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Dharnidharka VR, Scobell RR, Kallash M, Davies AJG, Marchesani N, Maltenfort MG, Walther L, Kelton M, Bock M, Blanchette E, Stone HK, Gluck C, Hullekes F, Riella LV, Smoyer WE, Mitsnefes M, Dixon BP, Flynn JT, Somers MJG, Forrest CB, Furth S, Denburg MR. Clinical characteristics and favorable treatment responses of recurrent focal segmental glomerulosclerosis or steroid-resistant nephrotic syndrome in children after kidney transplantation. Pediatr Nephrol 2024:10.1007/s00467-024-06452-z. [PMID: 39001911 DOI: 10.1007/s00467-024-06452-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 06/17/2024] [Accepted: 06/18/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Recurrence of focal segmental glomerulosclerosis (FSGS) or steroid-resistant nephrotic syndrome (SRNS) after kidney transplant leads to significant morbidity and potentially earlier allograft loss. To date however, reported rates, risk factors and treatment outcomes have varied widely. METHODS We applied computational phenotypes to a multicenter aggregation of electronic health records data from 7 large pediatric health systems in the USA, to identify recurrence rates, risk factors, and treatment outcomes. We refined the data collection by chart review. RESULTS From > 7 million patients, we compared children with primary FSGS/SRNS who received a kidney transplant between 2009 and 2020 and who either developed recurrence (n = 67/165; 40.6%) or did not (n = 98/165). Serum albumin level at time of transplant was significantly lower and recipient HLA DR7 presence was significantly higher in the recurrence group. By 36 months post-transplant, complete remission occurred in 58.2% and partial remission in 17.9%. Through 6 years post-transplant, no remission after recurrence was associated with an increased risk of allograft loss over time (p < 0.0001), but any remission showed similar allograft survival and function decline to those with no recurrence. Since treatments were used in non-random fashion, using spline curves and multivariable non-linear analyses, complete + partial remission chance was significantly higher with greater plasmapheresis sessions, CTLA4-Ig doses or LDL-apheresis sessions. Only treatment with anti-CD20, CTLA4-Ig agents, or LDL-apheresis sessions were associated with complete remission. Excluding 25 patients with mutations did not significantly change our results. CONCLUSIONS Our contemporary high-risk cohort had higher favorable response rates than most prior reports, from combinations of agents.
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Affiliation(s)
- Vikas R Dharnidharka
- Washington University School of Medicine and St. Louis Children's Hospital, Room NWT 10-119, CB 8116, 660 South Euclid Avenue, St. Louis, MO, 63110, USA.
| | | | - Mahmoud Kallash
- Department of Pediatrics, The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | | | | | | | - Leslie Walther
- Washington University School of Medicine and St. Louis Children's Hospital, Room NWT 10-119, CB 8116, 660 South Euclid Avenue, St. Louis, MO, 63110, USA
| | - Megan Kelton
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Margret Bock
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Eliza Blanchette
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Hillarey K Stone
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | - William E Smoyer
- Department of Pediatrics, The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Mark Mitsnefes
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bradley P Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Joseph T Flynn
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | - Susan Furth
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michelle R Denburg
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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2
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Raina R, Jothi S, Haffner D, Somers M, Filler G, Vasistha P, Chakraborty R, Shapiro R, Randhawa PS, Parekh R, Licht C, Bunchman T, Sethi S, Mangat G, Zaritsky J, Schaefer F, Warady B, Bartosh S, McCulloch M, Alhasan K, Swiatecka-Urban A, Smoyer WE, Chandraker A, Yap HK, Jha V, Bagga A, Radhakrishnan J. Post-transplant recurrence of focal segmental glomerular sclerosis: consensus statements. Kidney Int 2024; 105:450-463. [PMID: 38142038 DOI: 10.1016/j.kint.2023.10.017] [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: 12/22/2021] [Revised: 10/03/2023] [Accepted: 10/17/2023] [Indexed: 12/25/2023]
Abstract
Focal segmental glomerular sclerosis (FSGS) is 1 of the primary causes of nephrotic syndrome in both pediatric and adult patients, which can lead to end-stage kidney disease. Recurrence of FSGS after kidney transplantation significantly increases allograft loss, leading to morbidity and mortality. Currently, there are no consensus guidelines for identifying those patients who are at risk for recurrence or for the management of recurrent FSGS. Our work group performed a literature search on PubMed/Medline, Embase, and Cochrane, and recommendations were proposed and graded for strength of evidence. Of the 614 initially identified studies, 221 were found suitable to formulate consensus guidelines for recurrent FSGS. These guidelines focus on the definition, epidemiology, risk factors, pathogenesis, and management of recurrent FSGS. We conclude that additional studies are required to strengthen the recommendations proposed in this review.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA; Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Swathi Jothi
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Dieter Haffner
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Michael Somers
- Division of Nephrology, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Guido Filler
- Department of Pediatrics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada; Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Prabhav Vasistha
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Ronith Chakraborty
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA; Department of Nephrology, Akron Children's Hospital, Akron, Ohio, USA
| | - Ron Shapiro
- Recanati/Miller Transplantation Institute, The Mount Sinai Medical Center, New York, New York, USA
| | - Parmjeet S Randhawa
- Department of Pathology, Thomas E Starzl Transplant Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rulan Parekh
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christopher Licht
- Division of Pediatric Nephrology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Timothy Bunchman
- Pediatric Nephrology and Transplantation, Children's Hospital of Richmond at Virginia Commonwealth University (VCU), Richmond, Virginia, USA
| | - Sidharth Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Guneive Mangat
- Department of Nephrology, Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, Ohio, USA
| | - Joshua Zaritsky
- Division of Pediatric Nephrology, Nemours, A.I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Franz Schaefer
- Department of Pediatric Nephrology, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Bradley Warady
- Division of Nephrology, University of Missouri-Kansas City School of Medicine, Children's Mercy, Kansas City, Missouri, USA
| | - Sharon Bartosh
- Department of Pediatrics, University of Wisconsin Medical School, Madison, Wisconsin, USA
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Khalid Alhasan
- Nephrology Unit, Pediatrics Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Pediatric Kidney Transplant Division, Organ Transplant Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Agnieszka Swiatecka-Urban
- University of Virginia Children's Hospital, University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - William E Smoyer
- Center for Clinical and Translational Research and Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Anil Chandraker
- Transplantation Research Center, Kidney and Pancreas Transplantation, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hui Kim Yap
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Khoo Teck Puat-National University Children's Medical Institute, National University Hospital, Singapore, Singapore
| | - Vivekanand Jha
- George Institute for Global Health, University of New South Wales (UNSW), New Delhi, India; School of Public Health, Imperial College, London, UK; Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Arvind Bagga
- Division of Pediatric Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Jai Radhakrishnan
- Department of Medicine (Nephrology), Columbia University Medical Center, New York, New York, USA.
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Ma S, Qiu Y, Zhang C. Cytoskeleton Rearrangement in Podocytopathies: An Update. Int J Mol Sci 2024; 25:647. [PMID: 38203817 PMCID: PMC10779434 DOI: 10.3390/ijms25010647] [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: 11/22/2023] [Revised: 12/14/2023] [Accepted: 01/01/2024] [Indexed: 01/12/2024] Open
Abstract
Podocyte injury can disrupt the glomerular filtration barrier (GFB), leading to podocytopathies that emphasize podocytes as the glomerulus's key organizer. The coordinated cytoskeleton is essential for supporting the elegant structure and complete functions of podocytes. Therefore, cytoskeleton rearrangement is closely related to the pathogenesis of podocytopathies. In podocytopathies, the rearrangement of the cytoskeleton refers to significant alterations in a string of slit diaphragm (SD) and focal adhesion proteins such as the signaling node nephrin, calcium influx via transient receptor potential channel 6 (TRPC6), and regulation of the Rho family, eventually leading to the disorganization of the original cytoskeletal architecture. Thus, it is imperative to focus on these proteins and signaling pathways to probe the cytoskeleton rearrangement in podocytopathies. In this review, we describe podocytopathies and the podocyte cytoskeleton, then discuss the molecular mechanisms involved in cytoskeleton rearrangement in podocytopathies and summarize the effects of currently existing drugs on regulating the podocyte cytoskeleton.
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Affiliation(s)
| | | | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China; (S.M.); (Y.Q.)
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Gong X, Huang J, Zhang Y, Wang F, Wang X, Meng L, Cheng X, Liu G, Cui Z, Zhao M. Patients with primary focal segmental glomerulosclerosis with detectable urinary CD80 are more similar to patients with minimal change disease in clinicopathological features. Ren Fail 2023; 45:2279642. [PMID: 37942512 PMCID: PMC10653691 DOI: 10.1080/0886022x.2023.2279642] [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: 02/23/2023] [Accepted: 10/31/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Focal segmental glomerulosclerosis (FSGS) is an important cause of refractory nephrotic syndrome (NS) in children and adults. Urinary CD80 is elevated in some patients with primary FSGS, however, its clinical value is not fully clarified. This study aims to evaluate the clinical and pathological significance of urinary CD80 in patients with primary FSGS. METHODS Sixty-one adult patients with biopsy-proven primary FSGS, with standard treatment and long-term follow up, were enrolled retrospectively. Urinary CD80, on the day of kidney biopsy, was measured using commercial ELISA kits and adjusted by urinary creatinine excretion. Their associations with clinical and pathological parameters were investigated. RESULTS Urinary CD80 was detectable in 30/61 (49.2%) patients, who presented with a higher level of proteinuria (10.7 vs. 5.8 g/24h; p = 0.01), a lower level of serum albumin (19.3 ± 3.9 vs. 24.2 ± 8.2 g/L; p = 0.005), a higher prevalence of hematuria (70.0 vs. 38.7%; p = 0.01), and showed a lower percentage of segmental glomerulosclerosis lesion [4.8 (3.7-14.0) vs. 9.1 (5.6-21.1) %; p = 0.06]. The cumulative relapse rate was remarkably high in these patients (log-rank, p = 0.001). Multivariate analysis identified that the elevated urinary CD80 was an independent risk factor for steroid-dependent NS (OR 8.81, 95% CI 1.41-54.89; p = 0.02) and relapse (HR, 2.87; 95% CI 1.29-6.38; p = 0.01). CONCLUSIONS The elevated urinary CD80 is associated with mild pathological change and steroid-dependent cases of primary FSGS adults, which indicates these patients are more similar to minimal change disease (MCD) in clinicopathological features.
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Affiliation(s)
- Xiaojie Gong
- Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Beijing, China
| | - Jing Huang
- Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Beijing, China
| | - Yimiao Zhang
- Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Beijing, China
| | - Fang Wang
- Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Beijing, China
| | - Xin Wang
- Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Beijing, China
| | - Liqiang Meng
- Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Beijing, China
| | - Xuyang Cheng
- Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Beijing, China
| | - Gang Liu
- Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Beijing, China
| | - Zhao Cui
- Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Beijing, China
| | - Minghui Zhao
- Renal Division, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Disease, Ministry of Health of China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China; Beijing, China
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5
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Hayward S, Parmesar K, Saleem MA. What is circulating factor disease and how is it currently explained? Pediatr Nephrol 2023; 38:3513-3518. [PMID: 36952039 PMCID: PMC10514121 DOI: 10.1007/s00467-023-05928-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/15/2023] [Accepted: 02/20/2023] [Indexed: 03/24/2023]
Abstract
Nephrotic syndrome (NS) consists of the clinical triad of hypoalbuminaemia, high levels of proteinuria and oedema, and describes a heterogeneous group of disease processes with different underlying drivers. The existence of circulating factor disease (CFD) as a driver of NS has been epitomised by a subset of patients who exhibit disease recurrence after transplantation, alongside laboratory work. Several circulating factors have been proposed and studied, broadly grouped into protease components such as soluble urokinase-type plasminogen activator (suPAR), hemopexin (Hx) and calcium/calmodulin-serine protease kinase (CASK), and other circulating proteases, and immune components such as TNF-α, CD40 and cardiotrophin-like cytokine-1 (CLC-1). While currently there is no definitive way of assessing risk of CFD pre-transplantation, promising work is emerging through the study of 'multi-omic' bioinformatic data from large national cohorts and biobanks.
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Affiliation(s)
- Samantha Hayward
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
- MRC Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Kevon Parmesar
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Moin A Saleem
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Angeletti A, Bruschi M, Kajana X, La Porta E, Spinelli S, Caridi G, Lugani F, Verrina EE, Ghiggeri GM. Biologics in steroid resistant nephrotic syndrome in childhood: review and new hypothesis-driven treatment. Front Immunol 2023; 14:1213203. [PMID: 37705972 PMCID: PMC10497215 DOI: 10.3389/fimmu.2023.1213203] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/14/2023] [Indexed: 09/15/2023] Open
Abstract
Nephrotic syndrome affects about 2-7 per 100,000 children yearly and accounts for less than 15% of end stage kidney disease. Steroids still represent the cornerstone of therapy achieving remission in 75-90% of the cases The remaining part result as steroid resistant nephrotic syndrome, characterized by the elevated risk of developing end stage kidney disease and frequently presenting disease recurrence in case of kidney transplant. The pathogenesis of nephrotic syndrome is still far to be elucidated, however, efficacy of immune treatments provided the basis to suggest the involvement of the immune system in the pathogenesis of the disease. Based on these substrates, more immune drugs, further than steroids, were administered in steroid resistant nephrotic syndrome, such as antiproliferative and alkylating agents or calcineurin inhibitors. However, such treatments failed in inducing a sustained remission. In last two decades, the developments of monoclonal antibodies, including the anti-CD20 rituximab and inhibitor of B7-1 abatacept, represented a valid opportunity of treatment. However, also the effectiveness of biologics resulted limited. We here propose a new hypothesis-driven treatment based on the combining administration of rituximab with the anti-CD38 monoclonal antibody daratumumab (NCT05704400), sustained by the hypothesis to target the entire B-cells subtypes pool, including the long-lived plasmacells.
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Affiliation(s)
- Andrea Angeletti
- Division of Nephrology, Dialysis, Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Maurizio Bruschi
- Division of Nephrology, Dialysis, Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | - Xhuliana Kajana
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Edoardo La Porta
- Division of Nephrology, Dialysis, Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Sonia Spinelli
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Gianluca Caridi
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Francesca Lugani
- Division of Nephrology, Dialysis, Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Enrico Eugenio Verrina
- Division of Nephrology, Dialysis, Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, Transplantation, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genova, Italy
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7
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Burke GW, Mitrofanova A, Fontanella A, Ciancio G, Roth D, Ruiz P, Abitbol C, Chandar J, Merscher S, Fornoni A. The podocyte: glomerular sentinel at the crossroads of innate and adaptive immunity. Front Immunol 2023; 14:1201619. [PMID: 37564655 PMCID: PMC10410139 DOI: 10.3389/fimmu.2023.1201619] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/26/2023] [Indexed: 08/12/2023] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a common glomerular disorder that manifests clinically with the nephrotic syndrome and has a propensity to recur following kidney transplantation. The pathophysiology and therapies available to treat FSGS currently remain elusive. Since the podocyte appears to be the target of apparent circulating factor(s) that lead to recurrence of proteinuria following kidney transplantation, this article is focused on the podocyte. In the context of kidney transplantation, the performance of pre- and post-reperfusion biopsies, and the establishment of in vitro podocyte liquid biopsies/assays allow for the development of clinically relevant studies of podocyte biology. This has given insight into new pathways, involving novel targets in innate and adaptive immunity, such as SMPDL3b, cGAS-STING, and B7-1. Elegant experimental studies suggest that the successful clinical use of rituximab and abatacept, two immunomodulating agents, in our case series, may be due to direct effects on the podocyte, in addition to, or perhaps distinct from their immunosuppressive functions. Thus, tissue biomarker-directed therapy may provide a rational approach to validate the mechanism of disease and allow for the development of new therapeutics for FSGS. This report highlights recent progress in the field and emphasizes the importance of kidney transplantation and recurrent FSGS (rFSGS) as a platform for the study of primary FSGS.
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Affiliation(s)
- George W. Burke
- Division of Kidney−Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Alla Mitrofanova
- Research, Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Antonio Fontanella
- Research, Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Gaetano Ciancio
- Division of Kidney−Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - David Roth
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, and the Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Phil Ruiz
- Transplant Pathology, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Carolyn Abitbol
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Jayanthi Chandar
- Division of Pediatric Kidney Transplantation, Department of Pediatrics, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Sandra Merscher
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Alessia Fornoni
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, United States
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Bertrand D, Brunel M, Lebourg L, Scemla A, Lemoine M, Amrouche L, Laurent C, Legendre C, Guerrot D, Anglicheau D, Sberro-Soussan R. Conversion From Intravenous In-Hospital Belatacept Injection to Subcutaneous Abatacept Injection in Kidney Transplant Recipients During the First COVID-19 Stay-at-Home Order in France. Transpl Int 2023; 36:11328. [PMID: 37554319 PMCID: PMC10405172 DOI: 10.3389/ti.2023.11328] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 07/05/2023] [Indexed: 08/10/2023]
Abstract
The first COVID-19 stay-at-home order came into effect in France on 17 March 2020. Immunocompromised patients were asked to isolate themselves, and outpatient clinic visits were dramatically reduced. In order to avoid visits to the hospital by belatacept-treated kidney transplant recipients (KTRs) during the initial period of the pandemic, we promptly converted 176 KTRs at two French transplant centers from once-monthly 5 mg/kg in-hospital belatacept infusion to once-weekly 125 mg subcutaneous abatacept injection. At the end of follow-up (3 months), 171 (97.16%) KTRs survived with a functioning graft, 2 (1.14%) had died, and 3 (1.70%) had experienced graft loss. Two patients (1.1%) experienced acute T cell-mediated rejection. Nineteen patients (10.80%) discontinued abatacept; 47% of the KTRs found the use of abatacept less restrictive than belatacept, and 38% would have preferred to continue abatacept. Mean eGFR remained stable compared to baseline. Seven patients (3.9%) had COVID-19; among these, two developed severe symptoms but survived. Only one patient had a de novo DSA. Side effects of abatacept injection were uncommon and non-severe. Our study reports for the first time in a large cohort that once-weekly injection of abatacept appears to be feasible and safe in KTRs previously treated with belatacept.
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Affiliation(s)
- Dominique Bertrand
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Mélanie Brunel
- Department of Kidney Transplantation, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Ludivine Lebourg
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Anne Scemla
- Department of Kidney Transplantation, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Mathilde Lemoine
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Lucile Amrouche
- Department of Kidney Transplantation, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Charlotte Laurent
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
| | - Christophe Legendre
- Department of Kidney Transplantation, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Dominique Guerrot
- Department of Nephrology, Kidney Transplantation and Hemodialysis, Rouen University Hospital, Rouen, France
- INSERM U1096, University of Rouen Normandy, Rouen, France
| | - Dany Anglicheau
- Department of Kidney Transplantation, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Rebecca Sberro-Soussan
- Department of Kidney Transplantation, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
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9
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Flechner SM, Budde K. Back to the Future With Co-Stimulation Blockade. Transpl Int 2023; 36:11752. [PMID: 37554317 PMCID: PMC10405285 DOI: 10.3389/ti.2023.11752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/05/2023] [Indexed: 08/10/2023]
Affiliation(s)
- Stuart M. Flechner
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, United States
| | - Klemens Budde
- Department of Nephrology, Charité Universitätsmedizin Berlin, Berlin, Germany
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10
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Vincenti F, Angeletti A, Ghiggeri GM. State of the art in childhood nephrotic syndrome: concrete discoveries and unmet needs. Front Immunol 2023; 14:1167741. [PMID: 37503337 PMCID: PMC10368981 DOI: 10.3389/fimmu.2023.1167741] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 06/21/2023] [Indexed: 07/29/2023] Open
Abstract
Nephrotic syndrome (NS) is a clinical entity characterized by proteinuria, hypoalbuminemia, and peripheral edema. NS affects about 2-7 per 100,000 children aged below 18 years old yearly and is classified, based on the response to drugs, into steroid sensitive (SSNS), steroid dependent, (SDNS), multidrug dependent (MDNS), and multidrug resistant (MRNS). Forms of NS that are more difficult to treat are associated with a worse outcome with respect to renal function. In particular, MRNS commonly progresses to end stage renal failure requiring renal transplantation, with recurrence of the original disease in half of the cases. Histological presentations of NS may vary from minimal glomerular lesions (MCD) to focal segmental glomerulosclerosis (FSGS) and, of relevance, the histological patterns do not correlate with the response to treatments. Moreover, around half of MRNS cases are secondary to causative pathogenic variants in genes involved in maintaining the glomerular structure. The pathogenesis of NS is still poorly understood and therapeutic approaches are mostly based on clinical experience. Understanding of pathogenetic mechanisms of NS is one of the 'unmet needs' in nephrology and represents a significant challenge for the scientific community. The scope of the present review includes exploring relevant findings, identifying unmet needs, and reviewing therapeutic developments that characterize NS in the last decades. The main aim is to provide a basis for new perspectives and mechanistic studies in NS.
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Affiliation(s)
- Flavio Vincenti
- Division of Nephrology, Department of Medicine and Department of Surgery, University of California San Francisco, San Francisco, CA, United States
| | - Andrea Angeletti
- Nephrology Dialysis and Transplantation, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
| | - Gian Marco Ghiggeri
- Nephrology Dialysis and Transplantation, Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
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11
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Burke GW, Chandar J, Sageshima J, Ortigosa-Goggins M, Amarapurkar P, Mitrofanova A, Defreitas MJ, Katsoufis CP, Seeherunvong W, Centeno A, Pagan J, Mendez-Castaner LA, Mattiazzi AD, Kupin WL, Guerra G, Chen LJ, Morsi M, Figueiro JMG, Vianna R, Abitbol CL, Roth D, Fornoni A, Ruiz P, Ciancio G, Garin EH. Benefit of B7-1 staining and abatacept for treatment-resistant post-transplant focal segmental glomerulosclerosis in a predominantly pediatric cohort: time for a reappraisal. Pediatr Nephrol 2023; 38:145-159. [PMID: 35507150 PMCID: PMC9747833 DOI: 10.1007/s00467-022-05549-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/28/2022] [Accepted: 03/15/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Primary FSGS manifests with nephrotic syndrome and may recur following KT. Failure to respond to conventional therapy after recurrence results in poor outcomes. Evaluation of podocyte B7-1 expression and treatment with abatacept (a B7-1 antagonist) has shown promise but remains controversial. METHODS From 2012 to 2020, twelve patients developed post-KT FSGS with nephrotic range proteinuria, failed conventional therapy, and were treated with abatacept. Nine/twelve (< 21 years old) experienced recurrent FSGS; three adults developed de novo FSGS, occurring from immediately, up to 8 years after KT. KT biopsies were stained for B7-1. RESULTS Nine KTRs (75%) responded to abatacept. Seven of nine KTRs were B7-1 positive and responded with improvement/resolution of proteinuria. Two patients with rFSGS without biopsies resolved proteinuria after abatacept. Pre-treatment UPCR was 27.0 ± 20.4 (median 13, range 8-56); follow-up UPCR was 0.8 ± 1.3 (median 0.2, range 0.07-3.9, p < 0.004). Two patients who were B7-1 negative on multiple KT biopsies did not respond to abatacept and lost graft function. One patient developed proteinuria while receiving belatacept, stained B7-1 positive, but did not respond to abatacept. CONCLUSIONS Podocyte B7-1 staining in biopsies of KTRs with post-transplant FSGS identifies a subset of patients who may benefit from abatacept. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- George W. Burke
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, 1801 NW 9th Ave, Highland Professional Building, Miami, FL 33136 USA
| | - Jayanthi Chandar
- Division of Pediatric Kidney Transplantation, Department of Pediatrics, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Junichiro Sageshima
- Division of Transplant Surgery, Department of Surgery, University of California Davis School of Medicine, Sacramento, CA 95817 USA
| | - Mariella Ortigosa-Goggins
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, and the Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Pooja Amarapurkar
- Division of Nephrology, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30309 USA
| | - Alla Mitrofanova
- Research, Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Marissa J. Defreitas
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Chryso P. Katsoufis
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Wacharee Seeherunvong
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Alexandra Centeno
- Transplant Clinical Pharmacy Services, Miami Transplant Institute, Jackson Memorial Hospital, Miami, FL 33136 USA
| | - Javier Pagan
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, and the Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Lumen A. Mendez-Castaner
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, and the Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Adela D. Mattiazzi
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, and the Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Warren L. Kupin
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, and the Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Giselle Guerra
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, and the Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Linda J. Chen
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, 1801 NW 9th Ave, Highland Professional Building, Miami, FL 33136 USA
| | - Mahmoud Morsi
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, 1801 NW 9th Ave, Highland Professional Building, Miami, FL 33136 USA
| | - Jose M. G. Figueiro
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, 1801 NW 9th Ave, Highland Professional Building, Miami, FL 33136 USA
| | - Rodrigo Vianna
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, 1801 NW 9th Ave, Highland Professional Building, Miami, FL 33136 USA ,Division of Liver and GI Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Carolyn L. Abitbol
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - David Roth
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, and the Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Alessia Fornoni
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Phillip Ruiz
- Transplant Pathology, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, Miami, FL 33136 USA
| | - Gaetano Ciancio
- Division of Kidney-Pancreas Transplantation, Department of Surgery, Miami Transplant Institute, University of Miami Miller School of Medicine, 1801 NW 9th Ave, Highland Professional Building, Miami, FL 33136 USA
| | - Eduardo H. Garin
- Division of Nephrology, Department of Pediatrics, University of Florida School of Medicine, Gainesville, FL 32610 USA
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12
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Glomerular B7-1 staining: toward precision medicine for treatment of recurrent focal segmental glomerulosclerosis. Pediatr Nephrol 2023; 38:13-15. [PMID: 35725967 DOI: 10.1007/s00467-022-05650-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 01/10/2023]
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13
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Al Shamsi HR, Shaheen I, Aziz D. Management of recurrent focal segmental glomerulosclerosis (FSGS) post renal transplantation. Transplant Rev (Orlando) 2021; 36:100675. [PMID: 34952298 DOI: 10.1016/j.trre.2021.100675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 12/05/2021] [Accepted: 12/13/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND One of the common GN causing ESKD is focal segmental glomerulosclerosis (FSGS). Recurrence of FSGS post-transplantation can lead to graft loss. Data on management either prophylactically or once recurrence occurs are limited. This review article aims to assess the effective management of patients with FSGS recurrence post-transplantation, looking mainly at recurrence post prophylactic treatment and remission in case of treatment post recurrence. METHODS Twenty-three studies were included using the search MeSH terms "FSGS" "recurrence" "adults" "transplantation" "treatment". Search engines used were Pubmed, clinical key, Scopus and Cochrane library. Inclusion criteria were articles covered adult patients with recurrent FSGS post renal transplantation, treatment with rituximab and plasmapheresis, and articles published from 2000 tt2021. Excluded articles were paediatric population, studies with no reported outcomes of the treatment of FSGS, and Patients who received stem cell transplantation or galactose therapy. RESULTS Prophylactic PP did not show a reduction in recurrence of FSGS in 2/3 studies. Prophylactic rituximab was shown to reduce recurrence of FSGS in one-study and case reports. Treatment of recurrent FSGS with PP showed responses ranging from 41% to 100%. Only one study did not show improvement with PP use as treatment having a 27% remission. Treatment with rituximab showed variable results, with reports showing remission ranging from 57% to 100%. Whereas other reports showing no response at all. PP prescription reporting was variable. One study suggested intensified PP regimen while in most other studies PP was guided by the response reflected by the reduction of proteinuria. DISCUSSION Reviewing the treatment of recurrent FSGS is crucial, as there no consensus on treating FSGS as the disease is not very common in the adult population. The evidence of different modalities is based on small cohort studies. This paper supports the use of PP and RTX as treatment of recurrent FSGS. CONCLUSIONS In conclusion, PP and RTX are the main modalities to treat recurrent FSGS with varying response rates. Prophylactic PP does not play a role in preventing recurrent FSGS. Prophylactic rituximab might play a role in preventing FSGS post-transplantation. PP and RTX, when used as a treatment, show variable response rates. Larger RCTs are needed to have a strong level of evidence to base our clinical management on.
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14
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Cara-Fuentes G, Smoyer WE. Biomarkers in pediatric glomerulonephritis and nephrotic syndrome. Pediatr Nephrol 2021; 36:2659-2673. [PMID: 33389089 DOI: 10.1007/s00467-020-04867-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/16/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022]
Abstract
Glomerular diseases are often chronic or recurring and thus associated with a tremendous physical, psychological, and economic burden. Their etiologies are often unknown, and their pathogeneses are frequently poorly understood. The diagnoses and management of these diseases are therefore based on clinical features, traditional laboratory markers, and, often, kidney pathology. However, the clinical presentation can be highly variable, the kidney pathology may not establish a definitive diagnosis, and the therapeutic responses and resulting clinical outcomes are often unpredictable. To try to address these challenges, significant research efforts have been made over the last decade to identify potential biomarkers that can help clinicians optimize the diagnosis and prognosis at clinical presentation, as well as help predict long-term outcomes. Unfortunately, these efforts have to date only identified a single biomarker for glomerular disease that has been fully validated and developed for widespread clinical use (anti-PLA2R antibodies to diagnose membranous nephropathy). In this manuscript, we review the definitions and development of biomarkers, as well as the current knowledge on both historical and novel candidate biomarkers of glomerular disease, with an emphasis on those associated with idiopathic nephrotic syndrome.
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Affiliation(s)
- Gabriel Cara-Fuentes
- Department of Pediatrics, Division of Pediatric Nephrology, University of Colorado, 12700 E 19th Ave, R2 building, Room 7420D, Aurora, CO, 80045, USA.
| | - William E Smoyer
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
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15
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Theophilus UI, John JR, Ihab S, Ahmed H. Recurrent Focal Segmental Glomerulosclerosis After Kidney Transplantation in African Americans: Review of the Current Evidence. EXP CLIN TRANSPLANT 2021; 19:1245-1256. [PMID: 34269655 DOI: 10.6002/ect.2020.0542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES In many countries of sub-Saharan Africa, the most common causes of end-stage kidney disease are hypertension, chronic glomerulonephritis, and diabetes mellitus. So far, literature on recurrent focal segmental glomerulosclerosis in sub-Saharan African populations is limited. With the intention of providing guidance for best practices in sub-Saharan Africa, we reviewed available evidence for African Americans, a population with a similar genetic background. We chose this population as a pseudo-population to show how similar genetic backgrounds can predict disease occurrence in similar populations residing in different continents. MATERIALS AND METHODS Our extended PubMed and Scopus literature search used these key words: "focal segmental glomerulosclerosis in African Americans" (search 1), "recurrent focal segmental glomerulosclerosis after kidney transplantation" (search 2), "risk factors for recurrent focal segmental glomerulosclerosis" (search 3); and "APOL1 gene and kidney transplantation" (search 4). RESULTS/CONCLUSIONS Search 1 yielded 4 articles, search 2 yielded 44 articles, search 3 yielded 6 articles, and search 4 yielded 8 articles. African Americans were shown to be disproportionately predisposed to endstage kidney disease, traceable to focal segmental glomerulosclerosis (the most common cause of glomerulonephritis leading to end-stage kidney disease). Apolipoprotein L1 presence in 22% of African Americans explained the odds ratio of 17 in developing focal segmental glomerulosclerosis and 8 times lifetime risk of end-stage kidney disease. Focal segmental glomerulosclerosis recurred in 30% of kidney transplant recipients; risk factors included young age, rapid progression to end-stage kidney disease, and White race recipient. Circulating permeability factors played a central role in primary and recurrent focal segmental glomerulosclerosis. For recurrent cases, transplant biopsy has remained the gold standard for diagnosis, with treatment involving a multi-modal approach, often resulting in partial or complete remission of proteinuria; allograft loss can occur if treatment is not successful. More randomized clinical trials are needed to chart the way forward for prolonged allograft function.
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Affiliation(s)
- Umeizudike I Theophilus
- From the Department of Medicine, Lagos State University Teaching Hospital, Ikeja, Lagos State, Nigeria
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16
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Vallianou K, Marinaki S, Skalioti C, Lionaki S, Darema M, Melexopoulou C, Boletis I. Therapeutic Options for Recurrence of Primary Focal Segmental Glomerulonephritis (FSGS) in the Renal Allograft: Single-Center Experience. J Clin Med 2021; 10:jcm10030373. [PMID: 33498160 PMCID: PMC7863737 DOI: 10.3390/jcm10030373] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 01/09/2021] [Accepted: 01/14/2021] [Indexed: 12/12/2022] Open
Abstract
Focal Segmental Glomerulosclerosis (FSGS) recurrence after kidney transplantation (KTx) is relatively frequent and is associated with poor graft survival. The aim of this study was to investigate which management strategies were associated with better outcomes in our cohort of KTx recipients with primary FSGS. We retrospectively collected data on patients with primary FSGS who received a KTx between 1993 and 2019. A history of biopsy proven FSGS in native kidneys and new onset of significant proteinuria early post-KTx led to the diagnosis of recurrence, which was confirmed by graft biopsy. From 1993 to 2019 we performed 46 KTxs in patients with primary FSGS. We identified 26 episodes of recurrence in 25 patients, 67% of them occurring in males. They were younger at the time of KTx (33.8 vs. 41.1 years old, p = 0.067) and had progressed to end stage renal disease (ESRD) faster after FSGS diagnosis (61.4 vs. 111.2 months, p = 0.038), while they were less likely to have received prophylactic plasmapheresis (61.5% vs. 90%, p = 0.029). 76.7% of recurrences were found early, after a median of 0.5 months (IQR 0.1-1) with a median proteinuria was 8.5 (IQR 4.9-11.9) g/day. All patients with recurrence were treated with plasmapheresis, while 8 (30.7%) additionally received rituximab, 1 (3.8%) abatacept, and 4 (15.4%) ACTH. 7 (27%) patients experienced complete and 11 (42.3%) partial remission after a mean time of 3 (±1.79) and 4.4 (±2.25) months, respectively. Prognosis was worse for patients who experienced a recurrence. Eleven (42.3%) patients lost their graft from FSGS in a median time of 33 (IQR 17.5-43.3) months. In this series of patients, primary FSGS recurred frequently after KTx. Prophylacic plasmapheresis was shown efficacious in avoiding FSGS recurrence, while timely diagnosis and plasmapheresis-based regimens induced remission in more than half of the patients.
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17
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Lee JM, Kronbichler A, Shin JI, Oh J. Current understandings in treating children with steroid-resistant nephrotic syndrome. Pediatr Nephrol 2021; 36:747-761. [PMID: 32086590 PMCID: PMC7910243 DOI: 10.1007/s00467-020-04476-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 12/22/2019] [Accepted: 01/07/2020] [Indexed: 12/27/2022]
Abstract
Steroid-resistant nephrotic syndrome (SRNS) remains a challenge for paediatric nephrologists. SRNS is viewed as a heterogeneous disease entity including immune-based and monogenic aetiologies. Because SRNS is rare, treatment strategies are individualized and vary among centres of expertise. Calcineurin inhibitors (CNI) have been effectively used to induce remission in patients with immune-based SRNS; however, there is still no consensus on treating children who become either CNI-dependent or CNI-resistant. Rituximab is a steroid-sparing agent for patients with steroid-sensitive nephrotic syndrome, but its efficacy in SRNS is controversial. Recently, several novel monoclonal antibodies are emerging as treatment option, but their efficacy remains to be seen. Non-immune therapies, such as angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, have been proven efficacious in children with SRNS and are recommended as adjuvant agents. This review summarizes and discusses our current understandings in treating children with idiopathic SRNS.
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Affiliation(s)
- Jiwon M. Lee
- Department of Pediatrics, Chungnam National University Hospital, Daejeon, South Korea
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University Innsbruck, Innsbruck, Austria
| | - Jae Il Shin
- Department of Pediatrics, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, C.P.O. Box 8044, Seoul, 120-752 South Korea ,Division of Pediatric Nephrology, Severance Children’s Hospital, Seoul, South Korea ,Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Oh
- Department of Pediatrics Nephrology, University Hamburg-Eppendorf, Martinistrasse, 52 20246, Hamburg, Germany.
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18
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Dudreuilh C, Barbet C, Gatault P, Ferlicot S, Lebranchu Y, Rabot N, Beaudreuil S, Dürrbach A, Büchler M. Response to plasma exchange and graft survival in recurrent focal and segmental glomerulosclerosis after transplantation: does the time of recurrence matter? A retrospective study. Transpl Int 2020; 34:302-312. [PMID: 33275815 DOI: 10.1111/tri.13796] [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: 06/15/2020] [Revised: 07/10/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
Recurrence of primary focal and segmental glomerulosclerosis following kidney transplantation (rFSGS) is a frequent and severe disease. We studied the time to recurrence of FSGS and its impact on the response to plasma exchange (PE) and graft survival. Between 1990 and 2013, 2730 kidney transplants were performed, including 52 patients with a primary diagnosis of FSGS. Of these patients with primary FSGS, 34 (67%) developed rFSGS. We retrospectively divided these patients into two groups depending on the time to recurrence: early (up to three months after transplantation, n = 26) or late (more than three months after transplantation, n = 8). Survival did not significantly differ between the two groups. In cases of late recurrence, PE was started later and was performed less frequently, and remission was achieved after more PE sessions and longer PE treatment than for the early group (P = 0.01). In early recurrence, resistance to PE at 40 days was associated with no long-term response to PE. PE should be performed as soon as possible after rFSGS. Patients with late rFSGS need to be offered the same treatment regime as those with early rFSGS.
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Affiliation(s)
- Caroline Dudreuilh
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
| | - Christelle Barbet
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
| | - Philippe Gatault
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
| | - Sophie Ferlicot
- Department of Pathology, Bicetre University Hospital, Le Kremlin Bicêtre, France
| | - Yvon Lebranchu
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
| | - Nolwenn Rabot
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
| | - Severine Beaudreuil
- Nephrology Department, Hopitaux Universitaires Paris-Sud, APHP, Le Kremlin-Bicetre, France.,UMR 1197, University Paris Sud, INSERM, Paris-Saclay University, Villejuif, France
| | - Antoine Dürrbach
- Nephrology Department, Hopitaux Universitaires Paris-Sud, APHP, Le Kremlin-Bicetre, France.,UMR 1197, University Paris Sud, INSERM, Paris-Saclay University, Villejuif, France
| | - Matthias Büchler
- Department of Nephrology - Hypertension, Dialysis, Transplantation, CHRU, Tours, France.,EA4245 Dendritic Cells, Immunomodulation and Grafts, François-Rabelais University, Tours, France
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19
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Mühlbacher T, Amann K, Mahling M, Nadalin S, Heyne N, Guthoff M. Successful long-term management of recurrent focal segmental glomerulosclerosis after kidney transplantation with costimulation blockade. Clin Kidney J 2020; 14:1691-1693. [PMID: 34084465 PMCID: PMC8162848 DOI: 10.1093/ckj/sfaa267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Indexed: 11/26/2022] Open
Abstract
Recurrence of primary focal segmental glomerulosclerosis (FSGS) occurs in up to 50% of patients after kidney transplantation and is associated with poor allograft outcome. Novel therapeutic concepts directly target podocyte function via B7-1 with inconsistent response. We present the case of a 19-year-old patient with recurrent primary FSGS early after living donor kidney transplantation. Plasmapheresis and rituximab did not induce remission. Repetitive abatacept administration was able to achieve partial remission. Maintenance immunosuppression was subsequently switched to a belatacept-based calcineurin inhibitor-free immunosuppression, resulting in sustained complete remission with excellent allograft function throughout a follow-up of >56 months.
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Affiliation(s)
- Thomas Mühlbacher
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e. V.), Neuherberg, Germany
| | - Kerstin Amann
- Department of Nephropathology, Institute of Pathology, University Hospital Erlangen, Erlangen, Germany
| | - Moritz Mahling
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e. V.), Neuherberg, Germany
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University of Tübingen, Tübingen, Germany
| | - Nils Heyne
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e. V.), Neuherberg, Germany
| | - Martina Guthoff
- Department of Diabetology, Endocrinology, Nephrology, Section of Nephrology and Hypertension, University of Tübingen, Tübingen, Germany.,Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany.,German Center for Diabetes Research (DZD e. V.), Neuherberg, Germany
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20
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Podestà MA, Ponticelli C. Autoimmunity in Focal Segmental Glomerulosclerosis: A Long-Standing Yet Elusive Association. Front Med (Lausanne) 2020; 7:604961. [PMID: 33330569 PMCID: PMC7715033 DOI: 10.3389/fmed.2020.604961] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/26/2020] [Indexed: 01/17/2023] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a histological term that describes a pathologic renal entity affecting both adults and children, with a wide array of possible underlying etiologies. Podocyte damage with scarring, the hallmark of this condition, leads to altered permeability of the glomerular barrier, which may result in massive proteinuria and relentless renal function deterioration. A definite cause of focal segmental glomerulosclerosis can be confirmed in a minority of cases, while most forms have been traditionally labeled as primary or idiopathic. Despite this definition, increasing evidence indicates that primary forms are a heterogenous group rather than a single disease entity: several circulating factors that may affect glomerular permeability have been proposed as potential culprits, and both humoral and cellular immunity have been implicated in the pathogenesis of the disease. Consistently, immunosuppressive drugs are considered as the cornerstone of treatment for primary focal segmental glomerulosclerosis, but response to these agents and long-term outcomes are highly variable. In this review we provide a summary of historical and recent advances on the pathogenesis of primary focal segmental glomerulosclerosis, focusing on implications for its differential diagnosis and treatment.
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Gonzalez Guerrico AM, Lieske J, Klee G, Kumar S, Lopez-Baez V, Wright AM, Bobart S, Shevell D, Maldonado M, Troost JP, Hogan MC. Urinary CD80 Discriminates Among Glomerular Disease Types and Reflects Disease Activity. Kidney Int Rep 2020; 5:2021-2031. [PMID: 33163723 PMCID: PMC7609973 DOI: 10.1016/j.ekir.2020.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 07/17/2020] [Accepted: 08/04/2020] [Indexed: 02/07/2023] Open
Abstract
Introduction Heterogeneity of nephrotic diseases and a lack of validated biomarkers limits interventions and reduces the ability to examine outcomes. Urinary CD80 is a potential biomarker for minimal change disease (MCD) steroid-sensitive nephrotic syndrome (NS). We investigated and validated a CD80 enzyme-linked immunosorbent assay (ELISA) in urine in a large cohort with a variety of nephrotic diseases. Methods A commercial CD80 ELISA was enhanced and analytically validated for urine. Patients were from Mayo Clinic (307) and Nephrotic Syndrome Study Network Consortium (NEPTUNE; 104) as follows: minimal change disease (MCD, 56), focal segmental glomerulosclerosis (FSGS, 92), lupus nephritis (LN, 25), IgA nephropathy (IgAN, 20), membranous nephropathy (MN, 49), autosomal dominant polycystic kidney disease (ADPKD, 10), diabetic nephropathy (DN; 106), pyuria (19), and controls (34). Analysis was by Kruskal−Wallis test, generalized estimating equation (GEE) models, and receiver operating characteristic (AUC) curve. Results Urinary CD80/creatinine values were highest in MCD compared to other glomerular diseases and were increased in DN with proteinuria >2 compared to controls (control = 36 ng/g; MCD = 139 ng/g, P < 0.01; LN = 90 ng/g, P < 0.12; FSGS = 66 ng/g, P = 0.18; DN = 63, P = 0.03; MN = 69 ng/g, P = 0.33; ng/g, P = 0.07; IgA = 19 ng/g, P = 0.09; ADPKD = 42, P = 0.36; and pyuria 31, P = 0.20; GEE, median, P vs. control). In proteinuric patients, CD80 concentration appears to be independent of proteinuria levels, suggesting that it is unrelated to nonspecific passage across the glomeruli. CD80/creatinine values were higher in paired relapse versus remission cases of MCD and FSGS (P < 0.0001, GEE). Conclusion Using a validated ELISA, urinary CD80 levels discriminate MCD from other forms of NS (FSGS, DN, IgA, MN) and primary from secondary FSGS.
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Affiliation(s)
| | - John Lieske
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - George Klee
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sanjay Kumar
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Victor Lopez-Baez
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Adam M. Wright
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Shane Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Diane Shevell
- Bristol-Myers Squibb, Lawrenceville, New Jersey, USA
| | | | - Jonathan P. Troost
- Michigan Institute for Clinical and Health Research, University of Michigan, Ann Arbor, Michigan, USA
| | - Marie C. Hogan
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Correspondence: Marie C. Hogan, Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55902, USA.
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Abstract
Podocytopathies are kidney diseases in which direct or indirect podocyte injury drives proteinuria or nephrotic syndrome. In children and young adults, genetic variants in >50 podocyte-expressed genes, syndromal non-podocyte-specific genes and phenocopies with other underlying genetic abnormalities cause podocytopathies associated with steroid-resistant nephrotic syndrome or severe proteinuria. A variety of genetic variants likely contribute to disease development. Among genes with non-Mendelian inheritance, variants in APOL1 have the largest effect size. In addition to genetic variants, environmental triggers such as immune-related, infection-related, toxic and haemodynamic factors and obesity are also important causes of podocyte injury and frequently combine to cause various degrees of proteinuria in children and adults. Typical manifestations on kidney biopsy are minimal change lesions and focal segmental glomerulosclerosis lesions. Standard treatment for primary podocytopathies manifesting with focal segmental glomerulosclerosis lesions includes glucocorticoids and other immunosuppressive drugs; individuals not responding with a resolution of proteinuria have a poor renal prognosis. Renin-angiotensin system antagonists help to control proteinuria and slow the progression of fibrosis. Symptomatic management may include the use of diuretics, statins, infection prophylaxis and anticoagulation. This Primer discusses a shift in paradigm from patient stratification based on kidney biopsy findings towards personalized management based on clinical, morphological and genetic data as well as pathophysiological understanding.
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23
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Shabaka A, Tato Ribera A, Fernández-Juárez G. Focal Segmental Glomerulosclerosis: State-of-the-Art and Clinical Perspective. Nephron Clin Pract 2020; 144:413-427. [PMID: 32721952 DOI: 10.1159/000508099] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/20/2020] [Indexed: 12/18/2022] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a histological pattern of glomerular injury, rather than a single disease, that is caused by diverse clinicopathological entities with different mechanisms of injury with the podocyte as the principal target of lesion, leading to the characteristic sclerotic lesions in parts (i.e., focal) of some (i.e., segmental) glomeruli. The lesion of FSGS has shown an increasing prevalence over the past few decades and is considered the most common glomerular cause leading to ESKD. Primary FSGS, which usually presents with nephrotic syndrome, is thought to be caused by circulating permeability factors that have a main role in podocyte foot process effacement. Secondary forms of FSGS include maladaptive FSGS secondary to glomerular hyperfiltration such as in obesity or in cases of loss in nephron mass, virus-associated FSGS, and drug-associated FSGS that can result in direct podocyte injury. Genetic FSGS is increasingly been recognized and a careful evaluation of patients with atypical primary or secondary FSGS should be performed to exclude genetic causes. Unlike primary FSGS, secondary and genetic forms of FSGS do not respond to immunosuppression and tend not to recur after kidney transplantation. Distinguishing primary FSGS from secondary and genetic causes has a prognostic significance and is crucial for an appropriate management. In this review, we examine the pathogenesis, clinical approach to distinguish between the different causes, and current recommendations in the management of FSGS.
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Affiliation(s)
- Amir Shabaka
- Nephrology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Ana Tato Ribera
- Nephrology Department, Hospital Universitario Fundación Alcorcón, Madrid, Spain
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Zhang X, Herr F, Vernochet A, Lorenzo HK, Beaudreuil S, Dürrbach A. CASK, the Soluble Glomerular Permeability Factor, Is Secreted by Macrophages in Patients With Recurrent Focal and Segmental Glomerulo-Sclerosis. Front Immunol 2020; 11:875. [PMID: 32477353 PMCID: PMC7235163 DOI: 10.3389/fimmu.2020.00875] [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: 02/04/2020] [Accepted: 04/16/2020] [Indexed: 01/17/2023] Open
Abstract
Introduction: Focal and segmental glomerulosclerosis (FSGS) is a frequent form of glomerulonephritis that may be caused by a soluble permeability factor and regulated by the immune system. We previously described a soluble form of calcium/calmodulin-dependent serine/threonine kinase (CASK) acting as a permeability factor in patients with recurrent FSGS (rFSGS). Here, we aimed to identify the immune cells associated with CASK secretion in patients with rFSGS. Methods: FACS, western blotting and immunoprecipitation were performed to detect CASK in peripheral blood mononuclear cells, including CD3+, CD20+, and CD14+subsets, from patients with rFSGS, healthy donors, transplant patients and patients with nephrotic syndrome due to diabetes mellitus, and in KHM2 cells. Results: CASK was produced mostly by monocytes in patients with rFSGS but not by T or B lymphocytes. It was not detectein cells from control patients. CASK was also produced and secreted by M2 polarized macrophages and KMH2 cells, but not by M1 polarized macrophages. CASK secretion was not not inhibited by brefeldin A, suggesting an absence of classical secretion pathway involvement. Within cells, CASK was partly colocalized with ALIX, a molecule involved in exosome development, and these two molecules were coprecipitated from M2 macrophages. Moreover, exosomes derived from M2 macrophages induced podocyte cytoskeleton alterations and increased podocyte motility. Conclusion: These results suggest that the soluble permeability factor CASK is secreted by monocytes and M2 macrophages, via exosomes, to alter the glomerular filtration barrier in rFSGS.
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Affiliation(s)
- Xiaomeng Zhang
- INSERM U1197, Villejuif, France.,Division of Internal Medicine, Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Florence Herr
- INSERM U1197, Villejuif, France.,University of Paris-Saclay, Saint-Aubin, France.,Centre de Reference Maladie Rare du Syndrome Nephrotique Idiopatique, Paris, France
| | - Amelia Vernochet
- INSERM U1197, Villejuif, France.,University of Paris-Saclay, Saint-Aubin, France
| | - Hans K Lorenzo
- INSERM U1197, Villejuif, France.,University of Paris-Saclay, Saint-Aubin, France.,Department of Nephrology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Séverine Beaudreuil
- INSERM U1197, Villejuif, France.,Department of Nephrology, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Antoine Dürrbach
- INSERM U1197, Villejuif, France.,University of Paris-Saclay, Saint-Aubin, France.,Centre de Reference Maladie Rare du Syndrome Nephrotique Idiopatique, Paris, France.,Department of Nephrology, Henri Mondor Hospital, Creteil, France
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25
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CTLA4-Ig Abatacept Ameliorates Proteinuria by Regulating Circulating Treg/IL-17 in Adriamycin-Induced Nephropathy Rats. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2347827. [PMID: 32420329 PMCID: PMC7201454 DOI: 10.1155/2020/2347827] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 02/09/2020] [Accepted: 03/20/2020] [Indexed: 12/30/2022]
Abstract
Objective This study is aimed at investigating the efficacy of CTLA4-Ig abatacept in normalizing proteinuria and its possible mechanism in adriamycin-induced nephropathy (AIN) rats. Methods A total of 32 healthy male Sprague-Dawley rats were randomly divided into a normal group, an AIN group, an abatacept group, and a prednisone group. Adriamycin (6.5 mg/kg) was injected once via the tail vein of rats to induce nephrotic syndrome. After adriamycin treatment, the abatacept group rats were given abatacept (0.5 mg/kg) once by intraperitoneal injection on day 14. In addition, the prednisone group rats were given prednisone (12.5 mg/kg) daily consecutively by gavage from day 14 to day 21. Blood, urine, and kidney tissue specimens were collected when sacrificed on day 21. The 24-hour urinary protein, serum albumin, cholesterol, creatinine, and urea nitrogen were then detected. An enzyme-linked immunosorbent assay was used to determine the level of urine CD80 and serum IL-17. Flow cytometry was used to investigate the prevalence of circulating Treg. Hematoxylin-eosin staining and electron microscopy were used for a renal histological study. Immunofluorescence staining was performed to confirm the CD80 expression of renal tissue. Results The 24-hour urinary protein of the abatacept group was significantly lower than that of the prednisone group and the AIN group. The level of urine CD80 of the abatacept group was significantly lower than that of the AIN group. Compared with the AIN group and the prednisone group, the circulating Treg prevalence of the abatacept group was significantly higher, while the level of serum IL-17 was lower. A negative kidney staining of CD80 expression was demonstrated in each group in this study. The 24-hour urinary protein had a negative correlation with the circulating Treg prevalence and Treg/IL-17 and a positive correlation with the urine CD80 and serum IL-17. Urinary CD80 had a positive correlation with serum IL-17 and no correlation with the circulating Treg prevalence. Conclusions CTLA4-Ig abatacept can reduce proteinuria of adriamycin-induced nephropathy rats, possibly at least partially as a result of regulating circulating Treg/IL-17. CTLA4-Ig abatacept could be a promising regimen for idiopathic nephrotic syndrome.
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Morin G, Legendre C, Canaud G. Management of post-transplant recurrent focal and segmental glomerulosclerosis. Nephrol Dial Transplant 2020; 36:1994-1996. [DOI: 10.1093/ndt/gfaa021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Indexed: 11/13/2022] Open
Affiliation(s)
- Gabriel Morin
- Service de Néphrologie Transplantation Adultes, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
- INSERM U1151, Institut Necker Enfants Malades, Paris, France
| | - Christophe Legendre
- Service de Néphrologie Transplantation Adultes, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
- INSERM U1151, Institut Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
| | - Guillaume Canaud
- Service de Néphrologie Transplantation Adultes, Hôpital Necker-Enfants Malades, AP-HP, Paris, France
- INSERM U1151, Institut Necker Enfants Malades, Paris, France
- Université de Paris, Paris, France
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27
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Eroglu FK, Orhan D, İnözü M, Duzova A, Gulhan B, Ozaltin F, Topaloglu R. CD80 expression and infiltrating regulatory T cells in idiopathic nephrotic syndrome of childhood. Pediatr Int 2019; 61:1250-1256. [PMID: 31513327 DOI: 10.1111/ped.14005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 07/05/2019] [Accepted: 09/06/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND CD80 (also known as B7-1) is a co-stimulatory molecule that is expressed in biopsies and also excreted in urine in patients with minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS). CD80 is inhibited by the cytotoxic T-lymphocyte-associated-antigen 4 (CTLA4), which is mainly expressed on regulatory T cells (Tregs). Ineffective circulating Treg response is involved in the pathogenesis of nephrotic syndrome. In this study, we evaluated CD80 expression and infiltrating Tregs in children with MCD and FSGS. METHODS Evaluation of CD80 expression and semi-quantitative evaluation of Tregs (FOXP3-positive CD4 T cells) were carried out in 31 kidney biopsies (12 MCD, 19 FSGS) with immunofluorescence and immunohistochemistry staining. RESULTS All MCD sections were stained negative; whereas six out of 19 FSGS sections (all from steroid-resistant (SR) patients), including one from a Wilms' tumor 1 (WT1) mutation-positive FSGS patient, stained positive for anti-CD80 goat antibody, and negative for anti-CD80 rabbit antibody. FSGS biopsy specimens had significantly higher FOXP3-positive cells/mm2 compared with MCD and control samples (P < 0.001). Biopsy samples from SR-FSGS patients (n = 12) with positive CD80 staining (n = 6) had significantly less Tregs (FOXP3-positive CD4 T cells) compared with CD80 (-) biopsies (n = 6; P = 0.004). CONCLUSION CD80 expression was not detected in the majority of the archival biopsy sections and the results were not consistent across the different antibodies. In the SR-FSGS sections, however, CD80-positive biopsies had decreased FOXP3-positive CD4 T cells, suggesting that a decreased anti-inflammatory milieu may be the cause of increased CD80 expression.
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Affiliation(s)
- Fehime Kara Eroglu
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Diclehan Orhan
- Department of Pathology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Mihriban İnözü
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ali Duzova
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Bora Gulhan
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Fatih Ozaltin
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Rezan Topaloglu
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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28
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Lim WH, Shingde M, Wong G. Recurrent and de novo Glomerulonephritis After Kidney Transplantation. Front Immunol 2019; 10:1944. [PMID: 31475005 PMCID: PMC6702954 DOI: 10.3389/fimmu.2019.01944] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/01/2019] [Indexed: 12/13/2022] Open
Abstract
The prevalence, pathogenesis, predictors, and natural course of patients with recurrent glomerulonephritis (GN) occurring after kidney transplantation remains incompletely understood, including whether there are differences in the outcomes and advances in the treatment options of specific GN subtypes, including those with de novo GN. Consequently, the treatment options and approaches to recurrent disease are largely extrapolated from the general population, with responses to these treatments in those with recurrent or de novo GN post-transplantation poorly described. Given a greater understanding of the pathogenesis of GN and the development of novel treatment options, it is conceivable that these advances will result in an improved structure in the future management of patients with recurrent or de novo GN. This review focuses on the incidence, genetics, characteristics, clinical course, and risk of allograft failure of patients with recurrent or de novo GN after kidney transplantation, ascertaining potential disparities between “high risk” disease subtypes of IgA nephropathy, idiopathic membranous glomerulonephritis, focal segmental glomerulosclerosis, and membranoproliferative glomerulonephritis. We will examine in detail the management of patients with high risk GN, including the pre-transplant assessment, post-transplant monitoring, and the available treatment options for disease recurrence. Given the relative paucity of data of patients with recurrent and de novo GN after kidney transplantation, a global effort in collecting comprehensive in-depth data of patients with recurrent and de novo GN as well as novel trial design to test the efficacy of specific treatment strategy in large scale multicenter randomized controlled trials are essential to address the knowledge deficiency in this disease.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Meena Shingde
- NSW Health Pathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
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29
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Kienzl-Wagner K, Waldegger S, Schneeberger S. Disease Recurrence-The Sword of Damocles in Kidney Transplantation for Primary Focal Segmental Glomerulosclerosis. Front Immunol 2019; 10:1669. [PMID: 31379860 PMCID: PMC6652209 DOI: 10.3389/fimmu.2019.01669] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 07/04/2019] [Indexed: 12/21/2022] Open
Abstract
A major obstacle in kidney transplantation for primary focal segmental glomerulosclerosis (FSGS) is the risk of disease recurrence. Recurrent FSGS affects up to 60% of first kidney grafts and exceeds 80% in patients who have lost their first graft due to recurrent FSGS. Clinical and experimental evidence support the hypothesis that a circulating permeability factor is the mediator in the pathogenesis of primary and recurrent disease. Despite all efforts, the causing agent has not yet been identified. Several treatment options for the management of recurrent FSGS have been proposed. In addition to plasma exchange, B-cell depleting antibodies are effective in recurrent FSGS. This indicates, that the secretion and/or activity of the postulated circulating permeability factor(s) may be B-cell related. This review summarizes the current knowledge on permeability factor(s) possibly related to the disease and discusses strategies for the management of recurrent FSGS. These include profound B-cell depletion prior to transplantation, as well as the salvage of an allograft affected by recurrent FSGS by transfer into a second recipient.
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Affiliation(s)
- Katrin Kienzl-Wagner
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Siegfried Waldegger
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schneeberger
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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30
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Shah Y, Almeshari K, Aleid H, Broering D, Alahmadi I, Ali T. Successful Treatment With Abatacept in Recurrent Focal Segmental Glomerulosclerosis After Kidney Transplant. EXP CLIN TRANSPLANT 2019; 17:178-180. [PMID: 30777550 DOI: 10.6002/ect.mesot2018.p53] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Primary focal segmental glomerulosclerosis recurrence occurs in 10% to 50% of recipients after kidney transplant and may affect both children and adults. Treatment after recurrence with plasma exchange and immunosuppression is quite variable and challenging, and those who do not respond usually progress to allograft failure. Podocyte injury and B7-1 expression and subsequently its blockade (abatacept) have been reported to be associated with complete remission of proteinuria in 4 patients with focal segmental glomerulosclerosis recurrence after kidney transplantation and in 1 patient with focal segmental glomerulosclerosis in native kidney. Here, we report our experience of successfully treating 3 consecutive patients with focal segmental glomerulosclerosis recurrence after kidney transplant with abatacept, which induced proteinuria remission.
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Affiliation(s)
- Yaser Shah
- From the Department of Adult Kidney and Pancreas Transplantation, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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31
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Isom R, Shoor S, Higgins J, Cara-Fuentes G, Johnson RJ. Abatacept in Steroid-Dependent Minimal Change Disease and CD80-uria. Kidney Int Rep 2019; 4:1349-1353. [PMID: 31517155 PMCID: PMC6732767 DOI: 10.1016/j.ekir.2019.05.1155] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 02/07/2023] Open
Affiliation(s)
- Robert Isom
- Division of Nephrology. Stanford University School of Medicine, Stanford, California, USA
| | - Stanford Shoor
- Division of Immunology and Rheumatology, Stanford University School of Medicine, Stanford, California, USA
| | - John Higgins
- Pathology, Stanford University Medical Center, Stanford, California, USA
| | - Gabriel Cara-Fuentes
- Division of Pediatric Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard J Johnson
- Division of Renal Diseases and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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32
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Alhasan KA, Alherbish A, Osman A, Kari JA, Almojalli H. Successful Treatment of Recurrent Focal Segmental Glomerulosclerosis After Transplantation in Children: A Single-Center Experience. Transplant Proc 2019; 51:517-521. [PMID: 30879580 DOI: 10.1016/j.transproceed.2019.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We aim to report our experience managing cases of recurrent focal segmental glomerulosclerosis (FSGS) in a group of pediatric renal transplant recipients. METHODS This study was a retrospective chart review of pediatric patients who had their first kidney transplant at King Faisal Specialist Hospital & Research Center between 2014 and 2016. RESULTS We reviewed the files of 6 patients, 3 of whom were male. The median age of the children was 2.75 years (range, 2-4 years) at disease onset, with an average time of progression to end-stage renal disease of 19 months (range, 8-30 months). Five of the patients received a living related donor transplant, and 1 received a living nonrelated donor transplant. Patients had FSGS recurrence at varying intervals (1 to 3 days) post transplant. All cases had plasmapheresis prior to receiving abatacept or rituximab. The therapeutic strategy in 4 patients involved switching tacrolimus to cyclosporine. A complete response was observed in 5 of the 6 patients (83.3%), and treatment was well tolerated in 5 patients. Patient 1 had severe oliguria and required intermittent hemodialysis during the first 3 weeks post transplant. He showed minimal response to the therapeutic plasma exchange and rituximab and was subsequently treated with abatacept. However, he died 8 months post transplant of pneumonia and sepsis. CONCLUSION Rituximab and switching tacrolimus to cyclosporine, in conjunction with plasmapheresis, appeared to be effective and safe in children with recurrent FSGS. Conversely, abatacept did not appear to provide clinical benefit.
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Affiliation(s)
- K A Alhasan
- Department of Pediatrics, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia; Organ Transplant Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia.
| | - A Alherbish
- Department of Pediatrics, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia; Organ Transplant Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - A Osman
- Department of Pediatrics, College of Medicine, King Saud University, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - J A Kari
- Pediatric Nephrology Center of Excellence and Department of Pediatrics, King Abdulaziz University, Jeddah, Saudi Arabia
| | - H Almojalli
- Organ Transplant Center, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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Puig-Gay N, Jacobs-Cacha C, Sellarès J, Guirado L, González Roncero F, Jiménez C, Zárraga S, Paul J, Lauzurica R, Alonso Á, Fernández A, Beneyto I, Mazuecos A, Hernández D, Rodriguez-Benot A, Franco A, Jimeno L, Crespo M, Meseguer A, Moreso F, Seron D, Lopez-Hellin J, Cantarell C. Apolipoprotein A-Ib as a biomarker of focal segmental glomerulosclerosis recurrence after kidney transplantation: diagnostic performance and assessment of its prognostic value - a multi-centre cohort study. Transpl Int 2018; 32:313-322. [PMID: 30411406 DOI: 10.1111/tri.13372] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/05/2018] [Accepted: 10/31/2018] [Indexed: 01/02/2023]
Abstract
Recurrence of idiopathic focal segmental glomerulosclerosis (FSGS) is a serious complication after kidney transplantation. FSGS relapse is suspected by a sudden increase in proteinuria but there is not an accurate noninvasive diagnostic tool to confirm this entity or to detect patients at risk. We aimed to validate the diagnostic performance of ApoA-Ib to detect FSGS relapses by measuring urinary ApoA-Ib in a retrospective cohort of 61 kidney transplanted patients (37 FSGS and 24 non-FSGS). In addition, to assess the ApoA-Ib predictive ability, ApoA-Ib was measured periodically in a prospective cohort of 13 idiopathic FSGS patients who were followed during 1 year after transplantation. ApoA-Ib had a sensitivity of 93.3% and a specificity of 90.9% to diagnose FSGS relapses, with a high negative predictive value (95.2%), confirming our previous results. In the prospective cohort, ApoA-Ib predated the recurrence in four of five episodes observed. In the nonrelapsing group (n = 9), ApoA-Ib was negative in 37 of 38 samples. ApoA-Ib has the potential to be a good diagnostic biomarker of FSGS relapses, providing a confident criterion to exclude false positives even in the presence of high proteinuria. It has also the potential to detect patients at risk of relapse, even before transplantation.
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Affiliation(s)
- Natàlia Puig-Gay
- Renal Physiopathology Group-CIBBIM, Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Conxita Jacobs-Cacha
- Renal Physiopathology Group-CIBBIM, Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain.,Nephrology, Hospital Vall d'Hebron, Barcelona, Spain
| | | | | | | | - Carlos Jiménez
- Nephrology, Hospital Universitario La Paz, Madrid, Spain
| | | | - Javier Paul
- Nephrology, Hospital Miguel Servet, Zaragoza, Spain
| | | | - Ángel Alonso
- Nephrology, Hospital Universitario de A Coruña, A Coruña, Spain
| | | | - Isabel Beneyto
- Nephrology, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | | | | | | | | | - Luisa Jimeno
- Nephrology, Hospital Virgen de la Arrixaca, Murcia, Spain
| | | | - Anna Meseguer
- Renal Physiopathology Group-CIBBIM, Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | | | - Daniel Seron
- Nephrology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Joan Lopez-Hellin
- Renal Physiopathology Group-CIBBIM, Hospital Vall d'Hebron Institut de Recerca (VHIR), Barcelona, Spain
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Siligato R, Cernaro V, Nardi C, De Gregorio F, Gembillo G, Costantino G, Conti G, Buemi M, Santoro D. Emerging therapeutic strategies for minimal change disease and focal and segmental glomerulosclerosis. Expert Opin Investig Drugs 2018; 27:839-879. [PMID: 30360670 DOI: 10.1080/13543784.2018.1540587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Minimal change disease (MCD) and Focal and segmental glomerulosclerosis (FSGS) are two of the major causes of nephrotic syndrome (NS) in children and adults. According to KDIGO (Kidney Disease: Improving Global Outcomes) guidelines, the treatment of adult primary MCD and FSGS should be based on immunosuppressants and antiproteinuric drugs. Recently, Rituximab, a humanized monoclonal antibody (mAb) has emerged as a potential treatment for steroid or calcineurin inhibitor-dependent patients; it has however demonstrated lower efficacy in those with nephrotic syndrome that is resistant to the above indicated drugs. AREAS COVERED Analysis of ongoing and already completed clinical trials, retrieved from clinicaltrials.gov, clinicaltrialsregister.eu and PubMed involving new therapies for nephrotic syndrome secondary to MCD and FSGS. EXPERT OPINION The most promising drugs under investigation for MCD and FSGS are mAbs. We are hopeful that new therapeutic options to treat multi-drug resistant MCD and FSGS will emerge from currently ongoing studies. What appears certain is the difficulty in enrolling patients affected by orphan renal diseases and the selection of valid endpoints in clinical trials, such as kidney failure.
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Affiliation(s)
- Rossella Siligato
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Valeria Cernaro
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Chiara Nardi
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Francesca De Gregorio
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Guido Gembillo
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Giuseppe Costantino
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Giovanni Conti
- b Unit of Pediatric Nephrology and Rheumatology , University of Messina , Messina , Italy
| | - Michele Buemi
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
| | - Domenico Santoro
- a Unit of Nephrology and Dialysis, Department of Internal Medicine , Messina , Italy
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Tullus K, Webb H, Bagga A. Management of steroid-resistant nephrotic syndrome in children and adolescents. THE LANCET CHILD & ADOLESCENT HEALTH 2018; 2:880-890. [PMID: 30342869 DOI: 10.1016/s2352-4642(18)30283-9] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/18/2018] [Accepted: 08/21/2018] [Indexed: 02/08/2023]
Abstract
More than 85% of children and adolescents (majority between 1-12 years old) with idiopathic nephrotic syndrome show complete remission of proteinuria following daily treatment with corticosteroids. Patients who do not show remission after 4 weeks' treatment with daily prednisolone are considered to have steroid-resistant nephrotic syndrome (SRNS). Renal histology in most patients shows presence of focal segmental glomerulosclerosis, minimal change disease, and (rarely) mesangioproliferative glomerulonephritis. A third of patients with SRNS show mutations in one of the key podocyte genes. The remaining cases of SRNS are probably caused by an undefined circulating factor. Treatment with calcineurin inhibitors (ciclosporin and tacrolimus) is the standard of care for patients with non-genetic SRNS, and approximately 70% of patients achieve a complete or partial remission and show satisfactory long-term outcome. Additional treatment with drugs that inhibit the renin-angiotensin axis is recommended for hypertension and for reducing remaining proteinuria. Patients with SRNS who do not respond to treatment with calcineurin inhibitors or other immunosuppressive drugs can show declining kidney function and are at risk for end-stage renal failure. Approximately a third of those who undergo renal transplantation show recurrent focal segmental glomerulosclerosis in the allograft and often respond to combined treatment with plasma exchange, rituximab, and intensified immunosuppression.
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Affiliation(s)
- Kjell Tullus
- Nephrology Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK.
| | - Hazel Webb
- Nephrology Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, UK
| | - Arvind Bagga
- Division of Nephrology, Indian Council of Medical Research Advanced Center for Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India
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Difficult-to-treat idiopathic nephrotic syndrome: established drugs, open questions and future options. Pediatr Nephrol 2018; 33:1641-1649. [PMID: 28879428 DOI: 10.1007/s00467-017-3780-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 10/18/2022]
Abstract
The idiopathic nephrotic syndrome in childhood can be classified according to the International Study of Kidney Disease in Children (ISKDC) based on the response to steroids. Typically, steroid-sensitive nephrotic syndrome (SSNS) is characterised by minimal changes in disease (MCD) histology, whereas in steroid-resistant nephrotic syndrome (SRNS) focal segmental glomerulosclerosis (FSGS) is the most prevalent lesion. Patients with SSNS may develop frequent relapses and/or steroid dependency, which can be difficult to treat. New studies confirm the value of calcineurin inhibitors (CNIs) and mycophenolic acid in preventing relapses of SSNS. Rituximab also plays an important role, but many questions regarding initial dosing, repetitions of courses, and long-term side effects remain unclear. SRNS, especially when unresponsive to treatment, can lead to chronic kidney disease. In particular, treatment with CNIs has improved the prognosis and recent data indicate that treatment can even be discontinued in many patients with full remission. In CNI-unresponsive SRNS, rituximab is less effective than in SSNS and the role of other biologicals (such as ofatumumab, abatacept, and others) remains unclear. A significant proportion of children with FSGS have genetic causes and most patients do not respond to immunosuppression, although individual patients with partial and even complete response have been documented. Future studies should evaluate treatments leading to long-term remission without maintenance immunosuppression in SSNS; in both genetic and immune-mediated SRNS, novel options to decrease the number of treatment-unresponsive patients seem mandatory, as they are at a high risk of developing end-stage renal disease.
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Yu SMW, Nissaisorakarn P, Husain I, Jim B. Proteinuric Kidney Diseases: A Podocyte's Slit Diaphragm and Cytoskeleton Approach. Front Med (Lausanne) 2018; 5:221. [PMID: 30255020 PMCID: PMC6141722 DOI: 10.3389/fmed.2018.00221] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/18/2018] [Indexed: 01/19/2023] Open
Abstract
Proteinuric kidney diseases are a group of disorders with diverse pathological mechanisms associated with significant losses of protein in the urine. The glomerular filtration barrier (GFB), comprised of the three important layers, the fenestrated glomerular endothelium, the glomerular basement membrane (GBM), and the podocyte, dictates that disruption of any one of these structures should lead to proteinuric disease. Podocytes, in particular, have long been considered as the final gatekeeper of the GFB. This specialized visceral epithelial cell contains a complex framework of cytoskeletons forming foot processes and mediate important cell signaling to maintain podocyte health. In this review, we will focus on slit diaphragm proteins such as nephrin, podocin, TRPC6/5, as well as cytoskeletal proteins Rho/small GTPases and synaptopodin and their respective roles in participating in the pathogenesis of proteinuric kidney diseases. Furthermore, we will summarize the potential therapeutic options targeting the podocyte to treat this group of kidney diseases.
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Affiliation(s)
- Samuel Mon-Wei Yu
- Department of Medicine, Jacobi Medical Center, Bronx, NY, United States
| | | | - Irma Husain
- Department of Medicine, James J. Peters VA Medical Center, Bronx, NY, United States
| | - Belinda Jim
- Department of Medicine, Jacobi Medical Center, Bronx, NY, United States.,Renal Division, Jacobi Medical Center, Bronx, NY, United States
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Novelli R, Benigni A, Remuzzi G. The role of B7-1 in proteinuria of glomerular origin. Nat Rev Nephrol 2018; 14:589-596. [DOI: 10.1038/s41581-018-0037-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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39
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Bertelli R, Bonanni A, Caridi G, Canepa A, Ghiggeri GM. Molecular and Cellular Mechanisms for Proteinuria in Minimal Change Disease. Front Med (Lausanne) 2018; 5:170. [PMID: 29942802 PMCID: PMC6004767 DOI: 10.3389/fmed.2018.00170] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 05/15/2018] [Indexed: 12/15/2022] Open
Abstract
Minimal Change Disease (MCD) is a clinical condition characterized by acute nephrotic syndrome, no evident renal lesions at histology and good response to steroids. However, frequent recurrence of the disease requires additional therapies associated with steroids. Such multi-drug dependence and frequent relapses may cause disease evolution to focal and segmental glomerulosclerosis (FSGS) over time. The differences between the two conditions are not well defined, since molecular mechanisms may be shared by the two diseases. In some cases, genetic analysis can make it possible to distinguish MCD from FSGS; however, there are cases of overlap. Several hypotheses on mechanisms underlying MCD and potential molecular triggers have been proposed. Most studies were conducted on animal models of proteinuria that partially mimic MCD and may be useful to study glomerulosclerosis evolution; however, they do not demonstrate a clear-cut separation between MCD and FSGS. Puromycin Aminonucleoside and Adriamycin nephrosis are models of glomerular oxidative damage, characterized by loss of glomerular basement membrane polyanions resembling MCD at the onset and, at more advanced stages, by glomerulosclerosis resembling FSGS. Also Buffalo/Mna rats present initial lesions of MCD, subsequently evolving to FSGS; this mechanism of renal damage is clearer since this rat strain inherits the unique characteristic of overexpressing Th2 cytokines. In Lipopolysaccharide nephropathy, an immunological condition of renal toxicity linked to B7-1(CD80), mice develop transient proteinuria that lasts a few days. Overall, animal models are useful and necessary considering that they reproduce the evolution from MCD to FSGS that is, in part, due to persistence of proteinuria. The role of T/Treg/Bcells on human MCD has been discussed. Many cytokines, immunomodulatory mechanisms, and several molecules have been defined as a specific cause of proteinuria. However, the hypothesis of a single cell subset or molecule as cause of MCD is not supported by research and an interactive process seems more logical. The implication or interactive role of oxidants, Th2 cytokines, Th17, Tregs, B7-1(CD80), CD40/CD40L, c-Mip, TNF, uPA/suPAR, Angiopoietin-like 4 still awaits a definitive confirmation. Whole genome sequencing studies could help to define specific genetic features that justify a definition of MCD as a “clinical-pathology-genetic entity.”
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Affiliation(s)
| | | | | | - Alberto Canepa
- Nephrology, Dialysis, Transplantation Unit, Integrated Department of Pediatrics and Hemato-Oncology Sciences, Istituto Giannina Gaslini IRCCS, Genoa, Italy
| | - G M Ghiggeri
- Laboratory of Molecular Nephrology, Genoa, Italy.,Nephrology, Dialysis, Transplantation Unit, Integrated Department of Pediatrics and Hemato-Oncology Sciences, Istituto Giannina Gaslini IRCCS, Genoa, Italy
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40
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Bernard J, Bruel A, Allain-Launay E, Dantal J, Roussey G. Ofatumumab in post-transplantation recurrence of a pediatric steroid-resistant idiopathic nephrotic syndrome. Pediatr Transplant 2018; 22:e13175. [PMID: 29569812 DOI: 10.1111/petr.13175] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2018] [Indexed: 12/14/2022]
Abstract
Treatment of SRNS is a challenge. Antiproliferative agents and depleting antibodies have been reported to be effective. However, these agents are not always successful, and use of ofatumumab could provide a different treatment option. Our patient was diagnosed with a SRNS at 5 years of age. She developed ESRD, with FSGS. This was cause for a first renal transplantation. The NS relapsed, leading to loss of the graft, and a second renal transplantation was performed. Due to the recurrence of the NS, IAds were initiated and led to a complete remission. Our patient remained dependent on IAds, however, despite treatments with calcineurin inhibitors, corticosteroids, rituximab, and abatacept. Ofatumumab was introduced and led to a remission, thus allowing cessation of the IAd treatment. Another infusion of ofatumumab was administered 8 months after the last one, due to the recurrence of the NS and a renewed increase in B cells. Although it did not result in a complete remission, the proteinuria was stabilized in the absence of IAds. Ofatumumab may be an alternative treatment for post-transplantation rituximab-resistant SRNS, although this needs to be confirmed by further studies.
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Affiliation(s)
- Josselin Bernard
- Pediatric Department, University Hospital of Nantes, Nantes, France
| | - Alexandra Bruel
- Pediatric Department, University Hospital of Nantes, Nantes, France
| | | | - Jacques Dantal
- Nephrology and Immunology Department, University Hospital of Nantes, Nantes, France
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Kofman T, Oniszczuk J, Lang P, Grimbert P, Audard V. [Current insights about recurrence of glomerular diseases after renal transplantation]. Nephrol Ther 2018; 14:179-188. [PMID: 29706414 DOI: 10.1016/j.nephro.2018.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Recurrence of glomerular disease after renal transplantation is a frequent cause of graft loss. Incidence, risk factors and outcome of recurrence are widely due to the underlying glomerular disease. Graft biopsy analysis is required to confirm the definitive diagnosis of recurrence and to start an appropriate therapy that, in some cases, remains challenging to prevent graft failure. Increased use of protocol biopsy and recent advances in our understanding of the pathogenesis of some glomerular diseases with the identification of some relevant biomarkers provide a unique opportunity to initiate kidney-protective therapy at early stages of recurrence on the graft. This review summarizes our current knowledge on the management of many recurrent primary and secondary glomerulonephritis after kidney transplantation.
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Affiliation(s)
- Tomek Kofman
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Julie Oniszczuk
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Philippe Lang
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Philippe Grimbert
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France
| | - Vincent Audard
- Service de néphrologie et transplantation, hôpital Henri-Mondor, avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France; Institut francilien de recherche en néphrologie et transplantation (IFRNT), université Paris Est-Créteil (Upec), avenue du Maréchal-de-Lattre-de-Tassigny, 94010 Créteil cedex, France.
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42
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Hosohata K. Can Focal Segmental Glomerulosclerosis Be Differentiated From Minimal Change Nephrotic Syndrome Using Biomarkers? Am J Med Sci 2018; 355:305-306. [PMID: 29661342 DOI: 10.1016/j.amjms.2018.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/03/2018] [Accepted: 01/09/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Keiko Hosohata
- Education and Research Center for Clinical Pharmacy Osaka University of Pharmaceutical Sciences Takatsuki, Osaka, Japan.
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43
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Lal MA, Patrakka J. Understanding Podocyte Biology to Develop Novel Kidney Therapeutics. Front Endocrinol (Lausanne) 2018; 9:409. [PMID: 30083135 PMCID: PMC6065143 DOI: 10.3389/fendo.2018.00409] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 07/02/2018] [Indexed: 11/13/2022] Open
Abstract
Over the past two decades it has become increasing clear that injury and loss of podocytes is an early and common clinical observation presented in many forms of glomerulopathy and chronic kidney disease. Identification of disease-causing monogenic mutations in numerous podocyte-expressed genes as well as studies conducted using preclinical animal models have shown that the podocyte plays a central role in establishing kidney dysfunction. In this review, we summarize current knowledge regarding the potential for podocyte-targeted therapies and give our view on how a deeper understanding of the molecular makeup of the podocyte will enable future therapeutic interventions. Specifically, we recount some of the currently described podocentric strategies for therapy and summarize the status and evolution of various model systems used to facilitate our understanding of the molecular and functional underpinnings of podocyte biology.
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Affiliation(s)
- Mark A. Lal
- Bioscience, Cardiovascular, Renal and Metabolism, Innovative Medicines Biotech Unit, AstraZeneca, Gothenburg, Sweden
- *Correspondence: Mark A. Lal
| | - Jaakko Patrakka
- Karolinska Institutet/AstraZeneca Integrated Cardio Metabolic Center, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital Huddinge, Stockholm, Sweden
- Jaakko Patrakka
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44
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Trachtman H, Gipson DS, Somers M, Spino C, Adler S, Holzman L, Kopp JB, Sedor J, Overfield S, Elegbe A, Maldonado M, Greka A. Randomized Clinical Trial Design to Assess Abatacept in Resistant Nephrotic Syndrome. Kidney Int Rep 2017; 3:115-121. [PMID: 29340321 PMCID: PMC5762951 DOI: 10.1016/j.ekir.2017.08.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 07/28/2017] [Accepted: 08/21/2017] [Indexed: 11/18/2022] Open
Abstract
Introduction Treatment-resistant nephrotic syndrome is a rare form of glomerular disease that occurs in children and adults. No Food and Drug Administration-approved treatments consistently achieve remission of proteinuria and preservation of kidney function. CD80 (B7-1) can be expressed on injured podocytes, and administration of abatacept (modified CTLA4-Ig based on a natural ligand to CD80) has been associated with sustained normalization of urinary protein excretion and maintenance of glomerular filtration rate in experimental and clinical settings. Methods In this report, we describe the rationale for and design of a randomized, placebo-controlled, clinical trial of abatacept in patients with treatment-resistant nephrotic syndrome caused by focal segmental glomerulosclerosis or minimal change disease. The design is a hybrid of a parallel-group and crossover design (switchover) with the primary objectives assessed in the first period of the study and the secondary objectives assessed using data from both periods. All participants will receive the active agent in 1 of the periods. The duration of treatment will be 4 months per period. Results The primary outcome will be improvement in nephrotic-range proteinuria to subnephrotic range, that is, reduction from baseline to 4 months in urine protein:creatinine ratio ≥ 50% and to a level < 3. The projected sample size is 90 patients, which has 80% power to detect a treatment difference of 28%. Conclusion This study advances efforts to validate CD80 as a therapeutic target for treatment-resistant nephrotic syndrome, and implements a precision medicine-based approach to this serious kidney condition in which the selection of a therapeutic agent is guided by the underlying disease mechanism operating in individual patients.
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Affiliation(s)
- Howard Trachtman
- Division of Nephrology, Department of Pediatrics, New York University Langone Medical Center, New York, New York, USA
| | - Debbie S. Gipson
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Somers
- Division of Nephrology, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Sharon Adler
- Division of Nephrology and Hypertension, Harbor-University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Lawrence Holzman
- Department of Medicine, University of Pennsylvania Medical School, Philadelphia, Pennsylvania, USA
| | - Jeffrey B. Kopp
- Kidney Disease Section, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - John Sedor
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | | | | | | | - Anna Greka
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, and Broad Institute of Massachusetts Institute of Technology and Harvard, Cambridge, Massachusetts, USA
- Correspondence: Anna Greka, Brigham and Women’s Hospital, Harvard Medical School, Harvard Institutes of Medicine, 4 Blackfan Circle, Boston, Massachusetts 02115, USA; or The Broad Institute of MIT and Harvard, 415 Main Street, Cambridge, Massachusetts 02142, USA.Brigham and Women’s HospitalHarvard Medical SchoolHarvard Institutes of Medicine, 4 Blackfan Circle, Boston, Massachusetts 02115, USA; or The Broad Institute of MIT and Harvard415 Main StreetCambridgeMassachusetts 02142USA
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Multiple Targets for Novel Therapy of FSGS Associated with Circulating Permeability Factor. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6232616. [PMID: 28951873 PMCID: PMC5603123 DOI: 10.1155/2017/6232616] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 05/10/2017] [Accepted: 06/15/2017] [Indexed: 01/13/2023]
Abstract
A plasma component is responsible for altered glomerular permeability in patients with focal segmental glomerulosclerosis. Evidence includes recurrence after renal transplantation, remission after plasmapheresis, proteinuria in infants of affected mothers, transfer of proteinuria to experimental animals, and impaired glomerular permeability after exposure to patient plasma. Therapy may include decreasing synthesis of the injurious agent, removing or blocking its interaction with cells, or blocking signaling or enhancing cell defenses to restore the permeability barrier and prevent progression. Agents that may prevent the synthesis of the permeability factor include cytotoxic agents or aggressive chemotherapy. Extracorporeal therapies include plasmapheresis, immunoadsorption with protein A or anti-immunoglobulin, or lipopheresis. Oral or intravenous galactose also decreases Palb activity. Studies of glomeruli have shown that several strategies prevent the action of FSGS sera. These include blocking receptor-ligand interactions, modulating cell reactions using indomethacin or eicosanoids 20-HETE or 8,9-EET, and enhancing cytoskeleton and protein interactions using calcineurin inhibitors, glucocorticoids, or rituximab. We have identified cardiotrophin-like cytokine factor 1 (CLCF-1) as a candidate for the permeability factor. Therapies specific to CLCF-1 include potential use of cytokine receptor-like factor (CRLF-1) and inhibition of Janus kinase 2. Combined therapy using multiple modalities offers therapy to reverse proteinuria and prevent scarring.
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46
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Trachtman H. Investigational drugs in development for focal segmental glomerulosclerosis. Expert Opin Investig Drugs 2017; 26:945-952. [PMID: 28707483 DOI: 10.1080/13543784.2017.1351544] [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: 10/19/2022]
Abstract
INTRODUCTION Focal segmental glomerulosclerosis is an important cause of end stage kidney disease and is a paradigm for the study of glomerular scarring. There are no FDA approved treatments for this condition. Current therapies, assessed based on reduction in proteinuria, are generally effective in a subset of patients which suggests that FSGS is a heterogeneous group of glomerular disorders or podocytopathies that converge on a common histopathological phenotype. Areas covered: We searched for investigational drugs agents that target different pathophysiological pathways using the key words 'FSGS' and 'podocyte' in American and European clinical trial registers (clinicaltrials.gov; clinicaltrialsregister.eu). Published articles were searched in PubMed, Medline, the Web of Science and the Cochrane Central Register of Controlled Trials Library. Expert opinion: Progress is being made in defining the mechanism of action of subtypes of FSGS. Current and investigational therapies for FSGS target these different pathways of injury. It is anticipated that advances in systems biology will further refine the classification of FSGS by subdividing the disease based on the primary mechanism of glomerular injury, identify biomarkers to discriminate between different subtypes, and enable appropriate selection of appropriate therapy for each individual in accordance with the goals of precision medicine.
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Affiliation(s)
- Howard Trachtman
- a Department of Pediatrics, Division of Nephrology , NYU Langone Medical Center , New York , NY , USA
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Rifkin IR, Bonegio RG. Editorial: Podocytes as Active Participants in Lupus Nephritis. Arthritis Rheumatol 2017; 69:1517-1520. [PMID: 28544537 DOI: 10.1002/art.40157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 05/16/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Ian R Rifkin
- Boston University School of Medicine and VA Boston Healthcare System, Boston, Massachusetts
| | - Ramon G Bonegio
- Boston University School of Medicine and VA Boston Healthcare System, Boston, Massachusetts
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Beaudreuil S, Lorenzo HK, Elias M, Nnang Obada E, Charpentier B, Durrbach A. Optimal management of primary focal segmental glomerulosclerosis in adults. Int J Nephrol Renovasc Dis 2017; 10:97-107. [PMID: 28546764 PMCID: PMC5436760 DOI: 10.2147/ijnrd.s126844] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Focal segmental glomerulosclerosis (FSGS) is a frequent glomerular kidney disease that is revealed by proteinuria or even nephrotic syndrome. A diagnosis can be established from a kidney biopsy that shows focal and segmental glomerulosclerosis. This histopathological lesion may be caused by a primary podocyte injury (idiopathic FSGS) but is also associated with other pathologies (secondary FSGS). The first-line treatment for idiopathic FSGS with nephrotic syndrome is a prolonged course of corticosteroids. However, steroid resistance or steroid dependence is frequent, and despite intensified immunosuppressive treatment, FSGS can lead to end-stage renal failure. In addition, in some cases, FSGS can recur on a graft after kidney transplantation: an unidentified circulating factor may be implicated. Understanding of its physiopathology is unclear, and it remains an important challenge for the scientific community to identify a specific diagnostic biomarker and to develop specific therapeutics. This study reviews the treatment of primary FSGS and the recurrence of FSGS after kidney transplantation in adults.
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Affiliation(s)
- Séverine Beaudreuil
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre.,INSERM Unit 1197, Paris-Sud University Hospital, Villejuif, France
| | - Hans Kristian Lorenzo
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre.,INSERM Unit 1197, Paris-Sud University Hospital, Villejuif, France
| | - Michele Elias
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre
| | - Erika Nnang Obada
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre
| | - Bernard Charpentier
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre.,INSERM Unit 1197, Paris-Sud University Hospital, Villejuif, France
| | - Antoine Durrbach
- Department of Nephrology Dialysis Transplantation, Paris-Sud University Hospital, Le Kremlin Bicêtre.,INSERM Unit 1197, Paris-Sud University Hospital, Villejuif, France
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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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Available and incoming therapies for idiopathic focal and segmental glomerulosclerosis in adults. J Nephrol 2017; 31:37-45. [DOI: 10.1007/s40620-017-0402-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 04/10/2017] [Indexed: 01/30/2023]
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