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Liu Y, Tang Y, Le WB, Chen D, Liang D, Xu F, Liang S, Zhong Y, Zeng C. The correlation between anti-phospholipase A2 receptor antibodies and hypercoagulability in patients with idiopathic membranous nephropathy. Ren Fail 2024; 46:2374448. [PMID: 38973428 PMCID: PMC11232635 DOI: 10.1080/0886022x.2024.2374448] [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: 04/16/2024] [Accepted: 06/25/2024] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND Patients with idiopathic membranous nephropathy (IMN) are more likely to be complicated by venous thromboembolism (VTE). The aim of the study was to investigate the potential association between anti-phospholipase A2 receptor (PLA2R) antibodies and hypercoagulability in patients with IMN. METHODS A total of 168 patients with biopsy-proven IMN and 36 patients with biopsy-proven minimal change disease (MCD) were enrolled in this study. The clinical data, serum anti-PLA2R antibodies and coagulation-related indices of the patients were retrospectively analyzed. RESULTS Patients with IMN were categorized into glomerular PLA2R staining-positive (GAg+) IMN group and glomerular PLA2R staining-negative (GAg-) IMN group in the study. Patients with IMN who were GAg + had lower PT, APTT and R time than patients with IMN who were GAg-, while the CI value was higher in patients with IMN who were GAg+. Patients with IMN who were GAg + were divided into the SAb+/GAg + group and the SAb-/GAg + group. Patients with IMN who were SAb+/GAg + had higher Fib and MA values than patients with IMN who were SAb-/GAg+. Correlation analysis showed that serum anti-PLA2R antibodies were positively correlated with fibrinogen, D-dimer, K time, CI value, α-angle, and MA value. Multiple linear regression analysis indicated that anti-PLA2R antibodies were independently correlated with fibrinogen and MA value. CONCLUSION Our study provides a new perspective on the underlying mechanisms of hypercoagulability in patients with IMN. Anti-PLA2R antibodies are associated with hypercoagulability in patients with IMN and may affect coagulation in patients with IMN by affecting platelet aggregation function and fibrinogen counts.
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Affiliation(s)
- Yunyun Liu
- Jinling Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yujie Tang
- Jinling Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Wei-Bo Le
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Dacheng Chen
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Dandan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Feng Xu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Shaoshan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yongzhong Zhong
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
- Department of Nephrology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, China
| | - Caihong Zeng
- Jinling Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Feng Z, Guo FS, Wang Q, Wang M, Zhao MH, Cui Z, Lei X. Macrocarpal B blocks the binding between the phospholipase A2 receptor and its antibodies. Bioorg Med Chem 2024; 110:117793. [PMID: 38917622 DOI: 10.1016/j.bmc.2024.117793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Accepted: 06/06/2024] [Indexed: 06/27/2024]
Abstract
The pathogenic role of anti-phospholipase A2 receptor (PLA2R) antibodies in primary membranous nephropathy (MN) has been well-established. This study aimed to identify potential small-molecule inhibitors against the PLA2R-antibody interaction, offering potential therapeutic benefits. A comprehensive screening of over 4000 small-molecule compounds was conducted by ELISA to assess their inhibitory effects on the binding between the immobilized full-length extracellular PLA2R and its antibodies. The affinity of anti-PLA2R IgG from MN patients and the inhibitory efficacy of each compound were evaluated via surface plasmon resonance (SPR). Human podocyte injuries were analyzed using CCK-8 assay, wound healing assay, western blot analysis, and immunofluorescence, after exposure to MN plasma +/- blocking compound. Fifteen compounds were identified as potential inhibitors, demonstrating inhibition rates >20 % for the PLA2R-antibody interaction. Anti-PLA2R IgG exhibited a consistent affinity among patients (KD = 10-8 M). Macrocarpal B emerged as the most potent inhibitor, reducing the antigen-antibody interaction by nearly 30 % in a dose-dependent manner, comparable to the performance of the 31-mer peptide from the CysR domain. Macrocarpal B bound to the immobilized PLA2R with an affinity of 1.47 × 10-6 M, while showing no binding to anti-PLA2R IgG. Human podocytes exposed to MN plasma showed decreased podocin expression, impaired migration function, and reduced cell viability. Macrocarpal B inhibited the binding of anti-PLA2R IgG to podocytes and reduced the cellular injuries.
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Affiliation(s)
- Zixin Feng
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Fu-Sheng Guo
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Bioorganic Chemistry and Molecular Engineering of Ministry of Education, College of Chemistry and Molecular Engineering, Peking University, Beijing 100871, China; Peking-Tsinghua Center for Life Science, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing 100871, China
| | - Qian Wang
- State Key Laboratory of Natural and Biomimetic Drugs, School of Pharmaceutical Sciences, Peking University, Beijing 100191, China
| | - Miao Wang
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.
| | - Xiaoguang Lei
- Beijing National Laboratory for Molecular Sciences, Key Laboratory of Bioorganic Chemistry and Molecular Engineering of Ministry of Education, College of Chemistry and Molecular Engineering, Peking University, Beijing 100871, China; Peking-Tsinghua Center for Life Science, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing 100871, China.
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Musone D, Nicosia V, D'Alessandro R, Andrietti M, Steri PF, Ruosi C, Giuliana S, Elefante C, Cuccurullo P, Treglia A. Therapeutic plasmapheresis in idiopathic membranous nephropathy anti-PLA2R-related: A case series. J Clin Apher 2024; 39:e22134. [PMID: 38934513 DOI: 10.1002/jca.22134] [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: 01/03/2024] [Revised: 05/03/2024] [Accepted: 05/27/2024] [Indexed: 06/28/2024]
Abstract
Membranous nephropathy is the most common cause of nephrotic syndrome (NS) in non-diabetic adults; in 80% of patients it is idiopathic (PMN). PMN has an autoimmune pathogenesis, 70%-85% of patients have increased titer of antibodies to the podocyte membrane antigen PLA2R. The etiological, prognostic and predictive role of the Ab anti-PLA2R is demonstrated. Standard therapy consists in anti-CD20 monoclonal antibody rituximab (RTX) combined with steroids or immunosuppressants according to the risk of progressive loss of kidney function. The immunosuppressive therapies are potentially associated to severe adverse events that lead to protocol suspension. Given their pivotal pathogenetic role, serum clearance of anti-PLA2R with plasmapheresis could have a beneficial impact on NS, particularly in patients not requiring or tolerating standard therapies. In this series, we present three cases of PMN anti-PLA2R related treated with a RTX plus plasmapheresis approach and demonstrate its overall effective role on anti-PLA2R titer and clinical outcomes.
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Trujillo H, Caravaca-Fontán F, Praga M. Ten tips on immunosuppression in primary membranous nephropathy. Clin Kidney J 2024; 17:sfae129. [PMID: 38915435 PMCID: PMC11195618 DOI: 10.1093/ckj/sfae129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Indexed: 06/26/2024] Open
Abstract
Membranous nephropathy (MN) management poses challenges, particularly in selecting appropriate immunosuppressive treatments (IST) and monitoring disease progression and complications. This article highlights 10 key tips for the management of primary MN based on current evidence and clinical experience. First, we advise against prescribing IST to patients without nephrotic syndrome (NS), emphasizing the need for close monitoring of disease progression. Second, we recommend initiating IST in patients with persistent NS or declining kidney function. Third, we suggest prescribing rituximab (RTX) or RTX combined with calcineurin inhibitors in medium-risk patients. Fourth, we propose cyclophosphamide-based immunosuppression for high-risk patients. Fifth, we discourage the use of glucocorticoid monotherapy or mycophenolate mofetil as initial treatments. Sixth, we underscore the importance of preventing infectious complications in patients receiving IST. Seventh, we emphasize the need for personalized monitoring of IST by closely measuring kidney function, proteinuria, serum albumin and anti-M-type phospholipase A2 receptor levels. Eighth, we recommend a stepwise approach in the treatment of resistant disease. Ninth, we advise adjusting treatment for relapses based on individual risk profiles. Finally, we caution about the potential recurrence of MN after kidney transplantation and suggest appropriate monitoring and treatment strategies for post-transplantation MN. These tips provide comprehensive guidance for clinicians managing MN, aiming to optimize patient outcomes and minimize complications.
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Affiliation(s)
- Hernando Trujillo
- Department of Nephrology, Hospital Universitario, 12 de Octubre, Madrid, Spain
| | - Fernando Caravaca-Fontán
- Department of Nephrology, Hospital Universitario, 12 de Octubre, Madrid, Spain
- Instituto de Investigación Hospital, 12 de Octubre (i+12), Madrid, Spain
| | - Manuel Praga
- Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Ueki K, Tsuchimoto A, Matsukuma Y, Ataka E, Okamoto H, Tanaka S, Masutani K, Kitazono T, Nakano T. Combined evaluation of glomerular phospholipase A2 receptor and immunoglobulin G subclass in membranous nephropathy. Clin Kidney J 2024; 17:sfae104. [PMID: 38854426 PMCID: PMC11161704 DOI: 10.1093/ckj/sfae104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Indexed: 06/11/2024] Open
Abstract
Background Phospholipase A2 receptor (PLA2R) is a major target antigen in idiopathic membranous nephropathy (MN). Anti-PLA2R antibodies are mainly of the immunoglobulin G (IgG) subclass IgG4, although other IgG subclass depositions in glomeruli may also be detected. However, the importance of the subclass of the IgG deposit has not been proven. Thus we investigated clinical findings from patients with idiopathic MN in relation to glomerular PLA2R deposition and IgG subclass. Methods We enrolled 132 Japanese patients with biopsy-proven idiopathic MN in a multicentre retrospective observational study. We investigated the complete remission rate as the primary outcome and the development of end-stage kidney disease (ESKD) as the secondary outcome in relation to glomerular PLA2R deposition. Moreover, we evaluated prognostic factors, including glomerular IgG subclass, in the PLA2R-positive group. Results The percentage of cases with glomerular PLA2R deposition was 76.5% (n = 101). The first complete remission rate of the PLA2R-positive group was worse than that of the PLA2R-negative group (logrank test P < .001). ESKD incidence did not significantly differ between the glomerular PLA2R-negative and PLA2R-positive MN groups (logrank test P = .608). In the PLA2R-positive group, higher PLA2R intensities and IgG2 staining were associated with a poorer first complete remission rate (logrank test P < .001 and P = .032, respectively). Cox proportional hazards analysis also showed that strong PLA2R deposition and positive IgG2 staining were significantly associated with a failure to reach complete remission [hazard ratio 2.09 (P = .004) and 1.78 (P = .030), respectively]. Conclusions Our results suggest that intense glomerular PLA2R and IgG2 positivity predict a poor proteinuria remission rate in idiopathic MN.
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Affiliation(s)
- Kenji Ueki
- Department of Medicine and Clinical Science, Kyushu University, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Kyushu University, Fukuoka, Japan
| | - Yuta Matsukuma
- Department of Medicine and Clinical Science, Kyushu University, Fukuoka, Japan
| | - Eri Ataka
- Department of Medicine and Clinical Science, Kyushu University, Fukuoka, Japan
| | - Hirofumi Okamoto
- Department of Medicine and Clinical Science, Kyushu University, Fukuoka, Japan
| | - Shigeru Tanaka
- Department of Medicine and Clinical Science, Kyushu University, Fukuoka, Japan
| | - Kosuke Masutani
- Division of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Kyushu University, Fukuoka, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Kyushu University, Fukuoka, Japan
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Zhou K, Zhou J, Zhou L, Xue J, Liu B, Zhang Z, Zhang X, Cai T, Shao S, Huang B, Zhang Y, Hu Z, Wang L, Liu X. Predictive value of the domain specific PLA2R antibodies for clinical remission in patients with primary membranous nephropathy: A retrospective study. PLoS One 2024; 19:e0302100. [PMID: 38718066 PMCID: PMC11078387 DOI: 10.1371/journal.pone.0302100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 03/26/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND M-type phospholipase A2 receptor (PLA2R) is a major auto-antigen of primary membranous nephropathy(PMN). Anti-PLA2R antibody levels are closely associated with disease severity and therapeutic effectiveness. Analysis of PLA2R antigen epitope reactivity may have a greater predictive value for remission compared with total PLA2R-antibody level. This study aims to elucidate the relationship between domain-specific antibody levels and clinical outcomes of PMN. METHODS This retrospective analysis included 87 patients with PLA2R-associated PMN. Among them, 40 and 47 were treated with rituximab (RTX) and cyclophosphamide (CTX) regimen, respectively. The quantitative detection of -immunoglobulin G (IgG)/-IgG4 targeting PLA2R and its epitope levels in the serum of patients with PMN were obtained through time-resolved fluorescence immunoassays and served as biomarkers in evaluating the treatment effectiveness. A predictive PMN remission possibility nomogram was developed using multivariate logistic regression analysis. Discrimination in the prediction model was assessed using the area under the receiver operating characteristic curve (AUC-ROC).Bootstrap ROC was used to evaluate the performance of the prediction model. RESULTS After a 6-month treatment period, the remission rates of proteinuria, including complete remission and partial remission in the RTX and CTX groups, were 70% and 70.21% (P = 0.983), respectively. However, there was a significant difference in immunological remission in the PLA2R-IgG4 between the RTX and CTX groups (21.43% vs. 61.90%, P = 0.019). Furthermore, we found differences in PLA2R-CysR-IgG4(P = 0.030), PLA2R-CTLD1-IgG4(P = 0.005), PLA2R-CTLD678-IgG4(P = 0.003), and epitope spreading (P = 0.023) between responders and non-responders in the CTX group. Multivariate logistic analysis showed that higher levels of urinary protein (odds ratio [OR], 0.49; 95% confidence interval [CI], 0.26-0.95; P = 0.035) and higher levels of PLA2R-CTLD1-IgG4 (OR, 0.79; 95%CI,0.62-0.99; P = 0.041) were independent risk factors for early remission. A multivariate model for estimating the possibility of early remission in patients with PMN is presented as a nomogram. The AUC-ROC of our model was 0.721 (95%CI, 0.601-0.840), in consistency with the results obtained with internal validation, for which the AUC-ROC was 0.711 (95%CI, 0.587-0.824), thus, demonstrating robustness. CONCLUSIONS Cyclophosphamide can induce immunological remission earlier than rituximab at the span of 6 months. The PLA2R-CTLD1-IgG4 has a better predict value than total PLA2R-IgG for remission of proteinuria at the 6th month.
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Affiliation(s)
- Kezhi Zhou
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
| | - Junyi Zhou
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
| | - Leting Zhou
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
| | - Jing Xue
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
| | - Bin Liu
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
| | - Zhijian Zhang
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
| | - Xiran Zhang
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
| | - Ting Cai
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
| | - Sijia Shao
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
| | - Biao Huang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Yi Zhang
- NHC Key Laboratory of Nuclear Medicine, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, P.R. China
| | - Zhigang Hu
- Medical Laboratory, The Affiliated Wuxi Children’s Hospital of Nanjing Medical University, Wuxi, P.R. China
| | - Liang Wang
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
| | - Xiaobin Liu
- Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Wuxi People’s Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, P.R. China
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Sethi S, Fervenza FC. Membranous nephropathy-diagnosis and identification of target antigens. Nephrol Dial Transplant 2024; 39:600-606. [PMID: 37863839 DOI: 10.1093/ndt/gfad227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Indexed: 10/22/2023] Open
Abstract
Membranous nephropathy (MN) is a common cause of nephrotic syndrome in adults. MN is characterized by subepithelial accumulation of immune complexes along the glomerular basement membrane. The immune complexes are composed of immunoglobulin G and a target antigen. PLA2R is the target antigen in approximately 60% of MN cases, and MN is traditionally classified as PLA2R-positive or PLA2R-negative MN. Over the last 7 years, additional target antigens have been identified, which have specific disease associations, distinctive clinical and pathologic findings, and therapeutic implications. The newly discovered target antigens include NELL1, EXT1/EXT2, NCAM1, SEMA3B, PCDH7, FAT1, CNTN1, NTNG1, PCSK6 and NDNF. To group all these antigens into a generic 'PLA2R-negative' MN group is imprecise and un-informative. We propose a logical approach for detection of the target antigen which includes (i) currently available serology-based testing to detect anti-PLA2R and anti-THSD7A antibodies; and (ii) kidney biopsy testing to detect the target antigens. Determination of the antigen on kidney biopsy can be done by immunohistochemistry or immunofluorescence studies. Alternatively, laser capture microdissection (LCM) of glomeruli followed by mass spectrometry (MS) can be used to identify a target antigen. LCM/MS has the advantage of being a one-stop test and is particularly useful for detection of rare target antigens. At the current time, while it is possible to detect the newer antigens by immunohistochemistry/immunofluorescence/LCM/MS, serology-based tests to detect serum antibodies to the new antigens are not yet available. It is critical that serology-based tests should be developed not just for accurate diagnosis, but as a guide for treatment. We review the current methodology and propose an algorithm for diagnosis and detection of target antigens in MN that may shape the current practice in the future. Membranous nephropathy (MN) results from accumulation of subepithelial immune complexes along the glomerular basement membrane.PLA2R is the most common target antigen, but newly discovered target antigens have filled the void of PLA2R-negative MN.MN associated with the newly discovered target antigens have distinctive clinical and pathologic findings, treatment and prognostic implications. These include NELL1, EXT1/EXT2, NCAM1, PCDH7, SEMA3B, CNTN1, FAT1, NDNF and PCSK6.Immunohistochemistry/immunofluorescence methodology is currently in use for detecting target antigens in kidney biopsy tissue, although we anticipate laser capture microdissection of glomeruli followed by mass spectrometry will become available soon.Serologic testing is currently available for only detecting antibodies to PLA2R and THSD7A. It is critical that serologic tests become available for detecting antibodies to the newly discovered antigens.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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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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Liu X, Xue J, Li T, Wu Q, Sheng H, Yang X, Lin B, Zhou X, Qin Y, Huang Z, Zhou L, Wang L, Hu Z, Huang B. Quantitative detection and prognostic value of antibodies against M-type phospholipase A2 receptor and its cysteine-rich ricin domain and C-type lectin domains 1 and 6-7-8 in patients with idiopathic membranous nephropathy. PLoS One 2024; 19:e0298269. [PMID: 38386672 PMCID: PMC10883571 DOI: 10.1371/journal.pone.0298269] [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] [Received: 09/10/2023] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND M-type phospholipase A2 receptor (PLA2R) is the major autoantigen in adult idiopathic membranous nephropathy (IMN). Although reactive epitopes in the PLA2R domains have been identified, the clinical value of these domains recognized by anti-PLA2R antibodies remains controversial. Accordingly, this study aimed to quantitatively detect changes in the concentrations of different antibodies against epitopes of PLA2R in patients with IMN before and after treatment to evaluate the clinical value of epitope spreading. METHODS Highly sensitive time-resolved fluorescence immunoassay was used to quantitatively analyze the concentrations of specific IgG and IgG4 antibodies against PLA2R and its epitopes (CysR, CTLD1, CTLD6-7-8) in a cohort of 25 patients with PLA2R-associated membranous nephropathy (13 and 12 in the remission and non-remission groups, respectively) before and after treatment, and the results were analyzed in conjunction with clinical biochemical indicators. RESULTS The concentration of specific IgG (IgG4) antibodies against PLA2R and its epitopes (CysR, CTLD1 and CTLD6-7-8) in non-remission group was higher than that in remission group. The multipliers of elevation of IgG (IgG4) antibody were 5.6(6.2) fold, 3.0(24.3) fold, 1.6(9.0) fold, and 4.2(2.6) fold in the non-remission/remission group, respectively. However, the difference in antibody concentrations between the two groups at the end of follow-up was 5.6 (85.2), 1.7 (13.1), 1.0 (5.1), and 1.5 (22.3) times higher, respectively. When detecting concentrations of specific IgG antibodies against PLA2R and its different epitopes, the remission rate was 66.67% for only one epitope at M0 and 36.36% for three epitopes at M0. When detecting concentrations of specific IgG4 antibodies against PLA2R and its different epitopes, the remission rate was 100.00% for only one epitope at M0 and 50.00% for three epitopes at M0. A trivariate logistic regression model for the combined detection of eGFR, anti-CTLD678 IgG4, and urinary protein had an AUC of 100.00%. CONCLUSION Low concentrations of anti-CysR-IgG4, anti-CTLD1-IgG4, and anti-CTLD6-7-8-IgG4 at initial diagnosis predict rapid remission after treatment. The use of specific IgG4 against PLA2R and its different epitopes combined with eGFR and urinary protein provides a better assessment of the prognostic outcome of IMN.
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Affiliation(s)
- Xiaobin Liu
- Wuxi Medical Center, Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Nanjing Medical University, Wuxi, China
| | - Jing Xue
- Wuxi Medical Center, Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Nanjing Medical University, Wuxi, China
| | - Ting Li
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Qingqing Wu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Huiming Sheng
- Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xue Yang
- Wuxi Children’s Hospital, Wuxi, China
| | - Bo Lin
- Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Xiumei Zhou
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Yuan Qin
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | - Zijian Huang
- School of Life Science, Westlake University, Hangzhou, China
| | - Leting Zhou
- Wuxi Medical Center, Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Nanjing Medical University, Wuxi, China
| | - Liang Wang
- Wuxi Medical Center, Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Nanjing Medical University, Wuxi, China
| | - Zhigang Hu
- Wuxi Medical Center, Department of Nephrology, The Affiliated Wuxi People’s Hospital of Nanjing Medical University, Nanjing Medical University, Wuxi, China
- Wuxi Children’s Hospital, Wuxi, China
| | - Biao Huang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
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10
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Destere A, Teisseyre M, Merino D, Cremoni M, Gérard AO, Crepin T, Jourde-Chiche N, Graça D, Zorzi K, Fernandez C, Brglez V, Benzaken S, Esnault VL, Benito S, Drici MD, Seitz-Polski B. Optimization of Rituximab Therapy in Adult Patients With PLA2R1-Associated Membranous Nephropathy With Artificial Intelligence. Kidney Int Rep 2024; 9:134-144. [PMID: 38312797 PMCID: PMC10831377 DOI: 10.1016/j.ekir.2023.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/12/2023] [Accepted: 10/23/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Rituximab is a first-line treatment for membranous nephropathy. Nephrotic syndrome limits rituximab exposure due to urinary drug loss. Rituximab underdosing (serum level <2 μg/ml at month-3) is a risk factor for treatment failure. We developed a machine learning algorithm to predict the risk of underdosing based on patients' characteristics at rituximab infusion. We investigated the relationship between the predicted risk of underdosing and the cumulative dose of rituximab required to achieve remission. Methods Rituximab concentrations were measured at month-3 in 92 sera from adult patients with primary membranous nephropathy, split into a training (75%) and a testing set (25%). A forward-backward machine-learning procedure determined the best combination of variables to predict rituximab underdosing in the training data set, which was tested in the test set. The performances were evaluated for accuracy, sensitivity, and specificity in 10-fold cross-validation training and test sets. Results The best variables combination to predict rituximab underdosing included age, gender, body surface area (BSA), anti-phospholipase A2 receptor type 1 (anti-PLA2R1) antibody titer on day-0, serum albumin on day-0 and day-15, and serum creatinine on day-0 and day-15. The accuracy, sensitivity, and specificity were respectively 79.4%, 78.7%, and 81.0% (training data set), and 79.2%, 84.6% and 72.7% (testing data set). In both sets, the algorithm performed significantly better than chance (P < 0.05). Patients with an initial high probability of underdosing experienced a longer time to remission with higher rituximab cumulative doses required to achieved remission. Conclusion This algorithm could allow for early intensification of rituximab regimen in patients at high estimated risk of underdosing to increase the likelihood of remission.
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Affiliation(s)
- Alexandre Destere
- Département de Pharmacologie et de Pharmacovigilance, CHU de Nice, Université Côte d’Azur, France
- Université Côte d’Azur, Inria, CNRS, Laboratoire J.A. Dieudonné, Maasai team, Nice, France
| | - Maxime Teisseyre
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, CHU de Nice, Université Côte d’Azur, France
- Unité de Recherche Clinique Côte d’Azur (UR2CA), Université Côte d’Azur, CHU de Nice, France
- Département de Néphrologie, Dialyse et Transplantation, CHU de Nice, Université Côte d’Azur, France
| | - Diane Merino
- Département de Pharmacologie et de Pharmacovigilance, CHU de Nice, Université Côte d’Azur, France
| | - Marion Cremoni
- Unité de Recherche Clinique Côte d’Azur (UR2CA), Université Côte d’Azur, CHU de Nice, France
- Laboratoire d’Immunologie, CHU de Nice, Université Côte d’Azur, France
| | - Alexandre O Gérard
- Département de Pharmacologie et de Pharmacovigilance, CHU de Nice, Université Côte d’Azur, France
- Département de Néphrologie, Dialyse et Transplantation, CHU de Nice, Université Côte d’Azur, France
| | - Thomas Crepin
- Département de Néphrologie, Dialyse et Transplantation, CHU de Besançon, Besançon, France
| | - Noémie Jourde-Chiche
- Département de Néphrologie, Dialyse et Transplantation, Hôpital de la Conception, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Daisy Graça
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, CHU de Nice, Université Côte d’Azur, France
- Unité de Recherche Clinique Côte d’Azur (UR2CA), Université Côte d’Azur, CHU de Nice, France
- Laboratoire d’Immunologie, CHU de Nice, Université Côte d’Azur, France
| | - Kévin Zorzi
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, CHU de Nice, Université Côte d’Azur, France
- Unité de Recherche Clinique Côte d’Azur (UR2CA), Université Côte d’Azur, CHU de Nice, France
| | - Céline Fernandez
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, CHU de Nice, Université Côte d’Azur, France
- Unité de Recherche Clinique Côte d’Azur (UR2CA), Université Côte d’Azur, CHU de Nice, France
| | - Vesna Brglez
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, CHU de Nice, Université Côte d’Azur, France
- Unité de Recherche Clinique Côte d’Azur (UR2CA), Université Côte d’Azur, CHU de Nice, France
- Laboratoire d’Immunologie, CHU de Nice, Université Côte d’Azur, France
| | - Sylvia Benzaken
- Laboratoire d’Immunologie, CHU de Nice, Université Côte d’Azur, France
| | - Vincent L.M. Esnault
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, CHU de Nice, Université Côte d’Azur, France
- Département de Néphrologie, Dialyse et Transplantation, CHU de Nice, Université Côte d’Azur, France
| | | | - Milou-Daniel Drici
- Département de Pharmacologie et de Pharmacovigilance, CHU de Nice, Université Côte d’Azur, France
| | - Barbara Seitz-Polski
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, CHU de Nice, Université Côte d’Azur, France
- Unité de Recherche Clinique Côte d’Azur (UR2CA), Université Côte d’Azur, CHU de Nice, France
- Département de Néphrologie, Dialyse et Transplantation, CHU de Nice, Université Côte d’Azur, France
- Laboratoire d’Immunologie, CHU de Nice, Université Côte d’Azur, France
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McDonnell T, Storrar J, Chinnadurai R, Heal C, Chrysochou C, Ritchie J, Rainone F, Poulikakos D, Kalra P, Sinha S. The epidemiology of primary FSGS including cluster analysis over a 20-year period. BMC Nephrol 2023; 24:365. [PMID: 38072955 PMCID: PMC10712143 DOI: 10.1186/s12882-023-03405-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
INTRODUCTION Focal segmental glomerulosclerosis (FSGS) is one of the leading causes of nephrotic syndrome in adults. This epidemiological study describes a renal centre's 20-year experience of primary FSGS. METHODS Patients were identified with a diagnosis of primary FSGS after exclusion of known secondary causes. In this retrospective observational study, data was collected for baseline demographics, immunosuppression and outcomes. A two-step cluster analysis was used to identify natural groupings within the dataset. RESULTS The total cohort was made up of 87 patients. Those who received immunosuppression had lower median serum albumin than those who did not- 23g/L vs 40g/L (p<0.001) and higher median urine protein creatinine ratios (uPCR)- 795mg/mmol vs 318mg/mmol (p <0.001). They were more likely to achieve complete remission (62% vs 40%, p=0.041), but relapsed more 48.6% vs 22% (p=0.027). Overall 5 year mortality was 10.3% and 5 year progression to RRT was seen in 17.2%. Complete remission was observed in 49.4%. The 2-step cluster analysis separated the cohort into 3 clusters: cluster 1 (n=26) with 'nephrotic-range proteinuria'; cluster 2 (n=43) with 'non-nephrotic-range proteinuria'; and cluster 3 (n=18) with nephrotic syndrome. Immunosuppression use was comparable in clusters 1 and 3, but lower in cluster 2 (77.8% and 69.2% vs 11.6%, p<0.001). Rates of complete remission were greatest in clusters 1 and 3 vs cluster 2: 57.7% and 66.7% vs 37.2%. CONCLUSION People who received immunosuppression had lower serum albumin and achieved remission more frequently, but were also prone to relapse. Our cluster analysis highlighted 3 FSGS phenotypes: a nephrotic cluster that clearly require immunosuppression; a cohort with preserved serum albumin and non-nephrotic range proteinuria who will benefit from supportive care; and lastly a cluster with heavy proteinuria but serum albumin > 30g/L. This group may still have immune mediated disease and thus could potentially benefit from immunosuppression. TRIAL REGISTRATION This study protocol was reviewed and approved by the 'Research and Innovation committee of the Northern Care Alliance NHS Group', study approval number (Ref: ID 22HIP54).
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Affiliation(s)
- Thomas McDonnell
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Salford, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Oxford Road, Manchester, UK
| | - Joshua Storrar
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Salford, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Oxford Road, Manchester, UK
| | - Rajkumar Chinnadurai
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Salford, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Oxford Road, Manchester, UK
| | - Calvin Heal
- Centre for Biostatistics, University of Manchester, Oxford Road, Manchester, UK
| | - Constantina Chrysochou
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Salford, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Oxford Road, Manchester, UK
| | - James Ritchie
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Salford, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Oxford Road, Manchester, UK
| | - Francesco Rainone
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Salford, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Oxford Road, Manchester, UK
| | - Dimitrios Poulikakos
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Salford, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Oxford Road, Manchester, UK
| | - Philip Kalra
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Salford, UK
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Oxford Road, Manchester, UK
| | - Smeeta Sinha
- Donal O'Donoghue Renal Research Centre, Northern Care Alliance NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Salford, UK.
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Oxford Road, Manchester, UK.
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12
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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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13
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Sun M, Li P, Dong J, Li Z, Li C, Zhang S, Chen B. Clinical characteristics and prognosis of patients with idiopathic membranous nephropathy with kidney tubulointerstitial damage. Ren Fail 2023; 45:2205951. [PMID: 37125531 PMCID: PMC10134950 DOI: 10.1080/0886022x.2023.2205951] [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: 05/02/2023] Open
Abstract
BACKGROUND To investigate the clinical and kidney pathological features and prognosis of idiopathic membranous nephropathy (IMN) with kidney tubulointerstitial damage (TID). METHODS Based on the presence or absence of kidney TID by kidney biopsy, 300 patients diagnosed with IMN were categorized into non-TID (TID-) and tubulointerstitial injury (TID+) groups. The clinical and pathological data were analyzed retrospectively. All patients were followed up for 6-24 months after treatment with glucocorticoids (GCs) combined with cyclophosphamide or GCs combined with calcineurin inhibitors (CNIs) to observe treatment effects on patient prognosis. RESULTS The patients in the TID + group were older and more likely to be male. The 24-h urine protein, blood urea nitrogen, serum creatinine, cystatin C, β2-microglobulin, and antiphospholipase A2 receptor antibody levels were higher than those in the TID - group and the pathological manifestations were more severe. After 1 year of follow-up, the overall response rate (complete response + partial response) in the TID + group was lower (66.67% vs. 80.89%, p = .022) than in the other. After combined GC and CNI therapy, the complete remission rate in the TID + group was significantly lower than that in the TID - group (13.79% vs. 35.46%, p = .022). The 24-h urine protein level was an independent risk factor for worsening kidney condition (p = .038). CONCLUSION Patients with IMN with TID have more severe clinical manifestations and pathological damage and lower remission rates. IMN with TID is a risk factor for worsening kidney condition; however, it is not an independent risk factor.
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Affiliation(s)
- Mengyao Sun
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Ping Li
- Department of Nephrology and Rheumatology, Affiliated Hospital of Shandong Medical College, Linyi, Shandong, China
| | - Jianwei Dong
- Department of Thoracic surgery, The people's Hospital of Rongcheng, Rongcheng, Shandong, China
| | - Zhuo Li
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Chaofan Li
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Shasha Zhang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Bing Chen
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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Sun Y, Ren Y, Lan P, Yu X, Feng J, Hao D, Xie L. Clinico-pathological features of diabetic and non-diabetic renal diseases in type 2 diabetic patients: a retrospective study from a 10-year experience in a single center. Int Urol Nephrol 2023; 55:2303-2312. [PMID: 36879071 PMCID: PMC10406681 DOI: 10.1007/s11255-023-03478-4] [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: 11/14/2020] [Accepted: 01/19/2023] [Indexed: 03/08/2023]
Abstract
AIM To compare clinical and pathological characteristics as well as prognosis between diabetic nephropathy (DN) and non-diabetic renal disease (NDRD) so as to explore potential diagnostic criteria of DN and provide some guidance for the treatment of type 2 diabetes mellitus (T2DM) patients with kidney involvement. METHODS T2DM patients with renal impairment who underwent kidney biopsy were included in this study, who were classified into 3 groups (DN, NDRD, DN with NDRD) based on their renal pathological diagnosis. Baseline clinical characteristics as well as follow-up data were collected and analyzed among 3 groups. Logistic regression was performed to determine the best predictors for DN diagnosis. Additional 34 MN patients without diabetes were enrolled by propensity score matching method to compare serum PLA2R antibody titer and kidney outcomes between diabetic MN patients and MN alone. RESULTS Among 365 patients with type 2 diabetes who underwent kidney biopsy, 179 (49.0%) patients were diagnosed with NDRD alone and 37 (10.1%) patients with NDRD combined DN. Risk factors for DN development in T2DM patients were longer time since diabetes diagnosis, higher level of serum creatinine, absence of hematuria and presence of diabetic retinopathy by multivariate analysis. Lower rate of proteinuria remission and higher risk of renal progression were observed in DN group compared with NDRD group. Membranous nephropathy was the most common NDRD in diabetic patients. There was no difference in serum PLA2R antibody positiveness or titer between MN patients with or without T2DM. There was lower remission rate but similar renal progression in diabetic MN when age, gender, baseline eGFR, albuminuria and IFTA score were adjusted. CONCLUSIONS Non-diabetic renal disease is not uncommon in T2DM patients with renal impairment, which has better prognosis with proper treatment. Coexisting diabetic status does not exert negative impact on renal progression in MN patients, and immunosuppressive agents should be administered when necessary.
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Affiliation(s)
- Yuemeng Sun
- Department of Nephrology, Xi'an People's Hospital (Xi'an Forth Hospital), Xincheng District Jiefang Road 21, Xi'an, 710001, Shannxi, China
| | - Yawei Ren
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Yanta Western road 227, Xi'an, 710061, Shaanxi, China
| | - Ping Lan
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Yanta Western road 227, Xi'an, 710061, Shaanxi, China
| | - Xiaoyang Yu
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Yanta Western road 227, Xi'an, 710061, Shaanxi, China
| | - Jie Feng
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Yanta Western road 227, Xi'an, 710061, Shaanxi, China
| | - Dapeng Hao
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Yanta Western road 227, Xi'an, 710061, Shaanxi, China
| | - Liyi Xie
- Department of Nephrology, The First Affiliated Hospital of Xi'an Jiaotong University, Yanta Western road 227, Xi'an, 710061, Shaanxi, China.
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15
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Gaggar P, Madipally R, Raju SB. Rituximab, Use and B Cell Depletion in Patients with Membranous Nephropathy- A Retrospective, Observational Study. Indian J Nephrol 2023; 33:356-361. [PMID: 37881741 PMCID: PMC10593300 DOI: 10.4103/ijn.ijn_62_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/04/2022] [Accepted: 05/21/2022] [Indexed: 10/27/2023] Open
Abstract
Introduction Rituximab (Rtx), an anti-CD20 monoclonal antibody, results in selective B-cell depletion and has emerged as an important therapeutic option in idiopathic membranous nephropathy (MN). We conducted a retrospective observational study to evaluate the efficacy and tolerability of Rtx in MN with respect to the B-cell count depletion. Methods Twenty patients with biopsy proven primary MN, both treatment naïve and treatment resistant, who received a fixed dose protocol of 500mg IV Rtx 1month apart were retrospectively observed with a minimum follow-up period of 12 months. The primary clinical outcome was complete (CR) or partial remission (PR) at 12 months in relation to B-cell depletion at 6 and 12 months. Results All were patients (men, 90%) of PLA2R-Ab positive with MN with a mean age of 37.7 ± 12.5 years. The mean 24-h urinary protein was 7.5 ± 2.15 gm/day, serum albumin was 2.01 ± 0.6gm/dL, and eGFR was 86.5 ± 20 mL/min/1.73m2. Primary composite outcome at 12 months was 66.7%, with 5.6% CR and 61.1% PR.The mean PLA2R-Ab at 12 months was low in those with remission compared to those who did not achieve (17.8 ± 21.2 RU/mL vs 311.7 ± 356.0; P = 0.01). Sustained B cell depletion at 6 months was seen in 84.3% (OR = 2.2, 95% CI = 0.11-42.7; P = 0.53) and 32% at 12 months (OR = 2.25, 95% CI = 0.18-27.7, and P = 0.66). Conclusion Acceptable remission rates were seen with Rtx in both treatment naïve and treatment-resistant patients with MN. There was no significant association between B-cell depletion and remission.
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Affiliation(s)
- Payal Gaggar
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Ravitej Madipally
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Sree B. Raju
- Department of Nephrology, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
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Kakhsurueva PA, Kamyshova ES, Bobkova IN, Stavrovskaya EV, Rudenko TE, Andreeva EY. [Clinical significance of the determination of antibodies to thrombospondin type 1 containing domain 7A (THSD7A) in membranous nephropathy]. TERAPEVT ARKH 2023; 95:462-467. [PMID: 38158964 DOI: 10.26442/00403660.2023.06.202268] [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: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Membranous nephropathy (MN) is an immunocomplex glomerular disease, which is the most common cause of nephrotic syndrome in adults. Numerous studies have established that autoantibodies against the target podocyte autoantigens, including the thrombospondin type 1 domain containing 7A (THSD7A), play a leading role in the development of idiopathic MN. AIM To evaluate the prevalence of anti-THSD7A autoantibodies (anti-THSD7A AB) in a group of Russian patients with MN. MATERIALS AND METHODS Serum titers of anti-THSD7A AB were tested in 61 patients with biopsy-proven MN and 12 healthy controls. RESULTS The prevalence of anti-THSD7A AB was not differing significantly in patients with MN and in the control group (110.9 [71.63; 210.62] and 159.25 [125.64; 231.97] pg/ml, respectively; p=0.111). When comparing subgroups of anti-PLA2R-negative patients and patients who did not receive immunosuppressive therapy with the control group, there were also no statistically significant differences in the Anti-THSD7A AB levels (p>0.05). In the MN group, 1 (1.6%) patient was anti-THSD7A-positive: a 60-year-old man with anti-PLA2R-negative MN and the presence of hormonally inactive adenomas of both adrenal glands and colon polyps (villous adenoma with focal moderate dysplasia, tubulo-villous and tubular adenoma with focal moderate severe dysplasia). CONCLUSION THSD7-associated MN is a rare variant of MN and is usually detected in PLA2R-negative patients. Screening for malignancies in THSD7A-positive MN patients is proposed.
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Affiliation(s)
- P A Kakhsurueva
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E S Kamyshova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - I N Bobkova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E V Stavrovskaya
- Sechenov First Moscow State Medical University (Sechenov University)
| | - T E Rudenko
- Sechenov First Moscow State Medical University (Sechenov University)
| | - E Y Andreeva
- Sechenov First Moscow State Medical University (Sechenov University)
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McDonnell T, Wu HHL, Sinha S, Chinnadurai R. The Role of PLA2R in Primary Membranous Nephropathy: Do We Still Need a Kidney Biopsy? Genes (Basel) 2023; 14:1343. [PMID: 37510247 PMCID: PMC10380005 DOI: 10.3390/genes14071343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/24/2023] [Accepted: 06/24/2023] [Indexed: 07/30/2023] Open
Abstract
Membranous nephropathy (MN) is the most prevalent cause of nephrotic syndrome amongst the non-diabetic adult population. A fifth of idiopathic nephrotic syndrome cases can be attributed to MN, rising to more than 40% in older patients over 60 years. Most MN cases are classified as being of a primary cause, where there is absence of a secondary disease process explaining its manifestation. Traditionally, the standard approach of diagnosing MN involves performing a kidney biopsy as histological evaluation offers not only conclusive evidence of the diagnosis but also provides valuable information regarding disease chronicity and the presence of any other kidney histopathological features. Nevertheless, kidney biopsy is an invasive procedure which poses risks for the patient including bleeding and pain and bears greater costs for the health system. The identification of the phospholipase A2 receptor (PLA2R) antigen in 2009 was a landmark discovery, one which has evolved our understanding of the disease processes in MN and subsequently our management approach of this condition. Antibodies against PLA2R (PLA2RAb) have since emerged as an attractive non-invasive test option to be applied for the diagnosis and prognostication of primary MN. However, much debate and unknowns remain about the accuracy and reliability of testing for PLA2RAb across various primary MN scenarios. We provide a review summarizing the historical journey of PLA2R in relation to its significance in primary MN and, more importantly, evidence emerging over the years which contemplated the role of PLA2RAb as a diagnostic and prognostic tool in primary MN.
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Affiliation(s)
- Thomas McDonnell
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (T.M.); (S.S.); (R.C.)
| | - Henry H. L. Wu
- Renal Research Laboratory, Kolling Institute of Medical Research, Royal North Shore Hospital, The University of Sydney, Sydney, NSW 2065, Australia
| | - Smeeta Sinha
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (T.M.); (S.S.); (R.C.)
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK
| | - Rajkumar Chinnadurai
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust, Salford M6 8HD, UK; (T.M.); (S.S.); (R.C.)
- Faculty of Biology, Medicine & Health, The University of Manchester, Manchester M1 7HR, UK
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Liu Y, Zhang S, Hu R, Li C, Chen G, Shi X, Liu Y, Zheng K, Li H, Wen Y, Li X, Li X, Xia P, Qin Y. The Safety and Efficacy of Rituximab-Based Regimen in Atypical Membranous Nephropathy: A Single Center Retrospective Cohort Study. Int J Gen Med 2023; 16:1983-1993. [PMID: 37251282 PMCID: PMC10224685 DOI: 10.2147/ijgm.s410169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/16/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose There are increasing reports of atypical membranous nephropathy (AMN) cases with similar pathological characteristics to secondary membranous nephropathy (SMN) without definite underlying causes. Although rituximab has become a first-line option in treating idiopathic membranous nephropathy (IMN), the efficacy and safety of rituximab-based regimen for AMN is not clear. Patients and Methods This is a retrospective, single-center study. AMN patients who received rituximab-based therapy were included. IMN patients treated with rituximab during the same period were selected as the control group matched by gender, sex, baseline urinary protein and albumin levels. Baseline data and follow-up data were collected. Results A total of 20 AMN patients and 40 IMN patients were included. The baseline levels of urinary protein were comparable between the two groups [6.77 (IQR 3.34, 11.49) g/24 h vs 6.47 (IQR 3.4, 10.76) g/24 h, P=0.944]. The baseline levels of serum albumin were 26.15±6.71 g/L and 26.8±5.54 g/L (P=0.689) respectively. The cumulative remission rate for rituximab-based treatment at the 12th month was lower in AMN group than IMN group [13 (65%) vs 36 (90%), P=0.045]. In AMN group, non-responders showed a higher level of proteinuria and a worse renal function at baseline than those of responders. There was no significant difference in the overall adverse events or serious adverse events between the two groups. Conclusion In our study, AMN patients obtained proteinuria remission in a lower percentage compared with IMN patients. In general, rituximab-based therapy is effective in AMN patients with an acceptable safety profile.
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Affiliation(s)
- Yanan Liu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Shuo Zhang
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Rongrong Hu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Chao Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Gang Chen
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Xiaoxiao Shi
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Yan Liu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Ke Zheng
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Hang Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Yubing Wen
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Xuewang Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Peng Xia
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
| | - Yan Qin
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, People’s Republic of China
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19
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Kukuy OL, Cohen R, Gilburd B, Zeruya E, Weinstein T, Agur T, Dinour D, Beckerman P, Volkov A, Nissan J, Davidson T, Amital H, Shoenfeld Y, Shovman O. The Prognostic Value of Anti-PLA2R Antibodies Levels in Primary Membranous Nephropathy. Int J Mol Sci 2023; 24:ijms24109051. [PMID: 37240397 DOI: 10.3390/ijms24109051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Anti-PLA2R antibodies (Ab) are a diagnostic and prognostic biomarker in primary membranous nephropathy (PMN). We assessed the relationship between the levels of anti-PLA2R Ab at diagnosis and different variables related to disease activity and prognosis in a western population of PMN patients. Forty-one patients with positive anti-PLA2R Ab from three nephrology departments in Israel were enrolled. Clinical and laboratory data were collected at diagnosis and after one year of follow-up, including serum anti-PLA2R Ab levels (ELISA) and glomerular PLA2R deposits on biopsy. Univariable statistical analysis and permutation-based ANOVA and ANCOVA tests were performed. The median [(interquartile range (IQR)) age of the patients was 63 [50-71], with 28 (68%) males. At the time of diagnosis, 38 (93%) of the patients had nephrotic range proteinuria, and 19 (46%) had heavy proteinuria (≥8 gr/24 h). The median [IQR] level of anti-PLA2R at diagnosis was 78 [35-183] RU/mL. Anti-PLA2R levels at diagnosis were correlated with 24 h proteinuria, hypoalbuminemia and remission after one year (p = 0.017, p = 0.003 and p = 0.034, respectively). The correlations for 24 h proteinuria and hypoalbuminemia remained significant after adjustment for immunosuppressive treatment (p = 0.003 and p = 0.034, respectively). Higher levels of anti-PLA2R Ab at diagnosis in patients with active PMN from a western population are associated with higher proteinuria, lower serum albumin and remission one year after the diagnosis. This finding supports the prognostic value of anti-PLA2R Ab levels and their possible use in stratifying PMN patients.
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Affiliation(s)
- Olga Lesya Kukuy
- Institute of Nephrology and Hypertension, Sheba Medical Center, Ramat Gan 5265601, Israel
| | - Ron Cohen
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Boris Gilburd
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan 5265601, Israel
| | - Eleanor Zeruya
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan 5265601, Israel
| | - Talia Weinstein
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
- Department of Nephrology, Tel Aviv-Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Timna Agur
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
- Department of Nephrology and Hypertension, Rabin Medical Center, Petah-Tikva 4941492, Israel
| | - Dganit Dinour
- Institute of Nephrology and Hypertension, Sheba Medical Center, Ramat Gan 5265601, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Pazit Beckerman
- Institute of Nephrology and Hypertension, Sheba Medical Center, Ramat Gan 5265601, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Alexander Volkov
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
- Institute of Pathology, Sheba Medical Center, Ramat Gan 5265601, Israel
| | - Johnatan Nissan
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
| | - Tima Davidson
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
- Department of Nuclear Medicine, Sheba Medical Center, Ramat Gan 5265601, Israel
| | - Howard Amital
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan 5265601, Israel
- Department of Medicine 'B', Sheba Medical Center, Ramat Gan 5265601, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan 5265601, Israel
- Laboratory of the Mosaics of Autoimmunity, Saint Petersburg State University, 199034 Saint-Petersburg, Russia
| | - Ora Shovman
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6997801, Israel
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Ramat Gan 5265601, Israel
- Department of Medicine 'B', Sheba Medical Center, Ramat Gan 5265601, Israel
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20
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Cheng YJ, Wang M, Wang J, Cui Z, Zhao MH. The characters of antibodies against PLA2R in healthy individuals and in the patient with PLA2R associated membranous nephropathy. Eur J Med Res 2023; 28:128. [PMID: 36935517 PMCID: PMC10026444 DOI: 10.1186/s40001-023-01096-5] [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: 01/01/2023] [Accepted: 03/12/2023] [Indexed: 03/21/2023] Open
Abstract
BACKGROUND Most primary membranous nephropathy (MN) is mediated by anti-phospholipase A2 receptor (PLA2R) antibodies. Recently, these antibodies have been revealed months to years before the disease's onset. Their production and pathogenicity need further investigation. METHODS Anti-PLA2R antibodies were purified from plasma of eight healthy individuals, 12 patients with PLA2R-related MN and negative circulating antibody (Ab-), and 18 patients with positive anti-PLA2R antibodies (Ab +), using affinity column coupled with recombinant human PLA2R. The antigen specificity, antibody amount, titer, IgG subclass, and affinity were assessed by Western blot, immunofluorescence, ELISA, and surface plasmon resonance. RESULTS The natural anti-PLA2R antibodies recognized the conformational structure of PLA2R which locates on the cell membrane of podocytes. The amount of natural IgG was 0.12 ± 0.04 g/L, which accounted for 0.80% of total IgG and was lower than that of patients (2.36%, P < 0.001). The titer of natural antibodies was lower than that of patients in Ab- and Ab + groups (1:16 vs. 1:43 vs. 1:274, P < 0.001). IgG2(45.1%) was predominant in natural antibodies, while IgG4 was predominant in Ab + group (45.7 vs. 25.0%, P < 0.001). IgG1 was increasing from natural antibodies to Ab- and Ab + groups. The affinity of natural antibodies was lower than that of patients (KD: 641.0 vs. 269.0 vs. 99.6 nM, P = 0.002). The antibody titer, affinity, and IgG4 percentage were associated with the severity of proteinuria and the stages of membranous lesion. CONCLUSIONS The natural anti-PLA2R antibodies exist in healthy plasma. The antibody titer, IgG subclass, and affinity may participate in the pathogenesis of anti-PLA2R antibodies.
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Affiliation(s)
- Yan-Jiao Cheng
- Renal Division, Institute of Nephrology, Key Laboratory of Renal Disease, Key Laboratory of CKD Prevention and Treatment, Peking University First Hospital, Peking University, Ministry of Health of China, Ministry of Education of China, Beijing, 100034, People's Republic of China
- Renal Division, Peking University People's Hospital, Beijing, 100068, People's Republic of China
| | - Miao Wang
- Renal Division, Institute of Nephrology, Key Laboratory of Renal Disease, Key Laboratory of CKD Prevention and Treatment, Peking University First Hospital, Peking University, Ministry of Health of China, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Jia Wang
- Renal Division, Institute of Nephrology, Key Laboratory of Renal Disease, Key Laboratory of CKD Prevention and Treatment, Peking University First Hospital, Peking University, Ministry of Health of China, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Zhao Cui
- Renal Division, Institute of Nephrology, Key Laboratory of Renal Disease, Key Laboratory of CKD Prevention and Treatment, Peking University First Hospital, Peking University, Ministry of Health of China, Ministry of Education of China, Beijing, 100034, People's Republic of China.
| | - Ming-Hui Zhao
- Renal Division, Institute of Nephrology, Key Laboratory of Renal Disease, Key Laboratory of CKD Prevention and Treatment, Peking University First Hospital, Peking University, Ministry of Health of China, Ministry of Education of China, Beijing, 100034, People's Republic of China
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21
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Zhang XD, Lin CX, Cui Z, Gu QH, Yan BJ, Liu L, Song WC, Shi Y, Debiec H, Ronco P, Zhao MH. Mapping the T cell epitopes of the M-type transmembrane phospholipase A2 receptor in primary membranous nephropathy. Kidney Int 2023; 103:580-592. [PMID: 36549363 DOI: 10.1016/j.kint.2022.11.021] [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: 12/12/2021] [Revised: 10/09/2022] [Accepted: 11/14/2022] [Indexed: 12/24/2022]
Abstract
The M-type phospholipase A2 receptor (PLA2R) is the major autoantigen of primary membranous nephropathy (MN). Despite many studies on B-cell epitopes recognized by antibodies, little is known about T-cell epitopes. Herein, we synthesized 123 linear peptides, each consisting of 15-22 amino acids with 8-12 amino acid overlaps, across ten domains of PLA2R. Their binding capacity to risk (DRB1∗1501, DRB1∗0301) and protective (DRB1∗0901, DRB1∗0701) HLA molecules was then assessed by flow cytometry. Proliferation of CD4+ T cells from patients with anti-PLA2R positive MN was analyzed after peptide stimulation. Cytokines produced by activated peripheral blood mononuclear cells were measured by cytometric bead arrays. We identified 17 PLA2R peptides that bound to both DRB1∗1501 and DRB1∗0301 molecules with high capacity. Some of these peptides showed decreased binding to heterozygous DRB1∗1501/0901 and DRB1∗0301/0701. Ten of the 17 peptides (CysR1, CysR10, CysR12, FnII-3, CTLD3-9, CTLD3-10, CTLD3-11, CTLD5-2-1, CTLD7-1 and CTLD7-2) induced significant proliferation of CD4+ T cells from patients with MN than cells from healthy individuals. Upon activation by these peptides, peripheral blood mononuclear cells from patients with MN produced higher levels of pro-inflammatory cytokines, predominantly IL-6, TNF-α, IL-10, IL-9 and IL-17. Thus, we mapped and identified ten peptides in the CysR, FnII, CTLD3, CTLD5, and CTLD7 domains of PLA2R as potential T-cell epitopes of MN. These findings are a first step towards developing peptide-specific immunotherapies.
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Affiliation(s)
- Xiao-Dan Zhang
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Cai-Xia Lin
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Zhao Cui
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.
| | - Qiu-Hua Gu
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Department of Nephrology, Tianjin Medical University General Hospital, Tianjin, China
| | - Bing-Jia Yan
- Key Laboratory of Bioorganic Phosphorus Chemistry and Chemical Biology (Ministry of Education), Department of Chemistry, Tsinghua University, Beijing, China
| | - Lei Liu
- Key Laboratory of Bioorganic Phosphorus Chemistry and Chemical Biology (Ministry of Education), Department of Chemistry, Tsinghua University, Beijing, China; Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Wen-Chao Song
- Department of Pharmacology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Institute for Translational Medicine and Therapeutics, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Yi Shi
- Key Laboratory of Pathogenic Microbiology and Immunology, Institute of Microbiology, Chinese Academy of Sciences, Beijing, China
| | - Hanna Debiec
- Sorbonne Université, Paris, France; Institut National de la Santé et de la Recherche Médicale (Inserm), Unité Mixte de Recherche S1155, Paris, France
| | - Pierre Ronco
- Sorbonne Université, Paris, France; Institut National de la Santé et de la Recherche Médicale (Inserm), Unité Mixte de Recherche S1155, Paris, France; Department of Nephrology, Centre Hospitalier du Mans, Le Mans, France
| | - Ming-Hui Zhao
- Renal Division, Peking University First Hospital, Beijing, China; Institute of Nephrology, Peking University, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Peking-Tsinghua Center for Life Sciences, Beijing, China
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22
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Vink CH, Logt AEVD, van der Molen RG, Hofstra JM, Wetzels JF. Antibody-Guided Therapy in Phospholipase A2 Receptor-Associated Membranous Nephropathy. Kidney Int Rep 2023; 8:432-441. [PMID: 36938074 PMCID: PMC10014436 DOI: 10.1016/j.ekir.2022.12.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction A 6-month course of cyclophosphamide (CP) and steroids is effective in primary membranous nephropathy (MN), but unappealing because of long-term side effects. We evaluated efficacy of an "antibody-guided" treatment schedule. Methods Patients with phospholipase A2 receptor (PLA2R)-related MN and high risk of progression were treated with CP 1.5 mg/kg/d and steroids in cycles of 8 weeks. Anti-PLA2R antibodies were measured by indirect immunofluorescence (IIFT) at 8, 16, and 24 weeks, and a negative test resulted in withdrawal of CP, and rapid tapering of prednisone. In patients with persistent anti-PLA2R antibodies at 24 weeks, CP was switched to mycophenolate mofetil. Treatment was repeated in patients with a relapse. Results Our analysis included 65 patients (48 males, 17 females), age 61 ± 12 years, estimated glomerular filtration rate (eGFR) 46 ml/min per 1.73 m2 (35-68), urine protein-to-creatinine ratio 7.7 grams/10 mmol creatinine (5.4-11.1) and serum albumin 20 g/l (16-26). Immunologic remission rate was 71% after 8 weeks, 86% after 16 weeks, 88% after 24 weeks, and 94% after 3 years. Twenty-seven patients (42%) had persistent clinical remission after only 8 weeks of therapy. Sixteen patients needed a second course of therapy because of immunologic or clinical relapse. Follow-up was 37 (26-58) months. Overall partial remission rate was 92%. One patient developed end-stage kidney disease. Antibody-guided therapy (ABG) was as effective as the standard 6-month course, whereas providing a lower cumulative dose of CP (11.1 [8.0-18.5] vs. 18.9 [14.2-23.6] grams). Conclusion ABG is effective, and allows individualized therapy, with many patients responding to 8 weeks of CP-based therapy.
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Affiliation(s)
- Coralien H. Vink
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Anne-Els van de Logt
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
- Correspondence: Anne-Els van de Logt, Postbus 9101, 6500 HB Nijmegen, 464, The Netherlands.
| | | | - Julia M. Hofstra
- Deptartment of Internal Medicine, Ziekenhuis Gelderse Vallei, Ede, the Netherlands
| | - Jack F.M. Wetzels
- Department of Nephrology, Radboud Institute of Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
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23
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Caza TN, Larsen CP. False-positive anti-PLA2R ELISA testing in patients with diabetes mellitus. Kidney Int 2023; 103:425. [PMID: 36681457 DOI: 10.1016/j.kint.2022.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 01/21/2023]
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Zhang J, Fan Z, Wang P, Zhang AH. Phospholipase A2 Receptor Antibodies and Clinical Prognosis in Patients with Idiopathic Membranous Nephropathy: An Updated Systematic Review and Meta-Analysis. Kidney Blood Press Res 2023; 48:102-113. [PMID: 36720217 DOI: 10.1159/000529415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/23/2023] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Idiopathic membranous nephropathy (IMN) is the most common form of primary nephrotic syndrome in adults. Antibodies against the M-type phospholipase A2 receptor (PLA2R-ab) are considered as diagnostic biomarkers of IMN. OBJECTIVE Here, we performed an updated meta-analysis to assess the diagnostic value of PLA2R-ab for clinical remission in IMN patients. METHOD PubMed, Embase, and Cochrane databases were searched for relevant studies published before September 2022. Odds ratios and corresponding 95% confidence intervals were determined using a fixed or random effects model. The heterogeneity among studies was explored by subgroup analysis. RESULTS Sixteen studies involving 1,761 IMN participants were included. There were significant differences between PLA2R-ab (+) and PLA2R-ab (-) patients in terms of complete remission (CR) and spontaneous remission. The rates of partial remission (PR) and relapse were similar between the two groups. Patients with PLA2R-ab (-) were at a higher CR rate when treated with a calcineurin inhibitor or a treatment course for 3 months and 6 months, while the spontaneous remission rate was higher in PLA2R-ab seronegative patients from Asia. However, the CR and spontaneous remission rate only significantly declined in IMN patients with the highest titer, but not a middle titer, when compared to those with the lowest titer. CONCLUSION In contrast with previous meta-analyses, our results verified that PLA2R-ab can likely predict CR and spontaneous remission in IMN patients, instead of PR and relapse. Race, immunosuppressive agents, and duration of treatment may affect the prognostic value of PLA2R-ab. Considering that the remission rate of IMN patients with a middle level of PLA2R-ab was not different from that of patients with the lowest level, a proper cut-off value of PLA2R-ab for prognosis should be clarified.
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Affiliation(s)
- Jialing Zhang
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China,
| | - Zhengjia Fan
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Peixin Wang
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ai-Hua Zhang
- Department of Nephrology, Xuanwu Hospital, Capital Medical University, Beijing, China
- The National Clinical Research Center for Geriatric Disease, Xuanwu Hospital, Capital Medical University, Beijing, China
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25
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Qin Y, Wu Q, Sheng H, Li T, Liu X, Yang X, Lin B, Zhou X, Jin J, Wang L, Huang B, He Q, Hu Z. Quantitative detection of anti-PLA2R antibodies targeting different epitopes and its clinical application in primary membranous nephropathy. Clin Chem Lab Med 2023; 61:251-259. [PMID: 36351699 DOI: 10.1515/cclm-2022-0720] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aimed to establish time-resolved fluorescence immunoassays to quantitatively detect the autoantibodies targeting different epitopes of M-type phospholipase A2 receptor (PLA2R) and evaluate its clinical application in primary membranous nephropathy (PMN). METHODS PLA2R and its reactive epitope-specific IgG/IgG4 time-resolved fluorescence immunoassays (TRFIAs) were established using europium-labeled anti-human IgG/IgG4 antibodies, recombinant proteins, and patient serum. The levels of IgG/IgG4 targeting PLA2R and its epitopes in PMN patient serum were detected, and the relationship between epitope spreading of PLA2R and the severity of patients with PMN was evaluated. RESULTS The TRFIAs established in this study could quantitatively detect PLA2R and its epitope-specific IgG and IgG4. Sera from 59 patients with PMN were subjected to detection using anti-PLA2R IgG and anti-PLA2R IgG4. Among them, 46 and 54 patients were found positive for PLA2R antibodies, respectively. Moreover, the levels of PLA2R antibodies were strongly correlated with the severity of patients with PMN. Patients who were detected to have two or more epitopes had more serious renal injury. CONCLUSIONS PLA2R domain-specific IgG/IgG4 TRFIAs were established in this study, and detection with anti-PLA2R IgG4 could more sensitively screen the reactivity of patients to the PLA2R domain. Moreover, detection epitope spreading of PLA2R was confirmed which is related to the severity of patients with PMN.
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Affiliation(s)
- Yuan Qin
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Qingqing Wu
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Huiming Sheng
- Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Ting Li
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Xiaobin Liu
- Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, P.R. China
| | - Xue Yang
- Wuxi Children's Hospital, Wuxi, P.R. China
| | - Bo Lin
- Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, P.R. China
| | - Xiumei Zhou
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Juan Jin
- Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, P.R. China
| | - Liang Wang
- Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, P.R. China
| | - Biao Huang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, P.R. China
| | - Qiang He
- The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Traditional Chinese Medicine), Hangzhou, Zhejiang, P.R. China
| | - Zhigang Hu
- Wuxi People's Hospital affiliated to Nanjing Medical University, Wuxi, P.R. China
- Wuxi Children's Hospital, Wuxi, P.R. China
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Determination of Anti-Phospholipase A2 and Anti-Thrombospondin Type 1 Domain-Containing Protein 7A in Latin Patients with Membranous Nephropathy. Diagnostics (Basel) 2022; 13:diagnostics13010017. [PMID: 36611308 PMCID: PMC9818893 DOI: 10.3390/diagnostics13010017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/14/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022] Open
Abstract
Primary membranous nephropathy (MN) is caused by antibodies against podocyte antigens, especially the type M receptor of phospholipase A2 (PLA2R) and thrombospondin type-1 domain containing 7 A (THSD7A). This study's aim was the determination of anti-PLA2R, anti-THSD7A serum antibodies, and anti-PLA2R renal tissue staining prevalence in a Latin population with MN, as well as evaluating their role as biomarkers for disease activity. The performance of the two anti-PLA2R serum diagnostic methods-ELISA and indirect immunofluorescence (IFI)-was evaluated for the diagnosis of MN. Fifty-nine patients, including 29 with MN, 18 with lupus membranous nephropathy (LMN) and 12 with focal and segmental glomerulosclerosis (FSGS), were evaluated for serum antibodies. Renal biopsies were also evaluated for the presence of anti-PLA2R staining. Twenty-one patients with MN were followed for 1 year. Patients with LMN and FSGS were negative for both antibodies. All 29 MN patients were negative for anti-THSD7A; 16 MN patients were positive for anti-PLA2R by ELISA and/or IFI, and 3 MN patients were positive for anti-PLA2R only by IFI. Thus, the anti-PLA2R ELISA test demonstrated 45% sensitivity and 97% specificity, while the IFI test showed, respectively, 55% and 100% in our MN patients. Among the 28 MN renal biopsies, 20 presented anti-PLA2R positive staining, corresponding to a 72% sensitivity. Positive correlations were observed between the anti-PLA2R ELISA titer and proteinuria. In conclusion, determination of anti-PLA2R antibodies in the MN Latin population showed similar rates to those reported for other populations. The anti-PLA2R serum levels correlated with MN disease activity.
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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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Perna A, Ruggiero B, Podestà MA, Perico L, Orisio S, Debiec H, Remuzzi G, Ruggenenti P. Sexual dimorphic response to rituximab treatment: A longitudinal observational study in a large cohort of patients with primary membranous nephropathy and persistent nephrotic syndrome. Front Pharmacol 2022; 13:958136. [PMID: 36120314 PMCID: PMC9479107 DOI: 10.3389/fphar.2022.958136] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022] Open
Abstract
Rituximab is one of the first-line therapies for patients with membranous nephropathy (MN) at high risk of progression towards kidney failure. We investigated whether the response to Rituximab was affected by sex and anti-PLA2R antibody levels in 204 consecutive patients (148 males and 56 females) with biopsy-proven MN who were referred to the Nephrology Unit of the Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII from March 2001 to October 2016 and managed conservatively for at least 6 months. The primary outcome was a combined endpoint of complete (proteinuria <0.3 g/24 h) or partial (proteinuria <3.0 g/24 h and >50% reduction vs. baseline) remission. Patients gave written informed consent to Rituximab treatment. The study was internally funded. No pharmaceutical company was involved. Anti-PLA2R antibodies were detectable in 125 patients (61.3%). At multivariable analyses, female gender (p = 0.0198) and lower serum creatinine levels (p = 0.0108) emerged as independent predictors of better outcome (p = 0.0198). The predictive value of proteinuria (p = 0.054) and anti-PLA2R titer (p = 0.0766) was borderline significant. Over a median (IQR) of 24.8 (12.0–36.0) months, 40 females (71.4%) progressed to the combined endpoint compared with 73 males (49.3%). Anti-PLA2R titers at baseline [127.6 (35.7-310.8) vs. 110.1 (39.9–226.7) RU/ml] and after Rituximab treatment were similar between the sexes. However, the event rate was significantly higher in females than in males [HR (95%): 2.12 (1.44–3.12), p = 0.0001]. Forty-five of the 62 patients (72.3%) with anti-PLA2R titer below the median progressed to the combined endpoint versus 35 of the 63 (55.6%) with higher titer [HR (95%): 1.97 (1.26–3.07), p < 0.0029]. The highest probability of progressing to the combined endpoint was observed in females with anti-PLA2R antibody titer below the median (86.7%), followed by females with anti-PLA2R antibody titer above the median (83.3%), males with titer below the median (68.1%), and males with titer above the median (44.4%). This trend was statistically significant (p = 0.0023). Similar findings were observed for complete remission (proteinuria <0.3 g/24 h) and after analysis adjustments for baseline serum creatinine. Thus, despite similar immunological features, females were more resilient to renal injury following Rituximab therapy. These findings will hopefully open new avenues to identify the molecular pathways underlying sex-related nephroprotective effects.
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Affiliation(s)
- Annalisa Perna
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Barbara Ruggiero
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Manuel Alfredo Podestà
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Department of Health Sciences, Università Degli Studi di Milano, Milano, Italy
| | - Luca Perico
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Silvia Orisio
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Hanna Debiec
- Sorbonne Université and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche, Paris, France
| | - Giuseppe Remuzzi
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- *Correspondence: Giuseppe Remuzzi,
| | - Piero Ruggenenti
- Department of Renal Medicine, Centro di Ricerche Cliniche Aldo e Cale Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
- Unit of Nephrology and Dialysis, Azienda Socio Sanitaria Territoriale Papa Giovanni XXIII, Bergamo, Italy
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Anti-Phospholipase A2 Receptor Antibody Expression at Different Stages of Idiopathic Membranous Nephropathy. Int J Nephrol 2022; 2022:5962195. [PMID: 35942439 PMCID: PMC9356905 DOI: 10.1155/2022/5962195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/30/2022] [Accepted: 07/05/2022] [Indexed: 11/17/2022] Open
Abstract
The significance of blood anti-phospholipase A2 receptor (PLA2R) antibodies in the diagnosis of different stages of idiopathic membranous nephropathy (IMN) was investigated. The expression and distribution of anti-PLA2R antibodies in renal biopsy tissue of patients with different stages of IMN were examined by immunohistochemistry. In addition, blood anti-PLA2R antibodies were determined by indirect immunofluorescence for the same patients, and the results were compared with the anti-PLA2R antibody expression in renal biopsy tissue. The positive fluorescence intensities of IMN stages I, IV, and V were mostly ± or + (40/80). There was no significant difference in fluorescence titer between these stages (p > 0.05). These results were consistent with the immunohistochemistry results, and the kappa statistic was 0.95. The positive fluorescence intensities of IMN stages II and III were mostly ++ to ++++ (33/60). There was no significant difference in fluorescence intensities between these two stages (p > 0.05), but there was a significant difference in fluorescence intensities between stages II and III and stages I, IV, and V (p < 0.001). These results were consistent with the immunohistochemistry results, and the kappa statistic was 0.97 (p < 0.001). Therefore, blood anti-PLA2R levels were positively correlated with anti-PLA2R expression in renal biopsy tissue in patients with different stages of IMN. In addition, the fluorescence intensities of IMN stages II and III were significantly different from those of stages I, IV, and V. Therefore, blood anti-PLA2R levels can be used for in vitro differential diagnosis and the monitoring of treatment, as it can distinguish stage II; and III; from stage I, IV, and V IMN.
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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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Dong L, Li YQ, Guo SM, Xu G, Wei W, Han M. Hypercholesterolemia Correlates With Glomerular Phospholipase A2 Receptor Deposit and Serum Anti-Phospholipase A2 Receptor Antibody and Predicts Proteinuria Outcome in Idiopathic Membranous Nephropathy. Front Immunol 2022; 13:905930. [PMID: 35784308 PMCID: PMC9248763 DOI: 10.3389/fimmu.2022.905930] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background The anti-phospholipase A2 receptor (PLA2R) antibody is a non-invasive diagnostic tool and prognosis predictor of idiopathic membranous nephropathy (IMN). Baseline hypercholesterolemia independently predicts proteinuria outcomes in IMN patients. Thus, we investigated whether hyperlipidemia is correlated with anti-PLA2R and pathological indicators. Methods A total of 495 IMN patients identified by kidney biopsy in Wuhan Tongji Hospital, China, from January 2016 through December 2020 were enrolled in this study. Data on clinical features, pathology findings, and outcomes were collected. Results Total cholesterol (TC), non-high-density lipoprotein cholesterol (non-HDL-C), low-density lipoprotein cholesterol (LDL-C), and triglyceride (TG) were positively related to proteinuria, indicating damage to the renal glomerulus [Spearman’s rank correlation coefficient = 0.432, 0.462, 0.315, and 0.289, respectively, P < 0.001 for all]. In univariate logistic regression, low HDL-C [odds ratio (OR): 0.856; 95% CI: 0.778–0.939; P = 0.001] and high TG [OR: 1.025; 95% CI: 1.006–1.044; P = 0.011] were correlated with tubular atrophy, suggesting lesions on tubules. Increased TC [adjusted OR: 1.285; 95% CI: 1.119–1.475; P < 0.001], non-HDL-C [adjusted OR: 1.284; 95% CI: 1.113–1.482; P = 0.001], and LDL-C [adjusted OR: 1.178; 95% CI: 1.009–1.376; P = 0.039] independently predicted glomerular PLA2R deposit; similar results were observed for lipids in predicting the seropositivity of anti-PLA2R antibodies. After treatment, increased HDL-C [adjusted hazard ratio (HR): 1.764; 95% CI: 1.241–2.507; P = 0.002] and decreased non-HDL-C [adjusted HR: 0.884; 95% CI: 0.795–0.983; P = 0.022] independently predicted proteinuria remission. Conclusion Hypercholesterolemia is a potentially useful biomarker for disease severity, serum anti-PLA2R antibody, glomerular PLA2R deposit, and proteinuria outcome of IMN.
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Affiliation(s)
- Lei Dong
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yue-Qiang Li
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shui-Ming Guo
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Gang Xu
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wang Wei
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Han
- Department of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Sun IO, Bae YU, Lee H, Kim H, Jeon JS, Noh H, Choi JS, Doh KO, Kwon SH. Circulating miRNAs in extracellular vesicles related to treatment response in patients with idiopathic membranous nephropathy. J Transl Med 2022; 20:224. [PMID: 35568952 PMCID: PMC9107687 DOI: 10.1186/s12967-022-03430-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/05/2022] [Indexed: 12/29/2022] Open
Abstract
Background Extracellular vesicle (EV)-microRNAs (miRNAs) are potential biomarkers for various renal diseases. This study attempted to identify the circulating EV-miRNA signature not only for discriminating idiopathic membranous nephropathy (IMN) from idiopathic nephrotic syndrome (INS), but also to predict the treatment response of patients with IMN. Methods We prospectively enrolled 60 participants, including those with IMN (n = 19) and INS (n = 21) and healthy volunteers (HVs; n = 20) in this study. Using RNA sequencing, we assessed the serum EV-miRNA profiles of all participants. To identify the EV-miRNAs predictive of treatment response in IMN, we also analyzed EV-miRNAs among patients with IMN with and without clinical remission. Results The expression levels of 3 miRNAs differed between IMN patients, INS patients and HVs. In addition, compared to HVs, RNA sequencing revealed differential expression of 77 and 44 EV-miRNAs in patients with IMN without and with remission, respectively. We also identified statistically significant (|fold change ≥ 2, p < 0.05) differences in the expression levels of 23 miRNAs in IMN without remission. Biological pathway analysis of miRNAs in IMN without remission indicated that they are likely involved in various pathways, including renal fibrosis. Conclusion Our study identified EV-miRNAs associated with IMN as well as those associations with therapeutic response. Therefore, these circulating EV-miRNAs may be used as potential markers for the diagnosis and prediction of treatment response in patients with IMN. Supplementary Information The online version contains supplementary material available at 10.1186/s12967-022-03430-7.
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Affiliation(s)
- In O Sun
- Division of Nephrology, Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Republic of Korea
| | - Yun-Ui Bae
- Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Haekyung Lee
- Division of Nephrology, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Youngsan-gu, Seoul, 04401, Republic of Korea
| | - Hyoungnae Kim
- Division of Nephrology, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Youngsan-gu, Seoul, 04401, Republic of Korea
| | - Jin Seok Jeon
- Division of Nephrology, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Youngsan-gu, Seoul, 04401, Republic of Korea
| | - Hyunjin Noh
- Division of Nephrology, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Youngsan-gu, Seoul, 04401, Republic of Korea
| | - Jong-Soo Choi
- Department of Physiology, College of Medicine, Yeungnam University, Daegu, 42415, Republic of Korea
| | - Kyung-Oh Doh
- Department of Physiology, College of Medicine, Yeungnam University, Daegu, 42415, Republic of Korea.
| | - Soon Hyo Kwon
- Division of Nephrology, Soonchunhyang University Seoul Hospital, 59 Daesagwan-ro, Youngsan-gu, Seoul, 04401, Republic of Korea.
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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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Sun Y, Lan P, Feng J, Wang Z, Liu C, Xie L, Yu X. Analysis of glomerular PLA2R efficacy in evaluating the prognosis of idiopathic membranous nephropathy in the background of different serum anti-PLA2R levels. Ren Fail 2022; 44:731-740. [PMID: 35484851 PMCID: PMC9067982 DOI: 10.1080/0886022x.2022.2068442] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To verify glomerular PLA2R antigen and serum PLA2R antibody expression in membranous nephropathy as well as to explore glomerular PLA2R efficacy in evaluating the prognosis of idiopathic membranous nephropathy (IMN) in the background of different serum anti-PLA2R levels. METHODS We retrospectively analyzed 155 patients who were diagnosed with IMN by kidney biopsy. Patients were divided into six groups according to their serum PLA2R antibody or glomerular PLA2R antigen positiveness and the level of serum anti-PLA2R titer. Both clinical features and pathological characteristics were recorded, and the remission time was compared among groups. Correlation between clinical figures and the anti-PLA2R titer or semi-quantity of glomerular PLA2R antigen was detected. RESULTS A positive correlation between time to partial remission and serum anti-PLA2R titer was found. Among patients with serum anti-PLA2R titer <150 RU/ml, there were shorter remission time in negative glomerular PLA2R antigen group compared with positive glomerular PLA2R antigen, and a positive correlation between time to complete remission and semi-quantity of glomerular PLA2R antigen was found. CONCLUSION Both glomerular PLA2R antigen and serum anti-PLA2R play a role in disease presentation and prognosis in primary membranous nephropathy. Glomerular PLA2R antigen has a major role on disease prognosis when serum anti-PLA2R titer is less than 150RU/ml, while serum anti-PLA2R has predominant role in IMN prognosis when serum anti-PLA2R titer is above 150RU/ml.
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Affiliation(s)
- Yuemeng Sun
- Department of Nephrology, Kidney Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ping Lan
- Department of Nephrology, Kidney Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jie Feng
- Department of Nephrology, Kidney Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhigang Wang
- Department of Nephrology, Kidney Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Chao Liu
- Department of Nephrology, Kidney Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Liyi Xie
- Department of Nephrology, Kidney Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xiaoyang Yu
- Department of Nephrology, Kidney Hospital, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Zhu H, Xu L, Liu X, Liu B, Zhai C, Wang R, Yang X. Anti-PLA2R antibody measured by ELISA predicts the risk of vein thrombosis in patients with primary membranous nephropathy. Ren Fail 2022; 44:594-600. [PMID: 35380081 PMCID: PMC8986254 DOI: 10.1080/0886022x.2022.2057861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Primary membranous nephropathy (PMN) is associated with the highest risk for developing venous thrombosis compared with other nephrotic diseases. The aim of the study was to assess the predictive value of the pathognomonic anti-phospholipase A2 receptor (PLA2R) antibody with regard to incidence of venous thrombosis in PMN. Methods A total of 365 in-hospital patients diagnosed with PMN were enrolled in the study. Anti-PLA2R antibody was detected by commercial enzyme-linked immunosorbent assay. Multivariate logistic regression was used to detect the independent risk factors for venous thrombosis. Results Thirty-seven patients (10.14%) had venous thrombosis. Patients with venous thrombosis had higher levels of cholesterol (CHOL), low-density lipoprotein (LDL), and D-dimer than those without venous thrombosis (p < .05). Patients with venous thrombosis had significantly lower levels of albumin (23.95 ± 5.53 vs. 26.18 ± 6.59 g/L, p = .049). No significant differences were found in proteinuria, serum creatinine, estimated glomerular filtration rate, platelets, and fibrinogen between patients with and without thrombosis. Anti-PLA2R antibody levels in patients with venous thrombosis were significantly higher than in patients without it (p = .002). In the univariate logistic regression, Ln anti-PLA2R antibody (OR: 1.340; p = .004), albumin (OR: 0.945; p = .050), CHOL (OR: 1.191; p = .006), and LDL (OR: 1.271, p = .006) were associated with venous thrombosis. Ln anti-PLA2R antibody (OR = 1.269; 95%CI: 1.032–1.561), and LDL (OR = 1.213; 95%CI: 1.017–1.448) were the independent risk factors for venous thrombosis (p < .05) in multivariate analysis. Conclusions Anti-PLA2R antibody was the independent risk factor for venous thrombosis in PMN. Larger prospective studies were warranted to verify the results in future.
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Affiliation(s)
- Huizi Zhu
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, China
| | - Liang Xu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiang Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Bing Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Chunjuan Zhai
- Department of Cardiology, Shandong Provincial Hospital affiliated to Shandong First Medical University, Jinan, China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital, Shandong University, Jinan, China.,Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Xiaowei Yang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Ou JY, Chen YW, Li TL, Shan HZ, Cui S, Lai JJ, Xiao Y. Evaluation of efficacy of rituximab for membranous nephropathy: A systematic review and meta-analysis of 11 studies. Nephrol Ther 2022; 18:104-112. [PMID: 35074299 DOI: 10.1016/j.nephro.2021.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 09/24/2021] [Accepted: 10/02/2021] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The use of traditional immunosuppressive medicines for the treatment of membranous nephropathy is being challenged, owing to its limited efficacy and tolerability. Research on M-type phospholipase A2 receptor antibodies has provided a new way for evaluating the efficiency and prognosis of treatment of membranous nephropathy. However, the relationship between rituximab, a monoclonal antibody against CD20, and antiphospholipase A2 receptor antibodies and the drug regimen of rituximab for membranous nephropathy is uncertain. We conducted a meta-analysis to evaluate the efficacy of rituximab treatments in membranous nephropathy and compared the clinical effects of first-line and second-line rituximab therapies. METHODS PubMed, Embase, Web of Science, Scopus, the Cochrane Central Register ofControlled Trials, and ClinicalTrials.gov were searched to find articles about rituximab treatment of patients with membranous nephropathy between January 2000 and August 2020. The outcomes included remission, antiphospholipase A2 receptor antibodies, relapse, and adverse events. The Grading of Recommendations Assessment Development and Evaluation criteria were used to evaluate the strength of evidence. RESULTS A total of 723 participants from 11 trials were included in this meta-analysis. The other treatments included cyclosporine, cyclophosphamide, steroids, and non-immunosuppressive antiproteinuric treatment. Rituximab significantly improved cumulative remission (P=0.007; Odds Ratio [OR]=3.06; 95% confidence interval [CI]=1.35-6.94) compared with other treatments. It significantly reduced relapse (P<0.00001; OR=0.06; 95% CI=0.02-0.19), antiphospholipase A2 receptor antibody levels (P=0.0009; SMD=-0.52; 95% CI=-0.83 to -0.21), and the proportion of patients positive for anti-PLA2R antibodies (P=0.003; OR=6.11; 95% CI=1.85-20.24) compared with other treatments. Compared with the second-line, first-line rituximab therapy achieved a higher rate of cumulative remission (P=0.03; OR=0.32, 95% CI=0.11-0.91). CONCLUSIONS Rituximab can improve the rate of clinical remission in patients with membranous nephropathy. Rituximab was more effective than other treatments in reducing relapse, antiphospholipase A2 receptor antibody levels, and the proportion of patients positive for antiphospholipase A2 receptor antibodies. The clinical remission rate following first-line rituximab therapy was better than that of second-line rituximab therapy for membranous nephropathy.
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Affiliation(s)
- Jun-Yong Ou
- Department of nephrology, the First Affiliated Hospital of Guangzhou Medical University, 151, Yanjiang Road, 510120 Guangzhou, China; First clinical college, Guangzhou Medical University, 511436 Guangzhou, China
| | - Yuan-Wei Chen
- Department of nephrology, the First Affiliated Hospital of Guangzhou Medical University, 151, Yanjiang Road, 510120 Guangzhou, China; First clinical college, Guangzhou Medical University, 511436 Guangzhou, China
| | - Tian-Long Li
- Department of nephrology, the First Affiliated Hospital of Guangzhou Medical University, 151, Yanjiang Road, 510120 Guangzhou, China; First clinical college, Guangzhou Medical University, 511436 Guangzhou, China
| | - Hui-Zhi Shan
- Department of nephrology, the First Affiliated Hospital of Guangzhou Medical University, 151, Yanjiang Road, 510120 Guangzhou, China; Guangdong Key Laboratory of Urology, Kangda Road 1#, Haizhu District, 510230 Guangzhou, Guangdong, China
| | - Sini Cui
- Department of nephrology, the First Affiliated Hospital of Guangzhou Medical University, 151, Yanjiang Road, 510120 Guangzhou, China
| | - Jun-Ju Lai
- Department of nephrology, the First Affiliated Hospital of Guangzhou Medical University, 151, Yanjiang Road, 510120 Guangzhou, China
| | - Yun Xiao
- Department of nephrology, the First Affiliated Hospital of Guangzhou Medical University, 151, Yanjiang Road, 510120 Guangzhou, China.
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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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Prevalence of neural epidermal growth factor-like 1- and exostosin 1/exostosin 2-associated membranous nephropathy: a single-center retrospective study in Japan. Sci Rep 2022; 12:2967. [PMID: 35194125 PMCID: PMC8864000 DOI: 10.1038/s41598-022-07037-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 02/10/2022] [Indexed: 01/19/2023] Open
Abstract
Membranous nephropathy (MN) is the leading cause of nephrotic syndrome in adults. We previously reported that the prevalence of phospholipase A2 receptor (PLA2R)- and thrombospondin type 1 domain containing 7A (THSD7A)-associated MN patients in Japan is 52.7% and 9.1%, respectively. In addition to PLA2R and THSD7A, we assessed the presence of newly discovered target antigens, neural epidermal growth factor-like 1 (NELL-1), semaphorin 3B (SEMA3B), and exostosin 1/exostosin 2 (Ext1/Ext2), in renal specimens from patients with primary and secondary MN by immunohistochemistry. We found enhanced glomerular staining of PLA2R, THSD7A, NELL-1, and Ext1/Ext2 in 53.6%, 8.7%, 1.5%, and 13.0% of the renal samples, respectively, in patients with primary MN. None of the patient specimens showed enhanced staining of SEMA3B. Enhanced glomerular staining of PLA2R, NELL-1, and Ext1/Ext2 was detected in 5.7%, 8.6%, and 22.9% of the patients with secondary MN, respectively. Based on our findings, we recommend the assessment of PLA2R, THSD7A and NELL-1 in addition to clinical information and IgG4 staining to differentiate between primary and secondary MN. This would aid in distinguishing secondary MN patients from primary MN patients who coincidentally have some secondary characteristics.
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Stefan G, Stancu S, Zugravu A, Popa O, Zubidat D, Petre N, Mircescu G. Negative anti-phospholipase A2 receptor antibody status at three months predicts remission in primary membranous nephropathy. Ren Fail 2022; 44:258-268. [PMID: 35172682 PMCID: PMC8863379 DOI: 10.1080/0886022x.2022.2033265] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Background The value of anti-phospholipase A2 receptor antibody (anti-PLA2R ab) monitoring at 3 months after diagnosis in membranous nephropathy (MN) remains uncertain. Methods We retrospectively examined the outcome on 1 August 2020 of 59 adult patients (age 54 (44, 68) years, 69% male, SCr 1.0 (0.9, 1.3) mg/dL) diagnosed with MN (kidney biopsy, positive serum anti-PLA2R ab). The outcomes were: kidney survival; partial and/or complete remission. Results Most of the studied patients (97%) received immunosuppression, cyclophosphamide regimens were the most frequent (87%), followed by cyclosporine (10%). The median time to remission was 12.0 months and the cumulative remission rates were 34% at 6, 54% at 12, and 73% at 24 months. Forty (69%) patients had negative anti-PLA2R ab at 3 months, they had similar age, serum creatinine, albumin, proteinuria, and treatment with the group with positive ab at 3 months. In the Cox proportional hazard model, three months anti-PLA2R ab negativization (HR 0.4 (95%CI 0.1, 0.9)) was an independent predictor for remission, while baseline hypoalbuminemia (HR 3.0 (95%CI 1.5, 5.7)) was associated with absence of remission. Six (10%) patients died, mostly due to cardiovascular disease and infections. A total of five (9%) patients started dialysis. Mean kidney survival time was 50.3 months and there was no survival difference in relation to baseline anti-PLA2R ab titer (p .09) or 3 months negativization (p .8). Conclusions Three months anti-PLA2R ab negativization seems to be a late predictor of remission, and lower serum albumin at diagnosis is an early marker for remission absence. Abbreviations: anti-P LA2R ab, anti-phospholipase A2 receptor antibody; eGFR, estimated glomerular filtration rate; ESKD, end stage kidney disease; MN, membranous nephropathy; NELL-1, neural epidermal growth factor-like 1 protein; RAAS: renin–angiotensin–aldosterone system; RBC: red blood cells; RRT, renal replacement therapy; T HSD7A, thrombospondin type-1 domain containing 7A
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Affiliation(s)
- Gabriel Stefan
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Simona Stancu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Adrian Zugravu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Otilia Popa
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Dalia Zubidat
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Nicoleta Petre
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
| | - Gabriel Mircescu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania.,Dr. Carol Davila Teaching Hospital of Nephrology, Bucharest, Romania
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Deng L, Huang Q, Wang J, Luo K, Liu J, Yan W, Jiang F, Xu G. Efficacy and Safety of Different Immunosuppressive Therapies in Patients With Membranous Nephropathy and High PLA2R Antibody Titer. Front Pharmacol 2022; 12:786334. [PMID: 35111055 PMCID: PMC8801920 DOI: 10.3389/fphar.2021.786334] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: This study aimed to evaluate clinical features and prognosis and therapy option of patients with different risk ranks based on antibody against the M-type phospholipase-A2-receptor (PLA2Rab) level in seropositive M-type phospholipase-A2-receptor (PLA2R)-associated membranous nephropathy (MN) in a large sample size, multi-center study. Method: Based on the unvalidated cut-off value of PLA2Rab above 150 RU/ml as one of the clinical criteria for high risk of progressive kidney function loss in MN according to 2020 Kidney Disease: Improving Global Outcomes (KDIGO) draft guidelines recommendation, a total of 447 patients who received cyclophosphamide (CTX) or tacrolimus (TAC) combined with corticosteroids treatment for 12 months were divided into high titer (>150 RU/ml) group and non-high titer (20-150 RU/ml) group, which were subdivided into CTX subgroup and TAC subgroup. The overall cohort was classified into CTX group and TAC group as well. Clinical parameters levels and remission rates were recorded at 3, 6, and 12 months follow-up. PLA2Rab was tested by enzyme-linked immunosorbent assay. Results: Patients with high titer PLA2Rab were associated with more severe proteinuria and hypoalbuminemia compared to those with non-high titer antibody, accompanied by lower complete remission (CR) and total remission (TR) rates at 3, 6, and 12 months, which even took longer to remission. Similar remission rates differences between the two titer groups were observed in the CTX and TAC groups, respectively. PLA2Rab level at baseline was an independent predictive factor for CR and TR. In the high titer group, CR and TR rates in the CTX subgroup were significantly higher than those in the TAC subgroup at 12 months, although serious adverse events were more frequent in the former. Conclusion: High-risk rank patients with PLA2Rab level above 150 RU/ml have higher disease activity and worse prognosis among patients with seropositive PLA2R-associated MN, even under different immunosuppressive therapeutic models; moreover, CTX combined with corticosteroids was preferred compared to TAC plus corticosteroids, although serious adverse events were more frequent in the former. Additionally, baseline PLA2Rab level was an independent predictive factor for clinical remission.
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Affiliation(s)
- Le Deng
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Qipeng Huang
- Department of Nephrology, The Fifth Affiliated Hospital of Jinan University, Heyuan, China
| | - Jiang Wang
- Department of Hemodialysis, Jiujiang Hospital of Traditional Chinese Medicine, Jiangxi, China
| | - Kaiping Luo
- Department of Nephrology, Ganzhou City People's Hospital, Ganzhou, China
| | - Jiarong Liu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
| | - Wenjun Yan
- Department of Nephrology, The First Affiliated Hospital of Gannan Medical University, Jiangxi, China
| | - Fang Jiang
- Department of Nephrology, Xinyu City People's Hospital, Jiangxi, China
| | - Gaosi Xu
- Department of Nephrology, The Second Affiliated Hospital of Nanchang University, Jiangxi, China
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Structural determinants of the dominant conformational epitopes of phospholipase A2 receptor in primary membranous nephropathy. J Biol Chem 2022; 298:101605. [PMID: 35065076 PMCID: PMC8867125 DOI: 10.1016/j.jbc.2022.101605] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 01/10/2022] [Accepted: 01/12/2022] [Indexed: 12/27/2022] Open
Abstract
Anti-phospholipase A2 receptor autoantibody (PLA2R-Ab) plays a critical role in the pathogenesis of primary membranous nephropathy (PMN), an autoimmune kidney disease characterized by immune deposits in the glomerular subepithelial spaces and proteinuria. However, the mechanism of how PLA2R-Abs interact with the conformational epitope(s) of PLA2R has remained elusive. PLA2R is a single transmembrane helix receptor containing ten extracellular domains that begin with a CysR domain followed by a FnII and eight CTLD domains. Here, we examined the interactions of PLA2R-Ab with the full PLA2R protein, N-terminal domain truncations, and C-terminal domain deletions under either denaturing or physiological conditions. Our data demonstrate that the PLA2R-Abs against the dominant epitope (the N-terminal CysR-CTLD1 triple domain) possess weak cross-reactivities to the C-terminal domains beyond CTLD1. Moreover, both the CysR and CTLD1 domains are required to form a conformational epitope for PLA2R-Ab interaction, with FnII serving as a linker domain. Upon close examination, we also observed that patients with newly diagnosed PMN carry two populations of PLA2R-Abs in sera that react to the denatured CysR-CTLD3 (the PLA2R-Ab1) and denatured CysR-CTLD1 (the PLA2R-Ab2) domain complexes on Western blots, respectively. Furthermore, the PLA2R-Ab1 appeared at an earlier time point than PLA2R-Ab2 in patients, whereas the increased levels of PLA2R-Ab2 coincided with the worsening of proteinuria. In summary, our data support that an integrated folding of the three PLA2R N-terminal domains, CysR, FnII, and CTLD1, is a prerequisite to forming the PLA2R conformational epitope and that the dominant epitope-reactive PLA2R-Ab2 plays a critical role in PMN clinical progression.
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Poggiali E, Borio G, Magnacavallo A, Vercelli A, Cervellin G. Acute chest pain and dyspnoea as clinical presentation of primary membranous nephropathy. A case report and literature review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2022; 93:e2022216. [PMID: 36300242 PMCID: PMC9686161 DOI: 10.23750/abm.v93i5.12782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/14/2022] [Indexed: 01/25/2023]
Abstract
Membranous nephropathy (MN) is the commonest cause of nephrotic syndrome (NS) in adult male patients worldwide. Most of the cases (80%) are idiopathic (primary MN, PMN), whereas about 20% are associated with autoimmune diseases, malignancies or exposures (secondary MN). PMN is a kidney-specific autoimmune glomerular disease mediated by antibodies to the M-type phospholipase A2 receptor (anti-PLA2R) (85%), thrombospondin type 1 domain containing 7A (THSD7A) (3-5%), or by other still unidentified mechanisms (10%). Most of the patients with PMN present with NS (80%). Clinical course of PMN is characterised by spontaneous remissions (40%) and relapses (15-30%). One third develop end-stage renal disease (ESRD) within 5 to 15 years from the onset. Anti-PLA2R/THSD7A antibodies levels correlate with proteinuria, clinical course, and outcomes. The treatment still remains matter of debate. Hypertension, proteinuria, and hyperlipidaemia must be treated in all patients. Immunosuppressive therapy is indicated in patients with elevated anti-PLA2R/THSD7A levels and proteinuria >3.5 g/d at diagnosis. With proper management, only 10% or less will develop ESRD over the subsequent 10 years. Here we report a case of a 34-year-old male patient with a ten-year history of asymptomatic PMN, treated with ACE-inhibitors, who presented to our emergency room for acute chest pain and exertional dyspnoea due to ESRD that required urgent dialysis. (www.actabiomedica.it).
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Affiliation(s)
- Erika Poggiali
- Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Giorgia Borio
- Emergency Department, San Raffaele Hospital IRCCS, Milan, Italy
| | | | - Andrea Vercelli
- Emergency Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
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Jatem-Escalante E, Martín-Conde ML, Gràcia-Lavedan E, Benítez ID, Gonzalez J, Colás L, Garcia-Carrasco A, Martínez C, Segarra-Medrano A. Monitoring anti-PLA2R antibody titres to predict the likelihood of spontaneous remission of membranous nephropathy. Clin Kidney J 2021; 14:2556-2562. [PMID: 34950467 PMCID: PMC8690096 DOI: 10.1093/ckj/sfab116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Indexed: 11/14/2022] Open
Abstract
Background In anti-phospholipase A2 receptor (PLA2R) membranous nephropathy (MN) there is controversy whether spontaneous remission (SR) can be predicted using a single titre or by assessing the dynamic changes in anti-PLA2R antibody (ab) titres. The study objective was to identify the optimal dynamics of anti-PLA2Rab titres to predict SR in MN. Methods A total of 127 nephrotic patients with anti-PLA2R-MN were prospectively followed up for 6 months under conservative treatment. Anti-PLA2Rabs and proteinuria were assessed at diagnosis and monthly thereafter. The primary endpoint (PEP) was a reduction of proteinuria ≥50% at 6 months. Logistic models with baseline and evolutive anti-PLA2Rab titres were developed to predict the PEP. Results A total of 28 patients (22%) reached the PEP. These patients were more frequently female and had significantly lower baseline proteinuria and anti-PLA2Rab titres. An anti-PLA2R titre ≤97.5 RU/mL at diagnosis had a sensitivity of 71% and a specificity of 81% to predict the PEP. The model including baseline anti-PLA2Rabs and a reduction ≥15% at 3 months predicted the PEP with a sensitivity of 93% and a specificity of 80%, with an area under the curve that was significantly greater than that obtained with relative changes of proteinuria in the same period of time {odds ratio [OR] 0.95 [95% confidence interval (CI) 0.91–0.98 versus OR 0.79 [95% CI 0.70–0.88], respectively; P = 0.0013}. Conclusions Combining the baseline anti-PLA2Rab titres with their relative changes at 3 months after diagnosis gives the earliest prediction for achieving a reduction of urinary protein excretion ≥50% at 6 months in MN, thereby shortening the observation period currently recommended to make individualized decisions to start immunosuppressive therapy.
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Affiliation(s)
| | | | | | | | - Jorge Gonzalez
- Servicio de Nefrología, Hospital Universitario Arnau de Vilanova, Lleida, Spain
| | - Laura Colás
- Institut de Recerca Biomèdica, Lleida, Spain
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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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46
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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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47
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Teisseyre M, Cremoni M, Boyer-Suavet S, Crepin T, Benzaken S, Zorzi K, Esnault V, Brglez V, Seitz-Polski B. Rituximab Immunomonitoring Predicts Remission in Membranous Nephropathy. Front Immunol 2021; 12:738788. [PMID: 34721403 PMCID: PMC8548826 DOI: 10.3389/fimmu.2021.738788] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/21/2021] [Indexed: 11/25/2022] Open
Abstract
Primary membranous nephropathy (pMN) is an autoimmune kidney disease and a common cause of nephrotic syndrome in adults. Rituximab is becoming a first line therapy for patients with persistent nephrotic syndrome with proven safety and efficacy, achieving remission in 60%–80% of cases. For the remaining 20%–40% of patients there is an urgent need to identify early biomarkers of resistance to rituximab to adapt therapeutic management. In nephrotic patients, rituximab is found in the blood more transiently than in other autoimmune diseases without proteinuria, due to rituximab wasting in the urine. However, rituximab immunomonitoring is not routinely performed. We evaluated the predictive value of serum rituximab levels in patients with pMN three months after rituximab injection (month-3) on clinical remission rates six months (month-6) and 12 months (month-12) after injection and investigated predictive factors for serum rituximab levels at month-3. Sixty-eight patients treated with rituximab between July 2015 and January 2020 from two French nephrology centers were included. We identified residual rituximab levels at month-3 as a novel early predictor of remission at month-6 (p <0.0001) and month-12 (p = 0.001). Reduced likelihood of remission in patients with undetectable rituximab at month-3 was associated with lower serum albumin and higher anti-PLA2R1 titers at baseline and with lower serum albumin, higher proteinuria, higher CD19+ counts and higher anti-PLA2R1 titers during follow-up. In multivariate analysis, high baseline proteinuria and undetectable rituximab levels at month-3 were independent risk factors for treatment failure at month-6 and high baseline weight and undetectable rituximab levels at month-3 were independent risk factors for treatment failure at month-12. We identified serum albumin at baseline as a predictive factor for serum rituximab levels at month-3. Patients with serum albumin below 22.5 g/L at baseline had an 8.66-fold higher risk of having undetectable rituximab levels at month-3. Therefore, rituximab immunomonitoring in pMN patients treated with rituximab would allow the detection of patients at risk of treatment failure as early as month-3. Studies are needed to assess whether patients with low residual rituximab levels at month-3 may benefit from an early additional course of rituximab.
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Affiliation(s)
- Maxime Teisseyre
- Laboratoire d'Immunologie, Centre Hospitalier Universitaire de Nice (CHU de Nice), Université Côte d'Azur, Nice, France.,Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, Centre Hospitalier Universitaire de Nice (CHU de Nice), Université Côte d'Azur, Nice, France
| | - Marion Cremoni
- Service de Néphrologie-Dialyse-Transplantation, Centre Hospitalier Universitaire de Nice (CHU de Nice), Université Côte d'Azur, Nice, France
| | - Sonia Boyer-Suavet
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, Centre Hospitalier Universitaire de Nice (CHU de Nice), Université Côte d'Azur, Nice, France.,Service de Néphrologie-Dialyse-Transplantation, Centre Hospitalier Universitaire de Nice (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
| | - Thomas Crepin
- Centre Hospitalier Regional Universitaire de Besancon (CHU Besancon), Department of Nephrology, Dialysis, and Renal Transplantation, Besancon, France
| | - Sylvia Benzaken
- Laboratoire d'Immunologie, Centre Hospitalier Universitaire de Nice (CHU de Nice), Université Côte d'Azur, Nice, France
| | - Kévin Zorzi
- Unité de Recherche Clinique de la Côte d'Azur (UR2CA), Université Côte d'Azur, Nice, France
| | - Vincent Esnault
- Service de Néphrologie-Dialyse-Transplantation, Centre Hospitalier Universitaire de Nice (CHU de Nice), Université Côte d'Azur, Nice, France
| | - Vesna Brglez
- Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, Centre Hospitalier Universitaire de Nice (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
- Laboratoire d'Immunologie, Centre Hospitalier Universitaire de Nice (CHU de Nice), Université Côte d'Azur, Nice, France.,Centre de Référence Maladies Rares Syndrome Néphrotique Idiopathique, Centre Hospitalier Universitaire de Nice (CHU de Nice), Université Côte d'Azur, Nice, France.,Service de Néphrologie-Dialyse-Transplantation, Centre Hospitalier Universitaire de Nice (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
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48
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Cara-Fuentes G, Smoyer WE. Biomarkers in pediatric glomerulonephritis and nephrotic syndrome. Pediatr Nephrol 2021; 36:2659-2673. [PMID: 33389089 DOI: 10.1007/s00467-020-04867-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/16/2020] [Accepted: 11/18/2020] [Indexed: 12/21/2022]
Abstract
Glomerular diseases are often chronic or recurring and thus associated with a tremendous physical, psychological, and economic burden. Their etiologies are often unknown, and their pathogeneses are frequently poorly understood. The diagnoses and management of these diseases are therefore based on clinical features, traditional laboratory markers, and, often, kidney pathology. However, the clinical presentation can be highly variable, the kidney pathology may not establish a definitive diagnosis, and the therapeutic responses and resulting clinical outcomes are often unpredictable. To try to address these challenges, significant research efforts have been made over the last decade to identify potential biomarkers that can help clinicians optimize the diagnosis and prognosis at clinical presentation, as well as help predict long-term outcomes. Unfortunately, these efforts have to date only identified a single biomarker for glomerular disease that has been fully validated and developed for widespread clinical use (anti-PLA2R antibodies to diagnose membranous nephropathy). In this manuscript, we review the definitions and development of biomarkers, as well as the current knowledge on both historical and novel candidate biomarkers of glomerular disease, with an emphasis on those associated with idiopathic nephrotic syndrome.
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Affiliation(s)
- Gabriel Cara-Fuentes
- Department of Pediatrics, Division of Pediatric Nephrology, University of Colorado, 12700 E 19th Ave, R2 building, Room 7420D, Aurora, CO, 80045, USA.
| | - William E Smoyer
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
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49
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Kalantar-Zadeh K, Jafar TH, Nitsch D, Neuen BL, Perkovic V. Chronic kidney disease. Lancet 2021; 398:786-802. [PMID: 34175022 DOI: 10.1016/s0140-6736(21)00519-5] [Citation(s) in RCA: 448] [Impact Index Per Article: 149.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/11/2021] [Accepted: 02/19/2021] [Indexed: 12/11/2022]
Abstract
Chronic kidney disease is a progressive disease with no cure and high morbidity and mortality that occurs commonly in the general adult population, especially in people with diabetes and hypertension. Preservation of kidney function can improve outcomes and can be achieved through non-pharmacological strategies (eg, dietary and lifestyle adjustments) and chronic kidney disease-targeted and kidney disease-specific pharmacological interventions. A plant-dominant, low-protein, and low-salt diet might help to mitigate glomerular hyperfiltration and preserve renal function for longer, possibly while also leading to favourable alterations in acid-base homoeostasis and in the gut microbiome. Pharmacotherapies that alter intrarenal haemodynamics (eg, renin-angiotensin-aldosterone pathway modulators and SGLT2 [SLC5A2] inhibitors) can preserve kidney function by reducing intraglomerular pressure independently of blood pressure and glucose control, whereas other novel agents (eg, non-steroidal mineralocorticoid receptor antagonists) might protect the kidney through anti-inflammatory or antifibrotic mechanisms. Some glomerular and cystic kidney diseases might benefit from disease-specific therapies. Managing chronic kidney disease-associated cardiovascular risk, minimising the risk of infection, and preventing acute kidney injury are crucial interventions for these patients, given the high burden of complications, associated morbidity and mortality, and the role of non-conventional risk factors in chronic kidney disease. When renal replacement therapy becomes inevitable, an incremental transition to dialysis can be considered and has been proposed to possibly preserve residual kidney function longer. There are similarities and distinctions between kidney-preserving care and supportive care. Additional studies of dietary and pharmacological interventions and development of innovative strategies are necessary to ensure optimal kidney-preserving care and to achieve greater longevity and better health-related quality of life for these patients.
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Affiliation(s)
- Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension and Kidney Transplantation, University of California Irvine, Orange, CA, USA; Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA, USA.
| | - Tazeen H Jafar
- Duke-NUS Graduate Medical School, Singapore; Department of Renal Medicine, Singapore General Hospital, Singapore; Duke Global Health Institute, Durham, NC, USA
| | - Dorothea Nitsch
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK; United Kingdom Renal Registry, Bristol, UK; Department of Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Vlado Perkovic
- Faculty of Medicine, University of New South Wales Sydney, Sydney, NSW, Australia
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50
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Li SS, Tang DE, Dai Y. Advances in antigens associated with Idiopathic Membranous Nephropathy. J Formos Med Assoc 2021; 120:1941-1948. [PMID: 34244038 DOI: 10.1016/j.jfma.2021.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 04/22/2021] [Accepted: 06/17/2021] [Indexed: 10/20/2022] Open
Abstract
Membranous nephropathy (MN) is a common cause of nephrotic syndrome in adults. Idiopathic MN (IMN), one of the forms of MN, usually has an unknown etiology. IMN is described as an autoimmune disease, and its pathogenesis is quite complex. The discovery of the M-type phospholipase A2 receptor (PLA2R) plays an important role in promoting our understanding of IMN, although the exact mechanisms of its occurrence and development are still not completely clear. Other target antigens have been discovered one after another, as considerable progress has been made in the molecular pathomechanisms of IMN. Here, we review the findings about the target antigens associated with IMN in recent years. It is hoped that this article can provide researchers with some scientific issues or innovative ideas for future studies of IMN, which will provide clinicians with more knowledge about further improving their abilities to provide better medical care for IMN patients.
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Affiliation(s)
- Shan-Shan Li
- Clinical Medical Research Center, Guangdong Provincial Engineering Research Center of Autoimmune Disease Precision Medicine, Shenzhen Engineering Research Center of Autoimmune Disease, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, China
| | - Dong-E Tang
- Clinical Medical Research Center, Guangdong Provincial Engineering Research Center of Autoimmune Disease Precision Medicine, Shenzhen Engineering Research Center of Autoimmune Disease, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, China.
| | - Yong Dai
- Clinical Medical Research Center, Guangdong Provincial Engineering Research Center of Autoimmune Disease Precision Medicine, Shenzhen Engineering Research Center of Autoimmune Disease, The Second Clinical Medical College of Jinan University, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, China.
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