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Uchida T, Oda T. The Prevalence, Characteristics, and Putative Mechanisms of Dual Antigen-Positive Membranous Nephropathy: The Underestimated Condition. Int J Mol Sci 2024; 25:5931. [PMID: 38892120 PMCID: PMC11172907 DOI: 10.3390/ijms25115931] [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: 04/08/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Following the discovery of podocyte phospholipase A2 receptor and thrombospondin type-1 domain-containing 7A, various potential target antigens for membranous nephropathy (MN) have been reported one after another. MN target antigens have now been identified in a significant proportion of patients, and a new classification framework classifies patients with MN based on the detected antigen and associated disease phenotype. A serology-based approach that does not require a histological diagnosis for patients suspected of having MN has also been proposed. However, there have been cases in which dual positivity for MN antigens and/or corresponding antibodies has been shown. Importantly, some of them showed a transition of the affected patient's immune responses to MN antigens, suggesting that serological diagnosis changes depending on the timing of the analysis. In this review, we provide detailed information on these cases and present an overview of our recent understanding of their putative mechanisms involved in these cases. Greater awareness is required to adequately recognize and develop appropriate therapeutic strategies for this condition.
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Affiliation(s)
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Hachioji 193-0998, Japan;
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2
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Bruschi M, Angeletti A, Prunotto M, Meroni PL, Ghiggeri GM, Moroni G, Sinico RA, Franceschini F, Fredi M, Vaglio A, Cavalli A, Scapozza L, Patel JJ, Tan JC, Lo KC, Cavagna L, Petretto A, Pratesi F, Migliorini P, Locatelli F, Pazzola G, Pesce G, Giannese D, Manfredi A, Ramirez GA, Esposito P, Murdaca G, Negrini S, Bui F, Trezzi B, Emmi G, Cavazzana I, Binda V, Fenaroli P, Pisan I, Montecucco C, Santoro D, Scolari F, Mescia F, Volpi S, Mosca M, Tincani A, Ravelli A, Murtas C, Candiano G, Caridi G, La Porta E, Verrina E. A critical view on autoantibodies in lupus nephritis: Concrete knowledge based on evidence. Autoimmun Rev 2024; 23:103535. [PMID: 38552995 DOI: 10.1016/j.autrev.2024.103535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 04/07/2024]
Abstract
Deposition of autoantibodies in glomeruli is a key factor in the development of lupus nephritis (LN). For a long time, anti-dsDNA and anti-C1q antibodies were thought to be the main cause of the kidney damage. However, recent studies have shown that the list of autoantibidies that have renal tropism and deposit in the kidney in LN is increasing and the link between anti-dsDNA and renal pathology is weak due to potential confounders. Aspecific bindings of dsDNA with cationic antibodies and of anti-dsDNA with several renal antigens such as actinin, laminin, entactin, and annexinA2 raised doubts about the specific target of these antibodies in the kidney. Moreover, the isotype of anti-dsDNA in SLE and LN has never received adequate interest until the recent observation that IgG2 are preponderant over IgG1, IgG3 and IgG4. Based on the above background, recent studies investigated the involvement of anti-dsDNA IgG2 and of other antibodies in LN. It was concluded that circulating anti-dsDNA IgG2 levels do not distinguish between LN versus non-renal SLE, and, in patients with LN, their levels do not change over time. Circulating levels of other antibodies such as anti-ENO1 and anti-H2 IgG2 were, instead, higher in LN vs non-renal SLE at the time of diagnosis and decreased following therapies. Finally, new classes of renal antibodies that potentially modify the anti-inflammatory response in the kidney are emerging as new co-actors in the pathogenetic scenario. They have been defined as 'second wave antibodies' for the link with detoxifying mechanisms limiting the oxidative stress in glomeruli that are classically stimulated in a second phase of inflammation. These findings have important clinical implications that may modify the laboratory approach to LN. Serum levels of anti-ENO1 and anti-H2 IgG2 should be measured in the follow up of patients for designing the length of therapies and identify those patients who respond to treatments. Anti-SOD2 could help to monitor and potentiate the anti-inflammatory response in the kidney.
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Affiliation(s)
- Maurizio Bruschi
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Angeletti
- Division of Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marco Prunotto
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano-Istituto di Ricovero e Cura a Carattere Scientifico, Milano, Italy.
| | - Gian Marco Ghiggeri
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genoa, Italy; Division of Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Milan, Italy
| | | | - Franco Franceschini
- Rheumatology and Clinical Immunology, ASST SpedaliCivili and Università of Brescia, Italy
| | - Micaela Fredi
- Rheumatology and Clinical Immunology, ASST SpedaliCivili and Università of Brescia, Italy
| | - Augusto Vaglio
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, and Nephrology and Dialysis Unit, Meyer Children's Hospital, Firenze, Italy
| | - Andrea Cavalli
- Institute for Research in Biomedicine, Università della Svizzera Italiana, Bellinzona, Switzerland; Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Leonardo Scapozza
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | | | | | - Ken C Lo
- Nimble Therapeutics, Madison, WI, USA
| | - Lorenzo Cavagna
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Andrea Petretto
- Core Facilities-Proteomics Laboratory, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Federico Pratesi
- Clinical Immunology Unit, Department of Internal Medicine, University of Pisa, Italy
| | - Paola Migliorini
- Clinical Immunology Unit, Department of Internal Medicine, University of Pisa, Italy
| | - Francesco Locatelli
- Division of Rheumatology, University and IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Giulia Pazzola
- Nephrology and Dialysis, Arciospedale Santa Maria nuova, Reggio Emilia, Italy
| | - Giampaola Pesce
- Nephrology and Dialysis, Arciospedale Santa Maria nuova, Reggio Emilia, Italy
| | | | - Angelo Manfredi
- Unit of Internal Medicine and Immunology, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Giuseppe A Ramirez
- Unit of Internal Medicine and Immunology, IRCCS Ospedale San Raffaele, Milano, Italy
| | - Pasquale Esposito
- Division of Nephrology, University of Genoa and Policlinico San Martino, Genova, Italy
| | | | - Simone Negrini
- Department of Internal Medicine, University of Genoa, Italy
| | - Federica Bui
- Division of Nephrology, University of Genoa and Policlinico San Martino, Genova, Italy
| | - Barbara Trezzi
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Giacomo Emmi
- Lupus Clinic Department of biomedicine, University of Florence, University Hospital Careggi, Florence, Italy
| | - Ilaria Cavazzana
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Valentina Binda
- Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, and Nephrology and Dialysis Unit, Meyer Children's Hospital, Firenze, Italy
| | - Paride Fenaroli
- Nephrology Unit, University Hospital, University of Parma, Parma, Italy
| | - Isabella Pisan
- Nephrology Unit, University Hospital, University of Parma, Parma, Italy
| | | | - Domenico Santoro
- Nephrology and Dialysis Unit, University of Messina and G Martino Hospital, Messina, Italy
| | - Francesco Scolari
- Division of Nephrology and Dialysis, ASST SpedaliCivili and Università of Brescia, Brescia, Italy
| | - Federica Mescia
- Division of Nephrology and Dialysis, ASST SpedaliCivili and Università of Brescia, Brescia, Italy
| | - Stefano Volpi
- Division of Paediatric Rheumatology and Scientific Institute for Research and Health Care, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Marta Mosca
- Rheumatologu Unit, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Angela Tincani
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, Geneva, Switzerland
| | - Angelo Ravelli
- Division of Paediatric Rheumatology and Scientific Institute for Research and Health Care, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Corrado Murtas
- Nephrology and Dialysis Unit, Ospedale Belcolle, 01100 Viterbo, Italy
| | - Giovanni Candiano
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Gianluca Caridi
- Laboratory of Molecular Nephrology, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Edoardo La Porta
- Division of Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Enrico Verrina
- Division of Nephrology, Dialysis and Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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3
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Murtas C, Bruschi M, Spinelli S, Kajana X, Verrina EE, Angeletti A, Caridi G, Candiano G, Feriozzi S, Prunotto M, Ghiggeri GM. Novel biomarkers and pathophysiology of membranous nephropathy: PLA2R and beyond. Clin Kidney J 2024; 17:sfad228. [PMID: 38213493 PMCID: PMC10783244 DOI: 10.1093/ckj/sfad228] [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: 07/07/2023] [Indexed: 01/13/2024] Open
Abstract
Research on membranous nephropathy truly exploded in the last 15 years. This happened because of the application of new techniques (laser capture microdissection, mass spectrometry, protein G immunoprecipitation, arrays) to the study of its pathogenesis. After the discovery of PLA2R as the major target antigen, many other antigens were identified and others are probably ongoing. Clinical and pathophysiology rebounds of new discoveries are relevant in terms of diagnosis and prognosis and it is time to make a first assessment of the innovative issues. In terms of classification, target antigens can be divided into: 'membrane antigens' and 'second wave' antigens. The first group consists of antigens constitutionally expressed on the podocyte membrane (as PLA2R) that may become a target of an autoimmune process because of perturbation of immune-tolerance. 'Second wave' antigens are antigens neo-expressed by the podocyte or by infiltrating cells after a stressing event: this allows the immune system to produce antibodies against them that intensify and maintain glomerular damage. With this abundance of target antigens it is not possible, at the moment, to test all antibodies at the bedside. In the absence of this possibility, the role of histological evaluation is still irreplaceable.
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Affiliation(s)
- Corrado Murtas
- Nephrology and Dialysis Unit, Ospedale Belcolle, ASL Viterbo, Viterbo, Italy
| | - Maurizio Bruschi
- Department of Experimental Medicine (DIMES) University of Genoa, Italy
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Sonia Spinelli
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Xhuliana Kajana
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Enrico E Verrina
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Angeletti
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Gianluca Caridi
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Giovanni Candiano
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Sandro Feriozzi
- Nephrology and Dialysis Unit, Ospedale Belcolle, ASL Viterbo, Viterbo, Italy
| | - Marco Prunotto
- Institute of Pharmaceutical Sciences of Western Switzerland, School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Gian Marco Ghiggeri
- Nephrology, Dialysis and Transplantation Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
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4
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Szymczak M, Heidecke H, Żabińska M, Rukasz D, Wiśnicki K, Kujawa K, Kościelska-Kasprzak K, Krajewska M, Banasik M. Angiotensin II Type 2 Receptor Antibodies in Glomerular Diseases. Arch Immunol Ther Exp (Warsz) 2024; 72:aite-2024-0017. [PMID: 39166802 DOI: 10.2478/aite-2024-0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 06/24/2024] [Indexed: 08/23/2024]
Abstract
We evaluated the concentration of AT2R antibodies in 136 patients with primary and secondary glomerular diseases: membranous nephropathy (n = 18), focal and segmental glomerulosclerosis (n = 25), systemic lupus erythematosus (n = 17), immunoglobulin A (IgA) nephropathy (n = 14), mesangial (non-IgA) proliferative nephropathy (n = 6), c-ANCA vasculitis (n = 40), perinuclear anti-neutrophil cytoplasmic antibodies (p-ANCA) vasculitis (n = 16), and compared it with a healthy control group (22 patients). Serum creatinine levels, proteinuria, serum albumin, and total protein concentrations were prospectively recorded for 2 years. The mean levels of AT2R antibodies in the lupus nephropathy group were significantly higher compared to the control group, 64.12 ± 26.95 units/mL and 9.72 ± 11.88 units/mL, respectively. There was no association between this level and the clinical course of the disease. The AT2R levels in other kinds of glomerular disease were no different from the control group. We found significant correlations between AT1R and AT2R in patients with membranous nephropathy (r = 0.66), IgA nephropathy (r = 0.61), and c-ANCA vasculitis (r = 0.63). Levels of AT2R antibodies in systemic lupus erythematosus are higher compared to other types of glomerulonephritis, vasculitis, and a healthy control group. Levels of AT2R antibodies correlate with AT1R antibodies in the groups of patients with membranous nephropathy, IgA nephropathy, and c-ANCA vasculitis. These kinds of AT2R antibodies have a stimulative effect on AT2R, but we have not found the influence of these antibodies on the clinical course of glomerular diseases.
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MESH Headings
- Humans
- Female
- Male
- Middle Aged
- Adult
- Receptor, Angiotensin, Type 2/immunology
- Receptor, Angiotensin, Type 2/metabolism
- Autoantibodies/blood
- Autoantibodies/immunology
- Aged
- Kidney Glomerulus/immunology
- Kidney Glomerulus/pathology
- Glomerulonephritis, Membranous/immunology
- Glomerulonephritis, Membranous/blood
- Glomerulonephritis/immunology
- Glomerulonephritis/blood
- Antibodies, Antineutrophil Cytoplasmic/immunology
- Antibodies, Antineutrophil Cytoplasmic/blood
- Lupus Erythematosus, Systemic/immunology
- Lupus Erythematosus, Systemic/blood
- Glomerulonephritis, IGA/immunology
- Glomerulonephritis, IGA/blood
- Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis/immunology
- Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis/blood
- Lupus Nephritis/immunology
- Receptor, Angiotensin, Type 1/immunology
- Young Adult
- Kidney Diseases/immunology
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Affiliation(s)
- Maciej Szymczak
- 1Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | | | - Marcelina Żabińska
- 1Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Dagna Rukasz
- 1Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Wiśnicki
- 1Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Krzysztof Kujawa
- 3Statistical Analysis Centre, Wroclaw Medical University, Wroclaw, Poland
| | | | - Magdalena Krajewska
- 1Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Mirosław Banasik
- 1Department of Nephrology and Transplantation Medicine, Wroclaw Medical University, Wroclaw, Poland
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5
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Duan S, Sun L, Zhang C, Zeng M, Sun B, Yuan Y, Mao H, Xing C, Zhang B. The thickness of glomerular basement membrane predicts complete remission in primary membranous nephropathy. Ren Fail 2023; 45:2179335. [PMID: 36856323 PMCID: PMC9980401 DOI: 10.1080/0886022x.2023.2179335] [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] [Indexed: 03/02/2023] Open
Abstract
Objective: Glomerular basement membrane (GBM) thickening is a typical and essential histopathological characteristic for the diagnosis of primary membranous nephropathy (PMN). The present study aimed to explore the relationship between GBM thickness and treatment response in PMN patients.Methods: A total of 128 patients with nephrotic syndrome concurrent with PMN were studied. The highest GBM thickness was measured from at least five glomerular capillary loops using an electron microscope, and the mean value was obtained. Patients were categorized into three groups according to the tertiles of GBM thickness as follows: Group 1 (GBM thickness ≤ 1100 nm, n = 48), Group 2 (1100 nm < GBM thickness ≤ 1300 nm, n = 40), Group 3 (GBM thickness >1300 nm, n = 40). Clinicopathological features and treatment response were compared among the three groups. The associations of GBM thickness with complete remission (CR) were assessed by Cox proportional hazard analyses and a cubic spline curve.Results: During a median follow-up period of 25.80 months, 69 (53.9%) patients achieved CR. Kaplan-Meier analysis showed that the non-CR probability was significantly higher in the highest tertile of GBM thickness (p˂0.001). Univariate Cox proportional hazard analysis indicated that GBM thickness was associated with CR (HR per SD 0.617, 95% CI [0.471-0.809], p˂0.001). After adjusting for age, duration of PMN, estimated glomerular filtration rate (eGFR), urinary protein excretion, grade of C3 deposition, and titer of serum anti-phospholipase A2 receptor (PLA2R) antibody, GBM thickness remained an independent predictor of CR (HR per SD 0.580, 95% CI [0.436-0.772], p˂0.001). Further multivariable-adjusted restricted cubic spline analysis confirmed a significant reverse linear association between GBM thickness and CR (p for nonlinear = 0.1261).Conclusions: GBM thickness is an independent risk factor of CR. PMN patients with an increased level of GBM thickening at diagnosis have a lower probability of achieving CR.
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Affiliation(s)
- Suyan Duan
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Lianqin Sun
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Chengning Zhang
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Ming Zeng
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Bin Sun
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Yanggang Yuan
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Huijuan Mao
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China
| | - Changying Xing
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China,Changying Xing, Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, 300 Guangzhou Road, Nanjing, 210029, Jiangsu Province, P. R. China
| | - Bo Zhang
- Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, P.R. China,Department of Nephrology, Pukou Branch of JiangSu Province Hospital (Nanjing Pukou Central Hospital), Nanjing, P.R. China,CONTACT Bo Zhang
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6
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Liu Y, Lu Y, Li W, Wang Y, Zhang Z, Yang X, Yang Y, Li R, Zhou X. Prognostic prediction of idiopathic membranous nephropathy using interpretable machine learning. Ren Fail 2023; 45:2251597. [PMID: 37724550 PMCID: PMC10512811 DOI: 10.1080/0886022x.2023.2251597] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 08/19/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Established prognostic models of idiopathic membranous nephropathy (IMN) were limited to traditional modeling methods and did not comprehensively consider clinical and pathological patient data. Based on the electronic medical record (EMR) system, machine learning (ML) was used to construct a risk prediction model for the prognosis of IMN. METHODS Data from 418 patients with IMN were diagnosed by renal biopsy at the Fifth Clinical Medical College of Shanxi Medical University. Fifty-nine medical features of the patients could be obtained from EMR, and prediction models were established based on five ML algorithms. The area under the curve, recall rate, accuracy, and F1 were used to evaluate and compare the performances of the models. Shapley additive explanation (SHAP) was used to explain the results of the best-performing model. RESULTS One hundred and seventeen patients (28.0%) with IMN experienced adverse events, 28 of them had compound outcomes (ESRD or double serum creatinine (SCr)), and 89 had relapsed. The gradient boosting machine (LightGBM) model had the best performance, with the highest AUC (0.892 ± 0.052, 95% CI 0.840-0.945), accuracy (0.909 ± 0.016), recall (0.741 ± 0.092), precision (0.906 ± 0.027), and F1 (0.905 ± 0.020). Recursive feature elimination with random forest and SHAP plots based on LightGBM showed that anti-phospholipase A2 receptor (anti-PLA2R), immunohistochemical immunoglobulin G4 (IHC IgG4), D-dimer (D-DIMER), triglyceride (TG), serum albumin (ALB), aspartate transaminase (AST), β2-microglobulin (BMG), SCr, and fasting plasma glucose (FPG) were important risk factors for the prognosis of IMN. Increased risk of adverse events in IMN patients was correlated with high anti-PLA2R and low IHC IgG4. CONCLUSIONS This study established a risk prediction model for the prognosis of IMN using ML based on clinical and pathological patient data. The LightGBM model may become a tool for personalized management of IMN patients.
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Affiliation(s)
- Yanqin Liu
- Big data Center for Nephropathy, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Yuanyue Lu
- Big data Center for Nephropathy, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Wangxing Li
- Big data Center for Nephropathy, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Yanru Wang
- Big data Center for Nephropathy, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Ziting Zhang
- Big data Center for Nephropathy, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Xiaoyu Yang
- Big data Center for Nephropathy, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Yuxuan Yang
- Big data Center for Nephropathy, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Rongshan Li
- Big data Center for Nephropathy, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Provincial People’s Hospital, Taiyuan, China
- Shanxi Kidney Disease Institute, Taiyuan, China
| | - Xiaoshuang Zhou
- Big data Center for Nephropathy, The Fifth Clinical Medical College of Shanxi Medical University, Shanxi Provincial People’s Hospital, Taiyuan, China
- Shanxi Kidney Disease Institute, Taiyuan, China
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7
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Angeletti A, Bruschi M, Kajana X, Spinelli S, Verrina E, Lugani F, Caridi G, Murtas C, Candiano G, Prunotto M, Ghiggeri GM. Mechanisms Limiting Renal Tissue Protection and Repair in Glomerulonephritis. Int J Mol Sci 2023; 24:ijms24098318. [PMID: 37176025 PMCID: PMC10179029 DOI: 10.3390/ijms24098318] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/29/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023] Open
Abstract
Glomerulonephritis are renal disorders resulting from different pathogenic mechanisms (i.e., autoimmunity, complement, inflammatory activation, etc.). Clarifying details of the pathogenic cascade is basic to limit the progression from starting inflammation to degenerative stages. The balance between tissue injury, activation of protective systems and renal tissue repair determines the final outcome. Induction of an oxidative stress is part of glomerular inflammation and activation of protective antioxidant systems has a crucial role in reducing tissue effects. The generation of highly reactive oxygen species can be evaluated in vivo by tracing the inner-layer content of phosphatidyl ethanolamine and phosphatidyl serine in cell membranes. Albumin is the major antioxidant in serum and the level of oxidized albumin is another indirect sign of oxidative stress. Studies performed in Gn, specifically in FSGS, showed a high degree of oxidation in most contexts. High levels of circulating anti-SOD2 antibodies, limiting the detoxyfing activity of SOD2, have been detected in autoimmune Gn(lupus nephritis and membranous nephropathy) in association with persistence of proteinuria and worsening of renal function. In renal transplant, high levels of circulating anti-Glutathione S-transferase antibodies have been correlated with chronic antibody rejection and progressive loss of renal function. Annexins, mainly ANXA1 and ANXA2, play a general anti-inflammatory effect by inhibiting neutrophil functions. Cytosolic ANXA1 is decreased in apoptotic neutrophils of patients with glomerular polyangitis in association with delayed apoptosis that is considered the mechanism for polyangitis. High circulating levels of anti-ANXA1 and anti-ANXA2 antibodies characterize lupus nephritis implying a reduced anti-inflammatory effect. High circulating levels of antibodies targeting Macrophages (anti-FMNL1) have been detected in Gn in association with proteinuria. They potentially modify the intra-glomerular presence of protective macrophages (M2a, M2c) thus acting on the composition of renal infiltrate and on tissue repair.
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Affiliation(s)
- Andrea Angeletti
- Nephrology, Dialysis and Transplantation Unit, IRCCS, Istituto GianninaGaslini, 16147 Genova, Italy
| | - Maurizio Bruschi
- Nephrology, Dialysis and Transplantation Unit, IRCCS, Istituto GianninaGaslini, 16147 Genova, Italy
- Department of Experimental Medicine (DIMES), University of Genoa, 16126 Genoa, Italy
| | - Xuliana Kajana
- Nephrology, Dialysis and Transplantation Unit, IRCCS, Istituto GianninaGaslini, 16147 Genova, Italy
| | - Sonia Spinelli
- Nephrology, Dialysis and Transplantation Unit, IRCCS, Istituto GianninaGaslini, 16147 Genova, Italy
| | - Enrico Verrina
- Nephrology, Dialysis and Transplantation Unit, IRCCS, Istituto GianninaGaslini, 16147 Genova, Italy
| | - Francesca Lugani
- Nephrology, Dialysis and Transplantation Unit, IRCCS, Istituto GianninaGaslini, 16147 Genova, Italy
| | - Gialuca Caridi
- Nephrology, Dialysis and Transplantation Unit, IRCCS, Istituto GianninaGaslini, 16147 Genova, Italy
| | - Corrado Murtas
- Nephrology and Dialysis Unit, Ospedale Belcolle, 01100 Viterbo, Italy
| | - Giovanni Candiano
- Nephrology, Dialysis and Transplantation Unit, IRCCS, Istituto GianninaGaslini, 16147 Genova, Italy
| | - Marco Prunotto
- Institute of Pharmaceutical Sciences of Western Switzerland, School of Pharmaceutical Sciences, University of Geneva, 1205 Geneva, Switzerland
| | - Gian Marco Ghiggeri
- Nephrology, Dialysis and Transplantation Unit, IRCCS, Istituto GianninaGaslini, 16147 Genova, Italy
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8
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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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9
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Reichelt J, Sachs W, Frömbling S, Fehlert J, Studencka-Turski M, Betz A, Loreth D, Blume L, Witt S, Pohl S, Brand J, Czesla M, Knop J, Florea BI, Zielinski S, Sachs M, Hoxha E, Hermans-Borgmeyer I, Zahner G, Wiech T, Krüger E, Meyer-Schwesinger C. Non-functional ubiquitin C-terminal hydrolase L1 drives podocyte injury through impairing proteasomes in autoimmune glomerulonephritis. Nat Commun 2023; 14:2114. [PMID: 37055432 PMCID: PMC10102022 DOI: 10.1038/s41467-023-37836-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/03/2023] [Indexed: 04/15/2023] Open
Abstract
Little is known about the mechanistic significance of the ubiquitin proteasome system (UPS) in a kidney autoimmune environment. In membranous nephropathy (MN), autoantibodies target podocytes of the glomerular filter resulting in proteinuria. Converging biochemical, structural, mouse pathomechanistic, and clinical information we report that the deubiquitinase Ubiquitin C-terminal hydrolase L1 (UCH-L1) is induced by oxidative stress in podocytes and is directly involved in proteasome substrate accumulation. Mechanistically, this toxic gain-of-function is mediated by non-functional UCH-L1, which interacts with and thereby impairs proteasomes. In experimental MN, UCH-L1 becomes non-functional and MN patients with poor outcome exhibit autoantibodies with preferential reactivity to non-functional UCH-L1. Podocyte-specific deletion of UCH-L1 protects from experimental MN, whereas overexpression of non-functional UCH-L1 impairs podocyte proteostasis and drives injury in mice. In conclusion, the UPS is pathomechanistically linked to podocyte disease by aberrant proteasomal interactions of non-functional UCH-L1.
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Affiliation(s)
- Julia Reichelt
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wiebke Sachs
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Frömbling
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Fehlert
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maja Studencka-Turski
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Hamburg, Germany
| | - Anna Betz
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Desiree Loreth
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Blume
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Witt
- Protein production Core Facility, Centre for Structural Systems Biology, Deutsches Elektronen-Synchrotron DESY, Hamburg, Germany
| | - Sandra Pohl
- Skeletal Pathobiochemistry, Department of Osteology and Biomechanics, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Brand
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maire Czesla
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Knop
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bogdan I Florea
- Bio-organic synthesis group, Leiden University, Leiden, The Netherlands
| | - Stephanie Zielinski
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlies Sachs
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elion Hoxha
- III Medical Clinic and Polyclinic, Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Irm Hermans-Borgmeyer
- Transgenic Animal Service Group, Center for Molecular Neurobiology Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gunther Zahner
- III Medical Clinic and Polyclinic, Nephrology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thorsten Wiech
- Institute of Pathology, Nephropathology Section, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Elke Krüger
- Institute of Medical Biochemistry and Molecular Biology, University Medicine Greifswald, Hamburg, Germany
| | - Catherine Meyer-Schwesinger
- Institute of Cellular and Integrative Physiology, Center for Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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10
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Sakai T, Uchida T, Iwama S, Sugisaki K, Yamada M, Inamoto Y, Oda T. Chronic Graft-versus-host Disease-associated Membranous Nephropathy Following Bone Marrow Transplantation, Successfully Treated with Rituximab. Intern Med 2023; 62:269-273. [PMID: 35732451 PMCID: PMC9908386 DOI: 10.2169/internalmedicine.9655-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
A 67-year-old woman who had undergone bone marrow transplantation 2 years previously for acute myeloid leukemia (AML) developed complications of chronic graft-versus-host disease (cGVHD). She thereafter also developed nephrotic syndrome, and membranous nephropathy (MN) was diagnosed by a renal biopsy. Although the causative antigens of the MN were not detected, immunofluorescence staining showed codominant deposition of immunoglobulins G2 and G3, a finding indicating secondary MN, thereby suggesting an association between MN and cGVHD. Rituximab treatment was initiated, and her nephrotic syndrome gradually improved without relapse of AML. Our present case suggests that rituximab is a safe and effective therapeutic option for cGVHD-associated MN.
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Affiliation(s)
- Takashi Sakai
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| | - Takahiro Uchida
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| | - Sachiko Iwama
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| | - Kentaro Sugisaki
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| | - Muneharu Yamada
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
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11
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Vaglio A, Gattorno M, McAdoo S, Obici LP, Ghiggeri GM. Editorial: The kidney in auto-immune and auto-inflammatory processes: Definitions, mechanisms, and biomarkers. Front Med (Lausanne) 2023; 9:1129021. [PMID: 36703882 PMCID: PMC9872156 DOI: 10.3389/fmed.2022.1129021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023] Open
Affiliation(s)
- Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy,Department of Biomedical Experimental and Clinical Sciences, University of Firenze, Florence, Italy
| | - Marco Gattorno
- Center of Autoinflammatory Diseases and Immunodeficiencies, Department of Pediatrics and Rheumatology, IRCCS Istituto G. Gaslini, Genoa, Italy
| | - Stephen McAdoo
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, Hammersmith Campus, London, United Kingdom,Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom
| | - Laura Piera Obici
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - Gian Marco Ghiggeri
- Division of Nephrology, Dialysis, Transplantation, IRCCS Istituto Giannina Gaslini, Genoa, Italy,*Correspondence: Gian Marco Ghiggeri ✉
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12
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Discovery of anti-Formin-like 1 protein (FMNL1) antibodies in membranous nephropathy and other glomerular diseases. Sci Rep 2022; 12:13659. [PMID: 35953506 PMCID: PMC9372176 DOI: 10.1038/s41598-022-17696-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 07/29/2022] [Indexed: 12/28/2022] Open
Abstract
Evidence has shown that podocyte-directed autoantibodies can cause membranous nephropathy (MN). In the present work we investigated sera of MN patients using a high-density peptide array covering the whole coding sequences of the human genome encompassing 7,499,126 tiled peptides. A panel of 21 proteins reactive to MN sera were identified. We focused our attention on Formin-like 1 (FMNL1), a protein expressed by macrophages in MN patients tissues. High levels of anti-FMNL1 IgG4 were demonstrated in sera of MN patients with an orthogonal methodology (ELISA) contemporary demonstrating FMNL1 positive cells in kidney co-staining with CD68 in glomeruli. High levels of circulating anti-FMNL1 IgG4 were associated with lack of remission of proteinuria, potentially indicating that autoantibodies directed against cells other than podocytes, involved in tissue repair, might play a role in MN disease progression. High serum levels of anti-FMNL1 IgGs were also observed in other non-autoimmune glomerolonephrites, i.e. idiopathic and genetic FSGS, IgAGN. These findings are suggestive of a broader role of those autoantibodies in other glomerular disease conditions.
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13
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Manral P, Caza TN, Storey AJ, Beck LH, Borza DB. The Alternative Pathway Is Necessary and Sufficient for Complement Activation by Anti-THSD7A Autoantibodies, Which Are Predominantly IgG4 in Membranous Nephropathy. Front Immunol 2022; 13:952235. [PMID: 35874690 PMCID: PMC9301376 DOI: 10.3389/fimmu.2022.952235] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 06/16/2022] [Indexed: 12/12/2022] Open
Abstract
Membranous nephropathy (MN) is an immune kidney disease characterized by glomerular subepithelial immune complexes (ICs) containing antigen, IgG, and products of complement activation. Whereas proteinuria is caused by complement-mediated podocyte injury, the pathways of complement activation remain controversial due to the predominance of IgG4 in ICs, an IgG subclass considered unable to activate complement. THSD7A, a transmembrane protein expressed on podocytes, is the target autoantigen in ~3% of cases of primary MN. In this study, we analyzed sera from 16 patients with THSD7A-associated MN with regard to the anti-THSD7A IgG subclasses and their ability to fix complement in vitro. The serum concentration of anti-THSD7A IgG varied over two orders of magnitude (1.3-243 μg/mL). As a relative proportion of all IgG anti-THSD7A, IgG4 was by far the most abundant subclass (median 79%), followed by IgG1 (median 11%). IgG4 was the dominant subclass of anti-THSD7A antibodies in 14 sera, while IgG1 was dominant in one and co-dominant in another. One quarter of MN sera additionally contained low levels of anti-THSD7A IgA1. ICs formed by predominantly IgG4 anti-THSD7A autoantibodies with immobilized THSD7A were relatively weak activators of complement in vitro, compared to human IgG1 and IgG3 mAbs used as positive control. Complement deposition on THSD7A ICs was dose-dependent and occurred to a significant extent only at relatively high concentration of anti-THSD7A IgG. C3b fixation by THSD7A ICs was completely abolished in factor B-depleted sera, partially inhibited in C4-depleted sera, unchanged in C1q-depleted sera, and also occurred in Mg-EGTA buffer. These results imply that THSD7A ICs predominantly containing IgG4 activate complement at high IgG4 density, which strictly requires a functional alternative pathway, whereas the classical and lectin pathways are dispensable. These findings advance our understanding of how IgG4 antibodies activate complement.
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Affiliation(s)
- Pallavi Manral
- Department of Microbiology, Immunology and Physiology, Meharry Medical College, Nashville, TN, United States
| | | | - Aaron J. Storey
- Department of Biochemistry and Molecular Biology, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Laurence H. Beck
- Department of Medicine (Nephrology), Boston University School of Medicine and Boston Medical Center, Boston, MA, United States
| | - Dorin-Bogdan Borza
- Department of Microbiology, Immunology and Physiology, Meharry Medical College, Nashville, TN, United States
- *Correspondence: Dorin-Bogdan Borza,
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14
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Teisseyre M, Cremoni M, Boyer-Suavet S, Ruetsch C, Graça D, Esnault VLM, Brglez V, Seitz-Polski B. Advances in the Management of Primary Membranous Nephropathy and Rituximab-Refractory Membranous Nephropathy. Front Immunol 2022; 13:859419. [PMID: 35603210 PMCID: PMC9114510 DOI: 10.3389/fimmu.2022.859419] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/22/2022] [Indexed: 02/06/2023] Open
Abstract
Primary membranous nephropathy (pMN) is an auto-immune disease characterized by auto-antibodies targeting podocyte antigens resulting in activation of complement and damage to the glomerular basement membrane. pMN is the most common cause of nephrotic syndrome in adults without diabetes. Despite a very heterogeneous course of the disease, the treatment of pMN has for many years been based on uniform management of all patients regardless of the severity of the disease. The identification of prognostic markers has radically changed the vision of pMN and allowed KDIGO guidelines to evolve in 2021 towards a more personalized management based on the assessment of the risk of progressive loss of kidney function. The recognition of pMN as an antibody-mediated autoimmune disease has rationalized the use immunosuppressive drugs such as rituximab. Rituximab is now a first line immunosuppressive therapy for patients with pMN with proven safety and efficacy achieving remission in 60-80% of patients. For the remaining 20-40% of patients, several mechanisms may explain rituximab resistance: (i) decreased rituximab bioavailability; (ii) immunization against rituximab; and (iii) chronic glomerular damage. The treatment of patients with rituximab-refractory pMN remains controversial and challenging. In this review, we provide an overview of recent advances in the management of pMN (according to the KDIGO 2021 guidelines), in the understanding of the pathophysiology of rituximab resistance, and in the management of rituximab-refractory pMN. We propose a treatment decision aid based on immunomonitoring to identify failures related to underdosing or immunization against rituximab to overcome treatment resistance.
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Affiliation(s)
- Maxime Teisseyre
- 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
| | - Marion Cremoni
- 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
| | - Sonia Boyer-Suavet
- Unité de Recherche Clinique de la Côte d’Azur (UR2CA), Université Côte d’Azur, Nice, France
| | - Caroline Ruetsch
- Laboratoire d’Immunologie, CHU de Nice, Université Côte d’Azur, Nice, France
| | - Daisy Graça
- 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
| | - Vincent L. M. Esnault
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, CHU de Nice, Université Côte d’Azur, Nice, France
- Service de Néphrologie-Dialyse-Transplantation, CHU de Nice, Université Côte d’Azur, Nice, France
| | - Vesna Brglez
- 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
| | - 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
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15
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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: 44] [Impact Index Per Article: 22.0] [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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16
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Del Vecchio L, Allinovi M, Rocco P, Brando B. Rituximab Therapy for Adults with Nephrotic Syndromes: Standard Schedules or B Cell-Targeted Therapy? J Clin Med 2021; 10:5847. [PMID: 34945143 PMCID: PMC8709396 DOI: 10.3390/jcm10245847] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022] Open
Abstract
Rituximab is a chimeric anti-CD20 monoclonal antibody. It acts mainly through complement-dependent cytotoxicity on B cells expressing the CD20 marker. In this review, we analyse the efficacy and possible pitfalls of rituximab to treat nephrotic syndromes by taking into account pharmacological considerations and CD19 marker testing utility. Despite the fact that the drug has been in use for years, efficacy and treatment schedules in adults with nephrotic syndrome are still a matter of debate. Clinical trials have proven the efficacy and safety of rituximab in idiopathic membranous nephropathy. Data from observational studies also showed the efficacy of rituximab in minimal change disease and focal segmental glomerulosclerosis. Rituximab use is now widely recommended by new Kidney Disease Improved Outcome (KDIGO) guidelines in membranous nephropathy and in frequent-relapsing, steroid-dependent minimal change disease or focal segmental glomerulosclerosis. However, rituximab response has a large interindividual variability. One reason could be that rituximab is lost in the urine at a higher extent in patients with nonselective nephrotic proteinuria, exposing patients to different rituximab plasma levels. Moreover, the association between CD19+ levels and clinical response or relapses is not always present, making the use of this marker in clinical practice complex. High resolution flow cytometry has increased the capability of detecting residual CD19+ B cells. Moreover, it can identify specific B-cell subsets (including IgG-switched memory B cells), which can repopulate at different rates. Its wider use could become a useful tool for better understanding reasons of rituximab failure or avoiding unnecessary retreatments.
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Affiliation(s)
- Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant’Anna Hospital, ASST Lariana, 22042 Como, Italy
| | - Marco Allinovi
- Nephrology, Dialysis and Transplantation Unit, Careggi University Hospital, 50134 Florence, Italy;
| | - Paolo Rocco
- Department of Pharmaceutical Sciences, Università degli Studi di Milano, Via G. Colombo, 71-20133 Milan, Italy;
| | - Bruno Brando
- Haematology Laboratory and Transfusion Centre, Legnano General Hospital (Milan), 20025 Milan, Italy;
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17
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Angeletti A, Bruschi M, Moroni G, Sinico RA, Franceschini F, Fredi M, Vaglio A, Cavagna L, Petretto A, Pratesi F, Migliorini P, Locatelli F, Pazzola G, Pesce G, Bagnasco M, Manfredi A, Ramirez GA, Esposito P, Murdaca G, Negrini S, Cipriani L, Trezzi B, Emmi G, Cavazzana I, Binda V, d’Alessandro M, Fenaroli P, Pisani I, Garibotto G, Montecucco C, Santoro D, Scolari F, Volpi S, Mosca M, Tincani A, Candiano G, Prunotto M, Verrina E, Ravelli A, Ghiggeri GM. Second Wave Antibodies in Autoimmune Renal Diseases: The Case of Lupus Nephritis. J Am Soc Nephrol 2021; 32:3020-3023. [PMID: 34599042 PMCID: PMC8638388 DOI: 10.1681/asn.2021050659] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Clinical Trial registry name and registration number: Zeus study, NCT02403115.
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Affiliation(s)
- Andrea Angeletti
- Department of Integrated Pediatric and Hemato-Oncology Sciences, Laboratory of Molecular Nephrology, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
- Division of Nephrology, Dialysis and Transplantation, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Maurizio Bruschi
- Department of Integrated Pediatric and Hemato-Oncology Sciences, Laboratory of Molecular Nephrology, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Gabriella Moroni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | - Franco Franceschini
- Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, Azienda Socio Sanitaria Territoriale Spedali Civili and Università of Brescia, Brescia, Italy
| | - Micaela Fredi
- Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, Azienda Socio Sanitaria Territoriale Spedali Civili and Università of Brescia, Brescia, Italy
| | - Augusto Vaglio
- Department of Biomedical, Experimental and Clinical Sciences “Mario Serio,” University of Firenze, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy
| | - Lorenzo Cavagna
- Division of Rheumatology, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo, Pavia, Italy
| | - Andrea Petretto
- Integrated Department of Services and Laboratories, Core Facilities Proteomics Laboratory, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Federico Pratesi
- Clinical Immunology Unit, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | - Paola Migliorini
- Clinical Immunology Unit, Department of Internal Medicine, University of Pisa, Pisa, Italy
| | | | - Giulia Pazzola
- Department of Medical Specialties, Nephrology and Dialysis, Arciospedale Santa Maria Nuova, Reggio Emilia, Italy
| | - Giampaola Pesce
- Medical and Radiometabolic Therapy Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Marcello Bagnasco
- Medical and Radiometabolic Therapy Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Angelo Manfredi
- Unit of Internal Medicine and Immunology, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Giuseppe A. Ramirez
- Unit of Internal Medicine and Immunology, Istituto di Ricovero e Cura a Carattere Scientifico Ospedale San Raffaele, Milan, Italy
| | - Pasquale Esposito
- Unit of Nephrology, Dialysis and Transplantation, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Murdaca
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Simone Negrini
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Leda Cipriani
- Division of Nephrology, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Barbara Trezzi
- Department of Medicine and Surgery, University of Milan, Bicocca, Italy
| | - Giacomo Emmi
- Lupus Clinic Department of Biomedicine, University of Florence, University Hospital Careggi, Florence, Italy
| | - Ilaria Cavazzana
- Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, Azienda Socio Sanitaria Territoriale Spedali Civili and Università of Brescia, Brescia, Italy
| | - Valentina Binda
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Matteo d’Alessandro
- Division of Nephrology, Dialysis and Transplantation, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Paride Fenaroli
- Nephrology Unit, University Hospital, University of Parma, Parma, Italy
| | - Isabella Pisani
- Nephrology Unit, University Hospital, University of Parma, Parma, Italy
| | - Giacomo Garibotto
- Division of Nephrology, University of Genoa and Policlinico San Martino, Genoa, Italy
| | - Carlomaurizio Montecucco
- Division of Rheumatology, University of Pavia and Istituto di Ricovero e Cura a Carattere Scientifico Policlinico S. Matteo, Pavia, Italy
| | - Domenico Santoro
- Nephrology and Dialysis Unit, University of Messina and G Martino Hospital, Messina, Italy
| | - Francesco Scolari
- Division of Nephrology and Dialysis, University of Brescia and Ospedale di Montichiari, Brescia, Italy
| | - Stefano Volpi
- Division of Paediatric Rheumatology Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Marta Mosca
- Rheumatologu Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Angela Tincani
- Department of Clinical and Experimental Sciences, Rheumatology and Clinical Immunology, Azienda Socio Sanitaria Territoriale Spedali Civili and Università of Brescia, Brescia, Italy
| | - Giovanni Candiano
- Department of Integrated Pediatric and Hemato-Oncology Sciences, Laboratory of Molecular Nephrology, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Marco Prunotto
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Enrico Verrina
- Division of Nephrology, Dialysis and Transplantation, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Angelo Ravelli
- Division of Paediatric Rheumatology Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
| | - Gian Marco Ghiggeri
- Department of Integrated Pediatric and Hemato-Oncology Sciences, Laboratory of Molecular Nephrology, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
- Division of Nephrology, Dialysis and Transplantation, Scientific Institute for Research and Health Care, Istituto di Ricovero e Cura a Carattere Scientifico Istituto Giannina Gaslini, Genoa, Italy
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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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Abstract
The identification of the phospholipase A2 receptor 1 (PLA2R) and thrombospondin type-1 domain-containing protein 7A (THSD7A) as podocyte antigens in adult patients with membranous nephropathy (MN) has strongly impacted both experimental and clinical research on this disease. Evidence has been furnished that podocyte-directed autoantibodies can cause MN, and novel PLA2R- and THSD7A-specific animal models have been developed. Today, measurement of serum autoantibody levels and staining of kidney biopsies for the target antigens guides MN diagnosis and treatment worldwide. Additionally, anti-PLA2R antibodies have been proven to be valuable prognostic biomarkers in MN. Despite these impressive advances, a variety of questions regarding the disease pathomechanisms, clinical use of antibody measurement, and future treatments remain unanswered. In this review, we will outline recent advances made in the field of MN and discuss open questions and perspectives with a focus on novel antigen identification, mechanisms of podocyte injury, clinical use of antibody measurement to guide diagnosis and treatment, and the potential of innovative, pathogenesis-based treatment strategies.
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Mechanisms of Primary Membranous Nephropathy. Biomolecules 2021; 11:biom11040513. [PMID: 33808418 PMCID: PMC8065962 DOI: 10.3390/biom11040513] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/23/2021] [Accepted: 03/26/2021] [Indexed: 12/11/2022] Open
Abstract
Membranous nephropathy (MN) is an autoimmune disease of the kidney glomerulus and one of the leading causes of nephrotic syndrome. The disease exhibits heterogenous outcomes with approximately 30% of cases progressing to end-stage renal disease. The clinical management of MN has steadily advanced owing to the identification of autoantibodies to the phospholipase A2 receptor (PLA2R) in 2009 and thrombospondin domain-containing 7A (THSD7A) in 2014 on the podocyte surface. Approximately 50–80% and 3–5% of primary MN (PMN) cases are associated with either anti-PLA2R or anti-THSD7A antibodies, respectively. The presence of these autoantibodies is used for MN diagnosis; antibody levels correlate with disease severity and possess significant biomarker values in monitoring disease progression and treatment response. Importantly, both autoantibodies are causative to MN. Additionally, evidence is emerging that NELL-1 is associated with 5–10% of PMN cases that are PLA2R- and THSD7A-negative, which moves us one step closer to mapping out the full spectrum of PMN antigens. Recent developments suggest exostosin 1 (EXT1), EXT2, NELL-1, and contactin 1 (CNTN1) are associated with MN. Genetic factors and other mechanisms are in place to regulate these factors and may contribute to MN pathogenesis. This review will discuss recent developments over the past 5 years.
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