA, Levy Erez D, Zhao X, Faig W, Burnham J, O'Neil K, Klein-Gitelman MS, von Scheven E, Schanberg LE, Sullivan KE. Urinary HER2, TWEAK and VCAM-1 levels are associated with new-onset proteinuria in paediatric lupus nephritis. Lupus Sci Med 2022; 9:9/1/e000719. [PMID: 35918102 PMCID: PMC9351344 DOI: 10.1136/lupus-2022-000719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/27/2022] [Indexed: 01/13/2023]
Abstract
Objective Lupus nephritis is a key driver of morbidity and mortality in SLE. Detecting active nephritis on a background of pre-existing renal damage is difficult, leading to potential undertreatment and accumulating injury. An unmet need is a biomarker that distinguishes active lupus nephritis, particularly important in paediatrics where minimising invasive procedures is desirable. Methods This was a multicentre, prospective study of 113 paediatric patients with biopsy-proven lupus nephritis. Clinical data and urine were obtained every 3–4 months and patients averaged 2 years on study with seven time points. Urine was analysed for human epidermal growth factor receptor 2 (HER2), tumour necrosis factor-like weak inducer of apoptosis and vascular cell adhesion molecule-1 (VCAM-1) by ELISA. We defined active disease as either a rise in serum creatinine ≥0.3 mg/dL from baseline or a rise in renal Systemic Lupus Erythematosus Disease Activity Index score from the previous visit. These markers were also studied in patients with acute kidney injury, juvenile idiopathic arthritis (JIA), amplified pain syndrome and healthy controls. Results The rate of active disease was 56% over an average of 2 years of follow-up. HER2 and VCAM-1 were significantly elevated at time points with active disease defined by increased serum creatinine compared with time points with inactive disease or patients who never flared. All three biomarkers were associated with new-onset proteinuria and VCAM-1 was elevated at time points preceding new-onset proteinuria. These biomarkers were not increased in acute kidney injury or JIA. Conclusion All three biomarkers were associated with new onset proteinuria and increased VCAM-1 may predict impending proteinuria. These biomarkers provide potential non-invasive measures for monitoring that may be more sensitive to impending flare than conventional measures.
Collapse
Affiliation(s)
| | - Kelly Maurer
- Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michelle A Petri
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniella Levy Erez
- Department of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Xue Zhao
- Division of Allergy Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Walter Faig
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jon Burnham
- Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathleen O'Neil
- Department of Rheumatology, Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Marisa S Klein-Gitelman
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | | | - Laura Eve Schanberg
- Department of Pediatrics, Duke Children's Hospital and Health Center, Durham, North Carolina, USA
| | - Kathleen E Sullivan
- Allergy and Immunology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
9
|
Cody EM, Rose JE, Huang B, Qiu T, Brunner HI, Devarajan P. Stability of novel urinary biomarkers used for lupus nephritis. Front Pediatr 2022; 10:974049. [PMID: 35967565 PMCID: PMC9372620 DOI: 10.3389/fped.2022.974049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/11/2022] [Indexed: 11/22/2022] Open
Abstract
Background The Renal Activity Index for Lupus (RAIL) is a composite score of six urinary biomarkers (neutrophil gelatinase-associated lipocalin (NGAL), monocyte chemoattractant protein-1 (MCP-1), kidney injury molecule-1 (KIM-1), ceruloplasmin, adiponectin, and hemopexin) used to monitor lupus nephritis activity in children. We tested stability of RAIL biomarkers prior to meaningful clinical use. Methods Urine samples were tested by ELISA under shipping conditions, freeze/thaw, ambient and longer-term storage. Statistical analysis was performed via Deming Regression, Bland-Altman and Spearman Correlation Coefficient. Results Biomarker concentration were comparable to freshly collected urine following storage at -80 °C for up to 3 months, and at 4 or 25 °C up to 48 h followed by -80 °C. Neither shipping on dry or wet ice exposure nor addition of two freeze-thaw cycles led to loss of signal, with excellent Spearman Correlation coefficients under all conditions. Conclusions RAIL biomarkers are stable following short-term storage at clinically relevant conditions.
Collapse
Affiliation(s)
- Ellen M. Cody
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - James E. Rose
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Bin Huang
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Division of Biostatics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- School of Medicine, University of Cincinnati, Cincinnati, OH, United States
| | - Tingting Qiu
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- Division of Biostatics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Hermine I. Brunner
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- School of Medicine, University of Cincinnati, Cincinnati, OH, United States
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Prasad Devarajan
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
- School of Medicine, University of Cincinnati, Cincinnati, OH, United States
| |
Collapse
|
10
|
Ayoub I, Rovin BH. The Use of Serological Tests in the Care of Patients with Lupus Nephritis. Clin J Am Soc Nephrol 2022; 17:305-307. [PMID: 34853061 PMCID: PMC8823947 DOI: 10.2215/cjn.13431021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Isabelle Ayoub
- Division of Nephrology, Department of Medicine, The Ohio State University, Columbus, Ohio
| | - Brad H. Rovin
- Division of Nephrology, Department of Medicine, The Ohio State University, Columbus, Ohio
| |
Collapse
|
11
|
OUP accepted manuscript. J Appl Lab Med 2022; 7:1450-1467. [DOI: 10.1093/jalm/jfac036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/25/2022] [Indexed: 11/14/2022]
|
12
|
Caster DJ, Merchant ML. Collagen Remodeling Biomarkers in Lupus Nephritis. KIDNEY360 2021; 2:1395-1398. [PMID: 35373099 PMCID: PMC8786132 DOI: 10.34067/kid.0004732021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 08/18/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Dawn J. Caster
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
| | - Michael L. Merchant
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
| |
Collapse
|
13
|
Successful Urine Multiplex Bead Assay to Measure Lupus Nephritis Activity. Kidney Int Rep 2021; 6:1949-1960. [PMID: 34307989 PMCID: PMC8258454 DOI: 10.1016/j.ekir.2021.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 03/18/2021] [Accepted: 04/12/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Lupus nephritis (LN) confers a poor prognosis, mainly from lack of effective laboratory tests to diagnose and to evaluate therapies. We have previously shown that a set of 6 urinary biomarkers (NGAL, KIM-1, MCP-1, adiponectin, hemopexin, and ceruloplasmin) are highly sensitive and specific to identify adult and pediatric patients with active LN using renal biopsy as reference standard. Using these combinatorial urinary biomarkers, the Renal Activity Score for Lupus (RAIL) score was established, with biomarkers measured by enzyme-linked immunosorbent assay (ELISA). To enhance clinical utility of the biomarkers and RAIL, we tested the performance of RAIL with biomarkers measured by ELISA to that of biomarkers measured by the bead multiplex method, hypothesizing that the multiplex bead method would be comparable. Methods Spot urine samples (n = 341) of 46 patients aged 20 to 73 years with or without LN were used. Samples were assayed both by ELISA and multiplex using LUMINEX. RAIL scores and biomarker quantities were assessed for agreement with intraassay correlation coefficients and compared using Bland−Altman and regression. Results Biomarker measurement by LUMINEX was successful for NGAL, KIM-1, MCP-1, and adiponectin, but not for ceruloplasmin and hemopexin. There was good agreement of the RAIL obtained from these 4 biomarkers, irrespective of assay method (intraclass correlation coefficient [ICC] = 0.78, 95% confidence interval [CI] = 0.78−0.82). The RAIL scores from 4 biomarkers further correlated with those when considering all 6 biomarkers (ICC = 0.97, 95% CI = 0.96−0.98). Conclusion The LUMINEX platform allows for the convenient and simultaneous measurement of 4 RAIL biomarkers. RAIL scores considering only these 4 biomarkers may be sufficient to accurately capture LN activity.
Collapse
|
14
|
Yu KYC, Yung S, Chau MKM, Tang CSO, Yap DYH, Tang AHN, Ying SKY, Lee CK, Chan TM. Serum syndecan-1, hyaluronan and thrombomodulin levels in patients with lupus nephritis. Rheumatology (Oxford) 2021; 60:737-750. [PMID: 32793966 DOI: 10.1093/rheumatology/keaa370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/28/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES We investigated circulating syndecan-1, HA and thrombomodulin levels in patients with biopsy-proven Class III/IV ± V LN and their clinico-pathological associations. Patients with non-renal SLE or non-lupus chronic kidney disease, and healthy subjects served as controls. METHODS Serum syndecan-1, HA and thrombomodulin levels were determined by ELISAs. RESULTS Syndecan-1, HA and thrombomodulin levels were significantly higher during active LN compared with remission (P < 0.01, for all), and correlated with the level of proteinuria, estimated glomerular filtration rate, anti-dsDNA antibodies, complement 3 and serum creatinine. Longitudinal studies showed that syndecan-1 and thrombomodulin levels increased prior to clinical renal flare by 3.6 months, while HA level increased at the time of nephritic flare, and the levels decreased in parallel with treatment response. Receiver operating characteristic curve analysis showed that syndecan-1 and thrombomodulin levels distinguished patients with active LN from healthy subjects, LN patients in remission, patients with active non-renal lupus and patients with non-lupus chronic kidney disease (receiver operating characteristic area under curve of 0.98, 0.91, 0.82 and 0.95, respectively, for syndecan-1; and area under curve of 1.00, 0.84, 0.97 and 0.79, respectively, for thrombomodulin). HA level distinguished active LN from healthy subjects, LN patients in remission and non-lupus chronic kidney disease (receiver operating characteristic area under curve of 0.82, 0.71 and 0.90, respectively) but did not distinguish between renal vs non-renal lupus. Syndecan-1 and thrombomodulin levels correlated with the severity of interstitial inflammation, while HA level correlated with chronicity grading in kidney biopsies of active LN. CONCLUSION Our findings suggest potential utility of serum syndecan-1, thrombomodulin and HA levels in clinical management, and their potential contribution to LN pathogenesis.
Collapse
Affiliation(s)
- Kelvin Y C Yu
- Department of Medicine, The University of Hong Kong, Hong Kong
| | - Susan Yung
- Department of Medicine, The University of Hong Kong, Hong Kong
| | - Mel K M Chau
- Department of Medicine, The University of Hong Kong, Hong Kong
| | - Colin S O Tang
- Department of Medicine, The University of Hong Kong, Hong Kong
| | - Desmond Y H Yap
- Department of Medicine, The University of Hong Kong, Hong Kong
| | | | - Shirley K Y Ying
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | | | - Tak Mao Chan
- Department of Medicine, The University of Hong Kong, Hong Kong
| |
Collapse
|
15
|
Adiponectin Deregulation in Systemic Autoimmune Rheumatic Diseases. Int J Mol Sci 2021; 22:ijms22084095. [PMID: 33920997 PMCID: PMC8071452 DOI: 10.3390/ijms22084095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 02/06/2023] Open
Abstract
Deregulation of adiponectin is found in systemic autoimmune rheumatic diseases (SARDs). Its expression is downregulated by various inflammatory mediators, but paradoxically, elevated serum levels are present in SARDs with high inflammatory components, such as rheumatoid arthritis and systemic lupus erythematosus. Circulating adiponectin is positively associated with radiographic progression in rheumatoid arthritis as well as with cardiovascular risks and lupus nephritis in systemic lupus erythematosus. However, in SARDs with less prominent inflammation, such as systemic sclerosis, adiponectin levels are low and correlate negatively with disease activity. Regulators of adiponectin gene expression (PPAR-γ, Id3, ATF3, and SIRT1) and inflammatory cytokines (interleukin 6 and tumor necrosis factor α) are differentially expressed in SARDs and could therefore influence total adiponectin levels. In addition, anti-inflammatory therapy could also have an impact, as tocilizumab treatment is associated with increased serum adiponectin. However, anti-tumor necrosis factor α treatment does not seem to affect its levels. Our review provides an overview of studies on adiponectin levels in the bloodstream and other biological samples from SARD patients and presents some possible explanations why adiponectin is deregulated in the context of therapy and gene regulation.
Collapse
|
16
|
Tailliar M, Schanstra JP, Dierckx T, Breuil B, Hanouna G, Charles N, Bascands JL, Dussol B, Vazi A, Chiche L, Siwy J, Faguer S, Daniel L, Daugas E, Jourde-Chiche N. Urinary Peptides as Potential Non-Invasive Biomarkers for Lupus Nephritis: Results of the Peptidu-LUP Study. J Clin Med 2021; 10:jcm10081690. [PMID: 33920017 PMCID: PMC8071029 DOI: 10.3390/jcm10081690] [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: 02/15/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Lupus nephritis (LN) is a severe manifestation of Systemic Lupus Erythematosus (SLE). The therapeutic strategy relies on kidney biopsy (KB) results. We tested whether urinary peptidome analysis could non-invasively differentiate active from non-active LN. Design: Urinary samples were collected from 93 patients (55 with active LN and 38 with non-active LN), forming a discovery (n = 42) and an independent validation (n = 51) cohort. Clinical characteristics were collected at inclusion and prospectively for 24 months. The urinary peptidome was analyzed by capillary-electrophoresis coupled to mass-spectrometry, comparing active LN to non-active LN, and assessing chronic lesions and response to therapy. The value of previously validated prognostic (CKD273) and differential diagnostic (LN172) signatures was evaluated. Results: Urinary peptides could not discriminate between active and non-active LN or predict early response to therapy. Tubulo-interstitial fibrosis was correlated to the CKD273. The LN172 score identified 92.5% of samples as LN. Few patients developed new-onset CKD. Conclusions: We validated the CKD273 and LN172 classifiers but did not identify a robust signature that could predict active LN and replace KB. The value of urinary peptidome to predict long-term CKD, or renal flares in SLE, remains to be evaluated.
Collapse
Affiliation(s)
- Maxence Tailliar
- AP-HM, Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, 13005 Marseille, France; (M.T.); (B.D.)
| | - Joost P. Schanstra
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Metabolic and Cardiovascular Disease (I2MC), 31432 Toulouse, France; (J.P.S.); (B.B.); (S.F.)
- Université Toulouse III Paul-Sabatier, 31062 Toulouse, France
| | - Tim Dierckx
- Laboratory of Clinical and Epidemiological Virology, Department of Microbiology and Immunology, Rega Institute for Medical Research, KU Leuven, 3000 Leuven, Belgium;
| | - Benjamin Breuil
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Metabolic and Cardiovascular Disease (I2MC), 31432 Toulouse, France; (J.P.S.); (B.B.); (S.F.)
- Université Toulouse III Paul-Sabatier, 31062 Toulouse, France
| | - Guillaume Hanouna
- AP-HP, Service de Néphrologie, Hôpital Bichat, DMU VICTOIRE, 75018 Paris, France; (G.H.); (E.D.)
| | - Nicolas Charles
- Centre de Recherche sur l’Inflammation, Université de Paris, INSERM UMRS1149, CNRS ERL8252, Labex INFLAMEX, DHU FIRE, 75890 Paris, France;
| | - Jean-Loup Bascands
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1188-Université de La Réunion, 97490 Saint-Denis, France;
| | - Bertrand Dussol
- AP-HM, Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, 13005 Marseille, France; (M.T.); (B.D.)
- Centre d’Investigation Clinique, CHU Conception, AP-HM, 13005 Marseille, France;
| | - Alain Vazi
- Centre d’Investigation Clinique, CHU Conception, AP-HM, 13005 Marseille, France;
| | - Laurent Chiche
- Médecine Interne, Hôpital Européen, 13003 Marseille, France;
| | - Justyna Siwy
- Mosaiques Diagnostics GmbH, 30659 Hannover, Germany;
| | - Stanislas Faguer
- Institut National de la Santé et de la Recherche Médicale (INSERM), U1297, Institut of Metabolic and Cardiovascular Disease (I2MC), 31432 Toulouse, France; (J.P.S.); (B.B.); (S.F.)
- Université Toulouse III Paul-Sabatier, 31062 Toulouse, France
- CHU de Toulouse, Service de Néphrologie, 31300 Toulouse, France
| | - Laurent Daniel
- AP-HM, Laboratoire d’Ananatomie Pathologique, Hôpital de la Timone, 13005 Marseille, France;
- Center for CardioVascular and Nutrition Research (C2VN), Aix-Marseille University, INSERM, INRAE, 13005 Marseille, France
| | - Eric Daugas
- AP-HP, Service de Néphrologie, Hôpital Bichat, DMU VICTOIRE, 75018 Paris, France; (G.H.); (E.D.)
- Centre de Recherche sur l’Inflammation, Université de Paris, INSERM UMRS1149, CNRS ERL8252, Labex INFLAMEX, DHU FIRE, 75890 Paris, France;
| | - Noémie Jourde-Chiche
- AP-HM, Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, 13005 Marseille, France; (M.T.); (B.D.)
- Center for CardioVascular and Nutrition Research (C2VN), Aix-Marseille University, INSERM, INRAE, 13005 Marseille, France
- Correspondence:
| | | |
Collapse
|
17
|
Yu KY, Yung S, Chau MK, Tang CS, Yap DY, Tang AH, Ying SK, Lee CK, Chan TM. Clinico-pathological associations of serum VCAM-1 and ICAM-1 levels in patients with lupus nephritis. Lupus 2021; 30:1039-1050. [PMID: 33765901 DOI: 10.1177/09612033211004727] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE We investigated the clinico-pathological associations of serum VCAM-1 and ICAM-1 levels in patients with biopsy-proven Class III/IV±V lupus nephritis (LN). METHODS Serum VCAM-1 and ICAM-1 levels were determined by ELISAs. Sera from patients with non-renal SLE or non-lupus chronic kidney disease (CKD), and healthy subjects served as controls. RESULTS Seropositivity rate for VCAM-1 and ICAM-1 was 93.10% and 37.93% respectively at the time of nephritic flare, and 44.83% and 13.79% respectively at remission, with both showing higher levels during flare (P < 0.05, for both). VCAM-1 level correlated with proteinuria, serum creatinine, and anti-dsDNA antibodies, and inversely correlated with C3. VCAM-1 level also correlated with leukocyte infiltration and fibrinoid necrosis/karyorrhexis scores in active LN kidney biopsies. ICAM-1 level correlated with proteinuria, but not anti-dsDNA or C3, nor histopathological features. VCAM-1 level increased 4.5 months before renal flare, while ICAM-1 increase coincided with flare, and both decreased after treatment. ROC analysis showed that VCAM-1 distinguished active LN from healthy subjects, LN in remission, active non-renal lupus, and CKD (ROC AUC of 0.98, 0.86, 0.93 and 0.90 respectively). VCAM-1 level in combination with either proteinuria or C3 was superior in distinguishing active LN from remission compared to the measurement of individual markers. Serum ICAM-1 level distinguished active LN from healthy subjects and LN patients in remission (ROC AUC of 0.75 and 0.66 respectively), but did not distinguish between renal versus non-renal lupus. ICAM-1 level in combination with markers of endothelial cell activation (syndecan-1, hyaluronan and thrombomodulin) was superior to proteinuria, anti-dsDNA, or C3 in distinguishing active LN from quiescent disease. CONCLUSION Our findings suggest potential utility of serum VCAM-1 and ICAM-1 in clinical management. Monitoring VCAM-1 may facilitate early diagnosis of flare. Combining selected biomarkers may be advantageous in diagnosing active LN. VCAM-1 may have a pathogenic role in renal parenchymal inflammation in active LN.
Collapse
Affiliation(s)
- Kelvin Yc Yu
- Department of Medicine, The University of Hong Kong, Hong Kong
| | - Susan Yung
- Department of Medicine, The University of Hong Kong, Hong Kong
| | - Mel Km Chau
- Department of Medicine, The University of Hong Kong, Hong Kong
| | - Colin So Tang
- Department of Medicine, The University of Hong Kong, Hong Kong
| | - Desmond Yh Yap
- Department of Medicine, The University of Hong Kong, Hong Kong
| | | | - Shirley Ky Ying
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | | | - Tak Mao Chan
- Department of Medicine, The University of Hong Kong, Hong Kong
| |
Collapse
|
18
|
Liu L, Wang R, Ding H, Tian L, Gao T, Bao C. The utility of urinary biomarker panel in predicting renal pathology and treatment response in Chinese lupus nephritis patients. PLoS One 2020; 15:e0240942. [PMID: 33108403 PMCID: PMC7591050 DOI: 10.1371/journal.pone.0240942] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/06/2020] [Indexed: 02/07/2023] Open
Abstract
Given the urgent need for non-invasive biomarkers of LN, we aim to identify novel urinary biomarkers that facilitate diagnosis, assessment of disease activity and prediction of treatment response in a retrospective SLE cohort. A total of 154 SLE patients and 55 healthy controls were enrolled, among whom 73 were active LN patients. We measured renal activity by renal SLEDAI. The treatment response of the active LN patients who finished 6-month induction therapy was assessed based on the American College of Rheumatology response criteria. The expression levels of 10 urinary biomarkers (UBMs): β2-MG, calbindin D, cystatin C, IL-18, KIM-1, MCP-1, nephrin, NGAL, VCAM-1, and VDBP were tested using Luminex high-throughput proteomics technology. All but urinary nephrin levels were significantly increased in active LN compared to healthy controls. uCystatinC, uMCP-1, uKIM-1 levels were significantly higher in active LN group compared to inactive LN group. Correlation analysis revealed positive correlation between uCystatinC, uKIM-1, uMCP-1, uNGAL, uVDBP and RSLEDAI score. In renal pathology, uCystatinC, uKIM-1, uVCAM-1, and uVDBP positively correlated with activity index (AI) while uVCAM-1 positively correlated with chronicity index (CI). Moreover, the combination of uVCAM-1, uCystatinC, uKIM-1 discriminated proliferative LN from membranous LN with an AUC of 0.80 (95%CI: 0.69–0.90). Most importantly, baseline uNGAL demonstrated good prediction ability to discriminate responders from non-responders in active LN patients after 6-month induction therapy. Using a multiplex bead technique, we have identified the combination of uVCAM-1, uCystatinC, uKIM-1 as a biomarker panel to reflect renal pathology and NGAL as a promising urinary biomarker to both reflect disease activity and predict treatment response.
Collapse
Affiliation(s)
- Li Liu
- Department of Emergency Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ran Wang
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huihua Ding
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Tian
- Department of Emergency Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Gao
- Department of Emergency Medicine, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chunde Bao
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- * E-mail:
| |
Collapse
|
19
|
Elevated Urinary Neutrophil Gelatinase-Associated Lipocalin Is a Biomarker for Lupus Nephritis: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2768326. [PMID: 32685458 PMCID: PMC7346103 DOI: 10.1155/2020/2768326] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 05/30/2020] [Indexed: 01/20/2023]
Abstract
Objective Lupus nephritis (LN) is a major and severe complication of systemic lupus erythematosus (SLE). Neutrophil gelatinase-associated lipocalin (NGAL), as a promising next-generation biomarker in clinical nephrology, has received extensive attention. However, its diagnostic performance in LN has high variability. Therefore, we performed an updated meta-analysis to further evaluate the diagnostic accuracy of urinary NGAL (uNGAL). Materials and Methods PubMed, Embase, and Cochrane Library were searched from inception to October 27, 2019. Meta-analysis was performed with a bivariate random effects model. Additionally, the summary receiver operating characteristic (SROC) curves were established. The sources of heterogeneity were explored by meta-regression, subgroup analysis, and sensitivity analysis. Publication bias was assessed using the Deeks test. Results 19 articles consisting of 21 eligible studies were included. In diagnosing LN, the estimates (95% confidence interval (CI)) were as follows: sensitivity, 0.84 (0.71-0.91); specificity, 0.91 (0.70-0.98); and the SROC-AUC value, 0.92 (0.90-0.94). In identifying active LN, the estimates were as follows: sensitivity, 0.72 (0.56-0.84); specificity, 0.71 (0.51-0.84); and the AUC value, 0.77 (0.74-0.81). With respect to predicting renal flare, the estimates were as follows: sensitivity, 0.80 (0.57-0.92); specificity, 0.67 (0.58-0.75); and the AUC value, 0.74 (0.70-0.78). For the studies to distinguish proliferative LN, the estimates were as follows: sensitivity, 0.87 (0.66-0.97), and specificity, 0.69 (0.39-0.91). Deeks' funnel plot suggested that there was no significant publication bias. Conclusions Our meta-analysis indicates that uNGAL was a useful biomarker for diagnosis, estimation of activity, and prediction of renal flare of LN. In addition, the usefulness of uNGAL to distinguish pathological types of LN needs to be further investigated.
Collapse
|
20
|
Caster DJ, Powell DW. Utilization of Biomarkers in Lupus Nephritis. Adv Chronic Kidney Dis 2019; 26:351-359. [PMID: 31733719 DOI: 10.1053/j.ackd.2019.09.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 08/22/2019] [Accepted: 09/06/2019] [Indexed: 12/20/2022]
Abstract
Lupus nephritis (LN) occurs in up to 60% of SLE patients, and is a leading cause of disability and death. Current treatment of LN consists of a combination of high dose corticosteroids that non-specifically decrease inflammation and cytotoxic medications that reduce auto-antibody production. That combination of therapy is associated with significant side effects while remission rates remain inadequate. Since the introduction of biologics into the pharmacological armamentarium, there has been hope for less toxic and more effective therapies for LN. Unfortunately, after multiple clinical trials, no biologic has improved efficacy over standard of care therapies for LN. This is likely, in part, due to disease heterogeneity. The utilization of biomarkers in LN may provide a way to stratify patients and guide therapeutic options. In this review, we summarize traditional and novel LN biomarkers and discuss how they may be used to diagnose, stratify, and guide therapy in patients with LN, bringing precision medicine to the forefront of LN therapy.
Collapse
|
21
|
Aljaberi N, Bennett M, Brunner HI, Devarajan P. Proteomic profiling of urine: implications for lupus nephritis. Expert Rev Proteomics 2019; 16:303-313. [PMID: 30855196 DOI: 10.1080/14789450.2019.1592681] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Lupus nephritis (LN) is a common and significant manifestation, affecting 60% of adults and 80% of children with systemic lupus erythematosus, with up to 30% of patients progressing to end stage renal disease. There remains an unmet need for non-invasive markers of disease activity, damage, and response to therapy. In addition, non-invasive biomarkers that predict therapeutic efficacy are needed to enable cost-effective clinical trials of novel agents. Areas covered: This review examines the methodological aspects of urinary proteomics, the role of proteome profiling in identifying promising urinary biomarkers in LN, and the translation of research findings into clinically useful tools in the management of LN. Expert opinion: Targeted and unbiased proteomics have identified several promising urinary biomarkers that predict LN activity, damage (chronicity), and response to therapy. In particular, a combination of biologically plausible urinary biomarkers termed as RAIL (Renal Activity Index for Lupus) has emerged as an excellent predictor of LN activity as well as response to therapy, being able to predict efficacy within 3 months of therapy. If validated in additional large prospective studies, the RAIL biomarkers will transform the care of patients with LN, allowing for a personalized and predictive approach and improved outcomes.
Collapse
Affiliation(s)
- Najla Aljaberi
- a Divisions of Rheumatology, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Michael Bennett
- b Division of Nephrology & Hypertension, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Hermine I Brunner
- a Divisions of Rheumatology, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Prasad Devarajan
- b Division of Nephrology & Hypertension, Department of Pediatrics , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| |
Collapse
|
22
|
Brunner HI, Gulati G, Klein-Gitelman MS, Rouster-Stevens KA, Tucker L, Ardoin SP, Onel KB, Mainville R, Turnier J, Aydin POA, Witte D, Huang B, Bennett MR, Devarajan P. Urine biomarkers of chronic kidney damage and renal functional decline in childhood-onset systemic lupus erythematosus. Pediatr Nephrol 2019; 34:117-128. [PMID: 30159624 PMCID: PMC6294330 DOI: 10.1007/s00467-018-4049-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 07/20/2018] [Accepted: 08/07/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To delineate urine biomarkers that reflect kidney structural damage and predict renal functional decline in pediatric lupus nephritis (LN). METHODS In this prospective study, we evaluated kidney biopsies and urine samples of 89 patients with pediatric LN. Urinary levels of 10 biomarkers [adiponectin, ceruloplasmin, kidney injury molecule-1, monocyte chemotactic protein-1, neutrophil gelatinase-associated lipocalin, osteopontin, transforming growth factor-ß (TGFß), vitamin-D binding protein, liver fatty acid binding protein (LFABP), and transferrin] were measured. Regression analysis was used to identify individual and combinations of biomarkers that determine LN damage status [NIH-chronicity index (NIH-CI) score ≤ 1 vs. ≥ 2] both individually and in combination, and biomarker levels were compared for patients with vs. without renal functional decline, i.e., a 20% reduction of the glomerular filtration rate (GFR) within 12 months of a kidney biopsy. RESULTS Adiponectin, LFABP, and osteopontin levels differed significantly with select histological damage features considered in the NIH-CI. The GFR was associated with NIH-CI scores [Pearson correlation coefficient (r) = - 0.49; p < 0.0001] but not proteinuria (r = 0.20; p > 0.05). Similar to the GFR [area under the ROC curve (AUC) = 0.72; p < 0.01], combinations of osteopontin and adiponectin levels showed moderate accuracy [AUC = 0.75; p = 0.003] in discriminating patients by LN damage status. Renal functional decline occurred more commonly with continuously higher levels of the biomarkers, especially of TGFß, transferrin, and LFABP. CONCLUSION In combination, urinary levels of adiponectin and osteopontin predict chronic LN damage with similar accuracy as the GFR. Ongoing LN activity as reflected by high levels of LN activity biomarkers heralds renal functional decline. KEY MESSAGES • Levels of osteopontin and adiponectin measured at the time of kidney biopsy are good predictors of histological damage with lupus nephritis. • Only about 20% of children with substantial kidney damage from lupus nephritis will have an abnormally low urine creatinine clearance. • Continuously high levels of biomarkers reflecting lupus nephritis activity are risk factors of declining renal function.
Collapse
Affiliation(s)
- Hermine I. Brunner
- Division of Rheumatology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MC 4010, Cincinnati, OH 45229, USA
| | - Gaurav Gulati
- Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati, Cincinnati, USA
| | - Marisa S. Klein-Gitelman
- Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Kelly A. Rouster-Stevens
- Division of Rheumatology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, GA, USA
| | - Lori Tucker
- Division of Rheumatology, Department of Pediatrics, British Columbia Children’s Hospital, Vancouver, Canada
| | - Stacey P. Ardoin
- Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, USA
| | - Karen B. Onel
- Division of Pediatric Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Rylie Mainville
- Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jessica Turnier
- Division of Rheumatology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MC 4010, Cincinnati, OH 45229, USA
| | - Pinar Ozge Avar Aydin
- Division of Rheumatology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MC 4010, Cincinnati, OH 45229, USA
| | - David Witte
- Division of Pathology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children’s Hospital and Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - Michael R. Bennett
- Division of Rheumatology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MC 4010, Cincinnati, OH 45229, USA,Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Prasad Devarajan
- Division of Rheumatology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MC 4010, Cincinnati, OH 45229, USA,Division of Nephrology and Hypertension, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| |
Collapse
|
23
|
Brunner HI, Martini A, Lovell DJ, Ruperto N. Clinical trials in children and adolescents with systemic lupus erythematosus: methodological aspects, regulatory landscape and future opportunities. Ann Rheum Dis 2018; 78:162-170. [PMID: 30232192 DOI: 10.1136/annrheumdis-2018-213198] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 08/10/2018] [Accepted: 08/11/2018] [Indexed: 11/04/2022]
Abstract
Childhood-onset systemic lupus erythematosus (cSLE) is rare in many regions of the world, including Europe. Access to approved medications for cSLE is currently limited, among others, due to a lack of high-quality evidence from clinical trials. The objectives of the study were to evaluate the current regulatory framework regarding medication approvals, delineate barriers to clinical trial conduct, and strategies to improve access to new medications for cSLE. Relevant methodological and regulatory aspects, epidemiological data, study designs and outcome measures are reviewed, and the results of a survey among Paediatric Rheumatology International Trials Organisation/Pediatric Rheumatology Collaborative Study Group investigators are presented. Laws and regulations in the USA and Europe necessitate that novel medicines are studied in paediatric populations, if similar or the same diseases in adults have been found to benefit from them. Regulatory agencies consider cSLE the paediatric form of SLE in adults. For medicines that have been found safe and effective in adult SLE, paediatric extrapolation strategies can limit the number and complexity of studies needed to support the labelling of these medicines for use in cSLE. In this setting, specialised research networks, validated outcome measures, stakeholder input, study designs as well as statistical methods successfully used in other uncommon diseases will help improve study efficiency in an effort to enhance the speed with which new drugs for cSLE can be studied. Open-label pharmacokinetic-pharmacodynamic studies are preferred by paediatric rheumatologists over double-blind parallel designs for cSLE trials. Appropriate infrastructure, outcome measures and sufficient numbers of patients are available for the testing of new medicines for children with cSLE.
Collapse
Affiliation(s)
- Hermine I Brunner
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alberto Martini
- IRCCS Istituto Giannina Gaslini, Direzione Scientifica, Genova, Italy
| | - Daniel J Lovell
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, Direzione Scientifica, Genova, Italy
| |
Collapse
|
24
|
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.
Collapse
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
| |
Collapse
|
25
|
Brunner HI, Bennett MR, Gulati G, Abulaban K, Klein-Gitelman MS, Ardoin SP, Tucker LB, Rouster-Stevens KA, Witte D, Ying J, Devarajan P. Urine Biomarkers to Predict Response to Lupus Nephritis Therapy in Children and Young Adults. J Rheumatol 2017; 44:1239-1248. [PMID: 28620062 PMCID: PMC6719540 DOI: 10.3899/jrheum.161128] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To delineate urine biomarkers that forecast response to therapy of lupus nephritis (LN). METHODS Starting from the time of kidney biopsy, patients with childhood-onset systemic lupus erythematosus who were diagnosed with LN were studied serially. Levels of 15 biomarkers were measured in random spot urine samples, including adiponectin, α-1-acid glycoprotein (AGP), ceruloplasmin, hemopexin, hepcidin, kidney injury molecule 1, monocyte chemotactic protein-1, lipocalin-like prostaglandin D synthase (LPGDS), transforming growth factor-β (TGF-β), transferrin, and vitamin D binding protein (VDBP). RESULTS Among 87 patients (mean age 15.6 yrs) with LN, there were 37 treatment responders and 50 nonresponders based on the American College of Rheumatology criteria. At the time of kidney biopsy, levels of TGF-β (p < 0.0001) and ceruloplasmin (p = 0.006) were significantly lower among responders than nonresponders; less pronounced differences were present for AGP, hepcidin, LPGDS, transferrin, and VDBP (all p < 0.05). By Month 3, responders experienced marked decreases of adiponectin, AGP, transferrin, and VDBP (all p < 0.01) and mean levels of these biomarkers were all outstanding (area under the receiver-operating characteristic curve ≥ 0.9) for discriminating responders from nonresponders. Patient demographics and extrarenal disease did not influence differences in biomarker levels between response groups. CONCLUSION Low urine levels of TGF-β and ceruloplasmin at baseline and marked reduction of AGP, LPGDS, transferrin, or VDBP and combinations of other select biomarkers by Month 3 are outstanding predictors for achieving remission of LN. If confirmed, these results can be used to help personalize LN therapy.
Collapse
Affiliation(s)
- Hermine I Brunner
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA.
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine.
| | - Michael R Bennett
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Gaurav Gulati
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Khalid Abulaban
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Marisa S Klein-Gitelman
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Stacy P Ardoin
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Lori B Tucker
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Kelly A Rouster-Stevens
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - David Witte
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Jun Ying
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Prasad Devarajan
- From the Division of Rheumatology, and the Division of Nephrology and Hypertension, and the Division of Pathology, Cincinnati Children's Hospital Medical Center; Department of Pediatrics, University of Cincinnati College of Medicine; Division of Allergy and Rheumatology, Department of Medicine, and the Department of Environmental Health, University of Cincinnati, Cincinnati, Ohio, USA; Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada; DeVos Children's Hospital, Grand Rapids, Michigan; Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center, Columbus, Ohio; Emory University, Division of Rheumatology, Department of Pediatrics, Atlanta, Georgia, USA
- H.I. Brunner, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; M.R. Bennett, PhD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; G. Gulati, MD, Division of Allergy and Rheumatology, Department of Medicine, University of Cincinnati; K. Abulaban, MD, Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, and DeVos Children's Hospital; M.S. Klein-Gitelman, MD, Department of Pediatrics, Division of Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine; S.P. Ardoin, MD, Division of Rheumatology, Department of Internal Medicine, Ohio State University Wexner Medical Center; L.B. Tucker, MBBS, Division of Rheumatology, Department of Pediatrics, British Columbia Children's Hospital; K.A. Rouster-Stevens, MD, Division of Rheumatology, Emory University, Department of Pediatrics; D. Witte, MD, Division of Pathology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine; J. Ying, PhD; Department of Environmental Health, University of Cincinnati; P. Devarajan, MD, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine
| |
Collapse
|