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Zavala-Miranda MF, Sobrino-Vargas AM, Hernández-Andrade A, Caballero-Malacara V, Pérez-Arias AA, Márquez-Macedo SE, Nordmann-Gomes A, Navarro-Sánchez V, Juárez-Cuevas B, Uribe-Uribe NO, Mejia-Vilet JM. Exostosin-1/exostosin-2 expression and favorable kidney outcomes in lupus nephritis: a retrospective cohort study. Clin Rheumatol 2024:10.1007/s10067-024-07043-x. [PMID: 38922553 DOI: 10.1007/s10067-024-07043-x] [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: 03/20/2024] [Revised: 05/24/2024] [Accepted: 06/24/2024] [Indexed: 06/27/2024]
Abstract
INTRODUCTION/OBJECTIVES The heterodimer exostosin-1/exostosin-2 (EXO-1/2) is a novel antigen observed in membranous nephropathy associated with systemic lupus erythematosus. This study aimed to evaluate the association between EXO-1/2 positivity in kidney biopsy and kidney outcomes. METHODS The kidney biopsy tissue from 50 class 5 lupus nephritis (LN) and 55 mixed class 3/4 + 5 LN patients was stained for EXO-1/2. Baseline clinical and histological characteristics were compared between EXO-1/2 positive and EXO-1/2 negative patients. Time-to-event analyses were performed to compare rates of response to therapy, kidney flares, and progression to a 40% decline of the glomerular filtration rate (eGFR), doubling of serum creatinine, and kidney failure. RESULTS Fourteen out of 50 (28%) of class 5 and 5 out of 55 (9%) of mixed class 3/4 + 5 LN stained positive for EXO-1/2. Patients with class 5 LN and EXO-1/2 positive stain were younger, with better kidney function at presentation, and lower scarring in the kidney biopsy analysis. Over a median follow-up of 100 months, patients with positive EXO-1/2 staining had significantly lower rates of progression in the full cohort. When analyzed separately in class 5 and mixed class LN subgroups, there were significantly lower rates of progression to a 40% decline of the eGFR and non-statistically significant trends for doubling of serum creatinine and kidney failure. CONCLUSION EXO-1/2 is a novel antigen detected in class 5 LN and associated with a good prognosis of kidney function. The incorporation of EXO-1/2 staining in clinical practice can potentially modify the management of LN due to its prognostic implications. Key Points • Exostosin-1/exostosin-2 antigen has been found in cases of membranous nephropathy associated with autoimmune diseases such as systemic lupus erythematosus. • Exostosin-1/exostosin-2 staining in the kidney biopsy of class 5 or mixed class 3/4 + 5 lupus nephritis is associated with a good long-term prognosis of kidney function. • The incorporation of exostosin-1/exostosin-2 staining into clinical practice can potentially modify management due to its prognostic implications.
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Affiliation(s)
- Maria Fernanda Zavala-Miranda
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 15 Vasco de Quiroga, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Ana María Sobrino-Vargas
- Department of Pathology and Anatomic Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Adriana Hernández-Andrade
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 15 Vasco de Quiroga, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Valeria Caballero-Malacara
- Department of Pathology and Anatomic Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Abril A Pérez-Arias
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 15 Vasco de Quiroga, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Sofía E Márquez-Macedo
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 15 Vasco de Quiroga, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Alberto Nordmann-Gomes
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 15 Vasco de Quiroga, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Valeria Navarro-Sánchez
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 15 Vasco de Quiroga, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Bernardo Juárez-Cuevas
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 15 Vasco de Quiroga, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Norma O Uribe-Uribe
- Department of Pathology and Anatomic Pathology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Juan M Mejia-Vilet
- Department of Nephrology and Mineral Metabolism, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, 15 Vasco de Quiroga, Belisario Domínguez Sección XVI, Tlalpan, 14080, Mexico City, Mexico.
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Andeen NK, Hou J. Diagnostic Challenges and Emerging Pathogeneses of Selected Glomerulopathies. Pediatr Dev Pathol 2024:10935266241237656. [PMID: 38576387 DOI: 10.1177/10935266241237656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Abstract
Recent progress in glomerular immune complex and complement-mediated diseases have refined diagnostic categories and informed mechanistic understanding of disease development in pediatric patients. Herein, we discuss selected advances in 3 categories. First, membranous nephropathy antigens are increasingly utilized to characterize disease in pediatric patients and include phospholipase A2 receptor (PLA2R), Semaphorin 3B (Sema3B), neural epidermal growth factor-like 1 (NELL1), and protocadherin FAT1, as well as the lupus membranous-associated antigens exostosin 1/2 (EXT1/2), neural cell adhesion molecule 1 (NCAM1), and transforming growth factor beta receptor 3 (TGFBR3). Second, we examine advances in techniques for paraffin and light chain immunofluorescence (IF), including the former's function as a salvage technique and their necessity for diagnosis in adolescent cases of membranous-like glomerulopathy with masked IgG kappa deposits (MGMID) and proliferative glomerulonephritis with monotypic Ig deposits (PGNMID), respectively. Finally, progress in understanding the roles of complement in pediatric glomerular disease is reviewed, with specific attention to overlapping clinical, histologic, and genetic or functional alternative complement pathway (AP) abnormalities among C3 glomerulopathy (C3G), infection-related and post-infectious GN, "atypical" post-infectious GN, immune complex mediated membranoproliferative glomerulonephritis (IC-MPGN), and atypical hemolytic uremic syndrome (aHUS).
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Affiliation(s)
- Nicole K Andeen
- Oregon Health & Science University, Department of Pathology and Laboratory Medicine, Portland, OR, USA
| | - Jean Hou
- Cedars-Sinai Medical Center, Department of Pathology, Los Angeles, CA, USA
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3
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Xia X, Li S, Wang Z, Ye S, Fan Y, Peng W, Chen W, Huang F, Tang R, Chen W. Glomerular Exostosin-Positivity is Associated With Disease Activity and Outcomes in Patients With Membranous Lupus Nephritis. Kidney Int Rep 2024; 9:1040-1046. [PMID: 38765564 PMCID: PMC11101748 DOI: 10.1016/j.ekir.2024.01.008] [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: 11/13/2023] [Revised: 12/11/2023] [Accepted: 01/02/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction The relationship of exostosin 1 and exostosin 2 (EXT1/EXT2) expression and outcomes in membranous lupus nephritis (MLN) was controversial. Methods EXT1/EXT2 was performed by immunohistochemistry (IHC) in 283 consecutive patients with MLN. Clinicopathological characteristics and outcomes of EXT1/EXT2-positive patients were compared with EXT1/EXT2-negative patients. The primary end points were adverse renal events, including death, dialysis, and renal transplantation. Results Of the patients with MLN, 29.3% were positive for EXT1/EXT2. The prevalence of EXT1/2-positive MLN was significantly higher in pure class V MLN than those for mixed class V MLN (44.2% vs. 19.4%, P < 0.001). For EXT1/EXT2-positive patients, the median time between onset of lupus and renal biopsy, and lupus nephritis and renal biopsy is shorter (6 [interquartile range, IQR: 2-25] months vs. 12 [IQR: 3-49] months, P = 0.008 and 3 [IQR: 2-18] months vs. 6 [IQR: 2-23] months, P = 0.039) and they had significantly lower systemic lupus erythematosus Disease Activity Index (SLEDAI) scores (P = 0.015) and lower serum creatinine levels (P < 0.001), higher hemoglobin (P = 0.006) as well as lower blood pressure. The EXT1/EXT2-positive patients had significantly fewer chronicity features (glomerulosclerosis, P < 0.001; interstitial fibrosis, P = 0.006; and tubular atrophy, P = 0.002) and fewer activity indicators (endocapillary hypercellularity, P = 0.012; cellular crescents, P = 0.007; and fibrocellular crescents, P < 0.001) on renal biopsy. After a median follow-up of 65 (28-126) months, EXT1/EXT2-positive patients were less likely to experience adverse renal events (2.4% vs. 16.0%, P = 0.001). Conclusion Compared with EXT1/EXT2-negative patients, the EXT1/EXT2-positive patients presented with lower disease activity and were less likely to experience adverse renal events in relationship with the chronicity index.
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Affiliation(s)
- Xi Xia
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, People’s Republic of China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, People’s Republic of China
| | - Suchun Li
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, People’s Republic of China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, People’s Republic of China
| | - Zhipeng Wang
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, People’s Republic of China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, People’s Republic of China
| | - Siyang Ye
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, People’s Republic of China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, People’s Republic of China
| | - Yuting Fan
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, People’s Republic of China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, People’s Republic of China
| | - Wenxing Peng
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, People’s Republic of China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, People’s Republic of China
| | - Wenfang Chen
- Department of Pathology, The First Affiliated Hospital of Sun Yat-Sen University, People’s Republic of China
| | - Fengxian Huang
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, People’s Republic of China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, People’s Republic of China
| | - Ruihan Tang
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, People’s Republic of China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, People’s Republic of China
| | - Wei Chen
- Department of Nephrology, The First Affiliated Hospital of Sun Yat-Sen University, People’s Republic of China
- NHC Key Laboratory of Clinical Nephrology (Sun Yat-Sen University) and Guangdong Provincial Key Laboratory of Nephrology, People’s Republic of China
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Radhakrishnan Y, Zand L, Sethi S, Fervenza FC. Membranous nephropathy treatment standard. Nephrol Dial Transplant 2024; 39:403-413. [PMID: 37934599 DOI: 10.1093/ndt/gfad225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Indexed: 11/09/2023] Open
Abstract
Membranous nephropathy (MN) is characterized by deposition of immune complexes leading to thickening of glomerular basement membranes. Over time, the understanding of MN has evolved, with the identification of specific autoantibodies against novel podocyte antigens and the unraveling of intricate pathogenic pathways. Although the anti-CD20 monoclonal antibody rituximab is favored as part of the initial therapy in MN, a subgroup of MN patients may be resistant to rituximab necessitating the use of alternative agents such as cytotoxic therapies. In addition, newer agents such as novel anti-CD20 monoclonal antibodies, therapies targeting the CD38-positive plasma cells and anti-complement therapy are being studied in patients who are resistant to traditional treatment strategies. This manuscript furnishes a review of the novel developments in the pathophysiology of MN including the identification of target antigens and current treatment standards for MN, concentrating on evidenced-based interventions designed to attain remission and to prevent disease progression.
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Affiliation(s)
- Yeshwanter Radhakrishnan
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ladan Zand
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sanjeev Sethi
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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5
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Avasare R, Andeen N, Beck L. Novel Antigens and Clinical Updates in Membranous Nephropathy. Annu Rev Med 2024; 75:219-332. [PMID: 37552894 DOI: 10.1146/annurev-med-050522-034537] [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] [Indexed: 08/10/2023]
Abstract
Membranous nephropathy (MN), an autoimmune kidney disease and leading cause of nephrotic syndrome, leads to kidney failure in up to one-third of affected individuals. Most MN cases are due to an autoimmune reaction against the phospholipase A2 receptor (PLA2R) located on kidney podocytes. Serum PLA2R antibody quantification is now part of routine clinical practice because antibody titers correlate with disease activity and treatment response. Recent advances in target antigen detection have led to the discovery of more than 20 other podocyte antigens, yet the clinical impact of additional antigen detection remains unknown and is under active investigation. Here we review recent findings and hypothesize how current research will inform future care of patients with MN.
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Affiliation(s)
- Rupali Avasare
- Division of Nephrology and Hypertension, Oregon Health & Science University, Portland, Oregon, USA;
| | - Nicole Andeen
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA;
| | - Laurence Beck
- Section of Nephrology, Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
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Miyasaka R, Wada Y, Takeuchi K, Abe T, Uchitsubo R, Kawamura S, Sakurabayashi S, Naito S, Aoyama T, Shimizu A, Takeuchi Y. Lupus-like membranous nephropathy during the postpartum period expressing glomerular antigens exostosin 1/exostosin 2 and phospholipase A2 receptor: a case report. CEN Case Rep 2024:10.1007/s13730-023-00848-w. [PMID: 38280123 DOI: 10.1007/s13730-023-00848-w] [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: 11/16/2023] [Accepted: 12/24/2023] [Indexed: 01/29/2024] Open
Abstract
Recently, several target antigens of membranous nephropathy (MN), such as phospholipase A2 receptor (PLA2R) and exostosin 1/exostosin 2 (EXT1/2), have been discovered. A 30-year-old woman was referred to our hospital with nephrotic range proteinuria and microscopic hematuria. She was first noted to have proteinuria before pregnancy, and her proteinuria worsened in the postpartum period. A renal biopsy showed MN. Immunofluorescence microscopy showed IgG, IgA, IgM, C3, C4, and C1q depositions in the mesangial area and glomerular capillary walls (GCWs). Regarding the IgG subclass, IgG1 and IgG3 were detected on glomeruli. Electron microscopy showed subepithelial electron-dense deposits (EDDs). EDDs were also detected in paramesangial and subendothelial areas. The diagnosis of membranous lupus nephritis (MLN) was suspected, but she did not fulfill the criteria for systemic lupus erythematosus. Neither anti-nuclear antibody nor hypocomplementemia were detected. We further evaluated glomerular EXT1/2 expressions, which were evident on GCWs. In addition, PLA2R was also detected on GCWs, although serum antibody for PLA2R was negative. She responded to immunosuppressive therapy with decreased proteinuria. In the present case, glomerular PLA2R expression implied the possibility of primary MN. However, pathological findings with a full-house staining pattern and glomerular EXT1/2 expressions were very similar to those of lupus-associated MN. Glomerular PLA2R expression appeared not to reflect immunocomplexes of PLA2R and autoantibody when considering the results for glomerular IgG subclass and the absence of serum anti-PLA2R antibody. Collectively, it is plausible that this was a case of a relatively young postpartum female who developed latent MLN rather than primary MN.
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Affiliation(s)
- Ryoma Miyasaka
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yukihiro Wada
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Kazuhiro Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Tetsuya Abe
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Ryota Uchitsubo
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Sayumi Kawamura
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Shun Sakurabayashi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Shokichi Naito
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Togo Aoyama
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Yasuo Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa, 252-0374, Japan
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Sethi S, Theis JD, Palma LM, Madden B. From Patterns to Proteins: Mass Spectrometry Comes of Age in Glomerular Disease. J Am Soc Nephrol 2024; 35:117-128. [PMID: 37749770 PMCID: PMC10786612 DOI: 10.1681/asn.0000000000000221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 08/17/2023] [Indexed: 09/27/2023] Open
Abstract
Laser capture microdissection and mass spectrometry (LCM/MS) is a technique that involves dissection of glomeruli from paraffin-embedded biopsy tissue, followed by digestion of the dissected glomerular proteins by trypsin, and subsequently mass spectrometry to identify and semiquantitate the glomerular proteins. LCM/MS has played a crucial role in the identification of novel types of amyloidosis, biomarker discovery in fibrillary GN, and more recently discovery of novel target antigens in membranous nephropathy (MN). In addition, LCM/MS has also confirmed the role for complement proteins in glomerular diseases, including C3 glomerulopathy. LCM/MS is now widely used as a clinical test and considered the gold standard for diagnosis and typing amyloidosis. For the remaining glomerular diseases, LCM/MS has remained a research tool. In this review, we discuss the usefulness of LCM/MS in other glomerular diseases, particularly MN, deposition diseases, and diseases of complement pathways, and advocate more routine use of LCM/MS at the present time in at least certain diseases, such as MN, for target antigen detection. We also discuss the limitations of LCM/MS, particularly the difficulties faced from moving from a research-based technique to a clinical test. Nonetheless, the role of LCM/MS in glomerular diseases is expanding. Currently, LCM/MS may be used to identify the etiology in certain glomerular diseases, but in the future, LCM/MS can play a valuable role in determining pathways of complement activation, inflammation, and fibrosis.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Jason D. Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Lilian M.P. Palma
- Pediatric Nephrology, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Benjamin Madden
- Mayo Clinic Proteomics Core, Mayo Clinic, Rochester, Minnesota
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Liu Z, Wan C, Cao Y, Liu S, Xu Z, Zhang C, Su H. Distribution spectrum and clinical significance of glomerular exostosin (EXT1) deposits in PLA2R-positive membranous nephropathy. J Nephrol 2024; 37:149-158. [PMID: 37882962 DOI: 10.1007/s40620-023-01779-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/03/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND The discovery of antigen phospholipase A2 receptor (PLA2R) in 2009 ushered in the antigen-based study of membranous nephropathy. The further putative antigen exostosin 1/2 (EXT1/2) was described in 2019. However, the distribution spectrum of glomerular EXT1 deposits in membranous nephropathy has not been fully elucidated. METHODS We conducted a retrospective cohort study of biopsy-proven membranous nephropathy patients. Patients with complete baseline data and adequate tissue specimens were included in this study. Tests for glomerular expression of PLA2R and EXT1 and circulating anti-PLA2R antibodies were performed. Clinicopathological and outcome data were reviewed. RESULTS We included 626 patients, namely, 487 (77.8%) PLA2R-positive patients and 54 (8.6%) EXT1-positive patients; 32 (5.1%) patients were dual-positive for PLA2R and EXT1 (PLA2R + /EXT1 +). A higher percentage of dual-positive patients had low C3 levels (P < 0.001) and were more likely to have autoimmune diseases (P = 0.013) than PLA2R-positive and EXT1-negative (PLA2R + /EXT1-) patients. Kidney biopsy findings revealed that there was a higher percentage of glomerular IgG1, IgG2, IgA, C4, and C1q deposits (P < 0.05), "full-house" staining (P < 0.001), and stronger intensity of C1q staining (P = 0.002) in PLA2R + /EXT1 + patients. Based on Kaplan-Meier analysis, a higher percentage of PLA2R + /EXT1 + patients exhibited partial or complete remission of proteinuria. Furthermore, EXT1-positive expression was a favourable predictor for proteinuria remission, whereas interstitial fibrosis/tubular atrophy was an unfavourable predictor. A complement C3 level < 0.79 g/L was independently associated with EXT1 positivity in PLA2R-positive membranous nephropathy. CONCLUSIONS We describe a subgroup of PLA2R and EXT1 dual-positive patients. Patients in this subset exhibited more signs of autoimmunity and more frequent clinical remission. In PLA2R-positive membranous nephropathy, a complement C3 level < 0.79 g/L was independently associated with EXT1 positivity, which was a favourable predictor for proteinuria remission.
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Affiliation(s)
- Zezhou Liu
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cheng Wan
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiling Cao
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saiji Liu
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ziyu Xu
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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9
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Shida R, Iwakura T, Ohashi N, Ema C, Aoki T, Tashiro T, Ishigaki S, Isobe S, Fujikura T, Kato A, Nakamura T, Fujigaki Y, Shimizu A, Yasuda H. Anti-contactin 1 Antibody-associated Membranous Nephropathy in Chronic Inflammatory Demyelinating Polyneuropathy with Several Autoantibodies. Intern Med 2024; 63:699-705. [PMID: 38432895 PMCID: PMC10982023 DOI: 10.2169/internalmedicine.2126-23] [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: 04/17/2023] [Accepted: 06/01/2023] [Indexed: 03/05/2024] Open
Abstract
A 50-year-old man diagnosed with anti-contactin 1 (CNTN1) antibody-associated chronic inflammatory demyelinating polyneuropathy (CIDP) was referred to our department for the evaluation of proteinuria. A kidney biopsy revealed membranous nephropathy (MN). Immunohistochemistry for CNTN1 revealed positive granular staining along the glomerular basement membrane, confirming anti-CNTN1 antibody-associated MN. Immunofluorescence showed a full-house pattern, and several autoantibodies, such as anti-nuclear antibody, anti-double-strand DNA antibody, and anti-cardiolipin antibody, were detected in the patient's serum. Although limited autoantibodies have been investigated in some of the reported cases, a variety of autoantibodies might be produced in anti-CNTN1 antibody-associated CIDP, accompanied by MN.
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Affiliation(s)
- Ryutaro Shida
- First Department of Medicine, Division of Nephrology, Hamamatsu University School of Medicine, Japan
| | - Takamasa Iwakura
- First Department of Medicine, Division of Nephrology, Hamamatsu University School of Medicine, Japan
| | - Naro Ohashi
- First Department of Medicine, Division of Nephrology, Hamamatsu University School of Medicine, Japan
| | - Chiemi Ema
- First Department of Medicine, Division of Nephrology, Hamamatsu University School of Medicine, Japan
| | - Taro Aoki
- First Department of Medicine, Division of Nephrology, Hamamatsu University School of Medicine, Japan
| | - Takeshi Tashiro
- First Department of Medicine, Division of Nephrology, Hamamatsu University School of Medicine, Japan
| | - Sayaka Ishigaki
- Blood Purification Unit, Hamamatsu University School of Medicine, Japan
| | - Shinsuke Isobe
- First Department of Medicine, Division of Nephrology, Hamamatsu University School of Medicine, Japan
| | - Tomoyuki Fujikura
- First Department of Medicine, Division of Nephrology, Hamamatsu University School of Medicine, Japan
| | - Akihiko Kato
- Blood Purification Unit, Hamamatsu University School of Medicine, Japan
| | - Tomohiko Nakamura
- Department of Neurology, Hamamatsu University School of Medicine, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Japan
| | - Hideo Yasuda
- First Department of Medicine, Division of Nephrology, Hamamatsu University School of Medicine, Japan
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10
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Ye T, Jiang M, Zeng X, Zong D, Du Y, Li X, Huang B, Tang X. Clinical significance of exostosin 1 in confirmed and suspected lupus membranous nephropathy. Lupus Sci Med 2023; 10:e001051. [PMID: 38154829 PMCID: PMC10759090 DOI: 10.1136/lupus-2023-001051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/11/2023] [Indexed: 12/30/2023]
Abstract
OBJECTIVE This study aimed to investigate the clinical significance of exostosin 1 (EXT1) in confirmed and suspected lupus membranous nephropathy (LMN). METHODS EXT1 was detected in 67 renal tissues of M-type phospholipase A2 receptor (PLA2R)-negative and ANA-positive membranous nephropathy by immunohistochemistry, and cases were divided into confirmed LMN and suspected LMN. The clinicopathological data were compared among the above groups, as well as EXT1-positive group and EXT1-negative group. RESULTS Twenty-two cases (73.3%) of confirmed LMN and six cases (16.2%) of suspected LMN exhibited EXT1 expression on the glomerular basement membrane and/or mesangium area, showing a significant difference (p<0.001). Concurrently, lupus nephritis (LN) of pure class V demonstrated a lower frequency of EXT1 positivity compared with mixed class V LN in the confirmed LMN group (31.8% vs 68.2%, p=0.007). EXT1-positive patients in the confirmed and suspected LMN group showed significant differences in some clinicopathological data comparing with EXT1-negative patients (p<0.05). Follow-up data revealed that a greater proportion of patients in the EXT1-positive group achieved complete remission post-treatment (p<0.05). Cox regression analysis showed that EXT1 positivity was significantly correlated with complete remission across the entire study cohort (HR 5.647; 95% CI, 1.323 to 12.048; p=0.019). Kaplan-Meier analysis indicated that the EXT1-positive group had a higher rate of accumulated nephrotic remission compared with the EXT1-negative group in the whole study cohort (p=0.028). CONCLUSIONS The EXT1-positive group exhibited a higher active index and a more favourable renal outcome than the EXT1-negative group. It would be better to recognise suspected LMN with EXT1 positivity as a potential autoimmune disease and maintain close follow-up due to its similarities with confirmed LMN.
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Affiliation(s)
- Tian Ye
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Mengya Jiang
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xueyan Zeng
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Dan Zong
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yuanyuan Du
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xiaohong Li
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Biao Huang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, Zhejiang, China
| | - Xuanli Tang
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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11
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Bharati J, Caza T, Jhaveri KD. New glomerular disease classification: can it be this simple? Nephrol Dial Transplant 2023; 39:1-3. [PMID: 37422436 DOI: 10.1093/ndt/gfad155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Indexed: 07/10/2023] Open
Affiliation(s)
- Joyita Bharati
- Glomerular Center at Northwell Health, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck, NY, USA
| | | | - Kenar D Jhaveri
- Glomerular Center at Northwell Health, Division of Kidney Diseases and Hypertension, Northwell Health, Great Neck, NY, USA
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12
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Sethi S, Beck LH, Glassock RJ, Haas M, De Vriese AS, Caza TN, Hoxha E, Lambeau G, Tomas NM, Madden B, Debiec H, D'Agati VD, Alexander MP, Amer H, Appel GB, Barbour SJ, Caravaca-Fontan F, Cattran DC, Casal Moura M, D'Avila DO, Eick RG, Garovic VD, Greene EL, Herrera Hernandez LP, Jennette JC, Lieske JC, Markowitz GS, Nath KA, Nasr SH, Nast CC, Pani A, Praga M, Remuzzi G, Rennke HG, Ruggenenti P, Roccatello D, Soler MJ, Specks U, Stahl RAK, Singh RD, Theis JD, Velosa JA, Wetzels JFM, Winearls CG, Yandian F, Zand L, Ronco P, Fervenza FC. Mayo Clinic consensus report on membranous nephropathy: proposal for a novel classification. Kidney Int 2023; 104:1092-1102. [PMID: 37795587 DOI: 10.1016/j.kint.2023.06.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 10/06/2023]
Abstract
Membranous nephropathy (MN) is a pattern of injury caused by autoantibodies binding to specific target antigens, with accumulation of immune complexes along the subepithelial region of glomerular basement membranes. The past 20 years have brought revolutionary advances in the understanding of MN, particularly via the discovery of novel target antigens and their respective autoantibodies. These discoveries have challenged the traditional classification of MN into primary and secondary forms. At least 14 target antigens have been identified, accounting for 80%-90% of cases of MN. Many of the forms of MN associated with these novel MN target antigens have distinctive clinical and pathologic phenotypes. The Mayo Clinic consensus report on MN proposes a 2-step classification of MN. The first step, when possible, is identification of the target antigen, based on a multistep algorithm and using a combination of serology, staining of the kidney biopsy tissue by immunofluorescence or immunohistochemistry, and/or mass spectrometry methodology. The second step is the search for a potential underlying disease or associated condition, which is particularly relevant when knowledge of the target antigen is available to direct it. The meeting acknowledges that the resources and equipment required to perform the proposed testing may not be generally available. However, the meeting consensus was that the time has come to adopt an antigen-based classification of MN because this approach will allow for accurate and specific MN diagnosis, with significant implications for patient management and targeted treatment.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Laurence H Beck
- Section of Nephrology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California, USA
| | - Mark Haas
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
| | | | - Elion Hoxha
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gérard Lambeau
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, Valbonne Sophia Antipolis, France
| | - Nicola M Tomas
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Madden
- Mayo Clinic Proteomics Core, Mayo Clinic, Rochester, Minnesota, USA
| | - Hanna Debiec
- Sorbonne Université, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Paris, France
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Gerald B Appel
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fernando Caravaca-Fontan
- Department of Medicine, Complutense University, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Daniel C Cattran
- Toronto General Research Institute, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Marta Casal Moura
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Domingos O D'Avila
- Serviço de Nefrologia, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Renato G Eick
- Serviço de Nefrologia, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Eddie L Greene
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | | | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Karl A Nath
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cynthia C Nast
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Antonello Pani
- Nephrology, Dialysis and Transplantation, Arnas Brotzu, Cagliari, Italy; Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Manuel Praga
- Department of Medicine, Complutense University, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Helmut G Rennke
- Department of Pathology, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; Unit of Nephrology, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy; Center of Immuno-Rheumatology and Rare Diseases (CMID), Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Maria Jose Soler
- Department of Nephrology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, Barcelona, Spain; Centro de Referencia en Enfermedad, Glomerular Compleja del Sistema Nacional de Salud de España (CSUR), Barcelona, Spain
| | - Ulrich Specks
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rolf A K Stahl
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raman Deep Singh
- Renal Pathophysiology Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jorge A Velosa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack F M Wetzels
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Federico Yandian
- Department of Nephrology, Hospital de Clinicas Universidad de la Republica, Montevideo, Uruguay
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Pierre Ronco
- Sorbonne Université, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Paris, France; Division of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.
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13
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Kouri AM, Caza TN, Beck LH, Misurac JM, Evans MD, Phillips CL, Eadon MT, Larsen CP, Andreoli SP, Bu L, Rheault MN, Khalid M. Clinical and Histopathologic Characteristics of Pediatric Patients With Primary Membranous Nephropathy. Kidney Int Rep 2023; 8:2368-2375. [PMID: 38025223 PMCID: PMC10658230 DOI: 10.1016/j.ekir.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/05/2023] [Accepted: 08/14/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Primary membranous nephropathy (PMN) is uncommon in children. Therefore, data on the clinical course of affected children are scarce. In recent years, several novel antigens have been implicated in the pathogenesis of PMN. However, the histopathologic characteristics of pediatric patients with PMN remain poorly represented in the literature. Methods We have retrospectively analyzed the clinical presentation and outcomes data of 21 children with PMN from 3 centers in the United States. In addition, we have identified novel antigens in biopsy specimens from these patients and correlated their presence or absence to clinical outcomes. Finally, we compared the results of the novel antigen staining from our clinical cohort to a validation cohort of 127 biopsy specimens from children with PMN at Arkana Laboratories. Results The data from the 2 cohorts demonstrated similar overall antigen positivity rates of 62% to 63%, with phospholipase A2 receptor (PLA2R) and exostosin 1 (EXT1) being the most commonly found antigens. Results from the clinical cohort showed that overall, the kidney prognosis for children with PMN was good, with 17 of 21 patients entering a complete or partial remission. Children who were positive for PLA2R or EXT1 were significantly more likely to enter remission than those in the antigen negative group. Conclusion Approximately 60% of pediatric membranous cases are positive for a novel antigen on kidney biopsy and the clinical prognosis is generally favorable. More studies are needed to understand the clinical implications of each specific novel antigen.
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Affiliation(s)
- Anne M. Kouri
- Division of Pediatric Nephrology, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | | | - Laurence H. Beck
- Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Jason M. Misurac
- Division of Pediatric Nephrology, Dialysis and Transplantation, University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa, USA
| | - Michael D. Evans
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - Carrie L. Phillips
- Department of Pathology and Laboratory Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Michael T. Eadon
- Division of Nephrology, Indiana University, Indianapolis, Indiana, USA
| | | | - Sharon P. Andreoli
- Riley Hospital for Children at IU Health, Division of Pediatric Nephrology and Hypertension, Indianapolis, Indiana, USA
| | - Lihong Bu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Michelle N. Rheault
- Division of Pediatric Nephrology, University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota, USA
| | - Myda Khalid
- Riley Hospital for Children at IU Health, Division of Pediatric Nephrology and Hypertension, Indianapolis, Indiana, USA
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14
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Sethi S, Beck LH, Glassock RJ, Haas M, De Vriese AS, Caza TN, Hoxha E, Lambeau G, Tomas NM, Madden B, Debiec H, D'Agati VD, Alexander MP, Amer H, Appel GB, Barbour SJ, Caravaca-Fontan F, Cattran DC, Casal Moura M, D'Avila DO, Eick RG, Garovic VD, Greene EL, Herrera Hernandez LP, Jennette JC, Lieske JC, Markowitz GS, Nath KA, Nasr SH, Nast CC, Pani A, Praga M, Remuzzi G, Rennke HG, Ruggenenti P, Roccatello D, Soler MJ, Specks U, Stahl RAK, Singh RD, Theis JD, Velosa JA, Wetzels JFM, Winearls CG, Yandian F, Zand L, Ronco P, Fervenza FC. Mayo Clinic Consensus Report on Membranous Nephropathy: Proposal for a Novel Classification. Mayo Clin Proc 2023; 98:1671-1684. [PMID: 37804268 DOI: 10.1016/j.mayocp.2023.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 10/09/2023]
Abstract
Membranous nephropathy (MN) is a pattern of injury caused by autoantibodies binding to specific target antigens, with accumulation of immune complexes along the subepithelial region of glomerular basement membranes. The past 20 years have brought revolutionary advances in the understanding of MN, particularly via the discovery of novel target antigens and their respective autoantibodies. These discoveries have challenged the traditional classification of MN into primary and secondary forms. At least 14 target antigens have been identified, accounting for 80%-90% of cases of MN. Many of the forms of MN associated with these novel MN target antigens have distinctive clinical and pathologic phenotypes. The Mayo Clinic consensus report on MN proposes a 2-step classification of MN. The first step, when possible, is identification of the target antigen, based on a multistep algorithm and using a combination of serology, staining of the kidney biopsy tissue by immunofluorescence or immunohistochemistry, and/or mass spectrometry methodology. The second step is the search for a potential underlying disease or associated condition, which is particularly relevant when knowledge of the target antigen is available to direct it. The meeting acknowledges that the resources and equipment required to perform the proposed testing may not be generally available. However, the meeting consensus was that the time has come to adopt an antigen-based classification of MN because this approach will allow for accurate and specific MN diagnosis, with significant implications for patient management and targeted treatment.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Laurence H Beck
- Section of Nephrology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Richard J Glassock
- Department of Medicine, Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California, USA
| | - Mark Haas
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
| | | | - Elion Hoxha
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gérard Lambeau
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, Valbonne Sophia Antipolis, France
| | - Nicola M Tomas
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Hamburg Center for Kidney Health (HCKH), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benjamin Madden
- Mayo Clinic Proteomics Core, Mayo Clinic, Rochester, Minnesota, USA
| | - Hanna Debiec
- Sorbonne Université, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Paris, France
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Gerald B Appel
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fernando Caravaca-Fontan
- Department of Medicine, Complutense University, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Daniel C Cattran
- Toronto General Research Institute, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - Marta Casal Moura
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Domingos O D'Avila
- Serviço de Nefrologia, Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Renato G Eick
- Serviço de Nefrologia, Hospital Moinhos de Vento, Porto Alegre, Rio Grande do Sul, Brazil
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Eddie L Greene
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | | | - J Charles Jennette
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Karl A Nath
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cynthia C Nast
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Antonello Pani
- Nephrology, Dialysis and Transplantation, Arnas Brotzu, Cagliari, Italy; Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Manuel Praga
- Department of Medicine, Complutense University, Instituto de Investigación Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Helmut G Rennke
- Department of Pathology, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy; Unit of Nephrology, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit, San Giovanni Bosco Hub Hospital, ASL Città di Torino, Turin, Italy; Center of Immuno-Rheumatology and Rare Diseases (CMID), Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Maria Jose Soler
- Department of Nephrology, Vall d'Hebron University Hospital, Vall d'Hebron Institute of Research, Barcelona, Spain; Centro de Referencia en Enfermedad, Glomerular Compleja del Sistema Nacional de Salud de España (CSUR), Barcelona, Spain
| | - Ulrich Specks
- Division of Pulmonary and Critical Care, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Rolf A K Stahl
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Raman Deep Singh
- Renal Pathophysiology Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jorge A Velosa
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Jack F M Wetzels
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | - Federico Yandian
- Department of Nephrology, Hospital de Clinicas Universidad de la Republica, Montevideo, Uruguay
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Pierre Ronco
- Sorbonne Université, Paris, France; Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S 1155, Paris, France; Division of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.
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15
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Kawagoe M, Odajima K, Asakawa S, Nagura M, Arai S, Yamazaki O, Tamura Y, Ohashi R, Iwakura T, Yasuda H, Shibata S, Fujigaki Y. A Diagnostic and Therapeutic Dilemma Concerning Exostosin 1/Exostosin 2-associated Lupus-like Membranous Nephropathy with Positive Antinuclear Antibody in an Elderly Man with Various Immune Abnormalities. Intern Med 2023; 62:3187-3194. [PMID: 36948625 PMCID: PMC10686739 DOI: 10.2169/internalmedicine.1251-22] [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: 11/08/2022] [Accepted: 02/12/2023] [Indexed: 03/24/2023] Open
Abstract
Exostosin 1 (EXT1) and exostosin 2 (EXT2)-associated membranous nephropathy (MN) may be associated with active autoimmune disease. We encountered an elderly man who presented with EXT1/EXT2-associated lupus-like MN with full house immune deposits, monoclonal gammopathy of uncertain significance and Sjögren's syndrome. The patient exhibited various other immune abnormalities. Although he did not fulfill the criteria of clinical systemic lupus erythematosus (SLE), he met a stand-alone renal criterion of the Systemic Lupus International Collaborating Clinics (SLICC) 2012. Whether or not a stand-alone renal criterion with EXT1/EXT2 positivity, as in the present patient, can efficiently guide decisions regarding the diagnosis and treatment of SLE remains a clinical dilemma.
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Affiliation(s)
- Mika Kawagoe
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Kohei Odajima
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shinichiro Asakawa
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Michito Nagura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shigeyuki Arai
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Osamu Yamazaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Ryuji Ohashi
- Department of Integrated Diagnostic Pathology, Nippon Medical School, Japan
| | - Takamasa Iwakura
- Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Hideo Yasuda
- Department of Internal Medicine, Hamamatsu University School of Medicine, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
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16
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Avasare R, Drexler Y, Caster DJ, Mitrofanova A, Jefferson JA. Management of Lupus Nephritis: New Treatments and Updated Guidelines. KIDNEY360 2023; 4:1503-1511. [PMID: 37528520 PMCID: PMC10617804 DOI: 10.34067/kid.0000000000000230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/25/2023] [Indexed: 08/03/2023]
Abstract
Management of lupus nephritis has evolved considerably over the past years. Here, we provide a comprehensive review of clinical trials that form the basis for the Kidney Disease: Improving Global Outcomes and EULAR/ERA-EDTA updated guidelines and present day trials that will change the landscape of lupus nephritis therapy in years to come. In addition, we highlight the issues related to cost of therapy, resistant disease, and downstream adverse effects of specific therapies.
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Affiliation(s)
- Rupali Avasare
- Nephrology and Hypertension, Oregon Health & Science University School of Medicine, Portland, Oregon
| | - Yelena Drexler
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Dawn J. Caster
- Division of Nephrology and Hypertension, University of Louisville School of Medicine, Louisville, Kentucky
| | - Alla Mitrofanova
- Katz Family Division of Nephrology and Hypertension, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
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17
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Sivagnanam H, Anand M, Senthikumar PK, Velu KB, Vishwanathan R. A Case of Pla2r and Exostosin 1 Positive Membranous Nephropathy - The Diagnostic and Therapeutic Dilemma. Cureus 2023; 15:e43619. [PMID: 37719621 PMCID: PMC10504682 DOI: 10.7759/cureus.43619] [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] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
Membranous nephropathy is an immune disease that commonly presents as nephrotic syndrome. The understanding of the pathogenesis of membranous nephropathy has rapidly evolved over the past few years due to the discovery of newer antigens. Exostosin 1 and exostosin 2 are antigens discovered in 2019 and found to be specific for membranous nephropathy secondary to autoimmune disease and are usually not seen in M-type phospholipase A2-associated membranous nephropathy. However, fewer clinical and pathological details of exostosin 1 and 2 related nephropathies are known, owing to the novelty of the antigen. Here we report a 24-year-old female who presented with nephrotic range proteinuria. Initial blood investigations revealed a doubtful autoimmune disease background. A subsequent renal biopsy revealed membranous nephropathy with both PLA2r and exostosin 1 positivity, which posed challenges in both diagnosis and treatment. Immunoglobulin G staining and electron microscopy were performed to differentiate if it was a PLA2r-associated or a exostosin 1/ exostosin 2-related membranous nephropathy. Electron microscopy revealed subepithelial deposits and immunoglobulin G stained for immunoglobulin G4, signifying possible PLA2r-associated membranous nephropathy with exostosin deposits. The patient was treated with rituximab and had a good treatment response. Only one similar case has been reported with both PLA2R and exostosin positivity. The pathophysiologic mechanism of this unique association is still unclear.
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Affiliation(s)
| | - Murugesh Anand
- Nephrology, Tirunelveli Medical College, Tirunelveli, IND
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18
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Yamazaki T, Takahashi H, Takeuchi K, Sakamoto E, Tominaga K, Sakurabayashi S, Abe T, Sano T, Wada Y, Kuwahara N, Shimizu A, Takeuchi Y. Rare case of exostosin 1/exostosin 2-related membranous lupus nephritis concomitant with dual ANCA- and anti-GBM antibody-associated crescentic glomerulonephritis effectively diagnosed by mass spectrometry: a case report. BMC Nephrol 2023; 24:218. [PMID: 37488532 PMCID: PMC10364369 DOI: 10.1186/s12882-023-03268-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 07/13/2023] [Indexed: 07/26/2023] Open
Abstract
BACKGROUND Recent developments in mass spectrometry (MS) have revealed target antigens for membranous nephropathy (MN), including phospholipase A2 receptor and exostosin 1/exostosin 2 (EXT1/2). EXT1/2 are known antigens of autoimmune disease-related MN, especially membranous lupus nephritis. We describe the case of an elderly man who developed nephrotic syndrome followed by progressive renal dysfunction. CASE PRESENTATION A 78-year-old man presented with rapidly progressive renal dysfunction with proteinuria and hematuria. Three years previously, he had developed leg edema but did not receive any treatment. Laboratory tests showed elevated anti-nuclear antibody (Ab), anti-dsDNA Ab titer, and hypocomplementemia, indicating systemic lupus erythematous. Myeloperoxidase anti-neutrophil cytoplasmic Ab (ANCA) and anti-glomerular basement membrane (GBM) Ab were also detected. The renal pathologic findings were compatible with crescentic glomerulonephritis (GN), whereas non-crescentic glomeruli exhibited MN without remarkable endocapillary or mesangial proliferative change. Immunofluorescence microscopy revealed glomerular IgG, C3, and C1q deposition. All IgG subclasses were positive in glomeruli. Anti-PLA2R Ab in serum was negative. MS analysis was performed to detect the antigens of MN, and EXT1/2 was detected in glomeruli. Therefore, we reached a diagnosis of membranous lupus nephritis concurrent with both ANCA-associated vasculitis and anti-GBM-GN. The simultaneous occurrence of these three diseases is extremely rare. CONCLUSIONS This is the first report of EXT1/2-related membranous lupus nephritis concurrent with ANCA-associated vasculitis and anti-GBM-GN. This case demonstrates the usefulness of MS in diagnosing complicated cases of MN.
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Affiliation(s)
- Takuya Yamazaki
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | - Haruka Takahashi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
- Omigawahimawari Clinic, Chiba, Japan
| | - Kazuhiro Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan.
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan.
| | - Emi Sakamoto
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Kenta Tominaga
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Syun Sakurabayashi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | - Tetsuya Abe
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | | | - Yukihiro Wada
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
| | - Naomi Kuwahara
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Yasuo Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-Ku, SagamiharaKanagawa, 252-0374, Japan
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19
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Miyata KN, Nast CC. Implications of Incomplete Immunostaining in Membranous Lupus Nephritis. KIDNEY360 2023; 4:868-869. [PMID: 37499070 PMCID: PMC10374139 DOI: 10.34067/kid.0000000000000191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 06/02/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Kana N. Miyata
- Division of Nephrology, Department of Internal Medicine, Saint Louis University, Saint Louis, Missouri
| | - Cynthia C. Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
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20
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Windpessl M, Odler B, Bajema IM, Geetha D, Säemann M, Lee JM, Vaglio A, Kronbichler A. Glomerular Diseases Across Lifespan: Key Differences in Diagnostic and Therapeutic Approaches. Semin Nephrol 2023; 43:151435. [PMID: 37945450 DOI: 10.1016/j.semnephrol.2023.151435] [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] [Indexed: 11/12/2023]
Abstract
Glomerular diseases are common causes of chronic kidney disease in childhood, adolescence, and adulthood. The epidemiology of glomerular diseases differs between different age groups, with minimal change disease being the leading cause of nephrotic syndrome in childhood, while membranous nephropathy and focal segmental glomerulosclerosis are more common in adulthood. IgA vasculitis is also more common in childhood. Moreover, there is a difference in disease severity with more children presenting with a relapsing form of nephrotic syndrome and a more acute presentation of antineutrophil cytoplasmic antibody-associated vasculitis and concomitant glomerulonephritis, as highlighted by the higher percentage of cellular crescents on kidney biopsy specimens in comparison with older patients. There is also a female preponderance in antineutrophil cytoplasmic antibody-associated vasculitis and more children present with tracheobroncholaryngeal disease. This article aims to summarize differences in the presentation of different glomerular diseases that are encountered commonly by pediatric and adult nephrologists and potential differences in the management.
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Affiliation(s)
- Martin Windpessl
- Section of Nephrology, Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria; Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Balazs Odler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ingeborg M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands; Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria; Sigmund Freud University, Medical School, Vienna, Austria
| | - Jiwon M Lee
- Division of Rare Disease Management, Korea Disease Control and Prevention Agency, Cheongju-si, Republic of Korea
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Firenze, Nephrology Unit, Meyer Children's Hospital, Firenze, Italy
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria.
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21
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Miller P, Caza T. The expanding spectrum and utility of antigens in membranous nephropathy. Curr Opin Nephrol Hypertens 2023; 32:232-240. [PMID: 36811646 DOI: 10.1097/mnh.0000000000000876] [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] [Indexed: 02/24/2023]
Abstract
PURPOSE OF REVIEW Multiple antigenic targets were discovered in membranous nephropathy, representing distinct autoimmune diseases with a similar morphologic pattern of injury. An overview of recent developments, including antigen types, clinical associations, serologic monitoring, and advancements in understanding disease pathogenesis are provided. RECENT FINDINGS Several new antigenic targets have defined subtypes of membranous nephropathy, including Neural epidermal growth factor-like 1, protocadherin 7, HTRA1, FAT1, SEMA3B, NTNG1, NCAM1, exostosin 1/2, transforming growth factor beta receptor 3, CNTN1, proprotein convertase subtilisin/kexin type 6, and neuron-derived neurotrophic factor. Autoantigens in membranous nephropathy may demonstrate unique clinical associations, assisting the nephrologist to identify potential disease etiologies and triggers, such as autoimmune disease, cancer, medications, and infections. SUMMARY We are entering an exciting era for which an antigen-based approach will further define subtypes of membranous nephropathy, allow for development of noninvasive diagnostics, and improve care for patients.
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Affiliation(s)
- Paul Miller
- Arkana Laboratories, Little Rock, Arkansas, USA
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22
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Dantas M, Silva LBB, Pontes BTM, dos Reis MA, de Lima PSN, Moysés M. Membranous nephropathy. J Bras Nefrol 2023; 45:229-243. [PMID: 37527529 PMCID: PMC10627124 DOI: 10.1590/2175-8239-jbn-2023-0046en] [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: 04/03/2023] [Accepted: 05/31/2023] [Indexed: 08/03/2023] Open
Abstract
Membranous nephropathy is a glomerulopathy, which main affected target is the podocyte, and has consequences on the glomerular basement membrane. It is more common in adults, especially over 50 years of age. The clinical presentation is nephrotic syndrome, but many cases can evolve with asymptomatic non-nephrotic proteinuria. The mechanism consists of the deposition of immune complexes in the subepithelial space of the glomerular capillary loop with subsequent activation of the complement system. Great advances in the identification of potential target antigens have occurred in the last twenty years, and the main one is the protein "M-type phospholipase-A2 receptor" (PLA2R) with the circulating anti-PLA2R antibody, which makes it possible to evaluate the activity and prognosis of this nephropathy. This route of injury corresponds to approximately 70% to 80% of cases of membranous nephropathy characterized as primary. In the last 10 years, several other potential target antigens have been identified. This review proposes to present clinical, etiopathogenic and therapeutic aspects of membranous nephropathy in a didactic manner, including cases that occur during kidney transplantation.
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Affiliation(s)
- Márcio Dantas
- Universidade de São Paulo, Faculdade de Medicina, Hospital das
Clínicas, Ribeirão Preto, SP, Brazil
| | | | | | - Marlene Antônia dos Reis
- Universidade Federal do Triângulo Mineiro, Patologia Geral, Centro
de Pesquisa em Rim, Uberaba, MG, Brazil
| | | | - Miguel Moysés
- Universidade de São Paulo, Faculdade de Medicina, Hospital das
Clínicas, Ribeirão Preto, SP, Brazil
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23
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Caza TN, Storey AJ, Hassen SI, Herzog C, Edmondson RD, Arthur JM, Kenan DJ, Larsen CP. Discovery of seven novel putative antigens in membranous nephropathy and membranous lupus nephritis identified by mass spectrometry. Kidney Int 2023; 103:593-606. [PMID: 36638888 PMCID: PMC9974866 DOI: 10.1016/j.kint.2023.01.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 12/28/2022] [Accepted: 01/04/2023] [Indexed: 01/12/2023]
Abstract
Multiple autoantigens have been identified in membranous nephropathy (MN) by tissue-based proteomics. However, antigenic targets of disease are unknown for over 10% of patients with MN and over half of those with membranous lupus nephritis (MLN). Here, we identified multiple new targets in PLA2R-/THSD7A-/EXT-/NELL1-quadruple negative MN biopsies through mass spectrometry of immune complexes recovered from biopsy tissue of patients with MN. Patients with MN negative for these four antigens were identified from Arkana Laboratories case archives. Protein G immunoprecipitation recovered immune complexes from frozen biopsy tissue from 142 quadruple-negative cases and 278 cases of known antigen type, followed by interrogation by mass spectrometry. Potential putative antigens were confirmed through paraffin immunofluorescence and co-localization with IgG within immune deposits. Consecutive series of 165 cases of PLA2R-negative MN and 142 MLN biopsies were screened to determine the frequency for each potential antigen. Seven putative antigens were discovered within immune complexes from biopsies of patients with MN including FCN3, CD206, EEA1, SEZ6L2, NPR3, MST1, and VASN. Peptides from these proteins were not enriched in the 278 cases of known antigen type. Between three to 30 unique peptides were detected for each new target. Frequencies of each biomarker, determined by staining consecutive case series, ranged from under 1 to 4.9%. NPR3 and CD206 were only positive in index cases. All cases showed co-localization of IgG within the immune deposits. Thus, seven putative antigens were newly identified in MN and MLN. Due to the number of antigens identified, it is becoming impractical to type PLA2R-negative MN or MLN cases through immunostaining alone. A multiplex approach is needed for subtyping of these diseases.
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Affiliation(s)
| | - Aaron J Storey
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | | | - Christian Herzog
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Rick D Edmondson
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - John M Arthur
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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24
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Miller PP, Caza T, Larsen CP, Charu V. EXT1 and NCAM1-associated membranous lupus nephritis in a cohort of patients undergoing repeat kidney biopsies. Nephrol Dial Transplant 2023; 38:396-404. [PMID: 35278072 PMCID: PMC10111150 DOI: 10.1093/ndt/gfac058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Exostosin 1/2 (EXT1/2) and neural cell adhesion molecule 1 (NCAM1) associated membranous lupus nephritis (MLN) may represent distinct disease phenotypes with prognostic significance. METHODS We searched our archives for patients with systemic lupus erythematous (SLE) and at least two kidney biopsies demonstrating MLN. Each biopsy was stained for EXT1 and NCAM1 and scored as positive or negative. Histopathologic and clinical data were reviewed. RESULTS We identified 31 patients with a clinical diagnosis of SLE and at least two kidney biopsies with MLN. A total of 28 patients (90%) showed concordant staining for EXT1 and NCAM1 in both biopsies; 8 patients (26%) were EXT1 positive and NCAM1 negative, 18 patients (58%) were EXT1 negative and NCAM1 negative and 2 patients (7%) were EXT1 negative and NCAM1 positive. A total of three patients (10%) had discordant EXT1 staining between their first and last biopsies; two patients (7%) were EXT1 positive in their first biopsy and EXT1 negative in the last biopsy and one patient (3%) was EXT1 negative in his first biopsy and EXT1 positive in the last biopsy. Compared with the EXT1-negative cohort at the time of the first biopsy, the EXT1-positive cohort had a higher average estimated glomerular filtration rate (eGFR; 141 versus 108 mL/min/1.73 m2; P = 0.04), lower average percent global glomerulosclerosis (0.5 versus 12%; P = 0.05), lower average interstitial fibrosis and tubular atrophy (2.5 versus 11.7%; P = 0.06) and lower average total National Institutes of Health (NH) chronicity scores (0.75 versus 2.33; P = 0.05). On long-term follow-up, the rate of change in eGFR did not significantly differ between the two groups (P = 0.24). One EXT1-positive patient (12.5%) developed stage 4 chronic kidney disease (CKD) or end-stage kidney disease (ESKD) compared with four patients (20%) in the EXT-negative group and two of the three EXT1-discordant patients (P = 0.38). CONCLUSIONS We performed the largest retrospective repeat-biopsy study to evaluate EXT1 and NCAM1 autoantigens in MLN. Our data demonstrate that EXT1 positivity is associated with better kidney function at the time of diagnosis and raises the possibility that EXT1 status may change throughout the disease course of MLN.
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Affiliation(s)
- Paul P Miller
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | | | | | - Vivek Charu
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
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25
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Burbelo PD, Olson SW, Keller JM, Joshi M, Schwartz DM, Chuang YJ, Lambeau G, Beck LH, Waldman M. Prediagnostic Appearance of Thrombospondin Type-1 Domain 7A Autoantibodies in Membranous Nephropathy. KIDNEY360 2023; 4:217-225. [PMID: 36821613 PMCID: PMC10103354 DOI: 10.34067/kid.0005112022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 11/14/2022] [Indexed: 06/18/2023]
Abstract
Key Points
The entire extracellular domain of thrombospondin type-1 domain 7A (THSD7A) in the luciferase immunoprecipitation system immunoassay was required to detect autoantibodies with high sensitivity in membranous nephropathy (MN).In THSD7A-seropositive MN patients, changes in antibody levels precede changes in clinical status.Seropositive THSD7A antibodies were detected in some patients with MN considered to be secondary to autoimmunity or cancer.
Background
Pathogenic autoantibodies against thrombospondin type-1 domain 7A (THSD7A) are present in approximately 3% of patients with membranous nephropathy (MN). Compared with PLA2R antibodies, less is known about THSD7A autoantibodies (ABs) because of the relative rarity and the lack of a commercially available quantitative immunoassay.
Methods
In this study, we describe the development and validation of a highly quantitative luciferase immunoprecipitation system (LIPS) assay for detecting THSD7A ABs and used it to study dominant THSD7A epitopes, disease associations, and monitoring disease activity. The Department of Defense Serum Repository (DODSR) was then used to analyze THSD7A AB in 371 longitudinal serum samples collected before clinical diagnosis of MN from 110 PLA2R-negative MN subjects.
Results
LIPS analysis demonstrated that a near full-length THSD7A (amino acids 1–1656) detected robust autoantibody levels in all known seropositive MN patients with 100% sensitivity and specificity compared with ELISA and/or Western blotting. Most of the THSD7A-seropositive subjects in our pilot cohort had evidence of coexisting autoimmunity or cancer. Moreover, three THSD7A-seropositive patients undergoing immunosuppressive therapy showed longitudinal autoantibody levels that tracked clinical status. Additional epitope analysis of two smaller protein THSD7A fragments spanning amino acids 1-416 and 1-671 demonstrated lower sensitivity of 32% and 44%, respectively. In the DODSR cohort, THSD7A seropositivity was detected in 4.5% of PLA2R-negative MN patients. In one primary and in one secondary MN-associated with cancer, THSD7A ABs were detectable <1 month before biopsy-proven diagnosis. In addition, three patients with lupus membranous nephropathy had detectable THSD7A ABs years before hypoalbuminemia and biopsy-proven diagnosis.
Conclusions
Although further studies are needed to explore the significance of THSD7A ABs in lupus membranous nephropathy, this study describes a novel, highly sensitive LIPS immunoassay for detecting THSD7A ABs and adds to the existing literature on THSD7A-associated MN.
Clinical Trial registry name and registration number:
NCT00977977; registration date: September 16, 2009.
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Affiliation(s)
- Peter D Burbelo
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Stephen W Olson
- Nephrology Department, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Jason M Keller
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, Maryland
| | - Megha Joshi
- Nephrology Department, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Daniella M Schwartz
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Yung-Jen Chuang
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan, Republic of China
| | - Gérard Lambeau
- Université Côte d'Azur, Centre National de la Recherche Scientifique, Institut de Pharmacologie Moléculaire et Cellulaire, Valbonne Sophia Antipolis, France
| | - Laurence H Beck
- Department of Medicine, Section of Nephrology, Boston University School of Medicine, Boston, Massachusetts
| | - Meryl Waldman
- Kidney Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
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26
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Kronbichler A, Bajema I, Geetha D, Säemann M. Novel aspects in the pathophysiology and diagnosis of glomerular diseases. Ann Rheum Dis 2022; 82:585-593. [PMID: 36535746 DOI: 10.1136/ard-2022-222495] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/09/2022] [Indexed: 12/24/2022]
Abstract
Immune deposits/complexes are detected in a multitude of tissues in autoimmune disorders, but no organ has attracted as much attention as the kidney. Several kidney diseases are characterised by the presence of specific configurations of such deposits, and many of them are under a 'shared care' between rheumatologists and nephrologists. This review focuses on five different diseases commonly encountered in rheumatological and nephrological practice, namely IgA vasculitis, lupus nephritis, cryoglobulinaemia, anti-glomerular basement membrane disease and anti-neutrophil cytoplasm-antibody glomerulonephritis. They differ in disease aetiopathogenesis, but also the potential speed of kidney function decline, the responsiveness to immunosuppression/immunomodulation and the deposition of immune deposits/complexes. To date, it remains unclear if deposits are causing a specific disease or aim to abrogate inflammatory cascades responsible for tissue damage, such as neutrophil extracellular traps or the complement system. In principle, immunosuppressive therapies have not been developed to tackle immune deposits/complexes, and repeated kidney biopsy studies found persistence of deposits despite reduction of active inflammation, again highlighting the uncertainty about their involvement in tissue damage. In these studies, a progression of active lesions to chronic changes such as glomerulosclerosis was frequently reported. Novel therapeutic approaches aim to mitigate these changes more efficiently and rapidly. Several new agents, such as avacopan, an oral C5aR1 inhibitor, or imlifidase, that dissolves IgG within minutes, are more specifically reducing inflammatory cascades in the kidney and repeat tissue sampling might help to understand their impact on immune cell deposition and finally kidney function recovery and potential impact of immune complexes/deposits.
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Affiliation(s)
- Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK .,Vasculitis and Lupus Service, Addenbrooke's Hospital, Cambridge, UK
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden and Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
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27
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Miller P, Lei L, Charu V, Higgins J, Troxell M, Kambham N. Clinicopathologic features of non-lupus membranous nephropathy in a pediatric population. Pediatr Nephrol 2022; 37:3127-3137. [PMID: 35333973 DOI: 10.1007/s00467-022-05503-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Membranous nephropathy is an uncommon cause of nephrotic syndrome in pediatrics. METHODS We reviewed our kidney biopsy records for patients ≤ 20 years of age with membranous nephropathy without evidence of systemic lupus erythematosus within 6 months of biopsy (January 1995-September 2020). Staining for PLA2R, NELL1, THSD7A, SEMA3B, EXT2 (3 biopsies), and IgG-subclass were performed. RESULTS Sixteen children (≤ 12 years) and 25 adolescents (13-20 years) were identified. Four children and 15 adolescents showed autoantigen positivity: PLA2R+/SEMA3B- (13), SEMA3B+/PLA2R+ (2), SEMA3B+/PLA2R- (1), NELL1 (1), EXT2+ (2), and THSD7A (0). Co-morbidities associated with PLA2R positivity included IPEX syndrome, active hepatitis B, Von Hippel Lindau syndrome, solitary kidney, type 1 diabetes, hyperuricemia, pregnancy (1), obesity (3), type II diabetes, H. pylori, viral prodrome, and nephrolithiasis. The SEMA3B+/PLA2R- adolescent was pregnant, the NELL1+ adolescent was obese, and the two EXT2+ adolescents eventually met the clinical criteria for lupus (4, 9 years post-biopsy). Co-morbidities among the remaining 24 patients included remote hepatitis B (2), Down's syndrome, lysinuric protein intolerance, recurrent UTIs, hypothyroidism, pregnancy (3), and obesity (2). Follow-up data was available for 12 children and 16 adolescents. Of the 12 children, 6 achieved complete remission, 4 achieved partial remission, and 2 had no response to treatment (1 transplant). Of the 16 adolescents, 4 achieved complete remission, 4 achieved partial remission, and 8 had no response to treatment (3 transplants). A child with "full-house" immunofluorescence staining achieved spontaneous disease remission. CONCLUSION Our non-lupus membranous nephropathy cohort represents one of the largest pediatric studies to date. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Paul Miller
- Department of Pathology, Stanford University, H2110, 300 Pasteur Drive, Stanford, CA, 94305, USA.
| | - Li Lei
- Department of Pathology, Stanford University, H2110, 300 Pasteur Drive, Stanford, CA, 94305, USA.,UC Davis, Sacramento, CA, USA
| | - Vivek Charu
- Department of Pathology, Stanford University, H2110, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - John Higgins
- Department of Pathology, Stanford University, H2110, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Megan Troxell
- Department of Pathology, Stanford University, H2110, 300 Pasteur Drive, Stanford, CA, 94305, USA
| | - Neeraja Kambham
- Department of Pathology, Stanford University, H2110, 300 Pasteur Drive, Stanford, CA, 94305, USA
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Chung EYM, Wang YM, Keung K, Hu M, McCarthy H, Wong G, Kairaitis L, Bose B, Harris DCH, Alexander SI. Membranous nephropathy: Clearer pathology and mechanisms identify potential strategies for treatment. Front Immunol 2022; 13:1036249. [PMID: 36405681 PMCID: PMC9667740 DOI: 10.3389/fimmu.2022.1036249] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022] Open
Abstract
Primary membranous nephropathy (PMN) is one of the common causes of adult-onset nephrotic syndrome and is characterized by autoantibodies against podocyte antigens causing in situ immune complex deposition. Much of our understanding of the disease mechanisms underpinning this kidney-limited autoimmune disease originally came from studies of Heymann nephritis, a rat model of PMN, where autoantibodies against megalin produced a similar disease phenotype though megalin is not implicated in human disease. In PMN, the major target antigen was identified to be M-type phospholipase A2 receptor 1 (PLA2R) in 2009. Further utilization of mass spectrometry on immunoprecipitated glomerular extracts and laser micro dissected glomeruli has allowed the rapid discovery of other antigens (thrombospondin type-1 domain-containing protein 7A, neural epidermal growth factor-like 1 protein, semaphorin 3B, protocadherin 7, high temperature requirement A serine peptidase 1, netrin G1) targeted by autoantibodies in PMN. Despite these major advances in our understanding of the pathophysiology of PMN, treatments remain non-specific, often ineffective, or toxic. In this review, we summarize our current understanding of the immune mechanisms driving PMN from animal models and clinical studies, and the implications on the development of future targeted therapeutic strategies.
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Affiliation(s)
- Edmund Y. M. Chung
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- *Correspondence: Edmund Y. M. Chung,
| | - Yuan M. Wang
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
| | - Karen Keung
- Department of Nephrology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Min Hu
- The Centre for Transplant and Renal Research, Westmead Institute of Medical Research, Westmead, NSW, Australia
| | - Hugh McCarthy
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, Sydney Children’s Hospital, Randwick, NSW, Australia
| | - Germaine Wong
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, Westmead Hospital, Westmead, NSW, Australia
| | - Lukas Kairaitis
- Department of Nephrology, Blacktown Hospital, Blacktown, NSW, Australia
| | - Bhadran Bose
- Department of Nephrology, Nepean Hospital, Kingswood, NSW, Australia
| | - David C. H. Harris
- The Centre for Transplant and Renal Research, Westmead Institute of Medical Research, Westmead, NSW, Australia
- Department of Nephrology, Westmead Hospital, Westmead, NSW, Australia
| | - Stephen I. Alexander
- Centre for Kidney Research, The Children’s Hospital at Westmead, Westmead, NSW, Australia
- Department of Nephrology, The Children’s Hospital at Westmead, Westmead, NSW, Australia
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Miao H, Zhang Y, Yu X, Zou L, Zhao Y. Membranous nephropathy: Systems biology-based novel mechanism and traditional Chinese medicine therapy. Front Pharmacol 2022; 13:969930. [PMID: 36176440 PMCID: PMC9513429 DOI: 10.3389/fphar.2022.969930] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 08/10/2022] [Indexed: 12/05/2022] Open
Abstract
Membranous nephropathy (MN) is a renal-limited non-inflammatory autoimmune disease in the glomerulus, which is the second or third main cause of end-stage kidney diseases in patients with primary glomerulonephritis. Substantial achievements have increased our understanding of the aetiology and pathogenesis of murine and human MN. The identification of nephritogenic autoantibodies against neutral endopeptidase, phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing 7A (THSD7A) antigens provide more specific concept-driven intervention strategies for treatments by specific B cell-targeting monoclonal antibodies to inhibit antibody production and antibody-antigen immune complex deposition. Furthermore, additional antibody specificities for antigens have been discovered, but their pathogenic effects are uncertain. Although anti-PLA2R and anti-THSD7A antibodies as a diagnostic marker is widely used in MN patients, many questions including autoimmune response development, antigenic epitopes, and podocyte damage signalling pathways remain unresolved. This review describes the current available evidence regarding both established and novel molecular mechanisms based on systems biology approaches (gut microbiota, long non-coding RNAs, metabolite biomarkers and DNA methylation) in MN, with an emphasis on clinical findings. This review further summarizes the applications of traditional Chinese medicines such as Tripterygium wilfordii and Astragalus membranaceus for MN treatment. Lastly, this review considers how the identification of novel antibodies/antigens and unresolved questions and future challenges reveal the pathogenesis of MN.
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Affiliation(s)
- Hua Miao
- School of Pharmacy, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Yamei Zhang
- Key Laboratory of Clinical Genetics & Key Disciplines of Clinical Pharmacy, Affiliated Hospital and Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Xiaoyong Yu
- Department of Nephrology, Shaanxi Traditional Chinese Medicine Hospital, Xi’an, Shaanxi, China
- *Correspondence: Xiaoyong Yu, ; Liang Zou, ; Yingyong Zhao,
| | - Liang Zou
- School of Food and Bioengineering, Chengdu University, Chengdu, Sichuan, China
- *Correspondence: Xiaoyong Yu, ; Liang Zou, ; Yingyong Zhao,
| | - Yingyong Zhao
- School of Pharmacy, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- Key Laboratory of Clinical Genetics & Key Disciplines of Clinical Pharmacy, Affiliated Hospital and Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
- *Correspondence: Xiaoyong Yu, ; Liang Zou, ; Yingyong Zhao,
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Salvadori M, Tsalouchos A. Update on New Antigens in the Pathogenesis of Membranous Nephropathy. EUROPEAN MEDICAL JOURNAL 2022. [DOI: 10.33590/emj/22-00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Previously, membranous nephropathies were divided into primary and secondary categories when the exact mechanism or pathogenetic factor were unknown.
Approximately 70% accounted for primary membranous nephropathies. The
remaining 30% were called secondary because they developed due to well-known
diseases such as autoimmune diseases, tumours, infections, or drug assumptions.
The discoveries of the M-type phospholipase A2 receptor and of thrombospondin
type 1 domain containing 7A as causative antigens in a part of the so-called primary
membranous nephropathies opened new knowledge on the effective causes of
a large part of these diseases. The availability of novel techniques such as laser
micro-dissection and tandem mass spectrometry, as well as immunochemistry with
antibodies directed against novel proteins, allowed the confirmation of new antigens
involved. The use of confocal microscopy and Western blot allowed detection of the
new antigen on glomerular membrane, and the same antigen and relative antibodies
have been detected in serum samples.
Through these techniques, four new antigens were first detected, including neural
epidermal growth factor 1 and semaphorin 3B in the so-called primary membranous
nephropathy, and exostosin 1 and 2 and neural cell adhesion molecule 1 in lupus
membranous nephropathy.
The aim of this study is to describe the characteristics of the new antigens
discovered and their association with other diseases. In addition, new antigens
are on the horizon, and the story of primary membranous nephropathy is still to be
completely written and understood.
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Affiliation(s)
| | - Aris Tsalouchos
- Division of Nephrology, Santa Maria Annunziata Hospital, Florence, Italy
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Seitz-Polski B, Audard V, Ghiggeri GM, Tomas NM. Editorial: Immune dysfunction in nephrotic syndrome - recent advances and new roads ahead. Front Immunol 2022; 13:985925. [PMID: 35983048 PMCID: PMC9379314 DOI: 10.3389/fimmu.2022.985925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 07/13/2022] [Indexed: 11/17/2022] Open
Affiliation(s)
- Barbara Seitz-Polski
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, CHU de Nice, Université Côte d’Azur, Nice, France
- Unité de Recherche Clinique de la Côte d’Azur (UR2CA), Université Côte d’Azur, Nice, France
- Laboratoire d’Immunologie, CHU de Nice, Université Côte d’Azur, Nice, France
- Service de Néphrologie-Dialyse-Transplantation, CHU de Nice, Université Côte d’Azur, Nice, France
- *Correspondence: Barbara Seitz-Polski, ; Vincent Audard, ;Gian Marco Ghiggeri, ; Nicola M. Tomas,
| | - Vincent Audard
- Assistance Publique des Hôpitaux de Paris, Hôpitaux Universitaires Henri-Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare “Syndrome Néphrotique Idiopathique”, Fédération Hospitalo-Universitaire, Innovative Therapy for Immune Disorders, Créteil, France
- Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
- *Correspondence: Barbara Seitz-Polski, ; Vincent Audard, ;Gian Marco Ghiggeri, ; Nicola M. Tomas,
| | - Gian Marco Ghiggeri
- Laboratory on Molecular Medicine, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- Division of Nephrology, Dialysis, Transplantation, Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS) Istituto Giannina Gaslini, Genoa, Italy
- *Correspondence: Barbara Seitz-Polski, ; Vincent Audard, ;Gian Marco Ghiggeri, ; Nicola M. Tomas,
| | - Nicola M. Tomas
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Barbara Seitz-Polski, ; Vincent Audard, ;Gian Marco Ghiggeri, ; Nicola M. Tomas,
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Li H, Lan P, Yu X, Liu X, Sun J, Xie L, Lu W, Xie X. Analysis of the Expression of Exostosins and Clinicopathological Features in Membranous Lupus Nephritis in a Chinese Cohort. Kidney Int Rep 2022; 7:2295-2298. [PMID: 36217518 PMCID: PMC9546740 DOI: 10.1016/j.ekir.2022.07.164] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Huixian Li
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ping Lan
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xiaoyang Yu
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xiaoling Liu
- MOE Key Laboratory of Cell Activities and Stress Adaptations, School of Life Sciences, Lanzhou University, Lanzhou, China
| | - Jiping Sun
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Liyi Xie
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Wanhong Lu
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Correspondence: Wanhong Lu, Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277, West Yanta Road, Yanta District, Xi’an, Shaanxi 710061, China.
| | - Xinfang Xie
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
- Xinfang Xie, Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, No. 277, West Yanta Road, Yanta District, Xi’an, Shaanxi 710061, China.
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Salvadori M, Tsalouchos A. New antigens involved in membranous nephropathy beyond phospholipase A2 receptor. World J Nephrol 2022; 11:115-126. [PMID: 36161266 PMCID: PMC9353762 DOI: 10.5527/wjn.v11.i4.115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/24/2022] [Accepted: 07/11/2022] [Indexed: 02/06/2023] Open
Abstract
When the physiopathology of membranous nephropathy was first described, almost 30% of cases were recognized to be secondary to well-known diseases such as autoimmune diseases, tumors or infections. The remaining 70% cases were called primary membranous nephropathy as the exact mechanism or pathogenic factor involved was unknown. The discovery of the M type phospholipase A2 receptor and thrombospondin type 1 domain containing 7A as causative antigens in these “so called” primary membranous nephropathies provided new insights into the effective causes of a large proportion of these cases. Novel techniques such as laser microdissection and tandem mass spectrometry as well as immunochemistry with antibodies directed against novel proteins allowed the confirmation of new involved antigens. Finally, using confocal microscopy to localize these new antigens and immunoglobulin G and Western blot analysis of serum samples, these new antigens were detected on the glomerular membrane, and the related antibodies were detected in serum samples. The same antigens have been recognized in some cases of secondary membranous disease due to autoimmune diseases, tumors and infections. This has allowed examination of the relationship between antigens in primary membranous nephropathy and their presence in some secondary nephropathies. The aim of this study is to describe the characteristics of the new antigens discovered and their association with other diseases.
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Affiliation(s)
- Maurizio Salvadori
- Department of Renal Transplantation, Careggi University Hospital, Florence 50139, Tuscany, Italy
| | - Aris Tsalouchos
- Division of Nephrology, Santa Maria Annunziata, Florence 50012, Tuscany, Italy
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Caza T, Wijewardena C, Al-Rabadi L, Perl A. Cell type-specific mechanistic target of rapamycin-dependent distortion of autophagy pathways in lupus nephritis. Transl Res 2022; 245:55-81. [PMID: 35288362 PMCID: PMC9240418 DOI: 10.1016/j.trsl.2022.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 01/02/2023]
Abstract
Pro-inflammatory immune system development, metabolomic defects, and deregulation of autophagy play interconnected roles in driving the pathogenesis of systemic lupus erythematosus (SLE). Lupus nephritis (LN) is a leading cause of morbidity and mortality in SLE. While the causes of SLE have not been clearly delineated, skewing of T and B cell differentiation, activation of antigen-presenting cells, production of antinuclear autoantibodies and pro-inflammatory cytokines are known to contribute to disease development. Underlying this process are defects in autophagy and mitophagy that cause the accumulation of oxidative stress-generating mitochondria which promote necrotic cell death. Autophagy is generally inhibited by the activation of the mammalian target of rapamycin (mTOR), a large protein kinase that underlies abnormal immune cell lineage specification in SLE. Importantly, several autophagy-regulating genes, including ATG5 and ATG7, as well as mitophagy-regulating HRES-1/Rab4A have been linked to lupus susceptibility and molecular pathogenesis. Moreover, genetically-driven mTOR activation has been associated with fulminant lupus nephritis. mTOR activation and diminished autophagy promote the expansion of pro-inflammatory Th17, Tfh and CD3+CD4-CD8- double-negative (DN) T cells at the expense of CD8+ effector memory T cells and CD4+ regulatory T cells (Tregs). mTOR activation and aberrant autophagy also involve renal podocytes, mesangial cells, endothelial cells, and tubular epithelial cells that may compromise end-organ resistance in LN. Activation of mTOR complexes 1 (mTORC1) and 2 (mTORC2) has been identified as biomarkers of disease activation and predictors of disease flares and prognosis in SLE patients with and without LN. This review highlights recent advances in molecular pathogenesis of LN with a focus on immuno-metabolic checkpoints of autophagy and their roles in pathogenesis, prognosis and selection of targets for treatment in SLE.
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Affiliation(s)
| | - Chathura Wijewardena
- Departments of Medicine, State University of New York, Upstate Medical University, College of Medicine, Syracuse, New York
| | - Laith Al-Rabadi
- Department of Medicine, University of Utah, Salt Lake City, Utah
| | - Andras Perl
- Departments of Medicine, State University of New York, Upstate Medical University, College of Medicine, Syracuse, New York; Biochemistry and Molecular Biology, Neuroscience and Physiology, State University of New York, Upstate Medical University, College of Medicine, Syracuse, New York; Medicine, Microbiology and Immunology, Biochemistry and Molecular Biology, State University of New York, Upstate Medical University, College of Medicine, Syracuse, New York.
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35
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Wang C, Liu Y, Zhang M, Yang F, Xu F, Shi S, Zeng C, Chen X, Miao Y, Liu Z, Hu W. Glomerular Exostosin as a Subtype and Activity Marker of Class V Lupus Nephritis. Clin J Am Soc Nephrol 2022; 17:986-993. [PMID: 35584929 PMCID: PMC9269634 DOI: 10.2215/cjn.00350122] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 05/09/2022] [Indexed: 11/23/2022]
Abstract
Background and objectives There have been only several studies on the correlation between glomerular exostosin expression and membranous lupus nephritis. In this study, we validate the previous findings in Chinese patients with class V lupus nephritis. Design, setting, participants, and measurements 165 class V cases and varying numbers of control cases were included. Exostosin1/exostosin2 staining was performed by immunohistochemistry and the staining intensity was quantified using an imaging analysis system. Between-group comparisons were tested for statistical significance using Pearson's chi-square test, Fisher's exact test, unpaired t-test, Mann-Whitney U test, or one-way ANOVA. Results 46% of class V, 9% of class V+III/IV, and none of the other classes of lupus nephritis were exostosin positive. Only 3 cases were exostosin-positive among the 61 cases with other secondary membranous nephropathy. Exostosin-positive rate in cases with nephrotic syndrome was significantly higher than that without nephrotic syndrome(P<0.001) and the exostosin staining intensities of the exostosin- positive class V patients were positively correlated with proteinuria (r=0.53 P<0.001). Compared with the exostosin-negative cases, the exostosin-positive ones had higher proteinuria levels [3.9(IQR, 2.0-6.3)g/day vs 2.3 (IQR, 1.0-3.6)g/day] (P<0.001), lower scores of activity index [1(IQR, 1-2) vs 2 (IQR, 1-3)] (p=0.001), chronicity index [1(IQR, 0-2) vs 2(IQR, 1-2)] (P=0.02) and tubular atrophy score[0 (IQR, 0-1) vs 1 (IQR, 0-1)](P=0.008), a higher proportion of extensive subepithelial deposition [62% vs 27%](P<0.001), a similar treatment response and comparable time to kidney endpoint. Among the 47 class V cases who underwent repeat biopsy because of relapse or unresponsiveness to treatment, 97% of the exostosin-negative cases remained negative, while 44% of the exostosin-positive cases were still positive. The rate of histological transition in the exostosin-negative class V cases was significantly higher than that in the exostosin-positive class V cases (59% vs 22%, P=0.03). Conclusions exostosin positivity occured frequently in patients with class V lupus nephritis, and the exostosin-positive cases have more severe proteinuria and a lower rate of histologic transition than the exostosin-negative patients.
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Affiliation(s)
- Chengyu Wang
- C Wang, The First School of Clinical Medicine, Southern Medical University, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
| | - Yang Liu
- Y Liu, The First School of Clinical Medicine, Southern Medical University, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
| | - Mingchao Zhang
- M Zhang, Nanjing University School of Medicine, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
| | - Fan Yang
- F Yang, Nanjing University School of Medicine, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
| | - Feng Xu
- F Xu, Nanjing University School of Medicine, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
| | - Shaolin Shi
- S Shi, Nanjing University School of Medicine, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
| | - Caihong Zeng
- C Zeng, Nanjing University School of Medicine, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
| | - Xin Chen
- X Chen, Nanjing University School of Medicine, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
| | - Yiqi Miao
- Y Miao, Nanjing University School of Medicine, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
| | - Zhengzhao Liu
- Z Liu, Nanjing University School of Medicine, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
| | - Weixin Hu
- W Hu, The First School of Clinical Medicine, Southern Medical University, Jinling Hospital National Clinical Research Center of Kidney Diseases, Nanjing, China
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Santoriello D, Nasr SH. Novel approaches beyond standard immunofluorescence for kidney biopsies. Curr Opin Nephrol Hypertens 2022; 31:221-227. [PMID: 35256574 DOI: 10.1097/mnh.0000000000000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Immunofluorescence on frozen tissue (IF-F) utilizing antibodies against immunoglobulin (Ig) heavy and light chains (IgA, IgG and IgM, kappa and lambda) and components of classical and alternative complement pathways (C1q, C3c and C4) is the standard of renal pathology. However, conventional IF-F has limitations, particularly in nephropathies associated with organized and/or monoclonal Ig deposits. This review will discuss new applications of established methods beyond conventional IF-F and recent novel immunohistochemical methods. RECENT FINDINGS The combined application of paraffin immunofluorescence (IF-P) and IgG subtype staining excluded monotypic deposits in 62-66% of DNA J homolog subfamily B member 9-associated fibrillary glomerulonephritis (FGN) with apparent monotypic deposits by IF-F, whereas IF-P unmasks IgG deposits in a subset of cases of immunotactoid glomerulopathy. A novel IF technique targeting epitopes at the junction of the Ig heavy and light chains was introduced and unmasked polytypic deposits in a subset of glomerulonephritis with apparent monotypic deposits on IF-F. A recent study described the successful application of co-detection by indexing (CODEX) multiplexed IF to visualize more than a dozen target antigens within a single kidney tissue section. Finally, immunohistochemical protocols for detection of the novel antigens in membranous nephropathy have already entered the clinical practice of renal pathology. SUMMARY Novel ancillary techniques in renal pathology have the potential to significantly enhance our ability to evaluate renal biopsies.
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Affiliation(s)
- Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Membranous nephropathy: new pathogenic mechanisms and their clinical implications. Nat Rev Nephrol 2022; 18:466-478. [PMID: 35484394 DOI: 10.1038/s41581-022-00564-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2022] [Indexed: 12/24/2022]
Abstract
Membranous nephropathy (MN) is characterized histomorphologically by the presence of immune deposits in the subepithelial space of the glomerular filtration barrier; its clinical hallmarks are nephrotic range proteinuria with oedema. In patients with primary MN, autoimmunity is driven by circulating autoantibodies that bind to one or more antigens on the surface of glomerular podocytes. Compared with other autoimmune kidney diseases, the understanding of the pathogenesis of MN has substantially improved in the past decade, thanks to the discovery of pathogenic circulating autoantibodies against phospholipase A2 receptor 1 (PLA2R1) and thrombospondin type 1 domain-containing protein 7A (THSD7A). The subsequent identification of more proteins associated with MN, some of which are also endogenous podocyte antigens, might further advance the clinical characterization of MN, including its diagnosis, treatment and prognosis. Insights from studies in patients with MN, combined with the development of novel in vivo and in vitro experimental models, have potential to improve the management of patients with MN. Characterizing the interaction between autoimmunity and local glomerular lesions provides an opportunity to develop more specific, pathogenesis-based treatments.
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Liu Q, Liu J, Lin B, Zhang Y, Ma M, Yang M, Qin X. Novel Biomarkers in Membranous Nephropathy. Front Immunol 2022; 13:845767. [PMID: 35529848 PMCID: PMC9074781 DOI: 10.3389/fimmu.2022.845767] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/25/2022] [Indexed: 01/13/2023] Open
Abstract
Membranous nephropathy (MN) is the main cause of adult nephrotic syndrome (NS). The pathogenesis of MN is complex and involves subepithelial immune complex deposition. Approximately one-third of patients with MN develop end-stage renal disease (ESRD). Timely diagnosis and reasonable intervention are the keys to improving prognosis. In recent years, with the development of high-throughput technologies, such as mass spectrometry (MS), microarray, and sequencing technologies, the discovery of biomarkers for MN has become an important area of research. In this review, we summarize the significant progress in biomarker identification. For example, a variety of podocyte target antigens and their autoantibodies have been reported. Phospholipase A2 receptor (PLA2R) is the most well-established target antigen in MN. PLA2R and its autoantibodies have clinical significance, with both diagnostic and therapeutic value for MN. In addition, a variety of new biomarkers, including proteins, metabolites, noncoding RNAs (ncRNAs), and immune cells, have recently been found. These MN-related biomarkers have great significance in the diagnosis, progression, prognosis, and treatment response of MN.
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Affiliation(s)
- Qiuying Liu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
- Department of Laboratory Medicine, Beijing Haidian Hospital, Beijing Haidian Section of Peking University Third Hospital, Beijing, China
| | - Jianhua Liu
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Baoxu Lin
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yue Zhang
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Meichen Ma
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Mei Yang
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiaosong Qin
- Department of Laboratory Medicine, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Xiaosong Qin,
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New Insights into the Treatment of Glomerular Diseases: When Mechanisms Become Vivid. Int J Mol Sci 2022; 23:ijms23073525. [PMID: 35408886 PMCID: PMC8998908 DOI: 10.3390/ijms23073525] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 03/18/2022] [Accepted: 03/22/2022] [Indexed: 12/23/2022] Open
Abstract
Treatment for glomerular diseases has been extrapolated from the experience of other autoimmune disorders while the underlying pathogenic mechanisms were still not well understood. As the classification of glomerular diseases was based on patterns of juries instead of mechanisms, treatments were typically the art of try and error. With the advancement of molecular biology, the role of the immune agent in glomerular diseases is becoming more evident. The four-hit theory based on the discovery of gd-IgA1 gives a more transparent outline of the pathogenesis of IgA nephropathy (IgAN), and dysregulation of Treg plays a crucial role in the pathogenesis of minimal change disease (MCD). An epoch-making breakthrough is the discovery of PLA2R antibodies in the primary membranous nephropathy (pMN). This is the first biomarker applied for precision medicine in kidney disease. Understanding the immune system’s role in glomerular diseases allows the use of various immunosuppressants or other novel treatments, such as complement inhibitors, to treat glomerular diseases more reasonable. In this era of advocating personalized medicine, it is inevitable to develop precision medicine with mechanism-based novel biomarkers and novel therapies in kidney disease.
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Papa V, Brainer J, Henriksen KJ, Cenacchi G, Chang A. Extraglomerular immune complex deposition in lupus nephritis. Lupus 2021; 31:19-27. [PMID: 34911399 DOI: 10.1177/09612033211062535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Lupus nephritis (LN) is a common manifestation and a major cause of morbidity and mortality in systemic lupus erythematosus (SLE) patients. It is characterized by glomerular and often extraglomerular immune complex deposition. PURPOSE Given the emerging importance of the tubulointerstitial compartment, we conducted a retrospective study of 78 LN biopsies to enumerate the spectrum of extraglomerular immune complex deposition that can be observed in lupus nephritis by electron microscopy and to identify possible clinical or pathologic correlates. RESULTS The presence of tubulointerstitial immune complex deposition often accompanied interstitial inflammation, but some discrepancies were also seen. CONCLUSIONS As target antigens are identified, correlation with glomerular, tubulointerstitial, and vascular immune complex deposition will be of increasing interest.
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Affiliation(s)
- Valentina Papa
- Biomedical and Neuromotor Sciences Department, 9296Alma Mater University of Bologna, Bolgana, Italy
| | - James Brainer
- Department of Pathology, 21727UChicago Medicine, Chicago, IL, USA
| | | | - Giovanna Cenacchi
- Biomedical and Neuromotor Sciences Department, 9296Alma Mater University of Bologna, Bolgana, Italy
| | - Anthony Chang
- Department of Pathology, 21727UChicago Medicine, Chicago, IL, USA
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Caza TN, Al-Rabadi LF, Beck LH. How Times Have Changed! A Cornucopia of Antigens for Membranous Nephropathy. Front Immunol 2021; 12:800242. [PMID: 34899763 PMCID: PMC8662735 DOI: 10.3389/fimmu.2021.800242] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
The identification of the major target antigen phospholipase A2 receptor (PLA2R) in the majority of primary (idiopathic) cases of membranous nephropathy (MN) has been followed by the rapid identification of numerous minor antigens that appear to define phenotypically distinct forms of disease. This article serves to review all the known antigens that have been shown to localize to subepithelial deposits in MN, as well as the distinctive characteristics associated with each subtype of MN. We will also shed light on the novel proteomic approaches that have allowed identification of the most recent antigens. The paradigm of an antigen normally expressed on the podocyte cell surface leading to in-situ immune complex formation, complement activation, and subsequent podocyte injury will be discussed and challenged in light of the current repertoire of multiple MN antigens. Since disease phenotypes associated with each individual target antigens can often blur the distinction between primary and secondary disease, we encourage the use of antigen-based classification of membranous nephropathy.
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Affiliation(s)
| | - Laith F. Al-Rabadi
- Department of Internal Medicine (Nephrology & Hypertension), University of Utah, Salt Lake City, UT, United States
| | - Laurence H. Beck
- Department of Medicine (Nephrology), Boston University School of Medicine and Boston Medical Center, Boston, MA, United States
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Liu W, Huang G, Rui H, Geng J, Hu H, Huang Y, Huo G, Liu B, Xu A. Course monitoring of membranous nephropathy: Both autoantibodies and podocytes require multidimensional attention. Autoimmun Rev 2021; 21:102976. [PMID: 34757091 DOI: 10.1016/j.autrev.2021.102976] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/18/2021] [Accepted: 10/24/2021] [Indexed: 01/15/2023]
Abstract
A variety of podocyte antigens have been identified in human membranous nephropathy (MN), which is divided into various antigen-dominated subtypes, confirming the concept that MN is the common pattern of glomerular injury in multiple autoimmune responses. The detection of autoantibodies has been widely used, which promoted the clinical practice of MN toward personalized precision medicine. However, given the potential risks of immunosuppressive therapy, more autoantibodies and biomarkers need to be identified to predict the prognosis and therapeutic response of MN more accurately. In this review, we attempted to summarize the autoantigens/autoantibodies and autoimmune mechanisms that can predict disease states based on the current understanding of MN pathogenesis, especially the podocyte injury manifestations. In conclusion, both the autoimmune response and podocyte injury require multidimensional attention in the disease course of MN.
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Affiliation(s)
- Wenbin Liu
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Guangrui Huang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Hongliang Rui
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Jie Geng
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Haikun Hu
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Yujiao Huang
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Guiyang Huo
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China
| | - Baoli Liu
- Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China.
| | - Anlong Xu
- School of Life Sciences, Beijing University of Chinese Medicine, Beijing, China.
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Sethi S. Membranous nephropathy: a single disease or a pattern of injury resulting from different diseases. Clin Kidney J 2021; 14:2166-2169. [PMID: 34603694 PMCID: PMC8483682 DOI: 10.1093/ckj/sfab069] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Indexed: 12/13/2022] Open
Abstract
Membranous nephropathy (MN) is defined as disease entity characterized by thickening of the glomerular basement membranes due to subepithelial (SE) deposition of immune complexes. It is typically classified into primary MN (70%) when there is no disease association, and secondary MN (30%) when there is an underlying disease association such as lupus, malignancy, infections or drugs. Phospholipase A2 receptor (PLA2R) and thrombospondin type-1 domain-containing 7A (THSD7A) are target antigens in 70% and 1–5% of primary MN, respectively. The antigens in the remaining MN were not known. Recently, multiple novel proteins/target antigens have been identified in MN. These include exostosin 1/2, neural epidermal growth-like 1 protein, semaphorin 3B, protocadherin 7 and neural cell adhesion molecule 1. Some of these antigens are present in the setting of primary MN, some in secondary MN and some in both, thus blurring the lines between primary and secondary MN. Preliminary studies show that each of the new antigen-associated MN has distinct clinical, kidney biopsy findings and outcome data. We propose that each new protein/antigen-associated MN is a specific disease that results in the common MN pattern of injury characterized by thickened glomerular basement membrane (GBM) with or without spikes or pinholes on light microscopy, granular immunoglobulin G with or without complement 3 on immunofluorescence microscopy and SE electron-dense deposits on electron microscopy. In other words, MN is truly only a pattern of injury resulting from specific diseases that cause deposition of SE immune deposits along the GBM. It is of paramount importance to ascertain the specific disease entity causing the MN pattern not only for precise diagnosis and management, but also for future studies on these newly described diseases.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Mejia-Vilet JM, Malvar A, Arazi A, Rovin BH. The lupus nephritis management renaissance. Kidney Int 2021; 101:242-255. [PMID: 34619230 DOI: 10.1016/j.kint.2021.09.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 12/12/2022]
Abstract
Over the past year, and for the first time ever, the US Food and Drug Administration approved 2 drugs specifically for the treatment of lupus nephritis (LN). As the lupus community works toward understanding how to best use these new therapies, it is also an ideal time to begin to rethink the overall management strategy of LN. In addition to new drugs, this must include how to use kidney biopsies for management and not just diagnosis, how molecular technologies can be applied to interrogate biopsies and how such data can impact management, and how to incorporate LN biomarkers into management paradigms. Herein, we will review new developments in these areas of LN and put them into perspective for disease management now and in the future.
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Affiliation(s)
- Juan M Mejia-Vilet
- Department of Nephrology, Instituto Nacional de Ciencas Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
| | - Ana Malvar
- Department of Nephrology, Hospital Fernandez, Buenos Aires, Argentina
| | - Arnon Arazi
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Manhasset, New York, USA
| | - Brad H Rovin
- Department of Medicine and Division of Nephrology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
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Abstract
Membranous nephropathy (MN) is a glomerular disease that can occur at all ages. In adults, it is the most frequent cause of nephrotic syndrome. In ~80% of patients, there is no underlying cause of MN (primary MN) and the remaining cases are associated with medications or other diseases such as systemic lupus erythematosus, hepatitis virus infection or malignancies. MN is an autoimmune disease characterized by a thickening of the glomerular capillary walls due to immune complex deposition. Identification of the phospholipase A2 receptor (PLA2R) as the major antigen in adults in 2009 induced a paradigm shift in disease diagnosis and monitoring and several other antigens have since been characterized. Disease outcome is difficult to predict and around one-third of patients will undergo spontaneous remission. In those at high risk of progression, immunosuppressive therapy with cyclophosphamide plus corticosteroids has substantially reduced the need for kidney replacement therapy. Owing to carcinogenic risk, other treatments (calcineurin inhibitors and CD20-targeted B cell depletion therapy (rituximab)) have been developed. However, disease relapses are frequent when calcineurin inhibitors are stopped and the remission rate with rituximab is lower than with cyclophosphamide, particularly in patients with high PLA2R antibody titres. Other new drugs are already available and antigen-specific immunotherapies are being developed.
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Kant S, Kronbichler A, Sharma P, Geetha D. Advances in Understanding of Pathogenesis and Treatment of Immune-Mediated Kidney Disease: A Review. Am J Kidney Dis 2021; 79:582-600. [PMID: 34508831 DOI: 10.1053/j.ajkd.2021.07.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 07/25/2021] [Indexed: 12/21/2022]
Abstract
There continues to be rapid advancement in our understanding of the pathogenesis of immune-mediated kidney disease. This progress has culminated in the development of multiple therapeutic agents that have consistently improved renal and patient outcomes. The focus of this review is to discuss these recent advancements in immune-mediated kidney disease via the lens of direct and indirect immune-mediated mechanisms. In the direct immune-mediated disease, recently described antigens in anti-glomerular basement membrane (GBM) disease and membranous nephropathy are discussed, along with new therapeutic regimens in membranous nephropathy and focal segmental glomerulosclerosis. From an indirect immune-mediated disease standpoint, recent pivotal trials in antineutrophil cytoplasmic antibody vasculitis, lupus nephritis, and IgA nephropathy are examined from a real-world practice perspective. New molecular pathways in various disorders of alternate complement pathway are described, which in turn have led to development of various experimental therapies. In addition, pivotal and ongoing therapeutic trials in the aforementioned diseases are presented.
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Affiliation(s)
- Sam Kant
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Andreas Kronbichler
- Department of Internal Medicine IV (Nephrology and Hypertension), Medical University of Innsbruck, Innsbruck, Austria; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Purva Sharma
- Division of Kidney Diseases and Hypertension, Zucker School of Medicine, Hofstra University/Northwell Health, Hempstead, New York
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland.
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47
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Immunopathological analysis of the expression of glomerular exostosin 1 and exostosin 2 in Japanese patients with lupus nephritis. Virchows Arch 2021; 479:997-1005. [PMID: 34302213 DOI: 10.1007/s00428-021-03164-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/22/2021] [Accepted: 07/17/2021] [Indexed: 10/20/2022]
Abstract
Exostosin 1 and exostosin 2 (EXT1/EXT2) on glomerular basement membrane (GBM) were recently reported as novel putative antigens in secondary membranous nephropathy with autoimmune disease. However, the clinical significance of glomerular EXT1/EXT2 remains elusive in patients with lupus nephritis (LN). The immunofluorescence staining pattern of glomerular EXT1/EXT2 is also undetermined in membranous LN (MLN) or proliferative LN (PLN). We cross-sectionally analyzed patients with MLN (pure class V, n = 11) and PLN (class III, IV, and mixed class III/IV + V, n = 22) who underwent renal biopsies between 2010 and 2020 at Showa University Hospital. Glomerular EXT1/EXT2 expressions were evaluated by immunofluorescence. T-helper (Th) cell-related serum inflammatory cytokines were measured using enzyme-linked immunosorbent assay. The positivity for both EXT1/EXT2 was higher in patients with MLN than PLN (90.9% vs 63.6%, P = 0.212). MLN showed global and bright granular EXT1/EXT2 expressions along GBM, while PLN showed segmental and moderate expressions on GBM. Additionally, glomerular EXT1/EXT2 positivity was not associated with the degree of proteinuria or renal function in MLN and PLN patients, but the levels of serum anti-dsDNA antibody and circulating immune complexes were lower in patients with EXT1/EXT2-positive MLN than EXT1/EXT2-negative PLN. Moreover, serum complement levels and IL-4/IFN-γ ratios were elevated in EXT1/EXT2-positive MLN than EXT1/EXT2-negative PLN. Collectively, immunofluorescence staining for glomerular EXT1/EXT2 had characteristic patterns between MLN and PLN. Glomerular EXT1/EXT2 expressions tended to be high in Th2-dominant MLN patients without severe hypocomplementemia and elevated autoantibodies. Thus, EXT1/EXT2 might be involved in the unique developmental mechanism of MLN.
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48
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Jurubiță R, Obrișcă B, Sorohan B, Achim C, Micu GE, Mircescu G, Ismail G. Clinical Phenotypes and Predictors of Remission in Primary Membranous Nephropathy. J Clin Med 2021; 10:jcm10122624. [PMID: 34203607 PMCID: PMC8232294 DOI: 10.3390/jcm10122624] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/11/2021] [Accepted: 06/11/2021] [Indexed: 02/02/2023] Open
Abstract
(1) Background: We sought to investigate the clinical outcome and to identify the independent predictors of clinical remission in a prospectively followed cohort of patients with primary membranous nephropathy (pMN). (2) Methods: We conducted a prospective, observational, non-interventional study that included 65 consecutive patients diagnosed with pMN between January 2015 and December 2019 at our department and followed for at least 24 months. The primary outcomes evaluated during the follow-up period were the occurrence of immunological and clinical remission (either complete or partial remission). Univariate and multivariate Cox proportional hazard regression analyses were performed to identify independent predictors of clinical remission. (3) Results: In the study cohort, 13 patients had a PLA2R-negative pMN, while, of those with PLA2R-associated pMN, 27 patients had a low anti-PLA2R antibody titer (<200 RU/mL), and 25 patients had a high anti-PLA2R antibody titer at baseline (≥200 RU/mL). The clinical outcome was better in patients with PLA2R-negative pMN compared to patients with PLA2R-positive pMN. These patients had a higher percentage of complete remissions (46.2%, compared to 33.3% in those with low anti-PLA2R antibody titer or 24% in those with high anti-PLA2R antibody titer), a faster decline of 24 h proteinuria and lower time to complete remission. In multivariate Cox regression analysis, patients with PLA2R-negative pMN had a 3.1-fold and a 2.87-fold higher chance for achieving a complete or partial remission compared to patients with high anti-PLA2R antibody titer or to all PLA2R-positive patients, respectively. Additionally, patients with a baseline 24 h proteinuria of less than 8 g/day and with an immunological remission at 24 months had a 2.4-fold (HR, 2.4; 95%CI, 1.19-4.8) and a 2.2-fold (HR, 2.26; 95%CI, 1.05-4.87), respectively, higher chance of achieving a clinical response. By contrary, renal function at diagnosis, type of therapeutic intervention or anti-PLA2R antibody titer did not predict the occurrence of clinical remission. (4) Conclusions: We identified a different clinical phenotype between PLA2R-positive and PLA2R-negative pMN. Additionally, we have shown that baseline proteinuria seems to be a more important predictor of clinical outcome than anti-PLA2R-ab titer.
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Affiliation(s)
- Roxana Jurubiță
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
| | - Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Correspondence: ; Tel.: +40-721-256-797
| | - Bogdan Sorohan
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Camelia Achim
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
| | - Georgia Elena Micu
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
| | - Gabriel Mircescu
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
- Department of Nephrology, “Dr. Carol Davila” Teaching Hospital of Nephrology, 010731 Bucharest, Romania
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (R.J.); (B.S.); (C.A.); (G.E.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania;
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Saïdi M, Brochériou I, Estève E, Tuffet S, Amoura Z, Miyara M, Belenfant X, Ulinski T, Rouvier P, Debiec H, Ronco P, Buob D. The Exostosin Immunohistochemical Status Differentiates Lupus Membranous Nephropathy Subsets With Different Outcomes. Kidney Int Rep 2021; 6:1977-1980. [PMID: 34307993 PMCID: PMC8258496 DOI: 10.1016/j.ekir.2021.04.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Michèle Saïdi
- Service d’Anatomie et Cytologie Pathologiques, Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Sorbonne Université, Paris, France
- UMRS 1155, Institut National de la Santé et de la Recherche Médicale, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Isabelle Brochériou
- UMRS 1155, Institut National de la Santé et de la Recherche Médicale, Hôpital Tenon, Sorbonne Université, Paris, France
- Service d’Anatomie et Cytologie Pathologiques, La Pitié Salpêtrière, Assistance Publique—Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Emmanuel Estève
- UMRS 1155, Institut National de la Santé et de la Recherche Médicale, Hôpital Tenon, Sorbonne Université, Paris, France
- Service de Néphrologie et Dialyses, Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Sophie Tuffet
- Service de Pharmacologie Clinique et Plateforme de Recherche Clinique de l’Est Parisien (URCEST, CRB, CRC), Hôpital Saint-Antoine, Assistance Publique—Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Zahir Amoura
- Service de Médecine Interne 2, Maladies Autoimmunes et Systémiques, La Pitié Salpêtrière, Assistance Publique—Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Makoto Miyara
- Service de Médecine Interne 2, Maladies Autoimmunes et Systémiques, La Pitié Salpêtrière, Assistance Publique—Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Xavier Belenfant
- Service de Néphrologie-Dialyse, GHT Grand Paris Nord Est, Hôpital André Grégoire, Montreuil sous Bois, France
| | - Tim Ulinski
- Service de Néphrologie Pédiatrique, Hôpital Trousseau, Assistance Publique—Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Philippe Rouvier
- Service d’Anatomie et Cytologie Pathologiques, La Pitié Salpêtrière, Assistance Publique—Hôpitaux de Paris, Sorbonne Université, Paris, France
| | - Hanna Debiec
- UMRS 1155, Institut National de la Santé et de la Recherche Médicale, Hôpital Tenon, Sorbonne Université, Paris, France
| | - Pierre Ronco
- UMRS 1155, Institut National de la Santé et de la Recherche Médicale, Hôpital Tenon, Sorbonne Université, Paris, France
| | - David Buob
- Service d’Anatomie et Cytologie Pathologiques, Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Sorbonne Université, Paris, France
- UMRS 1155, Institut National de la Santé et de la Recherche Médicale, Hôpital Tenon, Sorbonne Université, Paris, France
- Correspondence: David Buob, Service d’Anatomie et Cytologie Pathologiques, Hôpital Tenon, Assistance Publique—Hôpitaux de Paris, Sorbonne Université, 4, rue de la Chine, 75970 Paris Cedex 20, France.
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50
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Sethi S, Madden B, Debiec H, Morelle J, Charlesworth MC, Gross L, Negron V, Buob D, Chaudhry S, Jadoul M, Fervenza FC, Ronco P. Protocadherin 7-Associated Membranous Nephropathy. J Am Soc Nephrol 2021; 32:1249-1261. [PMID: 33833079 PMCID: PMC8259689 DOI: 10.1681/asn.2020081165] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/21/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Membranous nephropathy (MN) results from deposition of antigen-antibody complexes along the glomerular basement membrane (GBM). PLA2R, THSD7A, NELL1, and SEMA3B account for 80%-90% of target antigens in MN. METHODS We performed laser microdissection and mass spectrometry (MS/MS) in kidney biopsies from 135 individuals with PLA2R-negative MN, and used immunohistochemistry/immunofluorescence and confocal microscopy to confirm the MS/MS finding, detect additional cases, and localize the novel protein. We also performed MS/MS and immunohistochemistry on 116 controls and used immunofluorescence microscopy to screen biopsy samples from two validation cohorts. Western blot and elution studies were performed to detect antibodies in serum and biopsy tissue. RESULTS MS/MS studies detected a unique protein, protocadherin 7 (PCDH7), in glomeruli of ten (5.7%) PLA2R-negative MN cases, which also were negative for PLA2R, THSD7A, EXT1/EXT2, NELL1, and SEMA3B. Spectral counts ranged from six to 24 (average 13.2 [SD 6.6]). MS/MS did not detect PCDH7 in controls (which included 28 PLA2R-positive cases). In all ten PCDH7-positive cases, immunohistochemistry showed bright granular staining along the GBM, which was absent in the remaining cases of PLA2R-negative MN and control cases. Four of 69 (5.8%) cases in the validation cohorts (all of which were negative for PLA2R, THSD7A, EXT1, NELL1, and SEMA3B) were PCDH7-positive MN. Kidney biopsy showed minimal complement deposition in 12 of the 14 PCDH7-associated cases. Confocal microscopy showed colocalization of PCDH7 and IgG along the GBM. Western blot analysis using sera from six patients showed antibodies to nonreduced PCDH7. Elution of IgG from frozen tissue of PCDH7-associated MN showed reactivity against PCDH7. CONCLUSIONS MN associated with the protocadherin PCDH7 appears to be a distinct, previously unidentified type of MN.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Benjamin Madden
- Medical Genome Facility, Proteomics Core, Mayo Clinic, Rochester, Minnesota
| | - Hanna Debiec
- Unité Mixte de Recherche S 1155, Sorbonne Université, Université Pierre et Marie Curie Paris 06 and Institut National de la Santé et de la Recherche Médicale, Paris, France
| | - Johann Morelle
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium,Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | | | - LouAnn Gross
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Vivian Negron
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - David Buob
- Unité Mixte de Recherche S 1155, Sorbonne Université, Université Pierre et Marie Curie Paris 06 and Institut National de la Santé et de la Recherche Médicale, Paris, France,Department of Pathology, Tenon Hospital, Paris, France
| | | | - Michel Jadoul
- Division of Nephrology, Cliniques universitaires Saint-Luc, Brussels, Belgium,Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | | | - Pierre Ronco
- Unité Mixte de Recherche S 1155, Sorbonne Université, Université Pierre et Marie Curie Paris 06 and Institut National de la Santé et de la Recherche Médicale, Paris, France,Division of Nephrology, Centre Hospitalier du Mans, Le Mans, France
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