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Li M, Lai X, Liu J, Yu Y, Li X, Liu X. Prediction model for treatment response of primary membranous nephropathy with nephrotic syndrome. Clin Exp Nephrol 2024; 28:740-750. [PMID: 38709377 DOI: 10.1007/s10157-024-02470-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/22/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE To investigate the predictors and establish a nomogram model for the prediction of the response to treatment in primary membranous nephropathy (PMN) with nephrotic syndrome (NS). METHODS The clinical, laboratory, pathological and follow-up data of patients with biopsy-proven membranous nephropathy at the Affiliated Hospital of Qingdao University were collected. A total of 373 patients were randomly assigned into development group (n = 262) and validation group (n = 111). Logistic regression analysis was performed in the development group to determine the predictors of treatment response. A nomogram model was established based on the multivariate logistic regression analysis and validated in the validation group. The C-index and calibration plots were used for the evaluation of the discrimination and calibration performance, respectively. RESULTS Serum albumin levels (OR = 1.151, 95% CI 1.078-1.229, P < 0.001) and glomerular C3 deposition (OR = 0.407, 95% CI 0.213-0.775, P = 0.004) were identified as independent predictive factors for treatment response in PMN with NS, then a nomogram was established combining the above indicators and treatment regimen. The C-indices of this model were 0.718 (95% CI 0.654-0.782) and 0.789 (95% CI 0.705-0.873) in the development and validation groups, respectively. The calibration plots showed that the predicted probabilities of the model were consistent with the actual probabilities (P > 0.05), which indicated favorable performance of this model in predicting the treatment response probability. CONCLUSIONS Serum albumin levels and glomerular C3 deposition were predictors for treatment response of PMN with NS. A novel nomogram model with good discrimination and calibration was constructed to predict treatment response probability at an early stage.
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Affiliation(s)
- Min Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Xiaoying Lai
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Jun Liu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yahuan Yu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Xianyi Li
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Xuemei Liu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China.
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Wang M, Yang J, Fang X, Lin W, Yang Y. Membranous nephropathy: pathogenesis and treatments. MedComm (Beijing) 2024; 5:e614. [PMID: 38948114 PMCID: PMC11214595 DOI: 10.1002/mco2.614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 05/16/2024] [Accepted: 05/20/2024] [Indexed: 07/02/2024] Open
Abstract
Membranous nephropathy (MN), an autoimmune disease, can manifest at any age and is among the most common causes of nephrotic syndrome in adults. In 80% of cases, the specific etiology of MN remains unknown, while the remaining cases are linked to drug use or underlying conditions like systemic lupus erythematosus, hepatitis B virus, or malignancy. Although about one-third of patients may achieve spontaneous complete or partial remission with conservative management, another third face an elevated risk of disease progression, potentially leading to end-stage renal disease within 10 years. The identification of phospholipase A2 receptor as the primary target antigen in MN has brought about a significant shift in disease management and monitoring. This review explores recent advancements in the pathophysiology of MN, encompassing pathogenesis, clinical presentations, diagnostic criteria, treatment options, and prognosis, with a focus on emerging developments in pathogenesis and therapeutic strategies aimed at halting disease progression. By synthesizing the latest research findings and clinical insights, this review seeks to contribute to the ongoing efforts to enhance our understanding and management of this challenging autoimmune disorder.
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Affiliation(s)
- Mengqiong Wang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Jingjuan Yang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Xin Fang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Weiqiang Lin
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
| | - Yi Yang
- Department of NephrologyCenter for Regeneration and Aging MedicineThe Fourth Affiliated Hospital of School of Medicineand International School of Medicine, International Institutes of MedicineZhejiang UniversityYiwuChina
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Wanaratwichit P, Chai-Adisaksopha C, Inmutto N, Noppakun K. Risk factors of worsening kidney function and mortality in patients with renal vein thrombosis: a retrospective study. J Nephrol 2024; 37:131-140. [PMID: 37702914 DOI: 10.1007/s40620-023-01761-2] [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: 05/22/2023] [Accepted: 08/06/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND The outcome of renal vein thrombosis, in particular as for the long-term impact on kidney function, is not fully known. We aimed to study the natural course and outcomes of patients with renal vein thrombosis, in a large, single-center cohort. METHODS A single-center retrospective cohort study including patients who were diagnosed with renal vein thrombosis between January 2006 and September 2021 was analyzed. The main outcomes analyzed were worsening kidney function, defined as a decrease in eGFR of at least 40% from baseline, and all-cause mortality. RESULTS Eighty-seven patients were included, 56.3% were female, median age was 57 years. Malignancy was the most common cause of renal vein thrombosis (60.9%), followed by post-surgery and trauma (16.1%) and nephrotic syndrome (12.6%). At initial presentation, 65.5% of the patients were asymptomatic; the main signs and symptoms were gross hematuria (20.7%), flank pain (18.4%), and flank tenderness (9.2%). During follow-up, 18 (21.4%) patients experienced worsening kidney function and 57 (65.5%) died. Multivariable analyses showed that the risk of worsening kidney function was higher in patients with nephrotic syndrome (hazard ratio [HR] 18.41; 95% confidence interval [CI], 1.57-216.04), body weight ≥ 60 kg (HR 4.82; 95% CI 1.43-16.32), and malignancy (HR 9.10; 95% CI 1.05-78.63). Symptomatic acute renal vein thrombosis was associated with a lower risk of worsening kidney function compared to asymptomatic or symptomatic chronic renal vein thrombosis (HR 0.12; 95% CI 0.01-0.96). Malignancy (HR 5.45; 95% CI 2.58-11.54), age ≥ 75 years (HR 3.44; 95% CI 1.49-7.93), and serum albumin < 3.0 g/dL (HR 2.88; 95% CI 1.65-5.05) were associated with an increased mortality risk. CONCLUSION Renal vein thrombosis is associated with a high rate of worsening kidney function and mortality. It is crucial to promptly identify patients at high risk and initiate early treatment to prevent negative outcomes.
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Affiliation(s)
- Puttinat Wanaratwichit
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chatree Chai-Adisaksopha
- Division of Hematology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
| | - Nakarin Inmutto
- Division of Intervention Radiology, Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Kajohnsak Noppakun
- Division of Nephrology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
- Pharmacoepidemiology and Statistics Research Center, Faculty of Pharmacy, Chiang Mai University, Chiang Mai, Thailand.
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Liu Y, Zhang S, Hu R, Li C, Chen G, Shi X, Liu Y, Zheng K, Li H, Wen Y, Li X, Li X, Xia P, Qin Y. The Safety and Efficacy of Rituximab-Based Regimen in Atypical Membranous Nephropathy: A Single Center Retrospective Cohort Study. Int J Gen Med 2023; 16:1983-1993. [PMID: 37251282 PMCID: PMC10224685 DOI: 10.2147/ijgm.s410169] [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: 03/09/2023] [Accepted: 05/16/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose There are increasing reports of atypical membranous nephropathy (AMN) cases with similar pathological characteristics to secondary membranous nephropathy (SMN) without definite underlying causes. Although rituximab has become a first-line option in treating idiopathic membranous nephropathy (IMN), the efficacy and safety of rituximab-based regimen for AMN is not clear. Patients and Methods This is a retrospective, single-center study. AMN patients who received rituximab-based therapy were included. IMN patients treated with rituximab during the same period were selected as the control group matched by gender, sex, baseline urinary protein and albumin levels. Baseline data and follow-up data were collected. Results A total of 20 AMN patients and 40 IMN patients were included. The baseline levels of urinary protein were comparable between the two groups [6.77 (IQR 3.34, 11.49) g/24 h vs 6.47 (IQR 3.4, 10.76) g/24 h, P=0.944]. The baseline levels of serum albumin were 26.15±6.71 g/L and 26.8±5.54 g/L (P=0.689) respectively. The cumulative remission rate for rituximab-based treatment at the 12th month was lower in AMN group than IMN group [13 (65%) vs 36 (90%), P=0.045]. In AMN group, non-responders showed a higher level of proteinuria and a worse renal function at baseline than those of responders. There was no significant difference in the overall adverse events or serious adverse events between the two groups. Conclusion In our study, AMN patients obtained proteinuria remission in a lower percentage compared with IMN patients. In general, rituximab-based therapy is effective in AMN patients with an acceptable safety profile.
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Affiliation(s)
- Yanan Liu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Shuo Zhang
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Rongrong Hu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Chao Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Gang Chen
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Xiaoxiao Shi
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Yan Liu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Ke Zheng
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Hang Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Yubing Wen
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Xuewang Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Peng Xia
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Yan Qin
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
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Vestergaard SV, Birn H, Jensen SK, Sørensen HT, Nitsch D, Christiansen CF. Twenty-four-Year Trends in Incidence and Mortality of Nephrotic Syndrome: A Population-Based Cohort Study. Epidemiology 2023; 34:411-420. [PMID: 36730008 DOI: 10.1097/ede.0000000000001576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND With the increasing prevalence of risk factors for nephrotic syndrome, updated epidemiologic data on the syndrome are needed. We examined its age- and sex-specific incidence, histopathology, and mortality over 24 years. METHODS This nationwide cohort study included all adults with first-time-recorded nephrotic syndrome in Denmark during 1995-2018 using the Danish National Patient Registry. We obtained data on age, sex, hospital-diagnosed comorbidities, and histopathologic findings. We computed overall, and age- and sex-specific, incidence rates of nephrotic syndrome, 1- and 5-year mortality by calendar period, and 1-year hazard ratios (HRs) of death using Cox models. RESULTS We identified 3,970 adults with first-time nephrotic syndrome diagnosis. Incidence was highest in men and increased with age to 11.77 per 100,000 person-years (95% confidence interval [CI]: 10.21-13.32) in men aged 80+ years, and 6.56 per 100,000 person-years (95% CI: 5.71-7.41) in women aged 80+ years. Incidence of nephrotic syndrome increased from 3.35 per 100,000 person-years (95% CI: 3.12-3.58) in 1995-2000 to 4.30 per 100,000 person-years (95% CI: 4.05-4.54) in 2013-2018. Over time, 1-year mortality of nephrotic syndrome was stable at 13%-16%, but HR of death was 0.54 (95% CI: 0.42-0.69), adjusted for age, sex, and comorbidities, in 2013-2018 compared with 1995-2000. Subdistribution of glomerulopathies was stable over time with membranous nephropathy and minimal change disease being the most common. CONCLUSION During 1995-2018, the incidence of recorded adult nephrotic syndrome increased slightly, and the adjusted mortality of nephrotic syndrome decreased markedly. Whether these findings reflect changes in epidemiology or awareness and coding of nephrotic syndrome, remains to be clarified.
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Affiliation(s)
- Søren Viborg Vestergaard
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Birn
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
- Department of Renal medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Simon Kok Jensen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Toft Sørensen
- Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Dorothea Nitsch
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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Li C, Shan W, Liang X, Zhang Q, Qin X, Jiang S, Hong X, Wang L, Li P, Gu H, Wang Y, Bao K. The efficacy and safety of Sanqi Qushi Granule in patients with idiopathic membranous nephropathy --protocol of a multicenter, randomized control trial (SQ-AUTUMN). BMC Complement Med Ther 2023; 23:134. [PMID: 37106336 PMCID: PMC10134584 DOI: 10.1186/s12906-023-03950-9] [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: 02/07/2023] [Accepted: 04/06/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Adult nephropathy is mainly caused by idiopathic membranous nephropathy (IMN). In cases of proteinuria, Modified Ponticelli Regimens (MPR) are often successful. However, it can cause adverse side effects. Oral Sanqi Qushi Granule (SQG) with MPR is effective in patients with IMN. However, whether it can improve the remission rate of IMN and shorten the remission time is unknown. In this trial, SQG with MPR on IMN will be evaluated clinically for its efficacy and safety. METHODS We will randomly assign IMN patients who meet the criteria to receives SQG plus cyclical Cyclophosphamide (CTX)/steroids or with placebo plus cyclical CTX/steroids for 6 months. A 12-month follow-up will be conducted on them. Status of remission will be used to assess treatment efficacy. DISCUSSION This study aims to appraise whether treatment with SQG plus cyclical CTX/steroids is superior to placebo plus cyclical CTX/steroids in the remission rate of patients with adult IMN. Adverse events of SQG plus MPR will be also evaluated for further researches about Chinese Medicine and MPR on whether it can improve the remission rate of IMN in half a year and shorten the remission time and relieve adverse effects will also be clarified. TRIAL REGISTRATION Chinese Clinical Trial Registry ChiCTR2200061953 . Registered on 13 July 2022.
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Affiliation(s)
- Chuang Li
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Guangdong-Hong Kong-Macau Joint Lab On Chinese Medicine and Immune Disease Research, Guangzhou, China
- Guangdong Provincial Key Laboratory of Chinese Medicine for Prevention and Treatment of Refractory Chronic Disease, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Nephrology Department, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Wenjun Shan
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Xing Liang
- Nephrology Department, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Qinghua Zhang
- Nephrology Department, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Xindong Qin
- Nephrology Department, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Sha Jiang
- Nephrology Department, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Xiaofan Hong
- Nephrology Department, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Lijuan Wang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ping Li
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- Nephrology Department, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China
| | - Haowen Gu
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yi Wang
- The Second Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Kun Bao
- State Key Laboratory of Dampness Syndrome of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
- Guangdong-Hong Kong-Macau Joint Lab On Chinese Medicine and Immune Disease Research, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Chinese Medicine for Prevention and Treatment of Refractory Chronic Disease, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
- Nephrology Department, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, China.
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Huang WN, Chuo CY, Lin CH, Chen YM, Lin WS, Tuckwell K, Jones NS, Galanter J, Lindsay L. Serious Infection Rates Among Patients with Select Autoimmune Conditions: A Claims-Based Retrospective Cohort Study from Taiwan and the USA. Rheumatol Ther 2023; 10:387-404. [PMID: 36572758 PMCID: PMC10011274 DOI: 10.1007/s40744-022-00525-x] [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: 10/05/2022] [Accepted: 12/13/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Serious infections are an important concern for patients with autoimmune conditions. We sought to estimate serious infection rates among patients with select autoimmune conditions relative to the general population in Taiwan and the USA. METHODS This retrospective cohort study estimated setting-specific standardized serious infection incidence rates and ratios among patients with systemic lupus erythematosus, including extra-renal lupus and lupus nephritis, rheumatoid arthritis and primary membranous nephropathy, compared with the general population using insurance claims for hospitalizations between 2000 and 2013. Multivariable Cox proportional hazard models were used to estimate adjusted hazard ratios for serious infections, adjusting for age, sex, index year, prior serious infection, comorbidities and medications. RESULTS In Taiwan, serious infection rates were 22.7, 28.7, 70.6, 43.4 and 215.3 per 1000 person-years among the general population and among cohorts of patients with primary membranous nephropathy, rheumatoid arthritis, extra-renal lupus and lupus nephritis, respectively. In the USA, serious infection rates were 2.6, 9.0, 15.6, 21.0 and 63.3 per 1000 person-years among the general population and among cohorts of patients with primary membranous nephropathy, rheumatoid arthritis, extra-renal lupus and lupus nephritis, respectively. Patients had significantly higher serious infection rates than the general population in both settings, largely driven by bacterial, respiratory, urinary tract and opportunistic infections. Patients with lupus nephritis had the highest burden of serious infections relative to the general population, with 7- to 25-fold higher adjusted hazard ratios in Taiwan and the USA, respectively. CONCLUSION This study identified a significant excess serious infection burden among patients with targeted autoimmune conditions compared with the general populations in Taiwan and the USA.
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Affiliation(s)
- Wen-Nan Huang
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Business Administration, Ling-Tung University, Taichung, Taiwan
- College of Medicine National Chung Hsing University, Taichung, Taiwan
| | - Ching-Yi Chuo
- RWD Enabling Platform, Product Development Data Science, Genentech Inc, South San Francisco, CA, USA
| | - Ching-Heng Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
- Institute of Public Health and Community Medicine Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Industrial Engineering and Enterprise Information, Tunghai University, Taichung, Taiwan
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Yi-Ming Chen
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- College of Medicine National Chung Hsing University, Taichung, Taiwan
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Szu Lin
- Department of Medical Research, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Katie Tuckwell
- Early Clinical Development, Genentech Inc, South San Francisco, CA, USA
| | - Nicholas S Jones
- Early Clinical Development, Genentech Inc, South San Francisco, CA, USA
| | - Joshua Galanter
- Early Clinical Development, Genentech Inc, South San Francisco, CA, USA
- Product Development Safety, Genentech Inc, South San Francisco, CA, USA
| | - Lisa Lindsay
- RWD Enabling Platform, Product Development Data Science, Genentech Inc, South San Francisco, CA, USA.
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Vink CH, Logt AEVD, van der Molen RG, Hofstra JM, Wetzels JF. Antibody-Guided Therapy in Phospholipase A2 Receptor-Associated Membranous Nephropathy. Kidney Int Rep 2023; 8:432-441. [PMID: 36938074 PMCID: PMC10014436 DOI: 10.1016/j.ekir.2022.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction A 6-month course of cyclophosphamide (CP) and steroids is effective in primary membranous nephropathy (MN), but unappealing because of long-term side effects. We evaluated efficacy of an "antibody-guided" treatment schedule. Methods Patients with phospholipase A2 receptor (PLA2R)-related MN and high risk of progression were treated with CP 1.5 mg/kg/d and steroids in cycles of 8 weeks. Anti-PLA2R antibodies were measured by indirect immunofluorescence (IIFT) at 8, 16, and 24 weeks, and a negative test resulted in withdrawal of CP, and rapid tapering of prednisone. In patients with persistent anti-PLA2R antibodies at 24 weeks, CP was switched to mycophenolate mofetil. Treatment was repeated in patients with a relapse. Results Our analysis included 65 patients (48 males, 17 females), age 61 ± 12 years, estimated glomerular filtration rate (eGFR) 46 ml/min per 1.73 m2 (35-68), urine protein-to-creatinine ratio 7.7 grams/10 mmol creatinine (5.4-11.1) and serum albumin 20 g/l (16-26). Immunologic remission rate was 71% after 8 weeks, 86% after 16 weeks, 88% after 24 weeks, and 94% after 3 years. Twenty-seven patients (42%) had persistent clinical remission after only 8 weeks of therapy. Sixteen patients needed a second course of therapy because of immunologic or clinical relapse. Follow-up was 37 (26-58) months. Overall partial remission rate was 92%. One patient developed end-stage kidney disease. Antibody-guided therapy (ABG) was as effective as the standard 6-month course, whereas providing a lower cumulative dose of CP (11.1 [8.0-18.5] vs. 18.9 [14.2-23.6] grams). Conclusion ABG is effective, and allows individualized therapy, with many patients responding to 8 weeks of CP-based therapy.
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Affiliation(s)
- Coralien H. Vink
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Anne-Els van de Logt
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
- Correspondence: Anne-Els van de Logt, Postbus 9101, 6500 HB Nijmegen, 464, The Netherlands.
| | | | - Julia M. Hofstra
- Deptartment of Internal Medicine, Ziekenhuis Gelderse Vallei, Ede, the Netherlands
| | - Jack F.M. Wetzels
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
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Gao J, Wang S, Xu L, Wang J, Guo J, Wang H, Sun J. Computer-aided diagnosis of primary membranous nephropathy using expert system. Biomed Eng Online 2023; 22:6. [PMID: 36732817 PMCID: PMC9893592 DOI: 10.1186/s12938-023-01063-5] [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: 09/05/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The diagnosis of primary membranous nephropathy (PMN) often depends on invasive renal biopsy, and the diagnosis based on clinical manifestations and target antigens may not be completely reliable as it could be affected by uncertain factors. Moreover, different experts could even have different diagnosis results due to their different experiences, which could further impact the reliability of the diagnosis. Therefore, how to properly integrate the knowledge of different experts to provide more reliable and comprehensive PMN diagnosis has become an urgent issue. METHODS This paper develops a belief rule-based system for PMN diagnosis. The belief rule base is constructed based on the knowledge of the experts, with 9 biochemical indicators selected as the input variables. The belief rule-based system is developed of three layers: (1) input layer; (2) belief rule base layer; and (3) output layer, where 9 biochemical indicators are selected as the input variables and the diagnosis result is provided as the conclusion. The belief rule base layer is constructed based on the knowledge of the experts. The final validation was held with gold pattern clinical cases, i.e., with known and clinically confirmed diagnoses. RESULTS 134 patients are used in this study, and the proposed method is defined by its sensitivity, specificity, accuracy and area under curve (AUC), which are 98.0%, 96.9%, 97.8% and 0.93, respectively. The results of this study present a novel and effective way for PMN diagnosis without the requirement of renal biopsy. CONCLUSIONS Through analysis of the diagnosis results and comparisons with other methods, it can be concluded that the developed system could help diagnose PMN based on biochemical indicators with relatively high accuracy.
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Affiliation(s)
- Jie Gao
- grid.460018.b0000 0004 1769 9639Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Siyang Wang
- grid.410570.70000 0004 1760 6682953th Hospital, Shigatse Branch, Army Medical University (Third Military Medical University), Shigatse, China
| | - Liang Xu
- grid.460018.b0000 0004 1769 9639Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jinyan Wang
- grid.460018.b0000 0004 1769 9639Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jiao Guo
- grid.460018.b0000 0004 1769 9639Department of Scientific Research, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Haiping Wang
- grid.460018.b0000 0004 1769 9639Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Jing Sun
- grid.460018.b0000 0004 1769 9639Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Zhong H, Li HY, Zhou T, Zhong Z. Clinical efficacy and safety of rituximab with membranous nephropathy: a meta-analysis. Arch Med Sci 2023; 19:411-419. [PMID: 37034519 PMCID: PMC10074182 DOI: 10.5114/aoms.2020.99899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 08/02/2019] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Membranous nephropathy (MN) is an organ-specific autoimmune disease, and its prevalence is increasing. B lymphocytes activated by T cells produce antibodies. CD19+/CD20+ plasma cells may contribute to autoantibody and alloantibody production. Rituximab has been effective in treating MN in many clinical trials. Thus, we conducted a meta-analysis to explore the clinical efficacy and safety of rituximab with MN. MATERIAL AND METHODS We searched Embase, PubMed, Cochrane Library and ClinicalTrials.gov without language or publication date limitations. Studies were classified in high-risk, medium-risk and low-risk groups based on baseline proteinuria. Follow-up periods and different administrations of rituximab were also compared. Complete remission (CR) and partial remission (PR) were assessed to measure the efficacy of rituximab, and adverse effects were also extracted. Dichotomous data were expressed by the odds ratio (OR), and the 95% confidence intervals (95% CI) were used for the recruited studies. RESULTS Fourteen articles, including 17 studies, were included in this meta-analysis. The pooled OR of overall PR and CR remission rate was 0.58 (95% CI: 0.53-0.63; p = 0.003). No studies belonged to the low-risk group. The overall PR and CR remission rate in the medium-risk group was 0.56 (95% CI: 0.36-0.73; p = 0.57). The pooled OR of overall PR and CR remission rate in the high-risk group was 0.59 (95% CI: 0.53-0.65; p = 0.03). At the 12-month follow-up, the pooled OR of overall PR and CR remission rate was 0.51 (95% CI: 0.43-0.59; p = 0.72). At the 24-month follow-up, the pooled OR of overall PR and CR remission rate was 0.71 (95% CI: 0.48-0.86; p = 0.07). The pooled OR of efficacy of rituximab at 375 mg/m2 × 4 was 0.63 (95% CI: 0.55-0.70; p = 0.001). Rituximab was tolerated in MN, and most adverse effects were mild. The pooled OR of infusion reaction rate of rituximab was 0.25 (95% CI: 0.13-0.44; p = 0.01) in MN. The pooled OR of cardiovascular-related event rate of rituximab in MN was 0.04 (95% CI: 0.02-0.11). The pooled OR of infection rate of rituximab in MN was 0.06 (95% CI: 0.03-0.12; p < 0.00001). CONCLUSIONS Rituximab is safe and effective in MN and a promising alternative treatment. More randomized control trials and studies on the role of MN are expected.
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Affiliation(s)
- Hongzhen Zhong
- Department of Nephrology, the Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Hong-Yan Li
- Department of Nephrology, Huadu District People’s Hospital of Guangzhou, Southern Medical University, Guangzhou, China
| | - Tianbiao Zhou
- Department of Nephrology, the Second Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Zhiqing Zhong
- Department of Nephrology, the Second Affiliated Hospital of Shantou University Medical College, Shantou, China
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11
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Hemanth Kumar M, Sandhu J, Sandhu JS. Profile and primary treatment outcomes in membranous nephropathy. Saudi Med J 2022; 43:1051-1056. [PMID: 36104046 PMCID: PMC9987665 DOI: 10.15537/smj.2022.43.9.20220459] [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: 06/14/2022] [Accepted: 08/10/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To assess the clinical profile and primary treatment response and outcomes in idiopathic membranous nephropathy (IMN) patients. METHODS This study was carried out between December 2013 and January 2019 in a tertiary care hospital in North India on 2 years retrospective and 3 years prospective renal biopsy proven patients with IMN presenting with nephrotic syndrome. Basic baseline investigations carried out were urinary proteins, serum albumin, serum creatinine, other special tests wherever necessary or possible (including phospholipase A2 receptor antibodies), and different treatment regimens were offered for treatment. The patients were followed up for a minimum period of 6 months after administration of treatment. RESULTS The study was carried out in 120 patients with mean age of 43±14.6 years and male female ratio of 1.65:1. Hypertension was noted in 36%, microscopic hematuria in 13%, and mean 24 hours urinary proteinuria 10.5±3.1 gm. Complete or partial response at 6 months was observed in 57% and 34% cases to cyclophosphamide, 60% and 40% to modified Ponticelli treatment, 81% and 19% to tacrolimus, and 40% and 36% cases to rituximab. Relapse was observed in 6% of cyclophosphamide and 13% in tacrolimus groups. CONCLUSION Our results show a good and comparable response to cyclophosphamide, tacrolimus, and rituximab at 6 months of follow up. The cases which achieved complete remission had significantly lower baseline proteinuria compared to those who did not respond.
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Affiliation(s)
- M.K. Hemanth Kumar
- From the Department of Nephrology (Kumar, J. S. Sandhu); from the Department of Pathology (J. Sandhu), Dayanand Medical College and Hospital, from the Department of Pathology (J. Sandhu), Gian Sagar Medical College and Hospital, and from the Department of Nephrology (J. S. Sandhu), Satguru Partap Singh Hospital, Punjab, India.
| | - Jashan Sandhu
- From the Department of Nephrology (Kumar, J. S. Sandhu); from the Department of Pathology (J. Sandhu), Dayanand Medical College and Hospital, from the Department of Pathology (J. Sandhu), Gian Sagar Medical College and Hospital, and from the Department of Nephrology (J. S. Sandhu), Satguru Partap Singh Hospital, Punjab, India.
| | - Jasvinder S. Sandhu
- From the Department of Nephrology (Kumar, J. S. Sandhu); from the Department of Pathology (J. Sandhu), Dayanand Medical College and Hospital, from the Department of Pathology (J. Sandhu), Gian Sagar Medical College and Hospital, and from the Department of Nephrology (J. S. Sandhu), Satguru Partap Singh Hospital, Punjab, India.
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12
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El-Reshaid K, Al-Bader S, Madda JP. Long-term Rituximab Therapy in Adult Patients with Idiopathic Nephrotic Syndrome. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2022; 33:509-515. [PMID: 37929543 DOI: 10.4103/1319-2442.388185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Patients with refractory idiopathic nephrotic syndrome (INS) are at risk of infections, renal failure, and the inherent side effects of immunosuppressive therapy. In the present study, we investigated the efficacy of yearly rituximab therapy in adult patients with this syndrome over 5-10 years. In the minimal change disease group, 14 of the 15 patients had complete remission (CR) and one had partial remission (PR). Of those who achieved CR, eight patients did not require rituximab 4 years later. The patient with PR was treated in the same way as those with focal segmental glomerulosclerosis (FSGS) group and remained stable by the end of the study. In the FSGS group, rituximab therapy resulted in the amelioration of INS in nine patients, although two were non-responders (NR) and developed end-stage renal disease (ESRD). In the membranous glomerulopathy group, 36 patients had CR but two were NR and developed ESRD. Twenty (55%) of those did not require treatment after 4 years, whereas the rest maintained CR with yearly rituximab. Nine women received rituximab after the third month of pregnancy without significant adverse effects on the fetus or subsequent conception. In conclusion, rituximab is a safe, practical, and effective long-term therapy for adult patients in these three groups of INS.
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Affiliation(s)
- Kamel El-Reshaid
- Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Shaikha Al-Bader
- Department of Medicine, Nephrology Unit, Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
| | - John Patrick Madda
- Department of Pathology, Amiri Hospital, Ministry of Health, Kuwait City, Kuwait
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13
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Poggiali E, Borio G, Magnacavallo A, Vercelli A, Cervellin G. Acute chest pain and dyspnoea as clinical presentation of primary membranous nephropathy. A case report and literature review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022216. [PMID: 36300242 PMCID: PMC9686161 DOI: 10.23750/abm.v93i5.12782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 01/25/2023]
Abstract
Membranous nephropathy (MN) is the commonest cause of nephrotic syndrome (NS) in adult male patients worldwide. Most of the cases (80%) are idiopathic (primary MN, PMN), whereas about 20% are associated with autoimmune diseases, malignancies or exposures (secondary MN). PMN is a kidney-specific autoimmune glomerular disease mediated by antibodies to the M-type phospholipase A2 receptor (anti-PLA2R) (85%), thrombospondin type 1 domain containing 7A (THSD7A) (3-5%), or by other still unidentified mechanisms (10%). Most of the patients with PMN present with NS (80%). Clinical course of PMN is characterised by spontaneous remissions (40%) and relapses (15-30%). One third develop end-stage renal disease (ESRD) within 5 to 15 years from the onset. Anti-PLA2R/THSD7A antibodies levels correlate with proteinuria, clinical course, and outcomes. The treatment still remains matter of debate. Hypertension, proteinuria, and hyperlipidaemia must be treated in all patients. Immunosuppressive therapy is indicated in patients with elevated anti-PLA2R/THSD7A levels and proteinuria >3.5 g/d at diagnosis. With proper management, only 10% or less will develop ESRD over the subsequent 10 years. Here we report a case of a 34-year-old male patient with a ten-year history of asymptomatic PMN, treated with ACE-inhibitors, who presented to our emergency room for acute chest pain and exertional dyspnoea due to ESRD that required urgent dialysis. (www.actabiomedica.it).
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Affiliation(s)
- Erika Poggiali
- Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Giorgia Borio
- Emergency Department, San Raffaele Hospital IRCCS, Milan, Italy
| | | | - Andrea Vercelli
- Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
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14
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Cheng YJ, Cheng XY, Zhang YM, Wang F, Wang X, Meng LQ, Liu G, Cui Z, Zhao MH. Effects of hydroxychloroquine on proteinuria in membranous nephropathy. J Nephrol 2021; 35:1145-1157. [PMID: 34846713 DOI: 10.1007/s40620-021-01182-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/07/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Many patients with primary membranous nephropathy have severe proteinuria unresponsive to optimized renin-angiotensin-aldosterone system inhibitors (RAASi). We evaluated the efficacy and safety of hydroxychloroquine as an adjunctive agent in membranous nephropathy (MN) treatments. METHODS We prospectively recruited 126 patients with biopsy-proven primary membranous nephropathy and urinary protein 1-8 g/day while receiving optimized RAASi treatment for ≥ 3 months and well-controlled blood pressure. Forty-three patients received hydroxychloroquine and RAASi (hydroxychloroquine-RAASi group), and 83 patients received RAASi alone (RAASi group). Treatment responses, including proteinuria reduction, complete and partial remission rates, and autoantibody against phospholipase A2 receptor (anti-PLA2R) levels, were compared between the two groups at 6 months and over the long term. RESULTS At 6 months, the effective response rate (proteinuria reduction > 30%) (57.5% vs. 28.9%, P = 0.002), clinical remission rate (35.0% vs. 15.7%, P = 0.015), and percentage change in proteinuria (- 51.7% vs. - 21.9%, P < 0.001) were higher, and the rate of switching to immunosuppressants (25.0% vs. 45.8%, P = 0.027) was lower in the hydroxychloroquine-RAASi group than in the RAASi group. Hydroxychloroquine administration was an independent protective factor with an effective response (OR 0.37, P = 0.021). In the long term, the clinical remission rate was higher in the HCQ-RAASi group (62.5% vs. 38.6%, P = 0.013). Hydroxychloroquine therapy was associated with a higher rate of anti-PLA2R reduction (< 20 U/ml) (HR 0.28, P = 0.031). We observed no serious adverse events associated with hydroxychloroquine. CONCLUSIONS Hydroxychloroquine could be an option for patients with membranous nephropathy seeking to achieve proteinuria reduction and anti-PLA2R antibody reduction in addition to optimized RAASi. Randomized controlled trials are needed to confirm these findings. TRIAL REGISTRATION ChiCTR2100045947, 20210430, retrospectively registered.
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Affiliation(s)
- Yan-Jiao Cheng
- Renal Division, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China
| | - Xu-Yang Cheng
- Renal Division, Peking University First Hospital, Beijing, 100034, People's Republic of China. .,Institute of Nephrology, Peking University, Beijing, People's Republic of China. .,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China. .,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China.
| | - Yi-Miao Zhang
- Renal Division, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China
| | - Fang Wang
- Renal Division, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China
| | - Xin Wang
- Renal Division, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China
| | - Li-Qiang Meng
- Renal Division, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China
| | - Gang Liu
- Renal Division, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Beijing, 100034, People's Republic of China. .,Institute of Nephrology, Peking University, Beijing, People's Republic of China. .,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China. .,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China.
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China.,Peking-Tsinghua Center for Life Sciences, Beijing, 100871, People's Republic of China
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15
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Rapamycin attenuates PLA2R activation-mediated podocyte apoptosis via the PI3K/AKT/mTOR pathway. Biomed Pharmacother 2021; 144:112349. [PMID: 34700229 DOI: 10.1016/j.biopha.2021.112349] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/11/2021] [Accepted: 10/19/2021] [Indexed: 01/01/2023] Open
Abstract
Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in adults without diabetes. Primary MN has been associated with circulating antibodies against native podocyte antigens, including phospholipase A2 receptor (PLA2R); however, precision therapy targeting the signaling cascade of PLA2R activation is lacking. Both PLA2R and the mammalian target of rapamycin (mTOR) exist in podocytes, but the interplay between these two proteins and their roles in MN warrants further exploration. This study aimed to investigate the crosstalk between PLA2R activation and mTOR signaling in a human podocyte cell line. We demonstrated that podocyte apoptosis was induced by Group IB secretory phospholipase A2 (sPLA2IB) in a concentration- and time-dependent manner via upregulation of phosphoinositide 3-kinase (PI3K), protein kinase B (AKT), and mTOR, and inhibited by rapamycin or LY294002. Furthermore, aberrant activation of the PI3K/AKT/mTOR pathway triggers both extrinsic (caspase-8 and caspase-3) and intrinsic (Bcl-2-associated X protein [BAX], B-cell lymphoma 2 [BCL-2], cytochrome c, caspase-9, and caspase-3) apoptotic cascades in podocytes. The therapeutic implications of our findings are that strategies to reduce PLA2R activation and PI3K/AKT/mTOR pathway inhibition in PLA2R-activated podocytes help protect podocytes from apoptosis. The therapeutic potential of rapamycin shown in this study provides cellular evidence supporting the repurposing of rapamycin for MN treatment.
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16
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 735] [Impact Index Per Article: 245.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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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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18
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Chen T, Zhou Y, Chen X, Chen B, Pan J. Acute kidney injury in idiopathic membranous nephropathy with nephrotic syndrome. Ren Fail 2021; 43:1004-1011. [PMID: 34157952 PMCID: PMC8231360 DOI: 10.1080/0886022x.2021.1942913] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The impact of acute kidney injury (AKI) on the progression of renal function in idiopathic membranous nephropathy (iMN) with nephrotic syndrome (NS) patients have not yet been reported, we sought to investigate the incidence, clinical features and prognosis of AKI in iMN with NS patients and determine clinical predictors for progression from AKI to advanced chronic kidney disease (CKD) stage. METHODS We analyzed clinical and pathological data of iMN with NS patients retrospectively collected from Jan 2012 to Dec 2018. The primary renal endpoint was defined as persistent eGFR <45ml/min per 1.73 m2 more than 3 months. Comparisons of survival without primary renal endpoint were performed by Kaplan-Meier curves and log-rank test. Univariate and multivariate Cox proportional hazard models were constructed to determine independent variables associated with primary renal endpoint . RESULTS 434 iMN with NS patients were enrolled. The incidence of AKI 1 stage, AKI 2 stage and AKI 3 stage was 23.1, 4.8 and 0.7% respectively. 66 (53.2%) patients with AKI had complete renal function recovery and 42 (33.9%) patients with AKI reached primary renal endpoint. Survival without primary renal endpoint was worse in AKI patients than No AKI patients (67.1 ± 5.3 and 43.7 ± 7.3% vs 99.5 ± 0.5 and 92.5 ± 4.2% at 2 and 4 years,p < 0.001). AKI was independently associated with primary renal endpoint, with an adjusted hazard ratio(HR) of 25.1 (95%CI 7.7-82.1, p < 0.001). CONCLUSIONS AKI was usually mild and overlooked in iMN patients with NS, but it had a strong association with poor clinical outcomes and was an independent risk factor for CKD progression.
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Affiliation(s)
- Tianxin Chen
- Department of nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ying Zhou
- Department of nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xinxin Chen
- Department of nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bo Chen
- Department of nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jingye Pan
- Department of ICU, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, Zhejian province, P.R.China; Key Laboratory of Intelligent Critical Care and Life Support Research of Zhejiang Province
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19
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Yang L, Xia P, Zhou Y, Cui Q, Chen G, Zheng K, Qin Y, Li X. Characteristics and risk factors for Pneumocystis jirovecii pneumonia in patients with idiopathic membranous nephropathy. Eur J Clin Microbiol Infect Dis 2021; 40:2305-2314. [PMID: 34047874 DOI: 10.1007/s10096-021-04227-0] [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: 12/23/2020] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
Pneumocystis jirovecii pneumonia (PCP) is a life-threatening opportunistic infection in idiopathic membranous nephropathy (IMN) patients, who are treated with immunosuppressive drugs. However, the risk factors of infection and their prognosis are rarely investigated. We aimed to characterize the clinical manifestations of PCP in patients with IMN, and to understand their risk factors, so that we can provide early warnings to patients with high risk and potential poor prognosis. We conducted a retrospective observational study of IMN patients in a referral center in China, from Jan 2012 to Dec 2018. Clinical and laboratory data were collected separately at the time of IMN and PCP diagnosis. Patients with PCP were matched to those without by gender and age at a ratio of 1:4. The risk factors and prognostic factors were determined by univariate and multivariate logistic regression analysis. A total of 879 patients with IMN were included, with a median follow-up of 267 (interquartile range (IQR) 64,842) days. In total, 26 (2.96%) of them were diagnosed with PCP. The infection rate increased to 3.87% among patients who received corticosteroids, and it further increased to 5.49% in those received over 0.5mg/kg prednisone. Univariate analysis indicated that initial usage of corticosteroids, use of cyclophosphamide, reduced estimated glomerular filtration rate (eGFR), and higher 24-h proteinuria were related to the PCP susceptibility. Multivariate analysis revealed that corticosteroid treatment and reduced eGFR increased the risk of the Pneumocystis jirovecii infection. The case fatality rate of the PCP patients was 23.08%, and increased to 75% among patients requiring invasive ventilation. Univariate analysis indicated that pulmonary insufficiency, invasive ventilation, decreased eGFR, and increased lactate dehydrogenase at presentation were linked to poor prognosis. PCP is not rare in patients with IMN, especially those on corticosteroids, and presented with decreased eGFR. Considering the high case fatality rate, further studies are in need for prevention and management of these patients.
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Affiliation(s)
- Lie Yang
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.,School of Medicine, Tsinghua University, Beijing, 100091, China
| | - Peng Xia
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yangzhong Zhou
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Quexuan Cui
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Gang Chen
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Ke Zheng
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yan Qin
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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20
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Zhao Q, Dai H, Liu X, Jiang H, Liu W, Feng Z, Zhang N, Gao Y, Dong Z, Zhou X, Du J, Zhang N, Rui H, Yuan L, Liu B. Helper T Cells in Idiopathic Membranous Nephropathy. Front Immunol 2021; 12:665629. [PMID: 34093559 PMCID: PMC8173183 DOI: 10.3389/fimmu.2021.665629] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/06/2021] [Indexed: 01/09/2023] Open
Abstract
Idiopathic membranous nephropathy (IMN) is an autoimmune disease in which the immune system produces an antibody response to its own antigens due to impaired immune tolerance. Although antibodies are derived from plasma cells differentiated by B cells, the T-B cells also contribute a lot to the immune system. In particular, the subsets of helper T (Th) cells, including the dominant subsets such as Th2, Th17, and follicular helper T (Tfh) cells and the inferior subsets such as regulatory T (Treg) cells, shape the immune imbalance of IMN and promote the incidence and development of autoimmune responses. After reviewing the physiological knowledge of various subpopulations of Th cells and combining the existing studies on Th cells in IMN, the role model of Th cells in IMN was explained in this review. Finally, the existing clinical treatment regimens for IMN were reviewed, and the importance of the therapy for Th cells was highlighted.
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Affiliation(s)
- Qihan Zhao
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Haoran Dai
- Shunyi Branch, Beijing Traditional Chinese Medicine Hospital, Beijing, China
| | - Xianli Liu
- Shunyi Branch, Beijing Traditional Chinese Medicine Hospital, Beijing, China
| | - Hanxue Jiang
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Wenbin Liu
- Beijing University of Chinese Medicine, Beijing, China
| | - Zhendong Feng
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China.,Beijing Chinese Medicine Hospital Pinggu Hospital, Beijing, China
| | - Na Zhang
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Yu Gao
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Zhaocheng Dong
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China.,Beijing University of Chinese Medicine, Beijing, China
| | - Xiaoshan Zhou
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China.,Beijing University of Chinese Medicine, Beijing, China
| | - Jieli Du
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China.,Beijing University of Chinese Medicine, Beijing, China
| | - Naiqian Zhang
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China.,Beijing University of Chinese Medicine, Beijing, China
| | - Hongliang Rui
- Beijing Institute of Traditional Chinese Medicine, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Li Yuan
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong, China
| | - Baoli Liu
- Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
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21
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Zou H, Jiang F, Xu G. Effectiveness and safety of cyclophosphamide or tacrolimus therapy for idiopathic membranous nephropathy. Intern Med J 2021; 50:612-619. [PMID: 31389094 DOI: 10.1111/imj.14446] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 04/15/2019] [Accepted: 07/30/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Guidelines recommend classical combined therapy of steroid and cyclophosphamide (CYC) for patients with idiopathic membranous nephropathy (IMN), while it is associated with severe adverse effects. AIMS We conducted an observational and retrospective study to evaluate the effectiveness and safety of steroids plus tacrolimus (TAC) versus steroids plus CYC for IMN. METHODS A total of 203 kidney-biopsy-proven IMN patients was enrolled in this study. One group (n = 142) received steroid combined with intravenous CYC (750 mg/m2 body surface) and the other group (n = 61) received steroid combined with oral TAC (target blood concentration of 4-8 ng/mL). The primary outcomes were achievement of remission. The secondary end-points included incidence of adverse events, relapse rates, 24 h urinary protein (UP), serum albumin, serum creatinine and estimated glomerular filtration rate. RESULTS Over the 18-month observation period, the study suggested that the remission rates at the first 3 months were significantly higher in TAC group than in CYC group (72.1% vs 54.9%, P < 0.05). Although the cumulative incidence of serious and non-serious adverse events was not different significantly between the two groups, the incidence after first 3 months was lower in TAC group. Levels of 24-h UP and serum albumin improved in the TAC group more than in the CYC group (P < 0.05) over the observed period. CONCLUSIONS Because of its short-term effectiveness and long-term safety profile, steroid plus TAC might be a better option for IMN.
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Affiliation(s)
- Honghong Zou
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fang Jiang
- Department of Nephrology, People's Hospital of Xinyu City, Xinyu, China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Nanchang, China
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22
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Logt AEVD, Justino J, Vink CH, van den Brand J, Debiec H, Lambeau G, Wetzels JF. Anti-PLA2R1 Antibodies as Prognostic Biomarker in Membranous Nephropathy. Kidney Int Rep 2021; 6:1677-1686. [PMID: 34169209 PMCID: PMC8207302 DOI: 10.1016/j.ekir.2021.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/02/2020] [Accepted: 11/10/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction Personalized treatment for patients with membranous nephropathy requires accurate prediction of the disease course at an early stage. In this study, we evaluated the value of baseline anti–phospholipase A2 receptor (PLA2R1) antibody titer as a prognostic biomarker in patients with PLA2R1-associated membranous nephropathy. Methods In this cohort study, we included 168 patients (118 men, 50 women) referred to our nephrology center between February 1995 and November 2016. Mean age was 52 ± 13 years. There were 156 patients with new-onset disease and 12 patients with a relapse (n = 10) or recent use of immunosuppressive therapy (n = 2). We measured anti-PLA2R1 titer at baseline and analyzed progression to severe disease (30% increase of serum creatinine or start of immunosuppressive therapy) as a primary study endpoint over 60 months. Results There was a clear association between anti-PLA2R1 antibody titer and severity of the nephrotic syndrome. In univariate analysis, anti-PLA2R1 antibody titer was also associated with disease progression. However, in Cox proportional hazard models that included proteinuria and serum creatinine, anti-PLA2R1 antibody titer was no longer associated with clinical outcome. Results were similar when limiting the analysis to the patients with new-onset disease. Conclusion Our study questions the relevance of single measurement of anti-PLA2R1 antibodies at baseline as a prognostic biomarker in membranous nephropathy. Future studies are needed to determine the possible role of sequential measurements of anti-PLA2R1 antibodies as a prognostic biomarker of disease progression.
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Affiliation(s)
- Anne-Els van de Logt
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Nephrology, Nijmegen, The Netherlands
| | - Joana Justino
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, UMR7275 Valbonne Sophia Antipolis, France
| | - Coralien H Vink
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Nephrology, Nijmegen, The Netherlands
| | - Jan van den Brand
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Nephrology, Nijmegen, The Netherlands
| | - Hanna Debiec
- Institut National de la Santé et de la Recherche Médicale (INSERM), UMR-S1155, Paris, France
| | - Gérard Lambeau
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, UMR7275 Valbonne Sophia Antipolis, France
| | - Jack F Wetzels
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Nephrology, Nijmegen, The Netherlands
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23
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van de Logt AE, Wetzels JF. Rituximab Is Preferable to Cyclophosphamide for Treatment of Membranous Nephropathy: CON. KIDNEY360 2021; 2:1699-1701. [PMID: 35372989 PMCID: PMC8785842 DOI: 10.34067/kid.0001432021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/16/2021] [Indexed: 02/04/2023]
Affiliation(s)
- Anne-Els van de Logt
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack F. Wetzels
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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24
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Gauckler P, Shin JI, Alberici F, Audard V, Bruchfeld A, Busch M, Cheung CK, Crnogorac M, Delbarba E, Eller K, Faguer S, Galesic K, Griffin S, van den Hoogen MW, Hrušková Z, Jeyabalan A, Karras A, King C, Kohli HS, Mayer G, Maas R, Muto M, Moiseev S, Odler B, Pepper RJ, Quintana LF, Radhakrishnan J, Ramachandran R, Salama AD, Schönermarck U, Segelmark M, Smith L, Tesař V, Wetzels J, Willcocks L, Windpessl M, Zand L, Zonozi R, Kronbichler A. Rituximab in Membranous Nephropathy. Kidney Int Rep 2021; 6:881-893. [PMID: 33912740 PMCID: PMC8071613 DOI: 10.1016/j.ekir.2020.12.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 12/14/2022] Open
Abstract
Membranous nephropathy (MN) is the most common cause of primary nephrotic syndrome among adults. The identification of phospholipase A2 receptor (PLA2R) as target antigen in most patients changed the management of MN dramatically, and provided a rationale for B-cell depleting agents such as rituximab. The efficacy of rituximab in inducing remission has been investigated in several studies, including 3 randomized controlled trials, in which complete and partial remission of proteinuria was achieved in approximately two-thirds of treated patients. Due to its favorable safety profile, rituximab is now considered a first-line treatment option for MN, especially in patients at moderate and high risk of deterioration in kidney function. However, questions remain about how to best use rituximab, including the optimal dosing regimen, a potential need for maintenance therapy, and assessment of long-term safety and efficacy outcomes. In this review, we provide an overview of the current literature and discuss both strengths and limitations of "the new standard."
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Affiliation(s)
- Philipp Gauckler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, Seoul, Korea
- Division of Pediatric Nephrology, Severance Children's Hospital, Seoul, Korea
- Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Korea
| | - Federico Alberici
- Nephrology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Vincent Audard
- Department of Nephrology and Transplantation, Rare French Disease Centre "Idiopathic Nephrotic syndrome", Henri-Mondor/Albert-Chenevier Hospital Assistance Publique-Hôpitaux de Paris, Inserm U955, Team 21, Paris-East University, Créteil, France
| | - Annette Bruchfeld
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Renal Medicine, CLINTEC, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Martin Busch
- Department of Internal Medicine III, University Hospital Jena, Friedrich-Schiller-University, Jena, Germany
| | - Chee Kay Cheung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- John Walls Renal Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Matija Crnogorac
- Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Elisa Delbarba
- Nephrology Unit, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Kathrin Eller
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
- Institut National de la Santé et de la Recherche Médicale, U1048 (Institut des Maladies Cardiovasculaires et Métaboliques-équipe 12), Toulouse, France
| | - Kresimir Galesic
- Department of Nephrology and Dialysis, Dubrava University Hospital, Zagreb, Croatia
| | - Siân Griffin
- Department of Nephrology and Transplantation, University Hospital of Wales, Cardiff, UK
| | | | - Zdenka Hrušková
- Department of Nephrology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Anushya Jeyabalan
- Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Alexandre Karras
- Service de Néphrologie, Hôpital Européen-Georges Pompidou, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Catherine King
- Department of Renal Medicine, Queen Elizabeth Hospital, University Hospitals Birmingham, Edgbaston, Birmingham, UK
| | - Harbir Singh Kohli
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gert Mayer
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Rutger Maas
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Masahiro Muto
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
| | - Sergey Moiseev
- Tareev Clinic of Internal Diseases, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Balazs Odler
- Clinical Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ruth J. Pepper
- University College London Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Luis F. Quintana
- Department of Nephrology and Renal Transplantation, Hospital Clínic, Centro de Referencia en Enfermedad Glomerular Compleja del Sistema Nacional de Salud (CSUR), Department of Medicine, University of Barcelona, IDIBAPS, Barcelona, Spain
| | - Jai Radhakrishnan
- Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Raja Ramachandran
- Nephrology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Alan D. Salama
- University College London Department of Renal Medicine, Royal Free Hospital, London, UK
| | - Ulf Schönermarck
- Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, Munich, Germany
| | - Mårten Segelmark
- Department of Clinical Sciences Lund, University, Skane University Hospital, Nephrology Lund, Lund, Sweden
| | - Lee Smith
- The Cambridge Centre for Sport and Exercise Science, Anglia Ruskin University, Cambridge, UK
| | - Vladimír Tesař
- Department of Nephrology, 1st Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jack Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lisa Willcocks
- Department of Renal Medicine, Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Martin Windpessl
- Department of Internal Medicine IV, Section of Nephrology, Klinikum Wels-Grieskirchen, Wels, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Reza Zonozi
- Division of Nephrology, Vasculitis and Glomerulonephritis Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
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25
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Lutz J. Pathophysiology, diagnosis, and treatment of membranous nephropathy. Nephrol Ther 2021; 17S:S1-S10. [PMID: 33910688 DOI: 10.1016/j.nephro.2021.03.001] [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: 02/24/2020] [Accepted: 03/23/2021] [Indexed: 11/20/2022]
Abstract
Nephrotic syndrome is in adult patients mainly due to membranous nephropathy (MN) characterized by thickening of the glomerular basement membrane (GBM) and immune complex formation between podocytes and the GBM. Autoantibodies directed against the M-type phospholipase A2 receptor (PLA2R) and thrombospondin 1 domain-containing 7 A (THSD7A) can be used as diagnostic biomarkers. THSD7A seems to be of direct pathogenic significance as is suggested by experimental models and plasmapheresis in humans. Recently, further antigens like NELL-1 (neural tissue encoding protein with EGF-like repeats-1), exostosin 1 and 2 have been discovered. Thus, MN should be classified into antibody positive and antibody negative MN. More specific immunosuppressive treatments directed against B-cells and antibody production like rituximab have been introduced in addition to already existing immunosuppressive protocols including steroids, chlorambucil, cyclophosphamide, and calcineurin inhibitors. Antibody removal using immunoadsorption or plasmapheresis leads to short-term reduction in proteinuria and might be indicated only in patients with very severe proteinuria and complications. Studies are needed to identify a more specific immunosuppression directed against the production and effects of autoantibodies in order to protect the kidneys from autoimmune mediated tissue damage and to identify patients who require an immunosuppressive treatment, as the remission rate is high in patients with MN.
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Affiliation(s)
- Jens Lutz
- Medical Clinic, Nephrology-Infectious Diseases, Central Rhine hospital group, Gemeinschaftsklinikum Mittelrhein, Koblenzer Straße 115-155, 56073 Koblenz, Germany.
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26
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Yanai H, Yoshida H. Secondary dyslipidemia: its treatments and association with atherosclerosis. Glob Health Med 2021; 3:15-23. [PMID: 33688591 PMCID: PMC7936375 DOI: 10.35772/ghm.2020.01078] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/01/2020] [Accepted: 12/07/2020] [Indexed: 04/15/2023]
Abstract
Dyslipidemia is classified into primary and secondary types. Primary dyslipidemia is basically inherited and caused by single or multiple gene mutations that result in either overproduction or defective clearance of triglycerides and cholesterol. Secondary dyslipidemia is caused by unhealthy lifestyle factors and acquired medical conditions, including underlying diseases and applied drugs. Secondary dyslipidemia accounts for approximately 30-40% of all dyslipidemia. Secondary dyslipidemia should be treated by finding and addressing its causative diseases or drugs. For example, treatment of secondary dyslipidemia, such as hyperlipidemia due to hypothyroidism, by using statin without controlling hypothyroidism, may lead to myopathy and serious adverse events such as rhabdomyolysis. Differential diagnosis of secondary dyslipidemia is very important for safe and effective treatment. Here, we describe an overview about diseases and drugs that interfere with lipid metabolism leading to secondary dyslipidemia. Further, we show the association of each secondary dyslipidemia with atherosclerosis and the treatments for such dyslipidemia.
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Affiliation(s)
- Hidekatsu Yanai
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan
- Address correspondence to:Hidekatsu Yanai, Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine Kohnodai Hospital, 1-7-1 Kohnodai, Ichikawa, Chiba 272- 8516, Japan. E-mail:
| | - Hiroshi Yoshida
- Department of Laboratory Medicine, The Jikei University Kashiwa Hospital, Chiba, Japan
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27
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Hacking S, Bijol V. Deep learning for the classification of medical kidney disease: a pilot study for electron microscopy. Ultrastruct Pathol 2021; 45:118-127. [PMID: 33583322 DOI: 10.1080/01913123.2021.1882628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Artificial intelligence (AI) is a new frontier and often enigmatic for medical professionals. Cloud computing could open up the field of computer vision to a wider medical audience and deep learning on the cloud allows one to design, develop, train and deploy applications with ease. In the field of histopathology, the implementation of various applications in AI has been successful for whole slide images rich in biological diversity. However, the analysis of other tissue medias, including electron microscopy, is yet to be explored. The present study aims to evaluate deep learning for the classification of medical kidney disease on electron microscopy images: amyloidosis, diabetic glomerulosclerosis, membranous nephropathy, membranoproliferative glomerulonephritis (MPGN), and thin basement membrane disease (TBMD). We found good overall classification with the MedKidneyEM-v1 Classifier and when looking at normal and diseased kidneys, the average area under the curve for precision and recall was 0.841. The average area under the curve for precision and recall on the disease only cohort was 0.909. Digital pathology will shape a new era for medical kidney disease and the present study demonstrates the feasibility of deep learning for electron microscopy. Future approaches could be used by renal pathologists to improve diagnostic concordance, determine therapeutic strategies, and optimize patient outcomes in a true clinical environment.
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Affiliation(s)
- Sean Hacking
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Northwell, Manhasset, New York, USA
| | - Vanesa Bijol
- Department of Pathology and Laboratory Medicine, Donald and Barbara Zucker School of Medicine at Northwell, Manhasset, New York, USA
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28
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Zhang C, Duan S, Guo M, Yuan Y, Huang Z, Zhu J, Sun B, Zhang B, Xing C. Effects of CYP3A5 Polymorphisms on Efficacy and Safety of Tacrolimus Therapy in Patients with Idiopathic Membranous Nephropathy. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2020; 13:141-149. [PMID: 32368128 PMCID: PMC7186213 DOI: 10.2147/pgpm.s247892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 03/31/2020] [Indexed: 12/18/2022]
Abstract
Background Tacrolimus (TAC) is beneficial for patients with idiopathic membranous nephropathy (IMN). It has a narrow therapeutic concentration range and many factors influence TAC blood concentration. CYP3A5 is the most important enzyme in TAC metabolism. The aim of this study was to analyze the effects of CYP3A5 gene polymorphisms on the efficacy and safety of TAC in IMN patients. Patients and Methods Patients with IMN who received oral TAC (0.05-0.075mg/kg/day) combined with prednisone (0.5mg/kg/day) from March 2016 to October 2018 were included. The data of clinical characteristics, therapeutic drugs and adverse reactions of patients were collected at baseline and during 24 weeks of treatment. Patients were divided into two groups according to different CYP3A5 genetic polymorphisms. The significant differences in the efficacy and side effects between the two groups were analyzed. Results A total of 76 patients who completed follow-up were divided into CYP3A5 nonexpresser (CYP3A5*3/*3) group and CYP3A5 expresser (CYP3A5 *1/*3) group. The significant association between the CYP3A5 phenotype and TAC metabolism was observed. A total of 43 case-times patients exhibited adverse effects. The infection rate in CYP3A5 nonexpresser group (21.95%) was remarkably higher than the rate in CYP3A5 expresser group (5.71%). Blood concentration and C0/D levels were risk factors for adverse events through logistic regression analysis. There was no statistical difference between the study groups with respect to the efficacy. Conclusion Our results demonstrated that CYP3A5 polymorphisms had important guiding roles in the treatment of IMN with tacrolimus. CYP3A5 expressers required higher daily doses of TAC to achieve the target drug concentration, but with fewer side effects. CYP3A5 genetic polymorphism might be used for TAC dosing adjustment to optimize the treatment for patients with IMN.
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Affiliation(s)
| | | | - Miao Guo
- Department of Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, People's Republic of China
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29
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Chen S, Ren S, Wang AY, Tran H, Li Z, Cheng X, Liu M, Li G, Wang L, Hong D. Comparison of the efficacy and safety of tacrolimus monotherapy and cyclophosphamide combined with glucocorticoid in the treatment of adult primary membranous nephropathy: protocol of a multicenter, randomized, controlled, open study. Trials 2020; 21:219. [PMID: 32093742 PMCID: PMC7041116 DOI: 10.1186/s13063-020-4144-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 02/05/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) remains the leading cause of adult nephrotic syndrome. Immunosuppressive therapy with cyclophosphamide (CTX) is often successful in reducing proteinuria, but its use is associated with severe side effects. Tacrolimus (TAC) is effective in achieving complete remission (CR) in patients with IMN. However, whether it is as effective as CTX in inducing and maintaining complete or partial remission in these patients is unknown. This trial aims to test TAC monotherapy for its non-inferiority to CTX in inducing long-term remission of proteinuria. METHODS Patients with biopsy-proven IMN with nephrotic syndrome will be randomized into a 12-month treatment period with oral TAC of 0.05-0.1 mg/kg/day for 6 months or with CTX + glucocorticoid. The efficacy of the treatment will be assessed by the remission status (based on changes in proteinuria) and relapse rate. DISCUSSION This study will test whether treatment with TAC monotherapy is superior to CTX with glucocorticoid in inducing long-term remission of proteinuria in patients with adult IMN. The role of serum anti-PLA2R antibodies in the early assessment of the response to therapy using different therapeutic regimens will also be clarified. TRIAL REGISTRATION ClinicalTrials.gov ChiCTR1800016140. Registered 12 June 2017. http://www.chictr.org.cn.
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Affiliation(s)
- Shasha Chen
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Song Ren
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Amanda Y Wang
- Renal and Metabolic Division, The George institute for global health, Sydney, Australia.,The Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Hieu Tran
- Department of Medicine, Ryde Hospital, Sydney, Australia
| | - Zheng Li
- Renal Department, Chengdu First People's Hospital, Chengdu, 610041, China
| | - Xiaoyun Cheng
- Renal department, Chengdu Second People's Hospital, Chengdu, 610017, China
| | - Manli Liu
- Renal department, Chengdu Third People's Hospital, Chengdu, 610031, China
| | - Guisen Li
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Li Wang
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China
| | - Daqing Hong
- Renal Division and Institute of Nephrology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Medical School of University of Electronic Science and Technology of China, Chengdu, 610072, China.
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30
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Zaghrini C, Seitz-Polski B, Justino J, Dolla G, Payré C, Jourde-Chiche N, Van de Logt AE, Booth C, Rigby E, Lonnbro-Widgren J, Nystrom J, Mariat C, Cui Z, Wetzels JFM, Ghiggeri G, Beck LH, Ronco P, Debiec H, Lambeau G. Novel ELISA for thrombospondin type 1 domain-containing 7A autoantibodies in membranous nephropathy. Kidney Int 2020; 95:666-679. [PMID: 30784662 DOI: 10.1016/j.kint.2018.10.024] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 09/18/2018] [Accepted: 10/11/2018] [Indexed: 11/28/2022]
Abstract
Autoantibodies against phospholipase A2 receptor 1 (PLA2R1) and thrombospondin type 1 domain-containing 7A (THSD7A) are emerging as biomarkers to classify membranous nephropathy (MN) and to predict outcome or response to treatment. Anti-THSD7A autoantibodies are detected by Western blot and indirect immunofluorescence test (IIFT). Here, we developed a sensitive enzyme-linked immunosorbent assay (ELISA) optimized for quantitative detection of anti-THSD7A autoantibodies. Among 1012 biopsy-proven MN patients from 6 cohorts, 28 THSD7A-positive patients were identified by ELISA, indicating a prevalence of 2.8%. By screening additional patients, mostly referred because of PLA2R1-unrelated MN, we identified 21 more cases, establishing a cohort of 49 THSD7A-positive patients. Twenty-eight patients (57%) were male, and male patients were older than female patients (67 versus 49 years). Eight patients had a history of malignancy, but only 3 were diagnosed with malignancy within 2 years of MN diagnosis. We compared the results of ELISA, IIFT, Western blot, and biopsy staining, and found a significant correlation between ELISA and IIFT titers. Anti-THSD7A autoantibodies were predominantly IgG4 in all patients. Eight patients were double positive for THSD7A and PLA2R1. Levels of anti-THSD7A autoantibodies correlated with disease activity and with response to treatment. Patients with high titer at baseline had poor clinical outcome. In a subgroup of patients with serial titers, persistently elevated anti-THSD7A autoantibodies were observed in patients who did not respond to treatment or did not achieve remission. We conclude that the novel anti-THSD7A ELISA can be used to identify patients with THSD7A-associated MN and to monitor autoantibody titers during treatment.
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Affiliation(s)
- Christelle Zaghrini
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, UMR7275 Valbonne Sophia Antipolis, France
| | - Barbara Seitz-Polski
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, UMR7275 Valbonne Sophia Antipolis, France; Laboratoire d'Immunologie, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France; Service de Néphrologie, Centre Hospitalier Universitaire de Nice, Université Côte d'Azur, Nice, France
| | - Joana Justino
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, UMR7275 Valbonne Sophia Antipolis, France
| | - Guillaume Dolla
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, UMR7275 Valbonne Sophia Antipolis, France
| | - Christine Payré
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, UMR7275 Valbonne Sophia Antipolis, France
| | - Noémie Jourde-Chiche
- Aix-Marseille Université, Centre Recherche en Cardiovasculaire et Nutrition, Institut National de la Recherche Agronomique 1260, Institut National de la Santé et de la Recherche Médicale 1263, Marseille, France; Assistance Publique-Hôpitaux de Marseille, Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, Marseille, France
| | - Anne-Els Van de Logt
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Caroline Booth
- Evelina London Children's Hospital, Lambeth, London, United Kingdom
| | - Emma Rigby
- Evelina London Children's Hospital, Lambeth, London, United Kingdom
| | - Jennie Lonnbro-Widgren
- Institute of Medicine, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Jenny Nystrom
- Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Christophe Mariat
- Service de Néphrologie Dialyse, Transplantation Rénale, Hôpital Nord, Lyon, France; CHU de Saint-Etienne, GIMAP, EA 3065, Université Jean Monnet, Saint-Etienne, Comue Université de Lyon, Lyon, France
| | - Zhao Cui
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Jack F M Wetzels
- Department of Nephrology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - GianMarco Ghiggeri
- Division of Nephrology, Dialysis and Transplantation, Laboratory of Molecular Nephrology, G. Gaslini Children Hospital, Genoa, Italy
| | - Laurence H Beck
- Renal Section, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Pierre Ronco
- Sorbonne Université, Université Pierre et Marie Curie, Université Paris 6, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche_S1155, Paris, France; Service de Néphrologie et Dialyses, Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - Hanna Debiec
- Sorbonne Université, Université Pierre et Marie Curie, Université Paris 6, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche_S1155, Paris, France
| | - Gérard Lambeau
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, UMR7275 Valbonne Sophia Antipolis, France.
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Zou H, Jiang F, Xu G. Effectiveness and safety of cyclophosphamide or tacrolimus therapy for idiopathic membranous nephropathy. Ren Fail 2020; 41:673-681. [PMID: 31354007 PMCID: PMC6711082 DOI: 10.1080/0886022x.2019.1637758] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: Guidelines recommend combined therapy of glucocorticoid and cyclophosphamide (CYC) for patients with idiopathic membranous nephropathy (IMN), while it is associated with severe adverse effects. We conducted a retrospective study to evaluate the effectiveness and safety of glucocorticoid plus tacrolimus (TAC) for IMN. Methods: Two hundred and three kidney-biopsy-proven IMN patients were enrolled in this study. One group (n = 142) received glucocorticoid combined with intravenous CYC (750 mg/m2 body surface) and the other group (n = 61) received glucocorticoid combined with oral TAC (target blood concentration of 4–8 ng/mL). The primary outcomes were achievement of remission and incidence of adverse events. The secondary end points included relapse rates, 24 h urinary protein (UP), serum albumin, serum creatinine and estimated glomerular filtration rate. Results: Over the 18-month observation period, the study suggested that the remission rates at the first 3 months were significantly higher in TAC group than in CYC group (72.1% versus 54.9%, p < .05). Although the cumulative incidence of serious and non-serious adverse events was not different significantly between the two groups, the incidence after first 3 months was lower in TAC group. 24hUP and serum albumin improved in TAC group more than the CYC group (p < .05) over the observed period. Conclusion: Because of its short-term effectiveness and long-term safety profile, glucocorticoid plus TAC might be a better option for IMN.
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Affiliation(s)
- Honghong Zou
- a Department of Nephrology, the Second Affiliated Hospital of Nanchang University , Nanchang , China
| | - Fang Jiang
- b Department of Nephrology, People's Hospital of Xinyu City , Xinyu , China
| | - Gaosi Xu
- a Department of Nephrology, the Second Affiliated Hospital of Nanchang University , Nanchang , China
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Maifata SM, Hod R, Zakaria F, Abd Ghani F. Primary Membranous Glomerulonephritis: The Role of Serum and Urine Biomarkers in Patient Management. Biomedicines 2019; 7:E86. [PMID: 31683874 PMCID: PMC6966460 DOI: 10.3390/biomedicines7040086] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 10/30/2019] [Accepted: 10/30/2019] [Indexed: 12/19/2022] Open
Abstract
The detection of phospholipase A2 receptor (PLA2R) and thrombospondin domain containing 7A THSD7A among primary membranous glomerulonephritis (MGN) patients transformed the diagnosis, treatment monitoring, and prognosis. Anti-PLA2R can be detected in 70-90% of primary MGN patients while anti-THSD7A in 2-3% of anti-PLA2R negative primary MGN patients depending on the technique used. Serum and urine samples are less invasive and non-invasive, respectively, and thus can detect the presence of anti-PLA2R and anti-THSD7A with higher sensitivity and specificity, which is significant in patient monitoring and prognosis. It is better than exposing patients to a frequent biopsy, which is an invasive procedure. Different techniques of detection of PLA2R and THSD7A in patients' urine and sera were reviewed to provide newer and alternative techniques. We proposed the use of biomarkers (PLA2R and THSD7A) in the diagnosis, treatment decision, and follow-up of patients with primary MGN. In addition, other prognostic renal biomarkers like retinol binding protein (RBP) and beta-2 microglobulin were reviewed to detect the progression of renal damage for early intervention.
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Affiliation(s)
- Sadiq Mu'azu Maifata
- Histopathology Unit, Department of Pathology, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Serdang, Selangor 43400, Malaysia.
- Physiology Unit, Department of Anatomy, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Serdang, Selangor 43400, Malaysia.
- Department of Physiology, Faculty of Basic Medical Science, College of Medicine, Federal University Lafia, Lafia, Nasarawa 950102, Nigeria.
| | - Rafidah Hod
- Physiology Unit, Department of Anatomy, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Serdang, Selangor 43400, Malaysia.
| | - Fadhlina Zakaria
- Nephrology Unit, Department of Medicine, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Serdang, Selangor 43400, Malaysia.
| | - Fauzah Abd Ghani
- Histopathology Unit, Department of Pathology, Faculty of Medicine and Health Science, Universiti Putra Malaysia, Serdang, Selangor 43400, Malaysia.
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Abstract
Accounting for about 20 to 50% of cases of primary nephrotic syndrome, membranous nephropathy (MN) is the leading cause of nephrotic syndrome in adults. A rat model created nearly 60 years ago to research the primary MN disorder, Heymann nephritis, has provided us with a plethora of important information. Recently, our knowledge about MN has dramatically progressed. Heymann nephritis and human MN are now known to share a high degree of similarity in pathogenesis. This review summarizes our current understanding of MN pathogenesis while focusing particularly on the immunological aspects.
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Affiliation(s)
- Shin'ichi Akiyama
- Division of Nephrology, Department of Internal Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Hyōgo, Japan
| | - Shoichi Maruyama
- Division of Nephrology, Department of Internal Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Tang Z, Wang Y, Tao L, Guo Y, Zheng Y, Zheng D. The elevated levels of urinary angiotensinogen are correlated with the severity of idiopathic membranous nephropathy. BMC Nephrol 2018; 19:357. [PMID: 30541470 PMCID: PMC6291953 DOI: 10.1186/s12882-018-1165-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 11/29/2018] [Indexed: 12/27/2022] Open
Abstract
Background Immunosuppressive treatment will predispose an idiopathic membranous nephropathy (iMN) patient to opportunistic infections. Disease severity is one of the main concerns for making the treatment decision. Urinary angiotensinogen (UAGT) level has been shown highly correlated with intrarenal renin-angiotensin system (RAS) activity and severity of chronic kidney diseases (CKD). We aimed to test the relationship between the UAGT level and the severity of iMN. Methods This cross-sectional study included a total of 48 biopsy-proven iMN patients, 46 minimal change disease (MCD) patients, and 44 healthy volunteers. The clinical and laboratory data and urine samples were collected from all subjects before the use of RAS inhibitors. We determined the UAGT levels with a method of enzyme-linked immunosorbent assay. Results The UAGT levels were not different between the iMN (277.05 ± 61.25, μg/g.Cr) and MCD patients (244.19 ± 40.24, μg/g.Cr), but both of them were significantly higher than those of healthy controls (6.85 ± 1.10, μg/g.Cr). UAGT levels were correlated negatively with serum albumin (r = − 0.393, p = 0.006) and estimated glomerular filtration rate (eGFR) (r = − 0.352, p = 0.014) and positively with 24-h proteinuria (r = 0.614, p < 0.001) in iMN patients but not in MCD patients. Multivariate linear regression analysis revealed that only proteinuria independently determinate the levels of UAGT (β = 0.649, p < 0.001) in iMN patients. Conclusions UAGT levels were correlated negatively with serum albumin and glomerular filtration rate and positively with proteinuria in iMN patients at the onset. This suggests that elevated levels of UAGT are associated with the severity of iMN. The UAGT level may be used as a cofactor for deciding immunosuppressive therapy in iMN patient.
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Affiliation(s)
- Ziyong Tang
- Department of Nephrology, Peking University Third Hospital, No. 49, North Garden Road, Haidian District, Beijing, 100191, China
| | - Yue Wang
- Department of Nephrology, Peking University Third Hospital, No. 49, North Garden Road, Haidian District, Beijing, 100191, China
| | - Liyuan Tao
- Department of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
| | - Yanhong Guo
- Department of Nephrology, Peking University Third Hospital, No. 49, North Garden Road, Haidian District, Beijing, 100191, China
| | - Yimu Zheng
- Department of Nephrology, Peking University Third Hospital, No. 49, North Garden Road, Haidian District, Beijing, 100191, China
| | - Danxia Zheng
- Department of Nephrology, Peking University Third Hospital, No. 49, North Garden Road, Haidian District, Beijing, 100191, China.
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Kanigicherla DAK, Hamilton P, Czapla K, Brenchley PE. Intravenous pulse cyclophosphamide and steroids induce immunological and clinical remission in New-incident and relapsing primary membranous nephropathy. Nephrology (Carlton) 2018; 23:60-68. [PMID: 27778424 DOI: 10.1111/nep.12955] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Revised: 09/19/2016] [Accepted: 10/11/2016] [Indexed: 11/30/2022]
Abstract
AIM Primary membranous nephropathy is associated with progression to end stage renal diseasein some patients. Standard therapy with cyclical cyclophosphamide and corticosteroids can be associated with significant adverse effects. We aimed to assess immunological and clinical response with intravenous pulse cyclophosphamide and oral steroids in patients with severe nephrotic syndrome - in a prospective observational cohort study. METHODS A total of 17 consecutive patients (nine new-incident and eight relapses) with severe nephrotic syndrome received monthly intravenous pulse cyclophosphamide and oral steroids after failure to achieve remission with supportive therapy. Immunosuppressive therapy was discontinued at 6 months or earlier if proteinuria regressed to <100 mg/mmol and patients were followed for 12 months. Achievement of partial remission was primary outcome; changes in clinical parameters and anti-PLA2 R were secondary outcomes. RESULTS Dose of cyclophosphamide received was 5.4 g in New-incident patients and 4.2 g in patients with relapses. All 17 patients achieved partial remission within 6 months: proteinuria improved from 656 to 102 mg/mmol at 6 months and 55 mg/mmol at 12 months (P < 0.001); eGFR improved from 31 to 48 mL/min per 1.73 m2 at 6 months and 45 mL/min per 1.73 m2 at 12 months (P < 0.05). Anti-PLA2 R levels reduced from 244 to 10 U/L at 6 months and 10 U/L at 12 months (P < 0.001). Two out of nine patients in the New-incident group developed subsequent relapse. Cumulative doses of cyclophosphamide and steroids that patients received was about half of the standard regime. CONCLUSION Pulse cyclophosphamide with oral steroids induced immunological and clinical partial remission at significantly reduced doses in primary membranous nephropathy.
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Affiliation(s)
- Durga Anil K Kanigicherla
- Manchester Institute of Nephrology and Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Patrick Hamilton
- Manchester Institute of Nephrology and Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Krystyna Czapla
- Manchester Institute of Nephrology and Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Paul Ec Brenchley
- Manchester Institute of Nephrology and Transplantation, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Membranous Nephropathy and Anti-Podocytes Antibodies: Implications for the Diagnostic Workup and Disease Management. BIOMED RESEARCH INTERNATIONAL 2018; 2018:6281054. [PMID: 29511687 PMCID: PMC5817285 DOI: 10.1155/2018/6281054] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 08/31/2017] [Accepted: 10/15/2017] [Indexed: 12/11/2022]
Abstract
The discovery of circulating antibodies specific for native podocyte antigens has transformed the diagnostic workup and greatly improved management of idiopathic membranous nephropathy (iMN). In addition, their identification has clearly characterized iMN as a largely autoimmune disorder. Anti-PLA2R1 antibodies are detected in approximately 70% to 80% and anti-THSD7A antibodies in only 2% of adult patients with iMN. The presence of anti-THSD7A antibodies is associated with increased risk of malignancy. The assessment of PLA2R1 and THSD7A antigen expression in glomerular immune deposits has a better sensitivity than measurement of the corresponding autoantibodies. Therefore, in the presence of circulating anti-podocytes autoantibodies and/or enhanced expression of PLA2R1 and THSD7A antigens MN should be considered as primary MN (pMN). Anti-PLA2R1 or anti-THSD7A autoantibodies have been proposed as biomarkers of autoimmune disease activity and their blood levels should be regularly monitored in pMN to evaluate disease activity and predict outcomes. We propose a revised clinical workup flow for patients with MN that recommends assessment of kidney biopsy for PLA2R1 and THSD7A antigen expression, screening for circulating anti-podocytes antibodies, and assessment for secondary causes, especially cancer, in patients with THSD7A antibodies. Persistence of anti-podocyte antibodies for 6 months or their increase in association with nephrotic proteinuria should lead to the introduction of immunosuppressive therapies. Recent data have reported the efficacy and safety of new specific therapies targeting B cells (anti-CD20 antibodies, inhibitors of proteasome) in pMN which should lead to an update of currently outdated treatment guidelines.
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Traditional Chinese Medicine for Refractory Nephrotic Syndrome: Strategies and Promising Treatments. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2018; 2018:8746349. [PMID: 29507594 PMCID: PMC5817219 DOI: 10.1155/2018/8746349] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/03/2017] [Indexed: 12/18/2022]
Abstract
Refractory nephrotic syndrome (RNS) is an immune-related kidney disease with poor clinical outcomes. Standard treatments include corticosteroids as the initial therapy and other immunosuppressants as second-line options. A substantial proportion of patients with RNS are resistant to or dependent on immunosuppressive drugs and often experience unremitting edema and proteinuria, cycles of remission and relapse, and/or serious adverse events due to long-term immunosuppression. Traditional Chinese medicine has a long history of treating complicated kidney diseases and holds great potential for providing effective treatments for RNS. This review describes the Chinese medical theories relating to the pathogenesis of RNS and discusses the strategies and treatment options using Chinese herbal medicine. Available preclinical and clinical evidence strongly supports the integration of traditional Chinese medicine and Western medicine for improving the outcome of RNS. Herbal medicine such as Astragalus membranaceus, Stephania tetrandra S. Moore, and Tripterygium wilfordii Hook F can serve as the alternative therapy when patients fail to respond to immunosuppression or as the complementary therapy to improve therapeutic efficacy and reduce side effects of immunosuppressive agents. Wuzhi capsules (Schisandra sphenanthera extract) with tacrolimus and tetrandrine with corticosteroids are two herb-drug combinations that have shown great promise and warrant further studies.
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Dobronravov VA, Mayer DA, Berezhnaya OV, Lapin SV, Mazing AV, Sipovsky VG, Smirnov AV. [Membranous nephropathy in a Russian population]. TERAPEVT ARKH 2017; 89:21-29. [PMID: 28745685 DOI: 10.17116/terarkh201789621-29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To analyze the clinical and morphological manifestations of membranous nephropathy (MN) and to evaluate the efficiency of its therapy. MATERIAL AND METHODS MN cases in 2009 to 2016 were retrospectively detected with a subsequent analysis of patients with primary MN (PMN). The titer of IgG-autoantibodies to phospholipase A2 receptor (anti-PLA2R Ab) was determined by an indirect immunofluorescence assay. Treatment outcomes, such as the time course of changes in proteinuria, nephrotic syndrome (NS), and the development of complete and partial remissions (CR and PR), were assessed. RESULTS MN was detected in 201 cases; the secondary etiology of the disease was established in 24.9%. The prevalence of MN among morphologically confirmed glomerulopathies was 14%; that of PMN was 10.4%. The median period to diagnosis PMN was 8 (5; 19) months. 150 patients with PMN (66.7% were men; age was 50±15 years) were distributed according to the following morphological stages: Stages I (23.9%), II (48.5%), III (26.1%), and IV (1.5%). Elevated anti-PLA2R Ab levels were found in 51.6% of cases; NS in the presence of proteinuria was detected in 85.6% of patients. An estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2 was seen in 25% of cases. Treatment outcomes were evaluated in 80 cases; the median follow-up period was 19 (8; 40) months. 68% of cases had CR (32%) or PR (36%) with a median follow-up of 26 (13; 44) months. Spontaneous CRs or PRs were observed in 7.5% of the patients. Multivariate analysis showed that the probability of CR or PR increased 3.2-fold in the use of cyclophosphamide and/or cyclosporine and decreased as eGFR dropped. CONCLUSION In Russia, PMN is a common type of glomerulopathy, the specific features of which should include the low rates of spontaneous remissions and detection of anti-PLA2R Abs. For renal protection, the majority of patients with PMN require timely diagnosis and treatment; individualization of the choice of treatment and its enhanced efficiency call for further investigations.
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Affiliation(s)
- V A Dobronravov
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - D A Mayer
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - O V Berezhnaya
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - S V Lapin
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - A V Mazing
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - V G Sipovsky
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
| | - A V Smirnov
- I.P. Pavlov First Saint Petersburg State Medical University, Ministry of Health of Russia, Saint Petersburg, Russia
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Cattran D, Brenchley P. Membranous nephropathy: thinking through the therapeutic options. Nephrol Dial Transplant 2017; 32:i22-i29. [PMID: 28391348 DOI: 10.1093/ndt/gfw404] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 10/18/2016] [Indexed: 11/13/2022] Open
Abstract
Idiopathic membranous nephropathy (IMN) remains the most common cause of the nephrotic syndrome in adults and one of the leading identifiable causes of end-stage kidney disease. Prior to considering the best approach to treatment, three important components need to be considered. First, the natural history of the typical membranous patient today; second, the importance of identifying the causative factors; and third, the integration of the current data on the known autoantibody/antigen systems involved in IMN into the diagnosis and management of the patient. Combining this with information on the known indicators associated with a poor prognosis plus new data on surrogate markers that provide important clues that the treatment plan is correct has provided us with a more secure platform for choosing the right treatment for each patient. This already provides a more rational and precise approach to the use of our current therapeutic options. Even today, we can slow disease progression and in the future new approaches and new therapies are likely to lead to prevention of progression or even reversal of the injury in IMN, thereby leading to improved quality of life of our patients.
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Affiliation(s)
- Daniel Cattran
- Department of Nephrology, University of Toronto, Toronto General Hospital, Toronto, Ontario, Cananda
| | - Paul Brenchley
- Department of Renal Medicine, University of Manchester, Manchester, UK
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Xu NX, Xie QH, Sun ZX, Wang J, Li Y, Wang L, Liu SJ, Xue J, Hao CM. Renal Phospholipase A2 Receptor and the Clinical Features of Idiopathic Membranous Nephropathy. Chin Med J (Engl) 2017; 130:892-898. [PMID: 28397717 PMCID: PMC5407034 DOI: 10.4103/0366-6999.204096] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: According to the renal phospholipase A2 receptor (PLA2R) immunohistochemistry, idiopathic membranous nephropathy (iMN) could be categorized into PLA2R-associated and non-PLA2R-associated iMN. This study aimed to examine whether the non-PLA2R-associated iMN had any difference in clinical features compared with PLA2R-associated iMN. Methods: A total of 231 adult patients diagnosed as iMN were recruited to this retrospective study. Renal PLA2R expression was examined by immunofluorescence. Among these patients, 186 (80.5%) with complete baseline clinical data were used for further study. Urinary protein excretion, serum albumin, and creatinine were analyzed. For those patients with follow-up longer than 1 year, the relationship between PLA2R and response to immunosuppressants were analyzed. The t-test was used for parametric analysis and the Mann-Whitney U-test was used for nonparametric analysis. Categorical variables were described as frequencies or percentages, and the data were analyzed with Pearson's Chi-square test or Fisher's exact test. Results: Of the 231 iMN patients, 189 showed renal detectable PLA2R expression (81.8%). The baseline serum creatinine, serum albumin, and urine protein excretion were not significantly different between PLA2R-associated (n = 145) and non-PLA2R-associated iMN patients (n = 41). However, about 1/3 of the non-PLA2R-associated iMN had abnormal serological tests, significantly more common than PLA2R-associated iMN (31.7% vs. 8.3%, P = 0.000). The non-PLA2R-associated iMN had lower C4 levels compared with PLA2R-associated iMN (P = 0.004). The non-PLA2R-associated iMN patients also showed a better response to immunosuppressants (complete remission [CR] 42.9%; partial remission [PR] 14.3%) compared with PLA2R-associated iMN (CR 3.2%; PR 48.4%, P = 0.004) at the 3rd month. Conclusions: There were no significant differences in serum creatinine, albumin, and urine protein excretion between PLA2R-associated and non-PLA2R-associated iMN, while the non-PLA2R-associated iMN patients showed more abnormal serological tests. The non-PLA2R-associated iMN seemed to respond more quickly to the immunosuppressive therapy compared with PLA2R-associated iMN.
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Affiliation(s)
- Ning-Xin Xu
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Qiong-Hong Xie
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Zhu-Xing Sun
- Department of Nephrology, Wuxi People's Hospital, Wuxi, Jiangsu 214023, China
| | - Jia Wang
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Yan Li
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Liang Wang
- Department of Nephrology, Wuxi People's Hospital, Wuxi, Jiangsu 214023, China
| | - Shao-Jun Liu
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jun Xue
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Chuan-Ming Hao
- Department of Nephrology, Huashan Hospital, Fudan University, Shanghai 200040, China
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Abstract
In patients with membranous nephropathy, alkylating agents (cyclophosphamide or chlorambucil) alone or in combination with steroids achieve remission of nephrotic syndrome more effectively than conservative treatment or steroids alone, but can cause myelotoxicity, infections, and cancer. Calcineurin inhibitors can improve proteinuria, but are nephrotoxic. Most patients relapse after treatment withdrawal and can become treatment dependent, which increases the risk of nephrotoxicity. The discovery of nephritogenic autoantibodies against podocyte M-type phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain- containing protein 7A (THSD7A) antigens provides a clear pathophysiological rationale for interventions that specifically target B-cell lineages to prevent antibody production and subepithelial deposition. The anti-CD20 monoclonal antibody rituximab is safe and achieves remission of proteinuria in approximately two-thirds of patients with membranous nephropathy. In those with PLA2R-related disease, remission can be predicted by anti-PLA2R antibody depletion and relapse by antibody re-emergence into the circulation. Thus, integrated evaluation of serology and proteinuria could guide identification of affected patients and treatment with individually tailored protocols. Nonspecific and toxic immunosuppressive regimens will fall out of use. B-cell modulation by rituximab and second-generation anti-CD20 antibodies (or plasma cell-targeted therapy in anti-CD20 resistant forms of disease) will lead to a novel therapeutic paradigm for patients with membranous nephropathy.
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42
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Abstract
Membranous nephropathy (MN) is a unique glomerular lesion that is the most common cause of idiopathic nephrotic syndrome in nondiabetic white adults. About 80% of cases are renal limited (primary MN, PMN) and 20% are associated with other systemic diseases or exposures (secondary MN). This review focuses only on PMN. Most cases of PMN have circulating IgG4 autoantibody to the podocyte membrane antigen PLA2R (70%), biopsy evidence PLA2R staining indicating recent immunologic disease activity despite negative serum antibody levels (15%), or serum anti-THSD7A (3%-5%). The remaining 10% without demonstrable anti-PLA2R/THSd7A antibody or antigen likely have PMN probably secondary to a different, still unidentified, anti-podocyte antibody. Considerable clinical and experimental data now suggests these antibodies are pathogenic. Clinically, 80% of patients with PMN present with nephrotic syndrome and 20% with non-nephrotic proteinuria. Untreated, about one third undergo spontaneous remission, especially those with absent or low anti-PLA2R levels, one-third progress to ESRD over 10 years, and the remainder develop nonprogressive CKD. Proteinuria can persist for months after circulating anti-PLA2R/THSD7A antibody is no longer detectable (immunologic remission). All patients with PMN should be treated with supportive care from the time of diagnosis to minimize protein excretion. Patients with elevated anti-PLA2R/THSD7A levels and proteinuria >3.5 g/d at diagnosis, and those who fail to reduce proteinuria to <3.5 g after 6 months of supportive care or have complications of nephrotic syndrome, should be considered for immunosuppressive therapy. Accepted regimens include steroids/cyclophosphamide, calcineurin inhibitors, and B cell depletion. With proper management, only 10% or less will develop ESRD over the subsequent 10 years.
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Affiliation(s)
- William G Couser
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
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43
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van den Brand JAJG, Ruggenenti P, Chianca A, Hofstra JM, Perna A, Ruggiero B, Wetzels JFM, Remuzzi G. Safety of Rituximab Compared with Steroids and Cyclophosphamide for Idiopathic Membranous Nephropathy. J Am Soc Nephrol 2017; 28:2729-2737. [PMID: 28487395 DOI: 10.1681/asn.2016091022] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 03/29/2017] [Indexed: 12/13/2022] Open
Abstract
Guidelines recommend steroid plus cyclical cyclophosphamide (St-Cp) therapy for patients with idiopathic membranous nephropathy at high risk of progression to ESRD. Rituximab (Rtx) may be a safer alternative. In this retrospective, observational cohort study, we compared time to any adverse event (primary outcome); serious or nonserious events; partial and complete remission of the nephrotic syndrome; and a composite of doubling of serum creatinine, ESRD, or death between 100 Rtx-treated patients and 103 patients who received daily St-Cp We monitored patients with standardized protocols and adjusted for baseline characteristics by Cox regression. Over a median follow-up of 40 months, the Rtx group had significantly fewer adverse events than the St-Cp group (63 versus 173; P<0.001), both serious (11 versus 46; P<0.001) and nonserious (52 versus 127; P<0.001). Cumulative incidence of any first (35.5% versus 69.0%; P<0.001), serious (16.4% versus 30.2%; P=0.002), or nonserious (23.6% versus 60.8%; P<0.001) event was significantly lower with Rtx Adjusted hazard ratios (95% confidence intervals) between Rtx and St-Cp groups were 0.27 (0.16 to 0.44) for any first adverse event, 0.32 (0.15 to 0.68) for serious adverse events, and 0.23 (0.13 to 0.41) for nonserious adverse events. Although the cumulative incidence of partial remission was lower in the Rtx group, rates of complete remission and the composite renal end point did not differ significantly between groups. Because of its superior safety profile, we suggest that Rtx might replace St-Cp as first-line immunosuppressive therapy in patients with idiopathic membranous nephropathy and nephrotic syndrome.
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Affiliation(s)
| | - Piero Ruggenenti
- Unit of Nephrology, Azienda Socio Sanitaria Territoriale Ospedale Papa Giovanni XXIII, Bergamo, Italy; and.,IRCCS - Instituto di Ricerche Farmacologiche "Mario Negri", Department of Renal Medicine, Clinical Research Center for Rare Diseases "Ado e Cele Daccò", Ranica, Bergamo, Italy
| | - Antonietta Chianca
- IRCCS - Instituto di Ricerche Farmacologiche "Mario Negri", Department of Renal Medicine, Clinical Research Center for Rare Diseases "Ado e Cele Daccò", Ranica, Bergamo, Italy
| | - Julia M Hofstra
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Annalisa Perna
- IRCCS - Instituto di Ricerche Farmacologiche "Mario Negri", Department of Renal Medicine, Clinical Research Center for Rare Diseases "Ado e Cele Daccò", Ranica, Bergamo, Italy
| | - Barbara Ruggiero
- IRCCS - Instituto di Ricerche Farmacologiche "Mario Negri", Department of Renal Medicine, Clinical Research Center for Rare Diseases "Ado e Cele Daccò", Ranica, Bergamo, Italy
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Giuseppe Remuzzi
- Unit of Nephrology, Azienda Socio Sanitaria Territoriale Ospedale Papa Giovanni XXIII, Bergamo, Italy; and .,IRCCS - Instituto di Ricerche Farmacologiche "Mario Negri", Department of Renal Medicine, Clinical Research Center for Rare Diseases "Ado e Cele Daccò", Ranica, Bergamo, Italy
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44
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Recent Treatment Advances and New Trials in Adult Nephrotic Syndrome. BIOMED RESEARCH INTERNATIONAL 2017; 2017:7689254. [PMID: 28553650 PMCID: PMC5434278 DOI: 10.1155/2017/7689254] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/12/2017] [Indexed: 12/13/2022]
Abstract
The etiology of nephrotic syndrome is complex and ranges from primary glomerulonephritis to secondary forms. Patients with nephrotic syndrome often need immunosuppressive treatment with its side effects and may progress to end stage renal disease. This review focuses on recent advances in the treatment of primary causes of nephrotic syndrome (idiopathic membranous nephropathy (iMN), minimal change disease (MCD), and focal segmental glomerulosclerosis (FSGS)) since the publication of the KDIGO guidelines in 2012. Current treatment recommendations are mostly based on randomized controlled trials (RCTs) in children, small RCTs, or case series in adults. Recently, only a few new RCTs have been published, such as the Gemritux trial evaluating rituximab treatment versus supportive antiproteinuric and antihypertensive therapy in iMN. Many RCTs are ongoing for iMN, MCD, and FSGS that will provide further information on the effectiveness of different treatment options for the causative disease. In addition to reviewing recent clinical studies, we provide insight into potential new targets for the treatment of nephrotic syndrome from recent basic science publications.
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Early initiation of immunosuppressive treatment in membranous nephropathy patients. J Formos Med Assoc 2017; 116:266-275. [PMID: 28202222 DOI: 10.1016/j.jfma.2017.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 12/22/2016] [Accepted: 01/12/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND/PURPOSE Suggestion for the management of idiopathic membranous nephropathy (IMN) includes 6 months of observation, followed with steroid plus alkylating agent. However, delayed immunosuppression exposes the kidneys to persistent damage. This study aimed to examine the benefit of early immunosuppression in IMN patients. METHODS A retrospective study was performed. From 1993 to 2013, 161 IMN patients were enrolled. Patients receiving immunosuppression within 6 months after diagnosis were classified as initial-treatment group, whereas other patients as initial-no-treatment group. The clinical outcomes and complication were examined. RESULT Patients in the initial-treatment group had lower serum albumin concentration, less diabetes, and were younger. Steroid monotherapy is the main immunosuppression (64.5%) in this group. The initial-treatment group had a higher complete and partial remission rate than the initial-no-treatment group 6 months (52.9% vs. 35.0%, p=0.05) and 12 months (71.1% vs. 45.0%, p=0.003) after diagnosis. A similar result was seen between initial-steroid monotherapy and initial-no-treatment patients. Early immunosuppression is an independent predictor of remission within 1 year [hazard ratio (HR)=2.09; 95% confidence interval (CI)=1.25-3.49; p=0.005] and estimated glomerular filtration rate (eGFR) decline over 50% during the follow-up. (HR=0.33; 95% CI=0.13-0.86; p=0.02). The initial-treatment group also had a low frequency of eGFR decline over 50% (p=0.001) and low combined end-stage renal disease/mortality (p=0.001) compared with the initial-no-treatment group, but without more immunosuppression-related complication. CONCLUSION In contrast to Western countries, early immunosuppression (even steroid monotherapy) in our patients is associated with better remission in the 1st year and renal preserve. Further randomized controlled trials are needed to clarify the benefit of early immunosuppression in IMN patients, especially with oriental ethnic background.
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46
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Cattran DC, Brenchley PE. Membranous nephropathy: integrating basic science into improved clinical management. Kidney Int 2017; 91:566-574. [PMID: 28065518 DOI: 10.1016/j.kint.2016.09.048] [Citation(s) in RCA: 127] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 08/26/2016] [Accepted: 09/08/2016] [Indexed: 02/08/2023]
Abstract
Idiopathic membranous nephropathy (INM) remains a common cause of the nephrotic syndrome in adults. The autoimmune nature of IMN was clearly delineated in 2009 with the identification of the glomerular-deposited IgG to be a podocyte receptor, phospholipase A2 receptor (PLA2R) in 70% to 75% of cases. This anti-PLA2R autoantibody, predominantly the IgG4 subclass, has been quantitated in serum using an enzyme-linked immunosorbent assay and has been used to aid diagnosis and monitor response to immunosuppressive therapy. In 2014, a second autoantigen, thrombospondin type 1 domain-containing 7A (THSD7A), was identified. Immunostaining of biopsy specimens has further detected either PLA2R or THSD7A antigen in the deposited immune complexes in 5% to 10% of cases autoantibody seronegative at the time of biopsy. Therefore, the term IMN should now be superseded by the term primary or autoimmune MN (AMN) (anti-PLA2R or anti-THSD7A positive) classifying ∼80% to 90% of cases previously designated IMN. Cases of secondary MN associated with other diseases show much lower association with these autoantibodies, but their true incidence in secondary cases still needs to be defined. How knowledge of the autoimmune mechanism and the sequential measurement of these autoantibodies is likely to change the clinical management and trajectory of AMN by more precisely defining its diagnosis, prognosis, and treatment is discussed. Their application early in the disease course to new and old therapies will provide additional precision to AMN management. We also review innovative therapeutic approaches on the horizon that are expected to lead to our ultimate goal of improved patient care in A(I)MN.
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Affiliation(s)
- Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada.
| | - Paul E Brenchley
- Renal Research Labs, Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
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Ayar Y, Ersoy A, Isiktas E, Ocakoglu G, Yildiz A, Oruc A, Demirayak D, Bayrakci I, Duger H, Bozbudak T. The analysis of patients with primary and secondary glomerular diseases: A single-center experience. Int J Organ Transplant Med 2016. [DOI: 10.1016/j.hkjn.2016.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
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48
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van de Logt AE, Hofstra JM, Wetzels JF. Pharmacological treatment of primary membranous nephropathy in 2016. Expert Rev Clin Pharmacol 2016; 9:1463-1478. [DOI: 10.1080/17512433.2016.1225497] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Anne-Els van de Logt
- Radboud Institute for Health Sciences, Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Julia M. Hofstra
- Radboud Institute for Health Sciences, Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jack F. Wetzels
- Radboud Institute for Health Sciences, Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
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49
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Dahan K, Debiec H, Plaisier E, Cachanado M, Rousseau A, Wakselman L, Michel PA, Mihout F, Dussol B, Matignon M, Mousson C, Simon T, Ronco P. Rituximab for Severe Membranous Nephropathy: A 6-Month Trial with Extended Follow-Up. J Am Soc Nephrol 2016; 28:348-358. [PMID: 27352623 DOI: 10.1681/asn.2016040449] [Citation(s) in RCA: 242] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 05/22/2016] [Indexed: 01/25/2023] Open
Abstract
Randomized trials of rituximab in primary membranous nephropathy (PMN) have not been conducted. We undertook a multicenter, randomized, controlled trial at 31 French hospitals (NCT01508468). Patients with biopsy-proven PMN and nephrotic syndrome after 6 months of nonimmunosuppressive antiproteinuric treatment (NIAT) were randomly assigned to 6-month therapy with NIAT and 375 mg/m2 intravenous rituximab on days 1 and 8 (n=37) or NIAT alone (n=38). Median times to last follow-up were 17.0 (interquartile range, 12.5-24.0) months and 17.0 (interquartile range, 13.0-23.0) months in NIAT-rituximab and NIAT groups, respectively. Primary outcome was a combined end point of complete or partial remission of proteinuria at 6 months. At month 6, 13 (35.1%; 95% confidence interval [95% CI], 19.7 to 50.5) patients in the NIAT-rituximab group and eight (21.1%; 95% CI, 8.1 to 34.0) patients in the NIAT group achieved remission (P=0.21). Rates of antiphospholipase A2 receptor antibody (anti-PLA2R-Ab) depletion in NIAT-rituximab and NIAT groups were 14 of 25 (56%) and one of 23 (4.3%) patients at month 3 (P<0.001) and 13 of 26 (50%) and three of 25 (12%) patients at month 6 (P=0.004), respectively. Eight serious adverse events occurred in each group. During the observational phase, remission rates before change of assigned treatment were 24 of 37 (64.9%) and 13 of 38 (34.2%) patients in NIAT-rituximab and NIAT groups, respectively (P<0.01). Positive effect of rituximab on proteinuria remission occurred after 6 months. These data suggest that PLA2R-Ab levels are early markers of rituximab effect and that addition of rituximab to NIAT does not affect safety.
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Affiliation(s)
- Karine Dahan
- Department of Nephrology and Dialysis, Assistance Publique Hôpitaux de Paris, Hôpital Tenon, Paris, France;
| | - Hanna Debiec
- Sorbonne Universités, Université Pierre et Marie Curie Paris 06, Paris, France.,Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1155, Paris, France
| | - Emmanuelle Plaisier
- Department of Nephrology and Dialysis, Assistance Publique Hôpitaux de Paris, Hôpital Tenon, Paris, France.,Sorbonne Universités, Université Pierre et Marie Curie Paris 06, Paris, France.,Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1155, Paris, France
| | - Marine Cachanado
- Department of Clinical Pharmacology and Unité de Recherche Clinique, Assistance Publique Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Alexandra Rousseau
- Department of Clinical Pharmacology and Unité de Recherche Clinique, Assistance Publique Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Laura Wakselman
- Department of Clinical Pharmacology and Unité de Recherche Clinique, Assistance Publique Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Pierre-Antoine Michel
- Department of Nephrology and Dialysis, Assistance Publique Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - Fabrice Mihout
- Department of Nephrology and Dialysis, Assistance Publique Hôpitaux de Paris, Hôpital Tenon, Paris, France
| | - Bertrand Dussol
- Department of Nephrology and Transplantation, Assistance Publique-Hôpitaux de Marseille, Hôpital de la Timone, Marseille, France
| | - Marie Matignon
- Department of Nephrology and Transplantation, Assistance Publique Hôpitaux de Paris, Hôpital Henri Mondor, Creteil, France; and
| | - Christiane Mousson
- Department of Nephrology and Transplantation, Centre Hospitalier Universitaire, Dijon, France
| | - Tabassome Simon
- Department of Clinical Pharmacology and Unité de Recherche Clinique, Assistance Publique Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
| | - Pierre Ronco
- Department of Nephrology and Dialysis, Assistance Publique Hôpitaux de Paris, Hôpital Tenon, Paris, France; .,Sorbonne Universités, Université Pierre et Marie Curie Paris 06, Paris, France.,Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 1155, Paris, France
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50
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Abstract
Most glomerulonephritides, even the more common types, are rare diseases. They are nevertheless important since they frequently affect young people, often cannot be cured, and can lead to chronic kidney disease, including end-stage renal failure, with associated morbidity and cost. For example, in young adults, IgA nephropathy is the most common cause of end-stage renal disease. In this Seminar, we summarise existing knowledge of clinical signs, pathogenesis, prognosis, and treatment of glomerulonephritides, with a particular focus on data published between 2008 and 2015, and the most common European glomerulonephritis types, namely IgA nephropathy, membranous glomerulonephritis, minimal change disease, focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis, and the rare complement-associated glomerulonephritides such as dense deposit disease and C3 glomerulonephritis.
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Affiliation(s)
- Jürgen Floege
- Department of Nephrology and Clinical Immunology, University Hospital, Rheinisch Westfälische Technische Hochschule Aachen, Aachen, Germany.
| | - Kerstin Amann
- Department of Nephropathology, Department of Pathology, University of Erlangen-Nürnberg, Erlangen, Germany
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