1
|
Vivarelli M, Barratt J, Beck LH, Fakhouri F, Gale DP, Goicoechea de Jorge E, Mosca M, Noris M, Pickering MC, Susztak K, Thurman JM, Cheung M, King JM, Jadoul M, Winkelmayer WC, Smith RJH. The role of complement in kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2024; 106:369-391. [PMID: 38844295 DOI: 10.1016/j.kint.2024.05.015] [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: 12/22/2023] [Revised: 04/25/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Uncontrolled complement activation can cause or contribute to glomerular injury in multiple kidney diseases. Although complement activation plays a causal role in atypical hemolytic uremic syndrome and C3 glomerulopathy, over the past decade, a rapidly accumulating body of evidence has shown a role for complement activation in multiple other kidney diseases, including diabetic nephropathy and several glomerulonephritides. The number of available complement inhibitor therapies has also increased during the same period. In 2022, Kidney Diseases: Improving Global Outcomes (KDIGO) convened a Controversies Conference, "The Role of Complement in Kidney Disease," to address the expanding role of complement dysregulation in the pathophysiology, diagnosis, and management of various glomerular diseases, diabetic nephropathy, and other forms of hemolytic uremic syndrome. Conference participants reviewed the evidence for complement playing a primary causal or secondary role in progression for several disease states and considered how evidence of complement involvement might inform management. Participating patients with various complement-mediated diseases and caregivers described concerns related to life planning, implications surrounding genetic testing, and the need for inclusive implementation of effective novel therapies into clinical practice. The value of biomarkers in monitoring disease course and the role of the glomerular microenvironment in complement response were examined, and key gaps in knowledge and research priorities were identified.
Collapse
Affiliation(s)
- Marina Vivarelli
- Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Laurence H Beck
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, Nantes, France; INSERM UMR S1064, Nantes, France
| | - Daniel P Gale
- Centre for Kidney and Bladder Health, University College London, UK
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and ORL, Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Marta Mosca
- Department of Clinical and Experimental Medicine-Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Marina Noris
- Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College, Hammersmith Campus, London, UK
| | - Katalin Susztak
- Division of Nephrology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Thurman
- Division of Nephrology and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Pediatrics, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
| |
Collapse
|
2
|
Wang Y, Shang S, Jiang S, Zou G, Gao H, Li W. Complement C3a/C3aR and C5a/C5aR deposits accelerate the progression of advanced IgA nephropathy to end-stage renal disease. Clin Exp Med 2024; 24:139. [PMID: 38951265 PMCID: PMC11217045 DOI: 10.1007/s10238-024-01410-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2024] [Accepted: 06/19/2024] [Indexed: 07/03/2024]
Abstract
IgA nephropathy (IgAN) is still one of the leading causes of end-stage kidney disease (ESRD), and complement system activation is a key to the pathogenesis of IgAN. The role of complement C3a/C3aR and C5a/C5aR in late stage of IgAN remains unknown. Renal specimens of 75 IgAN patients at the stage 4 CKD were stained using immunofluorescence and immunohistochemistry. The primary outcome was a composite of end-stage renal disease (ESRD) and death. Associations of complement components with baseline clinicopathological characteristics and outcomes were assessed using multivariable Cox regression and Spearman analyses. During a median follow-up of 15.0 months, 27 patients progressed to ESRD and none died. Lower eGFR [hazards ratio (HR), 0.827, 95% confidence interval (CI), 0.732-0.935; P = 0.002] and glomerular C3 deposition (HR, 3.179, 95% CI, 1.079-9.363; P = 0.036) were predictive of time to ESRD in stage 4 CKD IgAN. Higher expression of C3a (P = 0.010), C3aR (P = 0.005), C5a (P = 0.015), and C5aR (P < 0.001) was identified in ESRD group than in non-ESRD group. Glomerular C3a/C3aR and C5a/C5aR deposits were both correlated with a lower baseline eGFR, higher baseline 24 h-urinary protein (24 h-UP) and faster decline of eGFR. Besides, C3a and C5a deposits were found in patients with high S (S1) and T (T1/2) scores, respectively. Complement C3a/C3aR and C5a/C5aR in IgAN patients with stage 4 CKD may portend a faster deterioration of kidney function.
Collapse
Affiliation(s)
- Ying Wang
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China
| | - Shunlai Shang
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China.
| | - Shimin Jiang
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China
| | - Guming Zou
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China
| | - Hongmei Gao
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China
| | - Wenge Li
- Department of Nephrology, China-Japan Friendship Hospital, No. 2 East Yinghuayuan Street, Chaoyang District, Beijing, 100029, China.
| |
Collapse
|
3
|
Stea ED, D'Ettorre G, Mitrotti A, Gesualdo L. The complement system in the pathogenesis and progression of kidney diseases: What doesn't kill you makes you older. Eur J Intern Med 2024; 124:22-31. [PMID: 38461065 DOI: 10.1016/j.ejim.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 01/31/2024] [Accepted: 02/09/2024] [Indexed: 03/11/2024]
Abstract
The Complement System is an evolutionarily conserved component of immunity that plays a key role in host defense against infections and tissue homeostasis. However, the dysfunction of the Complement System can result in tissue damage and inflammation, thereby contributing to the development and progression of various renal diseases, ranging from atypical Hemolytic Uremic Syndrome to glomerulonephritis. Therapeutic interventions targeting the complement system have demonstrated promising results in both preclinical and clinical studies. Currently, several complement inhibitors are being developed for the treatment of complement-mediated renal diseases. This review aims to summarize the most recent insights into complement activation and therapeutic inhibition in renal diseases. Furthermore, it offers potential directions for the future rational use of complement inhibitor drugs in the context of renal diseases.
Collapse
Affiliation(s)
- Emma Diletta Stea
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), Nephrology and Urology Units, University of Bari Aldo Moro, Bari, Italy
| | | | - Adele Mitrotti
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), Nephrology and Urology Units, University of Bari Aldo Moro, Bari, Italy
| | - Loreto Gesualdo
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePre-J), Nephrology and Urology Units, University of Bari Aldo Moro, Bari, Italy.
| |
Collapse
|
4
|
Guo WY, Wang GQ, Kong LQ, Sun LJ, Xu XY, Cheng WR, Dong HR, Cheng H. Complement system is overactivated in patients with IgA nephropathy after COVID-19. Clin Immunol 2024; 263:110232. [PMID: 38701960 DOI: 10.1016/j.clim.2024.110232] [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: 01/23/2024] [Accepted: 04/26/2024] [Indexed: 05/06/2024]
Abstract
IgA nephropathy (IgAN), which has been confirmed as a complement mediated autoimmune disease, is also one form of glomerulonephritis associated with COVID-19. Here, we aim to investigate the clinical and immunological characteristics of patients with IgAN after COVID-19. The level of plasma level of C5a (p < 0.001), soluble C5b-9 (p = 0.018), FHR5 (p < 0.001) were all significantly higher in Group CoV (33 patients with renal biopsy-proven IgAN experienced COVID-19) compared with Group non-CoV (44 patients with IgAN without COVID-19), respectively. Compared with Group non-CoV, the intensity of glomerular C4d (p = 0.017) and MAC deposition (p < 0.001) and Gd-IgA1 deposition (p = 0.005) were much stronger in Group CoV. Our finding revealed that for IgAN after COVID-19, mucosal immune responses to SARS-CoV-2 infection may result in the overactivation of systemic and renal local complement system, and increased glomerular deposition of Gd-IgA1, which may lead to renal dysfunction and promote renal progression in IgAN patients.
Collapse
Affiliation(s)
- Wei-Yi Guo
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, China
| | - Guo-Qin Wang
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, China
| | - Ling-Qiang Kong
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, China
| | - Li-Jun Sun
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, China
| | - Xiao-Yi Xu
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, China
| | - Wen-Rong Cheng
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, China
| | - Hong-Rui Dong
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, China
| | - Hong Cheng
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, China.
| |
Collapse
|
5
|
Vaz de Castro PAS, Amaral AA, Almeida MG, Selvaskandan H, Barratt J, Simões E Silva AC. Examining the association between serum galactose-deficient IgA1 and primary IgA nephropathy: a systematic review and meta-analysis. J Nephrol 2024:10.1007/s40620-023-01874-8. [PMID: 38427309 DOI: 10.1007/s40620-023-01874-8] [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: 09/19/2023] [Accepted: 12/26/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND IgA nephropathy (IgAN) is a common primary glomerular disease. The O-glycosylation status of IgA1 plays a crucial role in disease pathophysiology. The level of poorly-O-galactosylated IgA1, or galactose-deficient IgA1 (Gd-IgA1), has also been identified as a potential biomarker in IgAN. We sought to examine the value of serum Gd-IgA1 as a biomarker in IgAN, by investigating its association with clinical, laboratory, and histopathological features of IgAN. METHODS The review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and was registered in PROSPERO (CRD42021287423). The literature search was conducted in PubMed, Web of Science, Cochrane, and Scopus, and the selected articles were evaluated for eligibility based on predefined criteria. The methodological quality of the studies was assessed using the Newcastle-Ottawa Scale. Statistical analysis was performed to calculate effect sizes and assess heterogeneity among the studies. RESULTS This review analyzed 29 out of 1,986 studies, conducted between 2005 and 2022, with participants from multiple countries. Gd-IgA1 levels were not associated with age and gender, while associations with hypertension, hematuria, and proteinuria were inconsistent. In the meta-analyses, a correlation between serum Gd-IgA1 and estimated glomerular filtration rate was identified, however, the relationships between Gd-IgA1 levels and chronic kidney disease (CKD) stage and progression to kidney failure were inconsistent. CONCLUSIONS Serum Gd-IgA1 levels were not associated with validated prognostic risk factors, but were negatively correlated with kidney function. Further research in larger studies using standardized assays are needed to establish the value of Gd-IgA1 as a prognostic risk factor in IgAN.
Collapse
Affiliation(s)
- Pedro Alves Soares Vaz de Castro
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Arthur Aguiar Amaral
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Mariana Godinho Almeida
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| | - Haresh Selvaskandan
- The Mayer IgA Nephropathy Laboratories, University of Leicester, Leicester, UK
| | - Jonathan Barratt
- The Mayer IgA Nephropathy Laboratories, University of Leicester, Leicester, UK.
- Department of Cardiovascular Sciences, University of Leicester, University Road, Leicester, LE1 7RH, UK.
| | - Ana Cristina Simões E Silva
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Belo Horizonte, Brazil
| |
Collapse
|
6
|
Dobó J, Kocsis A, Farkas B, Demeter F, Cervenak L, Gál P. The Lectin Pathway of the Complement System-Activation, Regulation, Disease Connections and Interplay with Other (Proteolytic) Systems. Int J Mol Sci 2024; 25:1566. [PMID: 38338844 PMCID: PMC10855846 DOI: 10.3390/ijms25031566] [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: 12/21/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
The complement system is the other major proteolytic cascade in the blood of vertebrates besides the coagulation-fibrinolytic system. Among the three main activation routes of complement, the lectin pathway (LP) has been discovered the latest, and it is still the subject of intense research. Mannose-binding lectin (MBL), other collectins, and ficolins are collectively termed as the pattern recognition molecules (PRMs) of the LP, and they are responsible for targeting LP activation to molecular patterns, e.g., on bacteria. MBL-associated serine proteases (MASPs) are the effectors, while MBL-associated proteins (MAps) have regulatory functions. Two serine protease components, MASP-1 and MASP-2, trigger the LP activation, while the third component, MASP-3, is involved in the function of the alternative pathway (AP) of complement. Besides their functions within the complement system, certain LP components have secondary ("moonlighting") functions, e.g., in embryonic development. They also contribute to blood coagulation, and some might have tumor suppressing roles. Uncontrolled complement activation can contribute to the progression of many diseases (e.g., stroke, kidney diseases, thrombotic complications, and COVID-19). In most cases, the lectin pathway has also been implicated. In this review, we summarize the history of the lectin pathway, introduce their components, describe its activation and regulation, its roles within the complement cascade, its connections to blood coagulation, and its direct cellular effects. Special emphasis is placed on disease connections and the non-canonical functions of LP components.
Collapse
Affiliation(s)
- József Dobó
- Institute of Molecular Life Sciences, HUN-REN Research Centre for Natural Sciences, Hungarian Research Network, 1117 Budapest, Hungary; (J.D.); (A.K.); (B.F.)
| | - Andrea Kocsis
- Institute of Molecular Life Sciences, HUN-REN Research Centre for Natural Sciences, Hungarian Research Network, 1117 Budapest, Hungary; (J.D.); (A.K.); (B.F.)
| | - Bence Farkas
- Institute of Molecular Life Sciences, HUN-REN Research Centre for Natural Sciences, Hungarian Research Network, 1117 Budapest, Hungary; (J.D.); (A.K.); (B.F.)
| | - Flóra Demeter
- Cell Biology and Cell Therapy Group, Research Laboratory, Department of Internal Medicine and Hematology, Semmelweis University, 1085 Budapest, Hungary; (F.D.); (L.C.)
| | - László Cervenak
- Cell Biology and Cell Therapy Group, Research Laboratory, Department of Internal Medicine and Hematology, Semmelweis University, 1085 Budapest, Hungary; (F.D.); (L.C.)
| | - Péter Gál
- Institute of Molecular Life Sciences, HUN-REN Research Centre for Natural Sciences, Hungarian Research Network, 1117 Budapest, Hungary; (J.D.); (A.K.); (B.F.)
| |
Collapse
|
7
|
Caravaca-Fontán F, Gutiérrez E, Sevillano ÁM, Praga M. Targeting complement in IgA nephropathy. Clin Kidney J 2023; 16:ii28-ii39. [PMID: 38053977 PMCID: PMC10695513 DOI: 10.1093/ckj/sfad198] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Indexed: 12/07/2023] Open
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. Recent years have witnessed significant improvements in the understanding of the pathogenesis of IgAN and particularly, the pathogenic role of complement activation. The alternative complement pathway is the major complement cascade activator in IgAN, and glomerular C3 deposition has been shown to correlate with disease progression. In addition, several studies have provided insight into the pathogenic role of factor H-related proteins -1 and -5 in IgAN, as independent players in complement dysregulation. The lectin pathway has also been shown to be associated with the severity of IgAN. Glomerular deposition of C4d has been associated with increased histologic disease activity, faster decline in estimated glomerular filtration rate and higher risk of kidney failure. On the other hand, although overlooked in the Oxford classification, numerous studies have shown that the coexistence of thrombotic microangiopathy in IgAN is a significant indicator of a poorer prognosis. All the breakthroughs in the understanding of the contributing role of complement in IgAN have paved the way for the development of new complement-targeted therapies in this disease. Several ongoing trials are evaluating the efficacy of new agents against factor B (iptacopan, Ionis-FB-LRX), C3 (pegcetacoplan), factor D (vemircopan, pelecopan), C5 (ravulizumab, cemdisiran) and C5a receptor 1 (avacopan). In this study, we provide a comprehensive review of the role of complement in IgAN, including the emerging mechanisms of complement activation and the promising potential of complement inhibitors as a viable treatment option for IgAN.
Collapse
Affiliation(s)
- Fernando Caravaca-Fontán
- Department of Nephrology, Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Eduardo Gutiérrez
- Department of Nephrology, Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
| | - Ángel M Sevillano
- Department of Nephrology, Hospital Universitario 12 de Octubre (imas12), Madrid, Spain
| | - Manuel Praga
- Department of Nephrology, Instituto de Investigación Hospital 12 de Octubre (imas12), Madrid, Spain
- Department of Medicine, Complutense University, Madrid, Spain
| |
Collapse
|
8
|
Duval A, Caillard S, Frémeaux-Bacchi V. The complement system in IgAN: mechanistic context for therapeutic opportunities. Nephrol Dial Transplant 2023; 38:2685-2693. [PMID: 37385820 DOI: 10.1093/ndt/gfad140] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Indexed: 07/01/2023] Open
Abstract
The complement system plays a crucial role in innate immunity, providing essential defense against pathogens. However, uncontrolled or prolonged activation of the complement cascade can significantly contribute to kidney damage, especially in cases of glomerulonephritis. Immunoglobulin A nephropathy (IgAN), the most prevalent form of primary glomerulonephritis, has growing evidence supporting the involvement of complement alternative and lectin pathways. In fact, patients with IgAN experience complement activation within their kidney tissue, which may be involved in the development of glomerular damage and the progression of IgAN. Complement activation has emerged as a significant area of interest in IgAN, with numerous complement-targeting agents currently being explored within this field. Nevertheless, the exact mechanisms of complement activation and their role in IgAN progression require comprehensive elucidation. This review seeks to contextualize the proposed mechanisms of complement activation within the various stages ("hits") of IgAN pathogenesis, while also addressing the clinical implications and anticipated outcomes of complement inhibition in IgAN.
Collapse
Affiliation(s)
- Anna Duval
- Centre de Recherche des Cordeliers, Inserm UMR S1138, Paris, France
- Department of Nephrology, Dialysis and Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Sophie Caillard
- Department of Nephrology, Dialysis and Transplantation, University Hospital of Strasbourg, Strasbourg, France
| | - Véronique Frémeaux-Bacchi
- Centre de Recherche des Cordeliers, Inserm UMR S1138, Paris, France
- Service d'Immunologie Biologique, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France
| |
Collapse
|
9
|
Xu L, Jiang H, Xie J, Xu Q, Zhou J, Lu X, Wang M, Dong L, Zuo D. Mannan-binding lectin ameliorates renal fibrosis by suppressing macrophage-to-myofibroblast transition. Heliyon 2023; 9:e21882. [PMID: 38034794 PMCID: PMC10685189 DOI: 10.1016/j.heliyon.2023.e21882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 09/21/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
Mannan-binding lectin (MBL) is a pattern-recognition molecule that plays a crucial role in innate immunity. MBL deficiency correlates with an increased risk of chronic kidney disease (CKD). However, the molecular mechanisms are not fully defined. Here, we established a CKD model in wild-type (WT) and MBL-deficient (MBL-/-) mice via unilateral ureteral obstruction (UUO). The result showed that MBL deficiency aggravated the pathogenesis of renal fibrosis in CKD mice. Strikingly, the in vivo macrophage depletion investigation revealed that macrophages play an essential role in the MBL-mediated suppression of renal fibrosis. We found that MBL limited the progression of macrophage-to-myofibroblast transition (MMT) in kidney tissues of UUO mice. Further in vitro study showed that MBL-/- macrophages exhibited significantly increased levels of fibrotic-related molecules compared with WT cells upon transforming growth factor beta (TGF-β) stimulation. We demonstrated that MBL inhibited the MMT process by suppressing the production of matrix metalloproteinase 9 (MMP-9) and activation of Akt signaling. In summary, our study revealed an expected role of MBL on macrophage transition during renal fibrosis, thus offering new insight into the potential of MBL as a therapeutic target for CKD.
Collapse
Affiliation(s)
- Li Xu
- Clinical Research Institute of Zhanjiang, Guangdong Medical University Zhanjiang Central Hospital, Zhanjiang, Guangdong Province, 524045, China
| | - Honglian Jiang
- Department of Laboratory Medicine, Guangzhou First People's Hospital, Guangzhou, Guangdong, 510030, China
- Department of Immunology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Jingwen Xie
- Institute of Molecular Immunology, School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Qishan Xu
- Clinical Research Institute of Zhanjiang, Guangdong Medical University Zhanjiang Central Hospital, Zhanjiang, Guangdong Province, 524045, China
- Institute of Molecular Immunology, School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Jia Zhou
- Department of Immunology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Xiao Lu
- Department of Immunology, School of Basic Medical Sciences, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Mingyong Wang
- Xinxiang Key Laboratory of Immunoregulation and Molecular Diagnostics, School of Medical Technology, Xinxiang Medical University, Xinxiang, 453003, China
- School of Medical Technology, Shangqiu Medical College, Shangqiu, 476100, China
| | - Lijun Dong
- Division of Vascular and Interventional Radiology, Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Daming Zuo
- Institute of Molecular Immunology, School of Laboratory Medicine and Biotechnology, Southern Medical University, Guangzhou, Guangdong, 510515, China
| |
Collapse
|
10
|
Rajasekaran A, Green TJ, Renfrow MB, Julian BA, Novak J, Rizk DV. Current Understanding of Complement Proteins as Therapeutic Targets for the Treatment of Immunoglobulin A Nephropathy. Drugs 2023; 83:1475-1499. [PMID: 37747686 PMCID: PMC10807511 DOI: 10.1007/s40265-023-01940-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2023] [Indexed: 09/26/2023]
Abstract
Immunoglobulin A nephropathy (IgAN) is the most common primary glomerulonephritis worldwide and a frequent cause of kidney failure. Currently, the diagnosis necessitates a kidney biopsy, with routine immunofluorescence microscopy revealing IgA as the dominant or co-dominant immunoglobulin in the glomerular immuno-deposits, often with IgG and sometimes IgM or both. Complement protein C3 is observed in most cases. IgAN leads to kidney failure in 20-40% of patients within 20 years of diagnosis and reduces average life expectancy by about 10 years. There is increasing clinical, biochemical, and genetic evidence that the complement system plays a paramount role in the pathogenesis of IgAN. The presence of C3 in the kidney immuno-deposits differentiates the diagnosis of IgAN from subclinical glomerular mesangial IgA deposition. Markers of complement activation via the lectin and alternative pathways in kidney-biopsy specimens are associated with disease activity and are predictive of poor outcome. Levels of select complement proteins in the circulation have also been assessed in patients with IgAN and found to be of prognostic value. Ongoing genetic studies have identified at least 30 loci associated with IgAN. Genes within some of these loci encode complement-system regulating proteins that can interact with immune complexes. The growing appreciation for the central role of complement components in IgAN pathogenesis highlighted these pathways as potential treatment targets and sparked great interest in pharmacological agents targeting the complement cascade for the treatment of IgAN, as evidenced by the plethora of ongoing clinical trials.
Collapse
Affiliation(s)
- Arun Rajasekaran
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Todd J Green
- Department of Microbiology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew B Renfrow
- Department of Biochemistry and Molecular Genetics, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Bruce A Julian
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jan Novak
- Department of Microbiology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Dana V Rizk
- Division of Nephrology, Department of Medicine, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
11
|
Tesař V, Radhakrishnan J, Charu V, Barratt J. Challenges in IgA Nephropathy Management: An Era of Complement Inhibition. Kidney Int Rep 2023; 8:1730-1740. [PMID: 37705895 PMCID: PMC10496078 DOI: 10.1016/j.ekir.2023.06.010] [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: 04/13/2023] [Revised: 06/01/2023] [Accepted: 06/12/2023] [Indexed: 09/15/2023] Open
Abstract
IgA nephropathy (IgAN) is the most common glomerular disease worldwide, with an estimated annual incidence of 25 per million adults. Despite optimized supportive care, some patients fail to achieve disease control and suffer progressive deterioration of kidney function. In this subpopulation of patients, the Kidney Disease: Improving Global Outcomes 2021 guidelines recommend consideration of corticosteroids; however, their use is associated with significant side effects. Ongoing clinical trials are expected to identify corticosteroid-sparing therapies to help improve treatment and prognosis for patients with IgAN. It has been well-documented that the complement system plays a significant role in IgAN pathogenesis, and several complement inhibitors are now entering late-stage clinical development. This review evaluates what we know about the role of complement in the pathophysiology of IgAN and considers how the availability of targeted complement inhibitors may impact future clinical practice. Key knowledge gaps are evaluated, and research opportunities are recommended to help guide clinical decision-making and optimize patient outcomes. Such gaps include evaluating the relative contribution of the alternative and lectin pathways to disease pathogenesis, and the importance of determining the dominant pathway driving IgAN progression. Continued research into the staining of complement proteins in kidney biopsies and identifying targeted biomarkers to assess disease progression and treatment responses will also be needed to support the implementation of newer therapies in clinical practice. Considering the future horizons for enhancing the care of patients with IgAN, tackling the outstanding challenges now will help prepare for the best possible future outcomes.
Collapse
Affiliation(s)
- Vladimir Tesař
- Department of Nephrology, Charles University, Prague, Czech Republic
| | | | - Vivek Charu
- Department of Pathology, Stanford University, Palo Alto, California, USA
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| |
Collapse
|
12
|
Guo Y, Zhang H, Yu X. A bibliometric analysis of complement in IgA nephropathy from 1991 to 2022. Front Pharmacol 2023; 14:1200193. [PMID: 37576817 PMCID: PMC10414182 DOI: 10.3389/fphar.2023.1200193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/17/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction: IgA nephropathy is a common glomerular disease on a global scale, which has resulted in significant economic burdens. The complement system plays a vital role in enhancing the efficacy of antibodies and phagocytic cells in eliminating microbes and damaged cells, and promoting inflammation. Complement activation has been found to contribute to the progression of various renal diseases, including IgA nephropathy. Methods: In this study, a thorough analysis was conducted on publications related to complement in IgAN from 1991 to 2022, retrieved from the Web of Science Core Collection and Scopus database. The analysis focused on various aspects such as annual publications, country, institution, author, journal, keywords, and co-cited references, utilizing Citespace and Vosviewer. Results: A total of 819 publications were obtained, and while there were slight fluctuations in annual publications, an overall upward trend was observed. China, Japan and the United States were the leading countries in terms of publications, with China having the highest number of publications (201). Collaborative network analysis revealed that England, University of Alabama Birmingham, and Robert J Wyatt were the most influential country, institution, and author, respectively, in this field of research. Furthermore, the analysis of references and keywords indicated that complement activation contributes to IgAN, and immunosuppression in IgAN are a hot topic of research. Discussion: This study identifies current research hotspots and advanced tendencies in the study of complement in IgAN, providing scholars with crucial directions in this research area.
Collapse
Affiliation(s)
- Yun Guo
- The First Clinical Medical College, Guangdong Medical University, Zhanjiang, China
- Department of Nephrology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | | | - Xueqing Yu
- The First Clinical Medical College, Guangdong Medical University, Zhanjiang, China
- Department of Nephrology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong-Hong Kong Joint Laboratory on Immunological and Genetic Kidney Diseases, Guangzhou, China
| |
Collapse
|
13
|
Barratt J, Lafayette RA, Zhang H, Tesar V, Rovin BH, Tumlin JA, Reich HN, Floege J. IgA Nephropathy: the Lectin Pathway and Implications for Targeted Therapy. Kidney Int 2023:S0085-2538(23)00395-2. [PMID: 37263354 DOI: 10.1016/j.kint.2023.04.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/30/2023] [Accepted: 04/14/2023] [Indexed: 06/03/2023]
Abstract
Many patients with IgA nephropathy (IgAN) progress to end-stage kidney disease even with optimal supportive care. An improved understanding of the pathophysiology of IgAN in recent years has led to the investigation of targeted therapies with acceptable tolerability that may address the underlying causes of IgAN or the pathogenesis of kidney injury. The complement system - particularly the lectin and alternative pathways of complement - have emerged as key mediators of kidney injury in IgAN and possible targets for investigational therapy. This review will focus on the lectin pathway. Examination of kidney biopsies has consistently shown glomerular deposition of mannan-binding lectin (one of six pattern-recognition molecules that activate the lectin pathway) together with IgA1 in up to 50% of patients with IgAN. Glomerular deposition of pattern-recognition molecules for the lectin pathway is associated with more severe glomerular damage and more severe proteinuria and hematuria. Emerging research suggests that the lectin pathway may also contribute to tubulointerstitial fibrosis in IgAN, and that collectin-11 is a key mediator of this association. This review summarizes the growing scientific and clinical evidence supporting the role of the lectin pathway in IgAN and examines the possible therapeutic role of lectin pathway inhibition for these patients.
Collapse
Affiliation(s)
| | | | - Hong Zhang
- Peking University Institute of Nephrology, Beijing, China
| | - Vladimir Tesar
- Charles University and General University Hospital, Prague, Czech Republic
| | - Brad H Rovin
- The Ohio State University Wexner Medical Center, Columbus OH, USA
| | | | - Heather N Reich
- University of Toronto and University Health Network, Toronto ON, Canada
| | | |
Collapse
|
14
|
Guo WY, Sun LJ, Dong HR, Wang GQ, Xu XY, Cheng WR, Zhao ZR, Ye N, Liu Y, Cheng H. Characterization of patients with IgA nephropathy with and without associated minimal change disease. FRONTIERS IN NEPHROLOGY 2023; 3:1105933. [PMID: 37675352 PMCID: PMC10479556 DOI: 10.3389/fneph.2023.1105933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/25/2023] [Indexed: 09/08/2023]
Abstract
Introduction Immunoglobulin A nephropathy (IgAN) presents various clinical manifestations and pathological phenotypes. Approximately 5% of patients with IgAN present with early onset nephrotic syndrome, mild mesangial lesions, and diffuse foot process effacement of podocytes, which resemble minimal change disease (MCD). These patients are defined as MCD-IgAN. Whether MCD-IgAN is a special type of IgAN or simply MCD accompanied by IgA deposition remains controversial. Methods A total of 51 patients diagnosed with MCD-IgAN at Beijing Anzhen Hospital from January 2010 to September 2022 were recruited. The clinical and pathological characteristics of IgA-MCD were analyzed. Patients with IgAN but without MCD (non-MCD-IgAN) and healthy participants were enrolled as controls. Galactose-deficient immunoglobulin A1 (Gd-IgA1) and complement C3 were detected both in the circulation and in renal tissues. Results We found that the levels of serum Gd-IgA1 were lower in participants with MCD-IgAN than in those with non-MCD-IgAN, but higher than in healthy participants. Gd-IgA1 was rarely deposited in the glomeruli of participants with MCD-IgAN, with a positive rate of only 13.7% (7/51); in contrast, the positive rate in participants with non-MCD-IgAN was 82.4% (42/51). Among renal Gd-IgA1-positive patients, Gd-IgA1 and immunoglobulin A (IgA) colocalized along the glomerular mesangial and capillary areas. Interestingly, we found that the circulating levels of complement C3 were significantly higher in participants with MCD-IgAN than in participants with non-MCD-IgAN. In addition, the intensity of C3c in glomeruli in participants with MCD-IgAN was significantly weaker than in participants with non-MCD-IgAN. Conclusions Our study suggests that, in MCD-IgAN, most of the IgA that is deposited on glomeruli is not the same pathogenic Gd-IgA1 as found in general IgAN. Complement activation both in the circulation and in the renal locality was much weaker in MCD-IgAN than in non-MCD-IgAN. Our study suggests that IgAN with MCD might be MCD with coincidental IgA deposition.
Collapse
Affiliation(s)
- Wei-yi Guo
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Li-jun Sun
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hong-rui Dong
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Guo-qin Wang
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiao-yi Xu
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wen-rong Cheng
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhi-rui Zhao
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Ye
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yun Liu
- Division of Nephrology, Affiliated Hospital of Chifeng University, Chifeng, Inner Mongolia, China
| | - Hong Cheng
- Renal Division, Department of Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
15
|
Guo WY, An XP, Sun LJ, Dong HR, Cheng WR, Ye N, Wang GQ, Xu XY, Zhao ZR, Cheng H. Overactivation of the complement system may be involved in intrarenal arteriolar lesions in IgA nephropathy. Front Med (Lausanne) 2022; 9:945913. [PMID: 35991640 PMCID: PMC9381866 DOI: 10.3389/fmed.2022.945913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction IgA nephropathy (IgAN) encompasses a wide range of clinical and histology features. Some patients present without hematuria, with or without hypertension, still rapidly progress in renal function. Renal pathology of this part of patients were predominant intrarenal arteriolar lesions, rarely presented glomerular proliferative lesions. We aim to investigate the clinical and pathological characteristics and prognosis of these IgAN patients and initially explore whether the abnormal activation of complement is involved in the intrarenal arteriolar lesions of IgAN. Methods A total of 866 patients with renal biopsy-proven IgAN diagnosed at Beijing Anzhen Hospital were recruited. IgAN patients without intrarenal arteriolar lesions and proliferative lesions were excluded (n = 115), the rest were divided into arteriolar lesions group (n = 202) and proliferative lesions group (n = 549). Among them, 255 patients were regularly followed up for at least 1 year. Renal biopsy tissues of 104 IgAN patients were stained for complement components by immunohistochemistry and immunofluorescence. Results Compared with proliferative lesions group, the arteriolar lesions group experienced high percentage of hypertension (p = 0.004), low percentage of gross hematuria (p = 0.001), microscopic hematuria (p < 0.001) and less initial proteinuria (p = 0.033). Renal survival between the two groups was not significantly different (p = 0.133). MBL, C4d, FH and FHR5, C3c, and MAC deposited on intrarenal arteriole in arteriolar lesions group. Compare with the proliferative lesion group, the arteriolar lesions group exhibited a higher intensity of C3c deposition on the intrarenal arterioles (p = 0.048). C3c and CD31 co-deposited on intrarenal arterioles area in patients with intrarenal arteriolar lesions. Conclusion Renal survival of the IgAN patients in arteriolar lesions group was not better than those in proliferative lesions group. Abnormal activation of complement may be involved in the pathogenesis of arteriolar damage through the injury of endothelial cells in this clinical phenotype of IgAN.
Collapse
|
16
|
Mizerska-Wasiak M. How to take advantage of easily available biomarkers in patients with IgA nephropathy: IgA and C3 in serum and kidney biopsies. Pediatr Nephrol 2022; 38:1439-1448. [PMID: 35916957 DOI: 10.1007/s00467-022-05644-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 05/03/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022]
Abstract
IgA nephropathy (IgAN) is the most common glomerulonephritis worldwide. It is diagnosed based on clinical and histological features including predominant IgA deposits in kidney biopsy. The multi-hit theory, based on the production of GDIgA1 and anti-GDIgA1 antibodies, and complement activation via alternative and lectin pathways and also a genetic tendency are crucial in the pathogenesis of IgAN. The aim of the present review is to summarize the utility of routine diagnostic tests in IgA nephropathy, such as IgA and C3 in serum and kidney biopsy specimens, for predicting the disease progression. The paper also contains data on new markers used in the diagnosis and prognosis of IgA nephropathy.
Collapse
|
17
|
Wen L, Zhao Z, Li F, Ji F, Wen J. ICAM-1 related long noncoding RNA is associated with progression of IgA nephropathy and fibrotic changes in proximal tubular cells. Sci Rep 2022; 12:9645. [PMID: 35688937 PMCID: PMC9187724 DOI: 10.1038/s41598-022-13521-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/25/2022] [Indexed: 11/09/2022] Open
Abstract
Intercellular adhesion molecule 1 (ICAM-1) related long noncoding RNA (ICR) is on the antisense strand of ICAM-1 and regulates ICAM-1 expression. ICAM-1 is involved in renal tubulointerstitial injury; however, the expression and clinical implication of ICR are not determined in IgA nephropathy (IgAN). We compared renal ICR levels in 337 IgAN patients with those of 89 biopsy controls, and a markedly increased ICR level was observed in IgAN patients. By Cox proportional hazards models, higher levels of renal ICR were independently associated with disease progression event defined as end-stage renal disease or ≥ 40% decline in estimated glomerular filtration rate. Patients in the highest tertile of renal ICR had a 3.5-fold higher risk for disease progression compared with those in the lowest tertile. The addition of renal ICR to a model with traditional risk factors improved risk prediction of disease progression (net reclassification index: 0.31 [95% CI 0.01–0.50]; integrated discrimination index: 0.10 [95% CI 0.04–0.16]). Inhibition of ICR by transfection with plasmids containing ICR shRNA significantly reduced expression of collagen I and α-SMA, and phosphorylation of Akt and mTOR in TGF-β1- treated HK-2 cells. Our findings suggest that renal ICR might be an independent predictor of IgAN progression and contribute to renal fibrosis.
Collapse
Affiliation(s)
- Lu Wen
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
| | - Zhanzheng Zhao
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
| | - Fanghua Li
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Fengping Ji
- Department of Urology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Jianguo Wen
- Henan Joint International Pediatric Urodynamic Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.
| |
Collapse
|
18
|
Elevated Serum Chloride Levels Contribute to a Poor Prognosis in Patients with IgA Nephropathy. J Immunol Res 2022; 2021:3598135. [PMID: 35005032 PMCID: PMC8739901 DOI: 10.1155/2021/3598135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/18/2021] [Accepted: 08/27/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction The identification of reliable prognostic factors is a crucial requirement for patients with IgA nephropathy (IgAN). Here, we explored the relationship between serum chloride levels and prognosis in patients with IgAN. Methods We recruited all patients with primary IgAN, as diagnosed by renal biopsy, between 1st January 2015 and 1st April 2019. Patients were divided two groups (high chloride group and low chloride group) based on the best cut-off values from survival receiver operating characteristic (ROC) curves. The baseline clinicopathological characteristics of two groups were then compared. Cox proportional hazard models were used to determine the prognostic value of serum chloride levels in patients with IgAN. Finally, we screened reliable prognostic indicators and built a clinical prediction model and validated the performance of the model. Results Compared with patients in the high chloride group, patients in the low chloride group had significantly lower levels of 24-hour urinary total protein (24 h-UTP), serum creatinine (sCr), and higher levels of hemoglobin (Hb), albumin (all p < 0.05), and less proportion of Oxford classification grade E1 (endothelial cell proliferation) and T2 (renal tubule atrophy or renal interstitial fibrosis). Cox analysis revealed that serum chloride level ≥ 105.4 mmol/L was a significant and independent risk factor for prognosis in patients with IgAN (p < 0.05). Serum chloride, sCr, T, hypertension, and Hb were used to generate a predictive model for prognosis. Thec-indices of our predictive model were 0.80, 0.86, and 0.78, for 1, 2, and 3 years, respectively; Brier scores were 0.06, 0.09, and 0.16, respectively. Conclusions A serum chloride level ≥ 105.4 mmol/l was identified as a significant and independent risk factor for the prognosis of patients with IgAN. A predictive prognosis model was generated using serum chloride, sCr, T, hypertension, and Hb; this model exhibited a good predictive effect.
Collapse
|
19
|
Zhao Y, Cai M, Jiang Z, Dong B, Yan Y, Wang Y, Zuo L. Association of serum mannose-binding lectin, anti-phospholipase A2 receptor antibody and renal outcomes in idiopathic membranous nephropathy and atypical membranous nephropathy: a single center retrospective cohort study. Ren Fail 2022; 44:428-433. [PMID: 35272568 PMCID: PMC8920381 DOI: 10.1080/0886022x.2022.2048016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Objectives Idiopathic membranous nephropathy (iMN) is a major cause of nephrotic syndrome. Atypical membranous nephropathy (aMN) is a new type of nephropathy in China, characterized by a ‘full-house’ on immunofluorescent examination, that is IgG, IgA, IgM, C3, C1q positive, but without clinical evidence of a secondary cause. Phospholipase A2 receptor (PLA2R) was the major target antigens in iMN patients. Activation of the mannose-binding lectin (MBL) pathway plays a vital role in the development of MN. Our objective was to investigate the role of PLA2R and MBL in the pathogenesis of iMN and aMN. Methods We conducted a retrospective observational study using propensity score matching by age, gender, and eGFR. All clinical, laboratory data, and follow-up data of the patients were collected. Serum levels of anti-PLA2R antibodies and MBL were tested. Results Finally, 30 iMN patients and 30 aMN patients were included, and 20 healthy controls were retrospectively collected in this study. The 24 h proteinuria level was higher and serum albumin was lower in anti-PLA2R (+) patients than in anti-PLA2R (−) patients in both iMN and aMN groups. In aMN patients, MBL levels were significantly higher in anti-PLA2R (+) patients than in anti-PLA2R (−) patients (p = .045). The serum level of anti-PLA2R positively correlated with no-remission in both iMN and aMN groups. Conclusions The complement lectin pathway has an association with the development of MN, especially in patients with positive anti-PLA2R antibodies. Serum MBL cannot differentiate between the two diseases. Serum MBL levels are not associated with clinical manifestations, nor with prognosis.
Collapse
Affiliation(s)
- Yuchao Zhao
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Meishun Cai
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Zhenbin Jiang
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Bao Dong
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Yu Yan
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Yina Wang
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| | - Li Zuo
- Department of Nephrology, Peking University People's Hospital, Beijing, China
| |
Collapse
|
20
|
Hilhorst M, Anders HJ. IgA Nephropathy Needs a Diagnostic Marker of Immunologic Activity to Select the Right Patients for Immunotherapies. J Am Soc Nephrol 2021; 32:2982-2984. [PMID: 34789549 PMCID: PMC8638387 DOI: 10.1681/asn.2021091239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Marc Hilhorst
- Department of Internal Medicine, Section of Nephrology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Hans-Joachim Anders
- Renal Division, Department of Medicine IV, University Hospital of the Ludwig Maximilian University, Munich, Germany
| |
Collapse
|
21
|
Poppelaars F, Faria B, Schwaeble W, Daha MR. The Contribution of Complement to the Pathogenesis of IgA Nephropathy: Are Complement-Targeted Therapies Moving from Rare Disorders to More Common Diseases? J Clin Med 2021; 10:4715. [PMID: 34682837 PMCID: PMC8539100 DOI: 10.3390/jcm10204715] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 12/29/2022] Open
Abstract
Primary IgA nephropathy (IgAN) is a leading cause of chronic kidney disease and kidney failure for which there is no disease-specific treatment. However, this could change, since novel therapeutic approaches are currently being assessed in clinical trials, including complement-targeting therapies. An improved understanding of the role of the lectin and the alternative pathway of complement in the pathophysiology of IgAN has led to the development of these treatment strategies. Recently, in a phase 2 trial, treatment with a blocking antibody against mannose-binding protein-associated serine protease 2 (MASP-2, a crucial enzyme of the lectin pathway) was suggested to have a potential benefit for IgAN. Now in a phase 3 study, this MASP-2 inhibitor for the treatment of IgAN could mark the start of a new era of complement therapeutics where common diseases can be treated with these drugs. The clinical development of complement inhibitors requires a better understanding by physicians of the biology of complement, the pathogenic role of complement in IgAN, and complement-targeted therapies. The purpose of this review is to provide an overview of the role of complement in IgAN, including the recent discovery of new mechanisms of complement activation and opportunities for complement inhibitors as the treatment of IgAN.
Collapse
Affiliation(s)
- Felix Poppelaars
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, The Netherlands; (B.F.); (M.R.D.)
| | - Bernardo Faria
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, The Netherlands; (B.F.); (M.R.D.)
- Nephrology and Infectious Disease R&D Group, INEB, Institute of Investigation and Innovation in Health (i3S), University of Porto, 4200-135 Porto, Portugal
| | - Wilhelm Schwaeble
- Department of Veterinary Medicine, University of Cambridge, Cambridge CB3 0ES, UK;
| | - Mohamed R. Daha
- Department of Internal Medicine, Division of Nephrology, University Medical Center Groningen, University of Groningen, 9700 AD Groningen, The Netherlands; (B.F.); (M.R.D.)
- Department of Nephrology, Leiden University Medical Center, University of Leiden, 2300 RC Leiden, The Netherlands
| |
Collapse
|
22
|
Zhang Z, Zhang Y, Zhang H. IgA Nephropathy: A Chinese Perspective. GLOMERULAR DISEASES 2021; 2:30-41. [PMID: 36751266 PMCID: PMC9677733 DOI: 10.1159/000520039] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/01/2021] [Indexed: 11/19/2022]
Abstract
Background IgA nephropathy (IgAN) is the most common primary glomerular disease worldwide and remains a leading cause of chronic kidney disease and end-stage renal disease. The disease prevalence, clinical and pathological phenotypes, the underlying pathogenic molecular mechanisms, and the response to treatments are highly heterogeneous in different ethnic populations, which raise the concern that IgAN may differ across different parts of the world. Summary From a Chinese perspective, we stated the disease burden of IgAN, summarized genome-wide association studies and research into pathological molecules, and compared them with findings based on other populations. The emerging biomarkers, indigenous clinical trials, and major challenges for Chinese researchers and nephrologists in studying IgAN are also discussed. Key Messages In this review, we described a higher risk of major susceptible loci in mucosal immunity, IgA production, and complement activation pathways in Chinese patients with IgAN. With our understanding of the pathogenesis of IgAN, novel biomarkers are emerging. Although there are challenges for conducting high-quality clinical trials in China, it is still feasible to conduct innovative and well-designed studies of IgAN. In the future, international collaborations on research infrastructure would be helpful to advance clinical and basic research in China.
Collapse
Affiliation(s)
- Zhao Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China,Institute of Nephrology, Peking University, Beijing, China,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Yuemiao Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China,Institute of Nephrology, Peking University, Beijing, China,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China,Institute of Nephrology, Peking University, Beijing, China,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Peking University, Ministry of Education, Beijing, China,*Hong Zhang,
| |
Collapse
|
23
|
Abstract
Complement is an evolutionarily conserved system which is important in the defense against microorganisms and also in the elimination of modified or necrotic elements of the body. Complement is activated in a cascade type manner and activation and all steps of cascade progression are tightly controlled and regulatory interleaved with many processes of inflammatory machinery. Overshooting of the complement system due to dysregulation can result in the two prototypes of primary complement mediated renal diseases: C3 glomerulopathy and thrombotic microangiopathy. Apart from these, complement also is highly activated in many other inflammatory native kidney diseases, such as membranous nephropathy, ANCA-associated necrotizing glomerulonephritis, and IgA nephropathy. Moreover, it likely plays an important role also in the transplant setting, such as in antibody-mediated rejection or in hematopoietic stem cell transplant associated thrombotic microangiopathy. In this review, these glomerular disorders are discussed with regard to the role of complement in their pathogenesis. The consequential, respective clinical trials for complement inhibitory therapy strategies for these diseases are described.
Collapse
|
24
|
Is complement the main accomplice in IgA nephropathy? From initial observations to potential complement-targeted therapies. Mol Immunol 2021; 140:1-11. [PMID: 34601376 DOI: 10.1016/j.molimm.2021.09.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/01/2021] [Accepted: 09/17/2021] [Indexed: 12/22/2022]
Abstract
IgA Nephropathy (IgAN) is the main cause of primary glomerulonephritis, globally. This disease is associated with a wide range of clinical presentations, variable prognosis and a spectrum of histological findings. More than fifty years after its first description, this heterogeneity continues to complicate efforts to understand the pathogenesis. Nevertheless, involvement of the complement system in IgAN was identified early on. Dysfunction of the immunoglobulin A (IgA) system, the principal offender in this disease, including modification of isoforms and glycoforms of IgA1, the nature of immune complexes and autoantibodies to galactose deficient IgA1 might all be responsible for complement activation in IgAN. However, the specific mechanisms engaging complement are still under examination. Research in this domain should allow for identification of patients that may benefit from complement-targeted therapy, in the foreseeable future.
Collapse
|
25
|
Ji FP, Wen L, Zhang YP, Liu EP, Wen JG. Serum complement factor B is associated with disease activity and progression of idiopathic membranous nephropathy concomitant with IgA nephropathy. Int Urol Nephrol 2021; 54:1287-1294. [PMID: 34585312 DOI: 10.1007/s11255-021-02997-2] [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: 04/13/2021] [Accepted: 09/19/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Few studies have reported the roles of the complement system in concomitant idiopathic membranous nephropathy and IgA nephropathy (IMN-IgAN). Complement factor B (CFB) is a crucial factor that involved in the alternative complement pathway. We aimed to evaluate the association between disease activity (eGFR, anti-PLA2R antibody levels and 24 h urinary protein excretion), progression and serum CFB levels of IMN-IgAN patients. METHODS In total, 39 IMN-IgAN patients (median follow-up, 46.6 months), 99 IMN patients and 92 IgAN patients participated in this study. The disease progression event was defined as end-stage renal disease (ESRD) or a 30% decline in estimated glomerular filtration rate (eGFR). The serum CFB concentration was measured by enzyme-linked immunosorbent assay. RESULTS Serum CFB levels were lower in IMN-IgAN patients than in patients with IgAN only (P < .001). Serum CFB levels correlated positively with serum creatinine levels, anti-PLA2R antibody levels and 24 h urinary protein excretion (P < .05). Kaplan-Meier analysis revealed that IMN-IgAN patients with high serum CFB levels had a significantly lower cumulative renal survival rate than patients with low levels (log-rank test, P = .009). Multivariate Cox regression analysis showed that high baseline serum CFB levels were significantly associated with poor renal outcome in patients with IMN-IgAN (HR: 2.727, 95% CI 1.076-6.913, P = .034). CONCLUSION High serum CFB levels correlated with increased serum creatinine, anti-PLA2R antibody and urinary protein excretion as well as poor renal prognosis in patients with IMN-IgAN, indicating that serum CFB may be a marker of disease activity and progression.
Collapse
Affiliation(s)
- Feng Ping Ji
- Pediatric Urodynamic Centre, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.,Department of Urology, First Affiliated Hospital of Zhengzhou University, Jianshe East Road No.1, Zhengzhou, 450052, China
| | - Lu Wen
- Department of Nephrology, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China
| | - Yan Ping Zhang
- Pediatric Urodynamic Centre, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.,Department of Urology, First Affiliated Hospital of Zhengzhou University, Jianshe East Road No.1, Zhengzhou, 450052, China
| | - Er Peng Liu
- Pediatric Urodynamic Centre, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China.,Department of Urology, First Affiliated Hospital of Zhengzhou University, Jianshe East Road No.1, Zhengzhou, 450052, China
| | - Jian Guo Wen
- Pediatric Urodynamic Centre, First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, China. .,Department of Urology, First Affiliated Hospital of Zhengzhou University, Jianshe East Road No.1, Zhengzhou, 450052, China.
| |
Collapse
|
26
|
Abstract
IgA nephropathy (IgAN) is the most common primary glomerulonephritis worldwide. It is considered that the pathogenesis of IgAN involves the ‘multiple hit theory’ and the immune-inflammatory mechanism; however, these theories have certain limitations. The gold standard for diagnosing IgAN is still renal biopsy. Although renal biopsy is accurate, it is traumatic and is associated with some risks and limitations, so there is a need for non-invasive diagnostic methods. According to recent studies, microRNAs (miRNAs) play important roles in the occurrence and development of IgAN; thus, they provide the possibility of the noninvasive diagnosis of IgAN and also have some value in predicting prognosis. This review summarizes the current research status of miRNAs in the occurrence, development, diagnosis, and prognosis of IgAN. We also highlight some interesting and challenging points that require further study.
Collapse
Affiliation(s)
- Xingchen Yao
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,The Renal Research Institution, Zhengzhou University, Zhengzhou, China
| | - Yaling Zhai
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,The Renal Research Institution, Zhengzhou University, Zhengzhou, China
| | - Huanping An
- Medicine Experiment Center, Hanzhong Vocational and Technical College, Hanzhong, China
| | - Jingge Gao
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,The Renal Research Institution, Zhengzhou University, Zhengzhou, China
| | - Yazhuo Chen
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,The Renal Research Institution, Zhengzhou University, Zhengzhou, China
| | - Wenhui Zhang
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,The Renal Research Institution, Zhengzhou University, Zhengzhou, China
| | - Zhanzheng Zhao
- Department of Nephrology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China.,The Renal Research Institution, Zhengzhou University, Zhengzhou, China
| |
Collapse
|
27
|
Wang S, Dong L, Pei G, Jiang Z, Qin A, Tan J, Tang Y, Qin W. High Neutrophil-To-Lymphocyte Ratio Is an Independent Risk Factor for End Stage Renal Diseases in IgA Nephropathy. Front Immunol 2021; 12:700224. [PMID: 34456912 PMCID: PMC8387559 DOI: 10.3389/fimmu.2021.700224] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/26/2021] [Indexed: 02/05/2023] Open
Abstract
Background Complex factors are involved in the development and progression of immunoglobulin A nephropathy (IgAN), a common primary glomerulonephritis worldwide. Autoimmunity and inflammation have been considered to be the basic mechanisms; however, the exact pathogenesis remains unclear. As a novel marker of inflammation, the neutrophil-to-lymphocyte ratio (NLR) has been studied in various diseases. Whether the NLR can predict the renal outcome of patients with IgAN remains unclear. We evaluated the relationships between the NLR and renal function, pathologic lesions, renal progression, and prognosis in patients with IgAN. Methods This retrospective study involved 966 patients with biopsy-proven IgAN. They were divided into two groups based on the cut-off value of the NLR: the high group (NLR ≥ 2.67, n = 384) and the low group (NLR < 2.67, n = 582). The endpoint was end-stage renal disease [estimated glomerular filtration rate (eGFR) of <15 mL/min/1.73 m2 or performance of renal replacement therapy]. A correlation test was conducted to explore the relationship between the NLR and other important parameters (eGFR, serum creatinine, proteinuria, hypertension and renal pathologic lesions). The predictive value was determined by the area under the receiver operating characteristics curve (AUROC). Kaplan–Meier and Cox proportional hazards analyses were performed to evaluate renal progression and prognosis. Results The NLR had the highest AUROC, which was 0.633 (p < 0.001). The correlation test revealed that the NLR was positively correlated with serum creatinine (r = 0.127, p < 0.001) and 24-hour urine protein (r = 0.18, p < 0.001) and negatively correlated with eGFR (r = 0.14, p < 0.001). Patients with IgAN who had a high NLR were more likely to have hypertension (p = 0.003). Multivariate Cox regression analysis indicated that a high NLR was an independent risk factor for IgAN even after adjustment for important clinical and pathological parameters (p = 0.043, HR = 1.74, 95%CI: 1.02-2.97). Kaplan–Meier analysis showed that a high NLR was significantly associated with the renal prognosis of patients with IgAN (p < 0.001), especially patients with stage 3 to 4 chronic kidney disease (p = 0.028) or 24-hour urine protein of >1 g/day (p < 0.001). Conclusion An elevated NLR affects the renal progression and prognosis in patients with IgAN and could be a marker for evaluation of renal function and pathologic lesions.
Collapse
Affiliation(s)
- Siqing Wang
- West China School of Medicine, Sichuan University, Chengdu, China.,Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Lingqiu Dong
- West China School of Medicine, Sichuan University, Chengdu, China.,Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Gaiqin Pei
- Division of Rehabilitation, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China.,Key Laboratory of Rehabilitation Medicine in Sichuan Province, Sichuan University, Chengdu, China
| | - Zheng Jiang
- West China School of Medicine, Sichuan University, Chengdu, China.,Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Aiya Qin
- West China School of Medicine, Sichuan University, Chengdu, China.,Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Jiaxing Tan
- West China School of Medicine, Sichuan University, Chengdu, China.,Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Yi Tang
- West China School of Medicine, Sichuan University, Chengdu, China.,Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China
| | - Wei Qin
- West China School of Medicine, Sichuan University, Chengdu, China.,Division of Nephrology, Department of Medicine, West China Hospital of Sichuan University, Chengdu, China
| |
Collapse
|
28
|
Zhang H, Barratt J. Is IgA nephropathy the same disease in different parts of the world? Semin Immunopathol 2021; 43:707-715. [PMID: 34417628 DOI: 10.1007/s00281-021-00884-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/29/2021] [Indexed: 12/30/2022]
Abstract
Since it was first described in 1968, immunoglobulin A nephropathy (IgAN) is understood to be the most common form of glomerulonephritis worldwide. The diagnosis of IgAN depends on the presence of dominant mesangial IgA1 deposition by renal biopsy. To date, a wide spectrum of clinical and pathologic features of IgAN have been observed, implying that IgAN might not be the same disease across the world. Here, we review the characteristics of IgAN from perspectives of epidemiology, clinical-pathological patterns, disease pathogenesis, and treatment response across different ethnic populations. Overall, IgAN is most prevalent in Asians, followed by Caucasians, and relatively rare in Africans. More severe clinical presentation and higher risk of disease progression have been reported in Asians than Europeans. Moreover, active lesions, such as endocapillary hypercellularity and crescents, are more commonly reported in Asians than Europeans. Response to corticosteroid/immunosuppression therapy is variably reported, with greater apparent efficacy reported in Asian than European studies. Although a multi-hit hypothesis has been suggested for IgAN, the relative importance of each "hit" may vary in different ethnic populations and this variation underlies the differences in presentation of IgAN. In the future, a better understanding of pathogenic pathways operating in different ethnic populations may help provide better biomarkers of disease and more precise targeting of treatment strategies for IgAN.
Collapse
Affiliation(s)
- Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.
- Institute of Nephrology, Peking University, Beijing, China.
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.
- Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester and Leicester General Hospital, Leicester, UK.
| |
Collapse
|
29
|
Medjeral-Thomas NR, Cook HT, Pickering MC. Complement activation in IgA nephropathy. Semin Immunopathol 2021; 43:679-690. [PMID: 34379175 PMCID: PMC8551128 DOI: 10.1007/s00281-021-00882-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/23/2021] [Indexed: 11/25/2022]
Abstract
IgA nephropathy pathogenesis is incompletely understood, and this limits the development of disease-specific biomarkers and effective therapies. Evidence of complement activity in IgA nephropathy is well established. However, a growing body of research indicates complement activity is an important contributor to IgA nephropathy pathology. In particular, multiple associations have been identified between complement alternative, lectin and terminal pathway proteins and IgA nephropathy severity. Recently, we have also gained insight into possible mechanisms that could link glomerular IgA deposition, complement activity, glomerular inflammation and disease severity. Ongoing clinical trials of therapeutic complement inhibitors will provide insight into the importance of complement activity to IgA nephropathy pathogenesis. Further research into mechanisms of complement activity is essential to improving our understanding and management of patients with IgA nephropathy.
Collapse
Affiliation(s)
- Nicholas R Medjeral-Thomas
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, W12 0NN, UK.
| | - H Terence Cook
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, W12 0NN, UK
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, W12 0NN, UK
| |
Collapse
|
30
|
Abstract
PURPOSE OF REVIEW In this review, we discuss recent studies showing the importance of the complement pathway in kidney disease. RECENT FINDINGS Recent findings in C3 glomerulopathy (C3G) include: acute postinfectious glomerulonephritis is characterised by the presence of antifactor B antibodies; human leukocyte antigen type, but not rare complement gene variation, is associated with primary immunoglobulin-associated membranoproliferative GN and C3G. Immunohistochemistry in C3G shows that factor H related protein 5 (FHR5) is the most prevalent complement protein and correlates with kidney function. A multicentre study supported the use of mycophenolate mofetil (MMF) in C3G even after a propensity matching analysis. In immunoglobulin A nephropathy (IgAN) several studies have emphasised the importance of complement. Imbalances of circulating FH and FHR1 and FHR5, which interfere with the regulatory functions of FH, associate with IgAN. Immunohistochemistry has shown associations between glomerular FHR5 deposition and C3 activation; glomerular FHR5 associated with clinical markers of IgAN severity. Data also suggest the lectin complement pathway contributes to IgAN severity. We also discuss complement activation in thrombotic microangiopathy and other kidney diseases. SUMMARY Complement activity can be detected in a wide range of kidney diseases and this provides pathogenic insight and potential for therapy with the ongoing development of several drugs directed at complement activation.
Collapse
|
31
|
Selvaskandan H, Kay Cheung C, Dormer J, Wimbury D, Martinez M, Xu G, Barratt J. Inhibition of the Lectin Pathway of the Complement System as a Novel Approach in the Management of IgA Vasculitis-Associated Nephritis. Nephron Clin Pract 2020; 144:453-458. [PMID: 32721954 DOI: 10.1159/000508841] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 05/20/2020] [Indexed: 11/19/2022] Open
Abstract
IgA vasculitis can present as a glomerulonephritis histologically indistinguishable from IgA nephropathy (IgAN). In IgAN, the alternative and lectin pathways mediate glomerular injury and contribute to kidney function decline. Narsoplimab is a monoclonal antibody against mannan-binding lectin serine peptidase 2 (MASP-2), a key component of the lectin pathway. It is being evaluated in a phase III trial in IgAN (NCT03608033). Histopathological similarities with IgAN suggest lectin pathway activation also occurs in IgAV-associated nephritis (IgAVN). Here, we report the first ever case of narsoplimab use for the treatment of IgAVN.
Collapse
Affiliation(s)
- Haresh Selvaskandan
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom, .,Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom,
| | - Chee Kay Cheung
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom.,Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - John Dormer
- Department of Pathology, University Hospitals of Leicester, Leicester, United Kingdom
| | - David Wimbury
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Maria Martinez
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom
| | - Gang Xu
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom
| | - Jonathan Barratt
- John Walls Renal Unit, Leicester General Hospital, University Hospitals of Leicester, Leicester, United Kingdom.,Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| |
Collapse
|
32
|
Li Q, Chen P, Shi S, Liu L, Lv J, Zhu L, Zhang H. Neutrophil-to-lymphocyte ratio as an independent inflammatory indicator of poor prognosis in IgA nephropathy. Int Immunopharmacol 2020; 87:106811. [PMID: 32711375 DOI: 10.1016/j.intimp.2020.106811] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/10/2020] [Accepted: 07/12/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND IgA nephropathy (IgAN) is achronic immuno-inflammatory progressive disease. Several systemic inflammatory indicators, mainly the neutrophil-to-lymphocyte ratio (NLR), are regarded as valuable markers for many diseases, such as IgA vasculitis and chronic kidney disease. Here, we investigated multiple peripheral blood indicators in a large IgAN registry with regular follow-up to evaluate their effects on IgAN phenotypes and progression. METHODS Totally, 1151 IgAN patients with regular follow-up, and 251 healthy volunteers were enrolled. Complete blood count test results, including counts of white blood cells (WBC), neutrophils (NE), lymphocyte (LY), and platelets (PLT), were collected from medical records. Then, NLR and PLR were calculated. RESULTS IgAN patients presented with increased WBC, NE, NLR and PLR levels and decreased LY levels compared with controls. In univariate survival analysis, WBC, NE and NLR showed significant associations with IgAN progression, and NLR had a higher area under the ROC curves than NE and WBC. When adjusted for well-known risk factors, NLR remained an independent risk factor for poor renal outcome in IgAN patients and performed better than NE. By using NLR 2.40 as cutoff point, IgAN patients were divided into two groups. IgAN patients in the high NLR group presented with lower eGFR, higher proteinuria, higher incidence of hypertension, and more severe pathological lesions, as well as lower event-free renal survival rate. CONCLUSIONS We found patients with IgAN had elevated NLR levels than healthy controls, and the easily available NLR in clinical practice could serve as an independent risk factor for IgAN progression.
Collapse
Affiliation(s)
- Qianqian Li
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, China
| | - Ping Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, China; Renal Division, The Affiliated People's Hospital of Shanxi Medical University, Shanxi Provincial People's Hospital, China
| | - Sufang Shi
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, China
| | - Lijun Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, China
| | - Li Zhu
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, China.
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Peking University Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, China
| |
Collapse
|
33
|
Chang S, Li XK. The Role of Immune Modulation in Pathogenesis of IgA Nephropathy. Front Med (Lausanne) 2020; 7:92. [PMID: 32266276 PMCID: PMC7105732 DOI: 10.3389/fmed.2020.00092] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 03/03/2020] [Indexed: 01/10/2023] Open
Abstract
IgA nephropathy (IgAN) is the most prevalent primary glomerulonephritis worldwide, with diverse clinical manifestations characterized by recurrent gross hematuria or microscopic hematuria, and pathological changes featuring poorly O-galactosylated IgA1 deposition in the glomerular mesangium. Pathogenesis has always been the focus of IgAN studies. After 50 years of research, most scholars agree that IgAN is a group of clinicopathological syndromes with certain common immunopathological characteristics, and multiple mechanisms are involved in its pathogenesis, including immunology, genetics, and environmental or nutritional factors. However, the precise pathogenetic mechanisms have not been fully determined. One hypothesis about the pathogenesis of IgAN suggests that immunological factors are engaged in all aspects of IgAN development and play a critical role. A variety of immune cells (e.g., dendritic cells, NK cells, macrophages, T-lymphocyte subsets, and B-lymphocytes, etc.) and molecules (e.g., IgA receptors, Toll-like receptors, complements, etc.) in innate and adaptive immunity are involved in the pathogenesis of IgAN. Moreover, the abnormality of mucosal immune regulation is the core of IgAN immunopathogenesis. The roles of tonsil immunity or intestinal mucosal immunity, which have received more attention in recent years, are supported by mounting evidence. In this review, we will explore the latest research insights on the role of immune modulation in the pathogenesis of IgAN. With a better understanding of immunopathogenesis of IgAN, emerging therapies will soon become realized.
Collapse
Affiliation(s)
- Sheng Chang
- Institute of Organ Transplantation, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Key Laboratory of Organ Transplantation, Ministry of Education NHC Key Laboratory of Organ Transplantation Key Laboratory of Organ Transplantation, Chinese Academy of Medical Sciences, Wuhan, China.,Division of Transplantation Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Xiao-Kang Li
- Division of Transplantation Immunology, National Research Institute for Child Health and Development, Tokyo, Japan.,Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
34
|
Medjeral-Thomas NR, O'Shaughnessy MM. Complement in IgA Nephropathy: The Role of Complement in the Pathogenesis, Diagnosis, and Future Management of IgA Nephropathy. Adv Chronic Kidney Dis 2020; 27:111-119. [PMID: 32553243 DOI: 10.1053/j.ackd.2019.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022]
Abstract
Immunoglobulin A (IgA) nephropathy (IgAN) is an important cause of chronic and end-stage kidney disease. IgAN pathogenesis is incompletely understood. In particular, we cannot adequately explain the heterogeneity in clinical and histologic features and severities that characterizes IgAN. This limits patient stratification to appropriate and effective treatments and the development of disease-targeted therapies. Studies of the role of the alternative, lectin, and terminal complement pathways in IgAN have enhanced our understanding of disease pathogenesis and inform the development of novel diagnostic and therapeutic strategies. For example, recent genetic, serologic, and immunohistologic evidence suggests that imbalances between the main alternative complement pathway regulator protein (factor H) and competitor proteins that deregulate complement activity (factor H-related proteins 1 and 5, FHR1, and FHR5) associate with IgAN severity: a relative abundance of FHR1 and FHR5 amplifies complement-dependent inflammation and exacerbates kidney injury. Ongoing characterization of the mechanisms by which complement activity contributes to IgAN pathogenesis will facilitate the development of complement-based diagnostic techniques, biomarkers of disease activity and severity, and novel targeted therapies.
Collapse
|
35
|
The Clinicopathologic Characteristics and Complement Activation of Antineutrophil Cytoplasmic Antibody-associated Vasculitides With Glomerular IgA Deposition. Appl Immunohistochem Mol Morphol 2019; 28:e87-e93. [DOI: 10.1097/pai.0000000000000819] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
36
|
Gaya da Costa M, Poppelaars F, Berger SP, Daha MR, Seelen MA. The lectin pathway in renal disease: old concept and new insights. Nephrol Dial Transplant 2019; 33:2073-2079. [PMID: 29701808 DOI: 10.1093/ndt/gfy073] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 02/18/2018] [Indexed: 02/06/2023] Open
Abstract
The complement system is composed of a network of at least 40 proteins, which significantly contributes to health and disease. The lectin pathway (LP) is one of three pathways that can activate the complement system. Next to protection of the host against pathogens, the LP has been shown to play a crucial role in multiple renal diseases as well as during renal replacement therapy. Therefore, several complement-targeted drugs are currently being explored in clinical trials. Among these complement inhibitors, specific LP inhibitors are also being tested in renal abnormalities such as in immunoglobulin A nephropathy and lupus nephritis. Using various in vitro models, Yaseen et al. (Lectin pathway effector enzyme mannan-binding lectin-associated serine protease-2 can activate native complement component 3 (C3) in absence of C4 and/or C2. FASEB J 2017; 31: 2210-2219) showed that Mannan-associated serine protease2 can directly activate C3 thereby bypassing C2 and C4 in the activation of the LP. These new findings broaden our understanding of the mechanisms of complement activation and could potentially impact our strategies to inhibit the LP in renal diseases. In support of these findings, we present data of human renal biopsies, demonstrating the occurrence of the LP bypass mechanism in vivo. In conclusion, this review provides a detailed overview of the LP and clarifies the recently described bypass mechanism and its relevance. Finally, we speculate on the role of the C4 bypass mechanism in other renal diseases.
Collapse
Affiliation(s)
- Mariana Gaya da Costa
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Felix Poppelaars
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Stefan P Berger
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mohamed R Daha
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Nephrology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Marc A Seelen
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
37
|
Complement Activation in Progression of Chronic Kidney Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1165:423-441. [PMID: 31399977 DOI: 10.1007/978-981-13-8871-2_20] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic kidney disease (CKD) is a public health problem worldwide, with increasing incidence and prevalence. The mechanisms underlying the progression to end-stage renal disease (ESRD) is not fully understood. The complement system was traditionally regarded as an important part of innate immunity required for host protection against infection and for maintaining host hemostasis. However, compelling evidence from both clinical and experimental studies has strongly incriminated complement activation as a pivotal pathogenic mediator of the development of multiple renal diseases and progressive replacement of functioning nephrons by fibrosis. Both anaphylatoxins, i.e., C3a and C5a, and membrane attack complex (MAC) contribute to the damage that occurs during chronic renal progression through various mechanisms including direct proinflammatory and fibrogenic activity, chemotactic effect, activation of the renal renin-angiotensin system, and enhancement of T-cell immunity. Evolving understanding of the mechanisms of complement-mediated renal injury has led to the emergence of complement-targeting therapeutics. A variety of specific antibodies and inhibitors targeting complement components have shown efficacy in reducing disease in animal models. Moreover, building on these advances, targeting complement has gained encouraging success in treating patients with renal diseases such as atypical hemolytic uremic syndrome (aHUS). Nevertheless, it still requires a great deal of effort to develop inhibitors that can be applied to treat more patients effectively in routine clinical practice.
Collapse
|
38
|
Chen P, Yu G, Zhang X, Xie X, Wang J, Shi S, Liu L, Lv J, Zhang H. Plasma Galactose-Deficient IgA1 and C3 and CKD Progression in IgA Nephropathy. Clin J Am Soc Nephrol 2019; 14:1458-1465. [PMID: 31511226 PMCID: PMC6777583 DOI: 10.2215/cjn.13711118] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 07/26/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Increased circulating galactose-deficient IgA1 and subsequently complement activation both play important roles in the pathophysiology of IgA nephropathy. However, their relationship to disease severity and progression remains unclear. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We assessed 1210 participants in a cohort study of biopsy-proven IgA nephropathy at Peking University First Hospital. Plasma concentrations of galactose-deficient IgA1 and complement component C3 were measured at the time of biopsy. We tested associations of galactose-deficient IgA1 and galactose-deficient IgA1/C3 ratio with CKD progression event, defined as ESKD or 50% decline in eGFR, using Cox proportional hazards models and restricted cubic splines. RESULTS After a median follow-up of 43 months (interquartile range, 24-76 months), 172 (14%) participants reached the CKD progression event. The association of galactose-deficient IgA1 levels and CKD progression event showed a nonlinear relationship. The risk of CKD progression events was greater with higher plasma galactose-deficient IgA1 levels but reached a plateau when galactose-deficient IgA1>325 U/ml, whereas the risk of CKD progression events monotonically increased with higher galactose-deficient IgA1/C3 ratio. After adjustment for traditional risk factors (demographics, eGFR, proteinuria, hypertension, Oxford pathologic score, and corticosteroids/immunosuppressive therapy), higher levels of galactose-deficient IgA1/C3 ratio were independently associated with CKD progression event (per natural log-transformed [galactose-deficient IgA1/C3], hazard ratio, 2.03; 95% confidence interval [95% CI], 1.25 to 3.29; P=0.004). In reference to the first quartile of the galactose-deficient IgA1/C3 ratio, hazard ratios were 1.71 (95% CI, 1.01 to 2.89) for the second quartile, 1.55 (95% CI, 0.91 to 2.63) for the third quartile, and 2.17 (95% CI, 1.33 to 3.56) for the fourth quartile. CONCLUSIONS In IgA nephropathy, plasma galactose-deficient IgA1/C3 ratio was associated with CKD progression event independent of clinical and biopsy characteristics.
Collapse
Affiliation(s)
- Pei Chen
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Guizhen Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Xue Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Xinfang Xie
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Jinwei Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Sufang Shi
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Lijun Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China; .,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Peking University Institute of Nephrology, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; and.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment (Peking University), Ministry of Education, Beijing, China
| |
Collapse
|
39
|
Tortajada A, Gutierrez E, Pickering MC, Praga Terente M, Medjeral-Thomas N. The role of complement in IgA nephropathy. Mol Immunol 2019; 114:123-132. [PMID: 31351413 DOI: 10.1016/j.molimm.2019.07.017] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 12/22/2022]
Abstract
IgA nephropathy (IgAN) is common and often progresses to end stage renal disease. IgAN encompasses a wide range of histology and clinical features. IgAN pathogenesis is incompletely understood; the current multi-hit hypothesis of IgAN pathogenesis does not explain the range of glomerular inflammation and renal injury associated with mesangial IgA deposition. Although associations between IgAN and glomerular and circulating markers of complement activation are established, the mechanism of complement activation and contribution to glomerular inflammation and injury are not defined. Recent identification of specific complement pathways and proteins in severe IgAN cases had advanced our understanding of complement in IgAN pathogenesis. In particular, a growing body of evidence implicates the complement factor H related proteins 1 and 5 and lectin pathway as pathogenic in a subset of patients with severe disease. These data suggest complement deregulation and activity may be dominant drivers of renal injury in IgAN. Thereby, markers of complement activation may identify IgAN patients likely to progress to significant renal impairment and complement inhibition may emerge as an effective method of preventing and reducing glomerular injury in IgAN.
Collapse
Affiliation(s)
- Agustin Tortajada
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine and 12 de Octubre Health Research Institute (imas12), Madrid, Spain
| | - Eduardo Gutierrez
- Department of Nephrology, Research Institute Universitary Hospital 12 de Octubre (imas12), Madrid, Spain
| | | | - Manuel Praga Terente
- Department of Nephrology, Research Institute Universitary Hospital 12 de Octubre (imas12), Madrid, Spain
| | | |
Collapse
|
40
|
Moran SM, Cattran DC. Recent advances in risk prediction, therapeutics and pathogenesis of IgA nephropathy. Minerva Med 2019; 110:439-449. [PMID: 31142099 DOI: 10.23736/s0026-4806.19.06165-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Immunoglobulin A nephropathy (IgAN) is the world's commonest primary glomerular disease with variable clinical presentation and progression rates that are dependent on clinical-pathologic phenotype and duration of follow-up. Overall 4-40% of patients progress to end-stage kidney disease (ESKD) by 10 years. Treatment decisions remain a challenge due to these variations. The ultimate goal of management is to prevent progression to ESKD and of vital importance is the potential reversible early detection of active glomerular inflammation prior to scarring. IgAN is globally, is the most common biopsy proven glomerulonephritis and a leading cause of ESKD. The Oxford pathological classification was devised by a collaborative pathology and nephrology network to provide an evidence-based scoring system with reproducible independent pathology features of predictive value. Clinical variables that alter prognosis include male sex, increasing age, increased body weight, smoking, Pacific Asian ethnicity, hypertension, proteinuria, and complement deficiency. Excellent conservative therapy is the cornerstone of therapy with tight blood control, renin-angiotensin system inhibition, and statin therapy. The role of immunosuppressive therapy including corticosteroids in IgAN remains open with ongoing clinical trials of low dose oral corticosteroids and enteric coated budesonide. Complement activation contributes to the pathogenic process of IgAN with evidence from genetic, serological, histological and in-vitro studies. This knowledge has translated to clinical trials of investigational agents directly targeting the alternative pathway.
Collapse
Affiliation(s)
- Sarah M Moran
- The Toronto Glomerulonephritis Registry and Division of Nephrology, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Trinity Health Kidney Center, Trinity College, Dublin, Ireland
| | - Daniel C Cattran
- The Toronto Glomerulonephritis Registry and Division of Nephrology, University Health Network, Toronto, ON, Canada - .,Department of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
41
|
Floege J, Daha MR. IgA nephropathy: new insights into the role of complement. Kidney Int 2019; 94:16-18. [PMID: 29933843 DOI: 10.1016/j.kint.2018.03.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 03/08/2018] [Accepted: 03/13/2018] [Indexed: 10/28/2022]
Abstract
Glomerular complement deposition is common in IgA nephropathy, and recent genome-wide association studies point to a role of complement factor H and complement factor H-related proteins in disease susceptibility. A number of recent studies have now documented elevated levels of some factor H-related proteins in IgA nephropathy, which might contribute to enhanced complement activation.
Collapse
Affiliation(s)
- Jürgen Floege
- Division of Nephrology and Immunology, RWTH University of Aachen, Aachen, Germany.
| | - Mohamed R Daha
- Department of Nephrology, University Medical Center Leiden and University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
42
|
Ouyang Y, Zhu L, Shi M, Yu S, Jin Y, Wang Z, Ma J, Yang M, Zhang X, Pan X, Ren H, Wang W, Zhang H, Xie J, Chen N. A Rare Genetic Defect of MBL2 Increased the Risk for Progression of IgA Nephropathy. Front Immunol 2019; 10:537. [PMID: 30967869 PMCID: PMC6438956 DOI: 10.3389/fimmu.2019.00537] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/27/2019] [Indexed: 12/23/2022] Open
Abstract
The aim of this study was to investigate the association between lectin pathway-related genetic variations and progression in IgA nephropathy. Biopsy-proven IgAN patients with eGFR ≥15 ml/min/1.73 m2 at baseline and a minimum follow-up of 12-months were enrolled. A total of 1,007 patients and 121 healthy controls were enrolled from two Chinese renal centers. The discovery cohort consisted of 606 patients, and the validation cohort consisted of 401 patients. First, promoters, all exons and their boundary regions of MBL2 and FCN2 were sequenced in 50 patients, and then 37 variations were identified. Of these variations, 7 expression-associated variations were selected and genotyped in the whole discovery cohort. We found that rs1800450 in MBL2 and rs7851696 in FCN2 were associated with an increased risk for ESRD as well as serum MBL or L-ficolin levels. However, only rs1800450 was successively validated for its association with ESRD (HR, 15.91; 3.27-77.34; P = 0.001) in the fully adjusted model in the validation cohort. In addition, 2.7% of patients, and 2.5% of healthy controls carried rs1800450-AA. IgAN patients with rs1800450-AA lacked expression of MBL in both serum and renal tissue and had more severe tubulointerstitial damage. Furthermore, a combined effect of rs1800450-AA with a previously reported clinical risk score was observed in which patients with both a high clinical risk score (≥1%) and rs1800450-AA had a strikingly increased 10-years ESRD risk by 37.1-fold (7.17 to 192.13-fold). In summary, IgAN patients carrying MBL2 rs1800450-AA have a high risk for renal function deterioration, probably due to inactivation of the complement MBL pathway.
Collapse
Affiliation(s)
- Yan Ouyang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Zhu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Manman Shi
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shuwen Yu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanmeng Jin
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhaohui Wang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Ma
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Meng Yang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoyan Zhang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoxia Pan
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Ren
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiming Wang
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Jingyuan Xie
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Nan Chen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
43
|
Tan Y, Zhao MH. Complement in glomerular diseases. Nephrology (Carlton) 2019; 23 Suppl 4:11-15. [PMID: 30298653 DOI: 10.1111/nep.13461] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2018] [Indexed: 10/28/2022]
Abstract
Complement activation has been identified to play a vital role in the pathogenesis of many glomerulonephritis, either as direct complement activation-driven factor in thrombotic microangiopathy and C3 glomerulopathy, and/or as an important contributor in lupus nephritis and anti-neutrophil cytoplasmic antibody-associated vasculitis. Recent studies indicated that complement activation may also play roles in the pathogenesis of immunoglobulin A nephropathy and focal segmental glomerulosclerosis. Interestingly, monoclonal immunoglobulins/light chains from patients with monoclonal gammopathy may interfere with complement activation and thus indirectly result in complement-mediated glomerulonephritis. Understanding of the pathogenic roles of complement activation in various glomerulonephritis will facilitate the identification of potential novel therapeutic targets in complement system.
Collapse
Affiliation(s)
- Ying Tan
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
| |
Collapse
|
44
|
Praga M, Caravaca F, Yuste C, Cavero T, Hernández E, Morales E, Mérida E, Moreno JA, Sevillano A, Gutiérrez E. IgA nephropathy: What patients are at risk of progression to end-stage renal disease and how should they be treated? Nefrologia 2018; 38:347-352. [PMID: 29636281 DOI: 10.1016/j.nefro.2018.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/04/2018] [Accepted: 01/15/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- Manuel Praga
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España; Departamento de Medicina, Universidad Complutense, Madrid, España.
| | - Fernando Caravaca
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Claudia Yuste
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Teresa Cavero
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Eduardo Hernández
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Enrique Morales
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Eva Mérida
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Juan Antonio Moreno
- Renal, Vascular and Diabetes Research Laboratory, Fundación Instituto de Investigaciones Sanitarias-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, España
| | - Angel Sevillano
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| | - Eduardo Gutiérrez
- Servicio de Nefrología, Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria, Hospital 12 de Octubre (imas12), Madrid, España
| |
Collapse
|
45
|
Medjeral-Thomas NR, Troldborg A, Constantinou N, Lomax-Browne HJ, Hansen AG, Willicombe M, Pusey CD, Cook HT, Thiel S, Pickering MC. Progressive IgA Nephropathy Is Associated With Low Circulating Mannan-Binding Lectin-Associated Serine Protease-3 (MASP-3) and Increased Glomerular Factor H-Related Protein-5 (FHR5) Deposition. Kidney Int Rep 2017; 3:426-438. [PMID: 29725647 PMCID: PMC5932138 DOI: 10.1016/j.ekir.2017.11.015] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 11/16/2017] [Accepted: 11/21/2017] [Indexed: 12/16/2022] Open
Abstract
Introduction IgA nephropathy (IgAN) is characterized by glomerular deposition of galactose-deficient IgA1 and complement proteins and leads to renal impairment. Complement deposition through the alternative and lectin activation pathways is associated with renal injury. Methods To elucidate the contribution of the lectin pathway to IgAN, we measured the 11 plasma lectin pathway components in a well-characterized cohort of patients with IgAN. Results M-ficolin, L-ficolin, mannan-binding lectin (MBL)-associated serine protease (MASP)-1 and MBL-associated protein (MAp) 19 were increased, whereas plasma MASP-3 levels were decreased in patients with IgAN compared with healthy controls. Progressive disease was associated with low plasma MASP-3 levels and increased glomerular staining for C3b/iC3b/C3c, C3d, C4d, C5b-9, and factor H-related protein 5 (FHR5). Glomerular FHR5 deposition positively correlated with glomerular C3b/iC3b/C3c, C3d, and C5b-9 deposition, but not with glomerular C4d. These observations, together with the finding that glomerular factor H (fH) deposition was reduced in progressive disease, are consistent with a role for fH deregulation by FHR5 in renal injury in IgAN. Conclusion Our data indicate that circulating MASP-3 levels could be used as a biomarker of disease severity in IgAN and that glomerular staining for FHR5 could both indicate alternative complement pathway activation and be a tissue marker of disease severity.
Collapse
Affiliation(s)
| | - Anne Troldborg
- Department of Biomedicine, Aarhus University, Aarhus, Denmark.,Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Nicholas Constantinou
- Centre for Complement and Inflammation Research, Imperial College London, London, UK
| | - Hannah J Lomax-Browne
- Centre for Complement and Inflammation Research, Imperial College London, London, UK
| | | | - Michelle Willicombe
- Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Charles D Pusey
- Renal and Vascular Inflammation Section, Imperial College London, London, UK
| | - H Terence Cook
- Centre for Complement and Inflammation Research, Imperial College London, London, UK
| | - Steffen Thiel
- Department of Biomedicine, Aarhus University, Aarhus, Denmark
| | - Matthew C Pickering
- Centre for Complement and Inflammation Research, Imperial College London, London, UK
| |
Collapse
|