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Nayak A, Ettenger R, Wesseling-Perry K. Recurrent disease after pediatric renal transplantation. Pediatr Transplant 2024; 28:e14676. [PMID: 38650536 DOI: 10.1111/petr.14676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/15/2023] [Accepted: 11/30/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND Recurrent disease after kidney transplant remains an important cause of allograft failure, accounting for 7-8% of graft loss and ranking as the fifth most common cause of allograft loss in the pediatric population. Although the pathophysiology of many recurrent diseases is incompletely understood, recent advances in basic science and therapeutics are improving outcomes and changing the course of several of these conditions. METHODS Review of the literature. RESULTS We discuss the diagnosis and management of recurrent disease. CONCLUSION We highlight new insights into the pathophysiology and treatment of post-transplant primary hyperoxaluria, focal segmental glomerulosclerosis, immune complex glomerulonephritis, C3 glomerulopathy, lupus nephritis, atypical hemolytic uremic syndrome, and IgA nephropathy.
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Affiliation(s)
- Anjali Nayak
- Phoenix Children's Hospital and the University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Robert Ettenger
- Mattel Children's Hospital and the University of California at Los Angeles, Los Angeles, California, USA
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Sousa P, Brás C, Menezes C, Vizcaino R, Costa T, Faria MS, Mota C. Percutaneous kidney biopsies in children: a 24-year review in a tertiary center in northern Portugal. J Bras Nefrol 2024; 46:e20230143. [PMID: 38591825 PMCID: PMC11287898 DOI: 10.1590/2175-8239-jbn-2023-0143en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 02/16/2024] [Indexed: 04/10/2024] Open
Abstract
INTRODUCTION Percutaneous kidney biopsy (KB) is crucial to the diagnosis and management of several renal pathologies. National data on native KB in pediatric patients are scarce. We aimed to review the demographic and clinical characteristics and histopathological patterns in children who underwent native percutaneous KB over 24 years. METHODS Retrospective observational study of patients undergoing native percutaneous KB in a pediatric nephrology unit between 1998 and 2021, comparing 3 periods: period 1 (1998-2005), period 2 (2006-2013), and period 3 (2014-2021). RESULTS We found that 228 KB were performed, 78 (34.2%) in period 1, 91 (39.9%) in period 2, and 59 (25.9%) in period 3. The median age at KB was 11 (7-14) years. The main indications for KB were nephrotic syndrome (NS) (42.9%), hematuria and/or non-nephrotic proteinuria (35.5%), and acute kidney injury (13.2%). Primary glomerulopathies were more frequent (67.1%), particularly minimal change disease (MCD) (25.4%), IgA nephropathy (12.7%), and mesangioproliferative glomerulonephritis (GN) (8.8%). Of the secondary glomerulopathies, lupus nephritis (LN) was the most prevalent (11.8%). In group 1, hematuria and/or non-nephrotic proteinuria were the main reasons for KB, as opposed to NS in groups 2 and 3 (p < 0.01). LN showed an increasing trend (period 1-3: 2.6%-5.3%) and focal segmental glomerular sclerosis (FSGS) showed a slight decreasing trend (period 1-3: 3.1%-1.8%), without statistical significance. CONCLUSIONS The main indication for KB was NS, which increased over time, justifying the finding of MCD as main histological diagnosis. LN showed an increase in incidence over time, while FSGS cases did not increase.
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Affiliation(s)
- Patrícia Sousa
- Hospital Senhora da Oliveira, Serviço de Pediatria, Guimarães,
Portugal
| | - Catarina Brás
- Hospital Professor Doutor Fernando Fonseca, Serviço de Nefrologia,
Lisboa, Portugal
| | - Catarina Menezes
- Centro Hospitalar Universitário de Santo António, Centro
Materno-Infantil do Norte, Serviço de Pediatria, Porto, Portugal
| | - Ramon Vizcaino
- Centro Hospitalar Universitário de Santo António, Serviço de
Anatomia Patológica, Porto, Portugal
| | - Teresa Costa
- Centro Hospitalar Universitário de Santo António, Centro
Materno-Infantil do Norte, Unidade de Nefrologia Pediátrica, Serviço de Pediatria,
Porto, Portugal
| | - Maria Sameiro Faria
- Centro Hospitalar Universitário de Santo António, Centro
Materno-Infantil do Norte, Unidade de Nefrologia Pediátrica, Serviço de Pediatria,
Porto, Portugal
- Unidade de Ciências Biomoleculares Aplicadas, Department of
Biological Science, Porto, Portugal
| | - Conceição Mota
- Centro Hospitalar Universitário de Santo António, Centro
Materno-Infantil do Norte, Unidade de Nefrologia Pediátrica, Serviço de Pediatria,
Porto, Portugal
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Pakfetrat M, Malekmakan L, Rezazadeh MH, Tadayon T, Bahmani M, Nikoo A. Five-Year study on renal outcomes in biopsy-proven focal segmental glomerulosclerosis patients in Shiraz, Iran. CASPIAN JOURNAL OF INTERNAL MEDICINE 2024; 15:519-526. [PMID: 39011448 PMCID: PMC11246676 DOI: 10.22088/cjim.15.3.519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/16/2023] [Accepted: 10/02/2023] [Indexed: 07/17/2024]
Abstract
Background Focal segmental glomerulosclerosis (FSGS) is a prevalent glomerular disease that often leads to nephrotic syndrome. It is characterized by consolidating a portion of the glomerular capillary tuft connected to Bowman's capsule. This retrospective cohort study aimed to determine the demographic characteristics, risk factors, and prognostic indicators associated with FSGS in Shiraz, Iran. Methods The study included 53 primary FSGS patients aged over 18 years who were referred to clinics affiliated with Shiraz University of Medical Sciences. Data were collected through a comprehensive data-gathering sheet encompassing demographic information, medical history, laboratory test results, and histopathological findings. Statistical analysis was performed using SPSS 18, considering a significance level of p<0.05. Results A five-year follow-up was conducted on the 53 patients, with the mean age of 41.0±13.3 years. The most common FSGS variants observed were "not otherwise specified" (NOS, 13.2%) and tip variant (7.5%). Older patients exhibited higher disease activity, whereas remission rates were higher among younger individuals (P=0.012). Patients achieving remission had lower creatinine and Pro/Cr ratios and higher glomerular filtration rates (p<0.05). Treatment involving a combination of corticosteroids and mycophenolate mofetil showed a significant correlation with remission (P=0.036). Conclusion Older patients with higher creatinine levels, higher Pro/Cr ratios, and lower glomerular filtration rates at disease onset may require more aggressive treatment. Combination therapy with mycophenolate mofetil and corticosteroids yields better outcomes, leading to increased remission rates. These findings provide valuable insights for managing FSGS patients.
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Affiliation(s)
- Maryam Pakfetrat
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Leila Malekmakan
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Taraneh Tadayon
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Bahmani
- Shiraz Nephro-Urology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirali Nikoo
- Student at University of Toronto Scarborough, Ontario, Canada
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Kalra S, Mukund B, Kumar M, Kanitkar M. Comparative analysis of blind vs real-time ultrasound-guided pediatric renal biopsies: A cross-sectional study. Med J Armed Forces India 2023; 79:409-413. [PMID: 37441299 PMCID: PMC10334249 DOI: 10.1016/j.mjafi.2021.05.014] [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: 07/31/2020] [Accepted: 05/14/2021] [Indexed: 11/20/2022] Open
Abstract
Background Renal biopsy has a definite role in the management of pediatric kidney diseases. Most centers have given up the earlier practice of performing blind biopsy using Tru-Cut needle and started doing real time ultrasound-guided renal biopsy with an automated spring-loaded gun, which has become standard of care in the last decade or so. Methods We performed a cross-sectional analysis of the pediatric biopsies conducted at our center over the years by both methods to evaluate whether ultrasound-guided renal biopsy with a disposable automated spring-loaded gun was superior to blind biopsy with a disposable needle of the same size in terms of reduction of complications and improving the yield. We also reviewed the indications and the histopathological diagnosis of pediatric renal biopsies at our center. Results A total of 45 native kidney biopsies were performed blind and 48 ultrasound-guided biopsies using the curvilinear probe (frequency 3-5 Hz) of GE Logiq P3 ultrasound machine with disposable spring-loaded automated guns. There was a significant increase in the yield of biopsy in terms of the number of glomeruli per pass. A significant increase in the mean number of glomeruli was noted when a biopsy was performed under ultrasound guidance (P < 0.0001). Gross hematuria was significantly reduced as compared to the earlier biopsies done blind i.e., without ultrasound (P ¼ 0.03). Nephrotic syndrome was the commonest indication for biopsy in our patients during both time periods studied. The most common histopathological diagnosis was MesPGN among the children who underwent kidney biopsy from 2005 to 2007, while Minimal Change Disease (MCD) and Focal Segmental Glomerulosclerosis (FSGS) were most frequently reported. Conclusion Ultrasound guided kidney biopsies in pediatric age group have significant reduction in incidence of post gross hematuria and significant increase in the mean number of glomeruli per pass.
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Affiliation(s)
- Suprita Kalra
- Classified Specialist & Associate Professor (Pediatrics), Army Hospital (R&R), Delhi Cantt, India
| | - Bal Mukund
- Classified Specialist & Associate Professor (Pediatrics), INHS Kalyani, Vishakapatnam, India
| | - Mritunjay Kumar
- Associate Professor (Pediatrics), AIIMS, Raebareli, UP, India
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He G, Tao L, Li C, Zhong X, Wang H, Ding J. The spectrum and changes of biopsy-proven kidney diseases in Chinese children. J Nephrol 2023; 36:417-427. [PMID: 36472788 DOI: 10.1007/s40620-022-01527-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/12/2022] [Indexed: 12/12/2022]
Abstract
AIM The study aimed to investigate the spectrum of biopsy-proven kidney disease in Chinese children. METHODS Records of children 0-17 years old who underwent native kidney biopsy from June 1st, 2013 to December 31st, 2018 in the national inpatients' database of China were analyzed. Biopsy-proven kidney diseases of different sex, age groups, and diagnosis, and the changing patterns of kidney disease compared with the previous study were analyzed. RESULTS A total of 21,311 patients from 232 hospitals with a median age of 11.34 years were included. Immunoglobulin A vasculitis with nephritis (IgAVN) was the most common pathological finding [29.17%, 95% confidence interval (confidence interval, CI) = 28.56-29.78], followed by IgA nephropathy (IgAN) (22.70%, 95% CI = 22.14-23.27). IgAN was the most common finding in patients with hematuria (60.75%, 95% CI = 58.83-62.65], proteinuria (33.43%, 95% CI = 30.54-36.42), and hematuria plus proteinuria (62.77%, 95% CI = 56.19-69.02). Minimal change disease was the most common finding (40.69%, 95% CI = 39.41-41.98) in nephrotic syndrome. The proportion of IgAVN in patients with biopsy-proven glomerular disease increased year by year during 2013-2018 (p for trend < 0.001) and was higher than that of 2004-2014 [29.41% (95% CI = 29.10-29.72) in 2013-2018 vs. 13.35% (95% CI = 12.97-13.73) 2004-2014, p < 0.001]. The proportion of hepatitis B virus associated nephritis during 2013-2018 was lower than that of 2004-2014 [0.44% (95% CI = 0.36-0.54) in 2013-2018 vs. 0.87% (95% CI = 0.67-1.10) in 2004-2014, p < 0.001]. CONCLUSIONS IgAVN and IgAN were the most common types of pathological findings in children who underwent kidney biopsies from 2013 to 2018. The pathological spectrum of kidney biopsy changed over time.
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Affiliation(s)
- Guohua He
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Liyuan Tao
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Chenglong Li
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Xuhui Zhong
- Department of Pediatrics, Peking University First Hospital, Beijing, China
| | - Haibo Wang
- Clinical Trial Unit, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jie Ding
- Department of Pediatrics, Peking University First Hospital, Beijing, China.
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Gjerstad AC, Skrunes R, Tøndel C, Åsberg A, Leh S, Klingenberg C, Døllner H, Hammarstrøm C, Bjerre AK. Kidney biopsy diagnosis in childhood in the Norwegian Kidney Biopsy Registry and the long-term risk of kidney replacement therapy: a 25-year follow-up. Pediatr Nephrol 2023; 38:1249-1256. [PMID: 35994104 PMCID: PMC9925570 DOI: 10.1007/s00467-022-05706-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 07/16/2022] [Accepted: 07/27/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND There is scarce information on biopsy-verified kidney disease in childhood and its progression to chronic kidney disease stage 5 (CKD 5). This study aims to review biopsy findings in children, and to investigate risk of kidney replacement therapy (KRT). METHODS We conducted a retrospective long-term follow-up study of children included in the Norwegian Kidney Biopsy Registry (NKBR) and in the Norwegian Renal Registry (NRR) from 1988 to 2021. RESULTS In total, 575 children with a median (interquartile range, IQR) age of 10.7 (6.1 to 14.1) years were included, and median follow-up time (IQR) after kidney biopsy was 14.3 (range 8.9 to 21.6) years. The most common biopsy diagnoses were minimal change disease (MCD; n = 92), IgA vasculitis nephritis (IgAVN; n = 76), IgA nephropathy (n = 63), and focal and segmental glomerulosclerosis (FSGS; n = 47). In total, 118 (20.5%) of the biopsied children reached CKD 5, median (IQR) time to KRT 2.3 years (7 months to 8.4 years). Most frequently, nephronophthisis (NPHP; n = 16), FSGS (n = 30), IgA nephropathy (n = 9), and membranoproliferative glomerulonephritis (MPGN; n = 9) led to KRT. CONCLUSIONS The risk of KRT after a kidney biopsy diagnosis is highly dependent on the diagnosis. None of the children with MCD commenced KRT, while 63.8% with FSGS and 100% with NPHP reached KRT. Combining data from kidney biopsy registries with registries on KRT allows for detailed information concerning the risk for later CKD 5 after biopsy-verified kidney disease in childhood. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Ann Christin Gjerstad
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway.
| | - Rannveig Skrunes
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Camilla Tøndel
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Anders Åsberg
- The Norwegian Renal Registry, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Department of Transplantation Medicine, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Department of Pharmacy, University of Oslo, Oslo, Norway
| | - Sabine Leh
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Claus Klingenberg
- Department of Pediatrics and Adolescence Medicine, University Hospital of North Norway, Tromsø, Norway
- Paediatric Research Group, Faculty of Health Sciences, UiT-The Arctic University of Norway, Tromsø, Norway
| | - Henrik Døllner
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Children's Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Clara Hammarstrøm
- Department of Pathology, Oslo University Hospital - Rikshospitalet, Oslo, Norway
| | - Anna Kristina Bjerre
- Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Zahir Z, Wani AS, Jain M, Agrawal V, Jain S. Pediatric Glomerular Diseases in North India-Epidemiology and Clinicopathologic Correlation. Indian J Nephrol 2023; 33:28-34. [PMID: 37197040 PMCID: PMC10185018 DOI: 10.4103/ijn.ijn_522_21] [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: 12/16/2021] [Revised: 03/26/2022] [Accepted: 04/04/2022] [Indexed: 11/04/2022] Open
Abstract
Background Glomerular diseases vary with age, and it is important to investigate the spectrum of glomerular diseases in pediatric patients to help in a more precise clinical diagnosis and optimize the management of patients. We aimed to study the clinicopathologic pattern of pediatric glomerular diseases in North India. Methods This is a 5-year retrospective, single-center cohort study. The database was searched to identify all pediatric patients with glomerular diseases in their native kidney biopsies. Results About 2890 native renal biopsies were studied, of which 409 were pediatric glomerular diseases. The median age was 15 years with a male preponderance. Nephrotic syndrome was the most common presentation (60.8%), followed by non-nephrotic proteinuria with hematuria (18.5%), rapidly proliferative glomerulonephritis (7%), isolated hematuria (5.3%), acute nephritic syndrome (3.4%), non-nephrotic proteinuria (1.9%), and advanced renal failure (0.7%). Minimal change disease (MCD) was the most common histological diagnosis, followed by focal segmental glomerulosclerosis (17.4%), IgA nephropathy (IgAN; 10%), membranous nephropathy (6.6%), lupus nephritis (5.9%), crescentic glomerulonephritis (2.9%), and C3 glomerulopathy (2.9%). Diffuse proliferative glomerulonephritis (DPGN) was the most common histological diagnosis in patients with hematuria and non-nephrotic as well as nephrotic range proteinuria. The most common histological diagnoses for isolated hematuria and acute nephritic syndrome were IgAN and postinfectious glomerulonephritis (PIGN), respectively. Conclusions MCD and lupus nephritis are the most common pediatric primary and secondary histopathologic diagnoses, respectively. The adolescent-onset glomerular diseases have a higher frequency of IgAN, membranous nephropathy, and DPGN. PIGN is still an important differential in our pediatric patients presenting with acute nephritic syndrome.
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Affiliation(s)
- Zafirah Zahir
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Asif Sadiq Wani
- Department of Nephrology and Renal Transplantation, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Manoj Jain
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vinita Agrawal
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shweta Jain
- Department of Pathology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Clinical and histopathological study of renal biopsy in Nepalese children: A single center experience. PLoS One 2022; 17:e0276172. [PMID: 36301960 PMCID: PMC9612495 DOI: 10.1371/journal.pone.0276172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 10/01/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Glomerular diseases are important causes of morbidity and mortality among children in developing countries. Renal biopsy is the gold standard for determining histological diagnosis, prognosis, and therapy options. This study aimed to investigate the clinical, histopathological, and direct immunofluorescence findings of renal biopsy results in Nepalese children under 18 years old. METHODS In this retrospective cross-sectional study, the available data from children who had undergone kidney biopsy between 2016 and the end of 2020 were evaluated. Demographic data, indications of biopsy, histopathologic findings, and direct immunofluorescence findings were collected and presented. RESULTS The mean age of the patients was 12.14 ± 4.07 years. Male/female ratio was 1:1. The majority of biopsy cases were aged between 11-15 years of age. The most common indication for biopsy in children was nephrotic syndrome (68.25%). Lupus nephritis with 28 cases (22.22%) had the highest frequency in overall renal biopsies. Minimal change disease (MCD) with 22 cases (17.46%) followed by Ig A nephropathy with 16 cases (12.69%) were the most frequent primary glomerulonephritis. Lupus nephritis showed full house positivity, and MCD showed full house negativity in all Direct immunofluorescence (DIF) parameters, whereas immunoglobulin A nephropathy showed 100% positivity in Ig A in DIF. CONCLUSIONS Nephrotic syndrome was the most common indication for renal biopsy. The most common primary glomerulonephritis was MCD, while secondary glomerulonephritis was lupus nephritis. Clinical data, light microscopy, and direct DIF played an integral role in the overall final diagnosis.
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Huang G, Liu F, Yu L, Wang J, Chen J, Mao J. Pediatric membranous nephropathy: In the novel antigens era. Front Immunol 2022; 13:962502. [PMID: 36016931 PMCID: PMC9396344 DOI: 10.3389/fimmu.2022.962502] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/21/2022] [Indexed: 01/10/2023] Open
Abstract
Membranous nephropathy (MN) falls within the scope of a glomerular disease. MN exhibits subepithelial immune- complex deposition and capillary wall thickening which could occur in all age groups. In comparison with adult patients with MN, MN in pediatric population has a lower incidence and more secondary factors (e.g., systemic lupus erythematosus, infection, malignancy, or drug toxicity). Two target antigens for the immune complexes, PLA2R (identified in 2009) and THSD7A (in 2014), found in previous studies and first presented in adult MN, are found in pediatric patients suffering from MN and their antibodies are now an effective tool for diagnosis and monitoring in children and adolescents. Several novel antigens have been identified (e.g., EXT1/EXT2, NELL1, Sema3B, PCDH7, HTRA1, and NCAM1) over the past few years. Each of them represents different clinical and pathologic findings. In-depth research should be conducted to gain insights into the outcomes and pathophysiology of the above novel antigen-associated MN. Targeted treatment opinions for different novel antigen-related MN are under development both in adults and pediatric patients.
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Abstract
Membranous nephropathy (MN) is a glomerular disease that can occur at all ages. In adults, it is the most frequent cause of nephrotic syndrome. In ~80% of patients, there is no underlying cause of MN (primary MN) and the remaining cases are associated with medications or other diseases such as systemic lupus erythematosus, hepatitis virus infection or malignancies. MN is an autoimmune disease characterized by a thickening of the glomerular capillary walls due to immune complex deposition. Identification of the phospholipase A2 receptor (PLA2R) as the major antigen in adults in 2009 induced a paradigm shift in disease diagnosis and monitoring and several other antigens have since been characterized. Disease outcome is difficult to predict and around one-third of patients will undergo spontaneous remission. In those at high risk of progression, immunosuppressive therapy with cyclophosphamide plus corticosteroids has substantially reduced the need for kidney replacement therapy. Owing to carcinogenic risk, other treatments (calcineurin inhibitors and CD20-targeted B cell depletion therapy (rituximab)) have been developed. However, disease relapses are frequent when calcineurin inhibitors are stopped and the remission rate with rituximab is lower than with cyclophosphamide, particularly in patients with high PLA2R antibody titres. Other new drugs are already available and antigen-specific immunotherapies are being developed.
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