Elevated levels of immunoglobulin E may indicate steroid resistance or relapse in adult primary nephrotic syndrome, especially in minimal change nephrotic syndrome

Serum IgE levels are a risk factor with prognosis of pediatric minimal change disease

BACKGROUND

Minimal change disease (MCD) is one of the most common primary glomerular disorders with high serum IgE levels. This study was aimed to investigate the clinical features of different serum IgE levels in pediatric MCD and evaluate the prognostic significance of serum IgE levels with regard to remission and relapse in pediatric cohort.

METHODS

This study enrolled 142 new-onset children diagnosed with biopsy-proven MCD from January 2010 to December 2021 at the Jinling Hospital in Nanjing, China. These cases were divided into three groups according to serum IgE levels. MCD patients' demographics, clinical parameters, and follow-up data were collected and analyzed. The primary and secondary outcomes were defined as the time to the first complete remission (CR) and the first relapse.

RESULTS

The results manifested that 85.2% (121/142) of MCD children had high serum IgE levels (IgE > 90.0 IU/ml). A total of 142 patients were divided into the normal-, low-, and high-IgE groups based on the normal reference value level (90.0 IU/ml) and median serum IgE level (597.5 IU/ml). The high-IgE group had a significantly lower cumulative rate of the first CR (log-rank, P = 0.032) and a higher rate of the first relapse (log-rank, P = 0.033) than the normal-IgE and low-IgE groups. Multivariate Cox analysis showed that IgE ≥597.5 IU/ml was independently associated with the delayed first CR [hazard ratio (HR) = 0.566, 95% confidence interval (CI) = 0.330-0.972, P = 0.039] and the early first relapse (HR = 2.767, 95% CI = 1.150-6.660, P = 0.023).

CONCLUSIONS

Serum IgE levels were an independent correlation factor for pediatric MCD-delayed remissions and early relapses.

Establishment of relapse risk model and multivariate logistic regression analysis on risk factors of relapse in children with primary nephrotic syndrome

This study aimed to investigate relapse risk factors in children with primary nephrotic syndrome (PNS) for prevention and early intervention via logistic regression. One hundred thirty-seven children with PNS were enrolled in this study. Clinical variables were analyzed by single-factor and multiple regression analysis to establish the regression equation. The predictive ability of the regression equation was investigated by the receiver operating characteristic curve (ROC). Files of 17 patients were lost, and 120 patients were enrolled finally in the study, among whom 55 cases (45.8%) had frequently relapsed. Single-factor analysis and multiple regression analysis revealed that concurrent infection on first onset, irregular glucocorticoid therapy, severe hypoalbuminemia, and persistent severe hyperlipidemia were the significant risk factors for frequent relapse on PNS (P < .05), among which infection remained to be the main inductive factor. Among the 4 indicators, serum albumin had the best diagnostic efficacy based on the area under the ROC curve (0.933), sensitivity (89.09%), and specificity (81.54%). The area under curve, sensitivity, and specificity for the combined diagnostic model of the 4 indices were 97.8%, 98.18%, and 90.77%, respectively, which had good predictive power for the relapse of patients. Concurrent infection, irregular glucocorticoid therapy, severe hypoalbuminemia, and persistent severe hyperlipemia were all the risk factors for PNS relapse. The established logistic regression model based on these factors above is reliable for predicting frequent PNS relapse. Much attention should be paid to these critical factors, and early intervention should be taken to reduce the incidence of relapse.

Serum IgE Levels Are Associated With the Prognosis of Minimal Change Disease

Background

Previous reports showed that some patients with minimal change disease (MCD) had high serum immunoglobulin E (IgE) levels. This study aimed to explore the proportion of MCD patients with high serum IgE levels and evaluate the correlation between serum IgE levels and MCD remission and relapse.

Methods

This study enrolled 222 new-onset patients with renal biopsy-confirmed MCD from October 2012 to October 2019 at the First Affiliated Hospital of Zhejiang University in Hangzhou, China. Patients’ demographics and clinical parameters were analyzed.

Results

The results indicated that 70.3% of 222 MCD patients had high serum IgE levels (IgE > 100.0 IU/mL). Moreover, 134 patients were treated with glucocorticoids alone and divided into the low- and high-IgE groups, according to the median serum IgE level (523.5 IU/mL). The mean time to complete remission of the low- and high-IgE groups was 29.0 ± 2.2 and 45.7 ± 4.2 days, respectively (log-rank test; P = 0.002). The mean time to total remission was 19.1 ± 1.4 and 31.6 ± 3.2 days of the low- and high-IgE groups, respectively (log-rank test; P < 0.001). The mean time to first relapse in the low- and high-IgE groups was 701.2 ± 65.0 and 425.0 ± 52.6 days, respectively (log-rank test; P = 0.002). Serum IgE ≥ 523.5 IU/mL was an independent correlation factor affecting the patients’ remission and relapse.

Conclusion

Serum IgE level was an independent correlation factor for MCD remission and relapse. MCD patients with high serum IgE levels were prone to delayed remissions and early relapses.

Serum immunoglobulin E level in children with nephrotic syndrome

Background and objective: The most supported theory for Nephrotic Syndrome (NS) etiology is that it is immune-mediated. This study aims to assess the level of serum IgE in children with Steroid Sensitive NS (SSNS) at relapse and remission, and its correlation with the presence of atopy. Methods: This cross-sectional study was approved by the Department of Pediatrics, College of Medicine, Al-Nahrain University (Baghdad, Iraq) and conducted at Al-Imamain Al-Kadhimain Medical City (Baghdad, Iraq), and Child Central Teaching Hospital (Baghdad, Iraq), and included 31 children SSNS. The data collected was: age, sex, residency, onset of NS, response to steroid, frequency of relapses, and the history of atopy of the patient and his relatives. Serum IgE level was measured during relapse for all patients and for 9 patients while in remission. Results: Atopy was present in 18 (58.06%) of patients. The median serum IgE level was 295.5 IU/mL (range 54-2864 IU/mL) in relapse, which is significantly higher (P-value =0.006) than in remission 228.5 IU/mL (range 62-2069 IU/mL). Median serum level of IgE in patients with atopy was 290.5 IU/mL (range 24-2864 IU/mL) which was higher than that of patients without atopy (median 231 IU/mL, range 23-1314 IU/m) (P-value = 0.029). Patients required longer period to respond to steroid therapy (>10 days) had a significantly higher median of IgE (341 IU/mL) than those who required <10 days to respond (161 IU/mL) (P-value =0.045). Conclusions: Increased IgE level is documented during relapse and in atopic children with SSNS. Longer duration to respond to steroid therapy is associated significantly with higher serum IgE during relapse.

Clinical features of acute kidney injury in patients with nephrotic syndrome and minimal change disease: a retrospective, cross-sectional study

Background:

Minimal change nephropathy (MCD) is a common pathological type of nephrotic syndrome and is often associated with acute kidney injury (AKI). This study aimed to investigate the clinical characteristics and related factors of AKI in patients with MCD and nephrotic syndrome.

Methods:

Patients from Chinese People's Liberation Army General Hospital who were diagnosed with pathological renal MCD with clinical manifestations of nephrotic syndrome were included from January 1, 2013 to December 31, 2017. Patients diagnosed with membranous nephropathy (MN) by renal biopsy from January 1, 2013 to December 31, 2017 are included as a control population. We retrospectively analyzed the clinical and pathological characteristics of patients as well as the percentages and clinical characteristics of AKI in different age groups. We assessed the correlation of pathological characteristics with serum creatinine using multivariate linear regression analysis.

Results:

A total of 367 patients with MCD were included in the analysis, with a sex ratio of 1.46: 1 (male: female) and an age range of 6 to 77 years. Among all the patients, 109 developed AKI (29.7%), and of these patients, 85 were male (78.0%). In the 586 patients with MN, 27 (4.6%) patients developed AKI. The percentage of AKI in MCD patients was significantly higher than that in MN patients (χ² = 41.063, P < 0.001). The percentage of AKI increased with age in the MCD patients. The percentage of AKI in patients aged 50 years or older was 52.9% (46/87), which was significantly higher than that [22.5% (63/280)] in patients under 50 years (χ² = 6.347, P = 0.013). We observed statistically significant differences in age (43 [27, 59] years vs. 28 [20, 44] years, Z = 5.487, P < 0.001), male (78.0% vs. 51.4%, χ² = 22.470, P < 0.001), serum albumin (19.9 ± 6.1 g/L vs. 21.5 ± 5.7 g/L, t = 2.376, P = 0.018), serum creatinine (129.5 [105.7, 171.1] μmol/L vs. 69.7 [57.7, 81.9] μmol/L, Z = 14.190, P < 0.001), serum urea (10.1 [6.2, 15.8] mmol/L vs. 4.7 [3.6, 6.4] mmol/L, Z = 10.545, P < 0.001), IgE (266.0 [86.7, 963.0] IU/ml vs. 142.0 [35.3, 516.5] IU/ml, Z = 2.742, P = 0.007), history of diabetes (6.4% vs. 1.2%, P = 0.009), and history of hypertension (23.9% vs. 5.1%, χ² = 28.238, P < 0.001) between the AKI group and the non-AKI group. According to multivariate linear regression analysis, among the renal pathological features analyzed, renal tubular epithelial cell damage (β = 178.010, 95% CI: 147.888−208.132, P < 0.001) and renal interstitial edema (β = 28.833, 95% CI: 11.966−45.700, P = 0.001) correlated with serum creatinine values.

Conclusions:

The percentage of AKI in MCD patients is significantly higher than that in MN patients. Patients over 50 years old are more likely to develop AKI. Renal tubular epithelial cell injury and renal interstitial edema may be the main pathological lesions that are associated with elevated serum creatinine in patients with MCD.

Establishment of a novel nomogram for the clinically diagnostic prediction of minimal change disease, -a common cause of nephrotic syndrome

Background

Minimal change disease (MCD) is one of the major causes of nephrotic syndrome (NS). A confirmed MCD diagnosis mainly depends on renal biopsy at present, which is an invasive procedure with many potential risks. The overall incidence of complications caused by renal biopsy procedures has been reported as approximately 11 and 6.6% outside and within China, respectively. Unfortunately, there is currently no noninvasive procedure or practical classification method for distinguishing MCD from other primary glomerular diseases available.

Method

A total of 1009 adult patients who underwent renal biopsy between January 2017 and November 2019 were enrolled in this study. Twenty-five parameters extracted from patient demographics, clinical manifestations, and laboratory test results were statistically analysed. LASSO regression analysis was further performed on these parameters. The parameters with the highest area under the curve (AUC) were selected and used to establish a logistic diagnostic prediction model.

Results

Of the 25 parameters, 14 parameters were significantly different (P < 0.05). MCD patients were mostly younger (36 (22, 55) vs. 41 (28.75, 53)) and male (59% vs. 52%) and had lower levels of diastolic blood pressure (DBP) (79 (71, 85.5) vs. 80 (74, 89)) and IgG (5.42 (3.17, 6.36) vs. 9.38 (6.79, 12.02)) and higher levels of IgM (1.44 (0.96, 1.88) vs. 1.03 (0.71, 1.45)) and IgE (160 (46.7, 982) vs. 47.3 (19, 126)) than those in the non-MCD group. Using the LASSO model, we established a classifier for adults based on four parameters: DBP and the serum levels of IgG, IgM, IgE. We were able to clinically classify adult patients with NS into MCD and non-MCD using this model. The validation accuracy of the logistic regression model was 0.88. A nomogram based on these four classifiers was developed for clinical use that could predict the probability of MCD in adult patients with NS.

Conclusions

A LASSO model can be used to distinguish MCD from other primary glomerular diseases in adult patients with NS. Combining the model and the nomogram potentially provides a novel and valuable approach for nephrologists to diagnose MCD, avoiding the complications caused by renal biopsy.

Increased number and activation of peripheral basophils in adult-onset minimal change disease

Nowadays, the pathogenesis of minimal change disease (MCD) is still not well‐known, and the current understanding on MCD is mainly based on data derived from children, and very few adults. Here, we comprehensively analysed the correlation between the changes of peripheral basophils and the incidence rate and relapse of adult‐onset MCD. The results showed that in patients at the onset of MCD, the ratio and activation of basophils were all higher than those of healthy controls (all P < .05). In vitro test results showed that basophils from healthy controls can be activated by the serum taken from patients with MCD. Among 62 patients at the onset of MCD, with complete remission after treatment and 1 year of follow‐up, the relative and absolute basophil counts before treatment were higher in the long‐term remission group (n = 33) than that of the relapse group (n = 29). The basophil counts were significantly higher in the infrequent relapse group (n = 13) than that of the frequent relapse group (n = 16; P < .05). These findings suggested that basophil may play a pathogenic role in adult‐onset MCD, and the increased number and activation of peripheral basophils could predict recurrence in adult MCD.

Respiratory Tract Infection: A Risk Factor for the Onset and Relapse of Adult-Onset Minimal Change Disease in Southern China

AIMS/INTRODUCTION

Steroid resistance and frequent relapse are problems in the treatment of minimal change disease (MCD). However, epidemiological factors that influence steroid-resistant and relapse of MCD are rarely reported. This study evaluated potential factors that influence the onset and relapse of MCD and the epidemiological features of southern Chinese patients with adult-onset MCD.

PATIENTS AND METHODS

Patients with adult-onset MCD were included from the Affiliated Hospital of Guangdong Medical University, which is located in the southernmost part of China's mainland, between 2015 and 2016. Potential influencing factors were investigated.

RESULTS

Eighty-seven patients with incipient MCD were enrolled, and 85 of these patients were followed up; 71.8% (61/85) were steroid-sensitive and 28.2% (24/85) were steroid-resistant. In terms of seasonal distribution, the highest rate of incipient cases was in spring (39.1%, 34/87), which also showed a high rate of relapse cases (29.7%, 22/74). Among patients who were followed up for more than half a year and whose proteinuria completely resolved (69.4%, 59/85), 52.5% (31/59) were without relapse and 47.5% (28/59) were with relapse. Patients without relapse were older than those with relapse (P<0.05). Before disease onset, 20.7% (18/87) of patients with incipient MCD were diagnosed with infection, including 94.5% (17/18) with respiratory tract infection. Fourteen patients in complete remission posttreatment developed an infection before relapse, including 85.7% (12/14) with respiratory tract infection.

CONCLUSION

Steroid resistance and frequent relapse are current challenges for the treatment of adult-onset MCD in southern China, and respiratory tract infection may be a risk factor for onset and relapse. Additionally, younger patients with MCD tend to have more frequent relapse.

Nephrotic syndrome during the tapering of oral steroids after pathological diagnosis of Kimura disease from a lacrimal gland mass: case report and review of 10 Japanese patients

A 42-year-old man with eosinophilia and high serum immunoglobulin E (IgE) developed a lacrimal gland mass on the left side. Excisional biopsy revealed hyperplasia of lymphoid follicles, and infiltration with lymphocytes and eosinophils around lacrimal gland acini, leading to the pathological diagnosis of Kimura disease. IgE-positive cells were mainly found along follicular dendritic cells, and a small number of IgG4-positive cells was present. One month after oral prednisolone was started at 40 mg daily and tapered to 10 mg daily, he developed lower leg edema on both sides and marked proteinuria (10.8 g/day). Renal biopsy showed no glomerular abnormalities, no immunoglobulin deposition, and no tubulointerstitial infiltration with eosinophils, leading to the diagnosis of minimal change nephrotic syndrome. Proteinuria subsided in response to an increased dose of prednisolone to 30 mg daily. Proteinuria relapsed three times in the following 5 years when oral prednisolone was tapered. In conclusion, Kimura disease manifested as an orbital mass and did not relapse. However, nephrotic syndrome relapsed frequently with background eosinophilia and high serum IgE. This study reviewed the clinical features of 10 Japanese patients with Kimura disease associated with proteinuria.

The clinicopathological features of patients with membranous nephropathy

Background

Membranous nephropathy (MN) represents a distinct glomerular disease which has been considered as a major cause of nephrotic syndrome (NS) in adults. Evidences show that the clinicopathological features of MN are various among MN cases. This study aimed to summarize and analyze the clinicopathological features of patients with MN.

Methods

A total of 231 MN patients were recruited in this study. Their clinical and pathological features were collected and analyzed according to their age, gender, pathological stages, and anti-phospholipase A2 receptor (anti-PLA2R) antibodies tests.

Results

Among the 231 MN cases, the ratio of male to female was 1.47 and the mean age was 47.43±14.32 years. Altogether, 163 (70.6%) cases were positive for NS. Their serum antiPLA2R, body mass index, total cholesterol, triglyceride, low density lipoprotein cholesterol, D2, IgA, and IgE were increased, but IgG was decreased. The majority of the patients were middle aged and old aged. In addition, the pathological stage was significantly correlated with gender (P=0.038), creatinine, (P=0.021) and IgE (P=0.003). A total of 74.9% MN patients were found to be positive for anti-PLA2R antibodies, and they were more likely to have abnormal serum indices.

Conclusion

The major clinicopathological characteristics of MN patients are summarized in this study. Male and elder MN cases are likely to have rapid disease progression. Advanced pathological stages and being positive for anti-PLA2R antibodies may be potential indicators for disease activity of MN.

Role of the glucocorticoid receptor in the recurrence of primary nephrotic syndrome

The present study aimed to investigate the changes in the expression levels of the glucocorticoid receptor (GR) and its subtypes in patients with recurrent renal syndrome. In addition, the effects of tumour necrosis factor α (TNF-α) and a TNF-α monoclonal antibody on these receptors in peripheral blood mononuclear cells (PBMCs) isolated from the patients was analysed. Furthermore, a new treatment method for recurrent renal syndrome was explored. The serum levels of TNF-α in the normal (A), stable renal syndrome (B) and renal syndrome recurrence (C) groups of patients were determined by enzyme-linked immunosorbent assay (ELISA). The mRNA and protein expression levels of GR, GRα and GRβ were determined by ELISA, western blot analysis and quantitative polymerase chain reaction in PBMC cultures from the three groups in the absence of intervention (blank control) and following stimulation with methylprednisolone, TNF-α and/or TNF-α monoclonal antibody. Group C exhibited higher expression levels of TNF-α and GRβ but a lower level of GRα expression (P<0.05) compared with the other groups. Regardless of methylprednisolone intervention, the expression levels of GR and GRβ in the three groups following stimulation by TNF-α were significantly higher compared with those in the respective blank control, whereas in group C, the GRα expression levels following TNF-α treatment were lower compared with those in the control group (P<0.05). The treatment of group C with TNF-α monoclonal antibodies resulted in higher GRα expression but lower GRβ expression compared with those in the blank control (P<0.05). The change in the ratios of the GR subtypes may be associated with renal syndrome recurrence. TNF-α may be involved in renal syndrome relapse by changing the levels of GR as well as the proportion of the GR subtypes. TNF-α monoclonal antibodies may mitigate the changes in the ratios of these subtypes.

A higher frequency of CD4⁺CXCR5⁺ T follicular helper cells in adult patients with minimal change disease

Background. T follicular helper (TFH) cells are involved in the humoral immune responses. This study is aimed at examining the frequencies of different subsets of CD4⁺CXCR5⁺ TFH cells in adult patients with minimal change disease (MCD). Methods. A total of 27 patients and 14 healthy controls (HC) were characterized for the levels of sera cytokines, inducible T-cell costimulator (ICOS), and programmed death 1 (PD-1) of positive TFH cells by flow cytometry. The level of sera IL-21 was examined; 24 h urinary protein and eGFR were calculated. The potential correlation between the frequency of different subsets of TFH cells and the values of clinical measures in MCD patients were analyzed. Results. The frequency of circulating CD4⁺CXCR5⁺, CD4⁺CXCR5⁺ICOS⁺, and CD4⁺CXCR5⁺PD-1⁺ TFH cells and the levels of sera IL-17A, IFN-γ, IL-2, IL-10, IL-4, and IL-21 were significantly higher in MCD patients (P < 0.05) than that in the HC group. Furthermore, the percentages of circulating CD4⁺CXCR5⁺ TFH cells were negatively correlated with the values of eGFR (r = −0.4849, P < 0.05) and the percentages of CD4⁺CXCR5⁺PD-1⁺ TFH cells were correlated positively with the levels of serum IL-21 (r = 0.6137, P < 0.05) and 24 h urinary protein (r = 0.1410, P < 0.05) in those patients. Also, the percentages of CD4⁺CXCR5⁺ICOS⁺ TFH cells were correlated positively with the levels of serum IL-21 (r = 0.6201, P < 0.05) and 24 h urinary protein (r = 0.7519, P < 0.05). Following standard therapies, the percentages of circulating CD4⁺CXCR5⁺, CD4⁺CXCR5⁺PD-1⁺, and CD4⁺CXCR5⁺ICOS⁺ TFH cells and the levels of serum IL-21 were significantly reduced, but the levels of serum IL-4 and IL-10 were increased (P < 0.05). Conclusions. A higher frequency of CD4⁺CXCR5⁺ TFH cells that existed in adult patients with MCD could be new target for intervention of MCD.

Role of basophils in the pathogenesis of minimal change nephrotic syndrome: A literature review

A number of studies have verified that minimal change nephrotic syndrome (MCNS) may result from the dysfunction of T cells and B cells, although the precise mechanisms are yet to be elucidated. It is widely recognized that MCNS is a T helper (Th)2-dominant glomerular disease caused by an imbalanced Th1/Th2 immune response. Increased levels of the Th2 cytokines, interleukin (IL)-4 and IL-13, have been demonstrated to be closely associated with disease activity. In addition, basophils can affect the Th1/Th2 balance by enhancing the Th2 response and impairing the Th1 response, which are then involved in the development of numerous diseases. However, whether basophils are vital in the pathogenesis of MCNS remains unknown. Frequent positivity of the human basophil degranulation test in patients with MCNS has been observed. Thus, basophils should be analyzed in order to determine their role in the pathogenesis of MCNS.

Proteinuria predicts relapse in adolescent and adult minimal change disease

OBJECTIVE

This study sought to outline the clinical and laboratory characteristics of minimal change disease in adolescents and adults and establish the clinical and laboratory characteristics of relapsing and non-relapsing patients.

METHODS

We retrospectively evaluated patients with confirmed diagnoses of minimal change disease by renal biopsy from 1979 to 2009; the patients were aged >13 years and had minimum 1-year follow-ups.

RESULTS

Sixty-three patients with a median age (at diagnosis) of 34 (23-49) years were studied, including 23 males and 40 females. At diagnosis, eight (12.7%) patients presented with microscopic hematuria, 17 (27%) with hypertension and 17 (27%) with acute kidney injury. After the initial treatment, 55 (87.3%) patients showed complete remission, six (9.5%) showed partial remission and two (3.1%) were nonresponders. Disease relapse was observed in 34 (54%) patients who were initial responders (n = 61). In a comparison between the relapsing patients (n = 34) and the non-relapsing patients (n = 27), only proteinuria at diagnosis showed any significant difference (8.8 (7.1-12.0) vs. 6.0 (3.6-7.3) g/day, respectively, p = 0.001). Proteinuria greater than 7 g/day at the initial screening was associated with relapsing disease.

CONCLUSIONS

In conclusion, minimal change disease in adults may sometimes present concurrently with hematuria, hypertension, and acute kidney injury. The relapsing pattern in our patients was associated with basal proteinuria over 7 g/day.