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Schwotzer N, Fakhouri F, Martins PV, Delmas Y, Caillard S, Zuber J, Moranne O, Mesnard L, Frémeaux-Bacchi V, El-Sissy C. Hot Spot of Complement Factor I Rare Variant p.Ile357Met in Patients With Hemolytic Uremic Syndrome. Am J Kidney Dis 2024; 84:244-249. [PMID: 38423159 DOI: 10.1053/j.ajkd.2023.12.021] [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: 06/28/2023] [Revised: 11/21/2023] [Accepted: 12/23/2023] [Indexed: 03/02/2024]
Abstract
Atypical hemolytic uremic syndrome (aHUS) is a rare kidney disease due to a dysregulation of the complement alternative pathway. Complement factor I (CFI) negatively regulates the alternative pathway and CFI gene rare variants have been associated to aHUS with a low disease penetrance. We report 10 unrelated cases of HUS associated to a rare CFI variant, p.Ile357Met (c.1071T>G). All patients with isolated p.Ile357Met CFI missense variant were retrospectively identified among patients included between January 2007 and January 2022 in the French HUS Registry. We identified 10 unrelated patients (70% women; median age at HUS diagnosis, 36.5 years) who carry the same rare variant p.Ile357Met in the CFI gene. Seven patients (cases 1-7) presented with aHUS in the native kidney associated with malignant hypertension in 5 patients. None received a C5 inhibitor. Two of these cases occurred in the peripartum period with complete recovery of kidney function, while 5 of these patients reached kidney failure requiring replacement therapy (KFRT). Four patients with KFRT subsequently underwent kidney transplantation. Three later developed C3 glomerulopathy in their kidney graft, but none had aHUS recurrence. Three other patients (cases 8-10) experienced de novo thrombotic microangiopathy after kidney transplantation, precipitated by various triggers. The rare CFI variant p.Ile357Met appears to be a facilitating genetic factor for HUS and for some forms of secondary HUS.
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Affiliation(s)
- Nora Schwotzer
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Paula Vieira Martins
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; Paris University, Paris, France
| | - Yahsou Delmas
- Nephrology Department, CHU de Bordeaux Bordeaux, France
| | - Sophie Caillard
- Nephrology Department, Strasbourg University Hospital, Strasbourg, France
| | - Julien Zuber
- Department of Renal and Metabolic Diseases, Transplantation, and Clinical Immunology Assistance Publique-Hôpitaux de Paris, Hôpital Necker, Paris, France
| | - Olivier Moranne
- Department of Nephrology, Dialysis and Apheresis, Nîmes Hôpital Universitaire, Nîmes, France
| | - Laurent Mesnard
- Sorbonne Université, Paris, France; Nephrology Intensive Care Unit, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Véronique Frémeaux-Bacchi
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; Paris University, Paris, France; Inflammation, Complement and Cancer Team, Cordeliers Research Center, INSERM Unité Mixte de Recherche (UMR) S1138, Paris, France
| | - Carine El-Sissy
- Department of Nephrology, Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France; Paris University, Paris, France
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2
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Ng MSY, Kaur G, Francis RS, Hawley CM, Johnson DW. Drug repurposing for glomerular diseases: an underutilized resource. Nat Rev Nephrol 2024:10.1038/s41581-024-00864-8. [PMID: 39085415 DOI: 10.1038/s41581-024-00864-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 08/02/2024]
Abstract
Drug repurposing in glomerular disease can deliver opportunities for steroid-free regimens, enable personalized multi-target options for resistant or relapsing disease and enhance treatment options for understudied populations (for example, children) and in resource-limited settings. Identification of drug-repurposing candidates can be data driven, which utilizes existing data on disease pathobiology, drug features and clinical outcomes, or experimental, which involves high-throughput drug screens. Information from databases of approved drugs, clinical trials and PubMed registries suggests that at least 96 drugs on the market cover 49 targets with immunosuppressive potential that could be candidates for drug repurposing in glomerular disease. Furthermore, evidence to support drug repurposing is available for 191 immune drug target-glomerular disease pairs. Non-immunological drug repurposing includes strategies to reduce haemodynamic overload, podocyte injury and kidney fibrosis. Recommended strategies to expand drug-repurposing capacity in glomerular disease include enriching drug databases with glomeruli-specific information, enhancing the accessibility of primary clinical trial data, biomarker discovery to improve participant selection into clinical trials and improve surrogate outcomes and initiatives to reduce patent, regulatory and organizational hurdles.
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Affiliation(s)
- Monica Suet Ying Ng
- Kidney Health Service, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
- Conjoint Internal Medicine Laboratory, Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia.
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
| | - Gursimran Kaur
- Department of Rheumatology, Saint Vincent's Hospital, Sydney, New South Wales, Australia
- Saint Vincent's Clinical School, Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Rheumatology Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Ross S Francis
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Carmel M Hawley
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Queensland, Australia
| | - David W Johnson
- Department of Kidney and Transplant Services, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Translational Research Institute, Brisbane, Queensland, Australia
- Centre for Kidney Disease Research, University of Queensland, Brisbane, Queensland, Australia
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3
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Vivarelli M, Barratt J, Beck LH, Fakhouri F, Gale DP, Goicoechea de Jorge E, Mosca M, Noris M, Pickering MC, Susztak K, Thurman JM, Cheung M, King JM, Jadoul M, Winkelmayer WC, Smith RJH. The role of complement in kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2024:S0085-2538(24)00389-2. [PMID: 38844295 DOI: 10.1016/j.kint.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/25/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Uncontrolled complement activation can cause or contribute to glomerular injury in multiple kidney diseases. Although complement activation plays a causal role in atypical hemolytic uremic syndrome and C3 glomerulopathy, over the past decade, a rapidly accumulating body of evidence has shown a role for complement activation in multiple other kidney diseases, including diabetic nephropathy and several glomerulonephritides. The number of available complement inhibitor therapies has also increased during the same period. In 2022, Kidney Diseases: Improving Global Outcomes (KDIGO) convened a Controversies Conference, "The Role of Complement in Kidney Disease," to address the expanding role of complement dysregulation in the pathophysiology, diagnosis, and management of various glomerular diseases, diabetic nephropathy, and other forms of hemolytic uremic syndrome. Conference participants reviewed the evidence for complement playing a primary causal or secondary role in progression for several disease states and considered how evidence of complement involvement might inform management. Participating patients with various complement-mediated diseases and caregivers described concerns related to life planning, implications surrounding genetic testing, and the need for inclusive implementation of effective novel therapies into clinical practice. The value of biomarkers in monitoring disease course and the role of the glomerular microenvironment in complement response were examined, and key gaps in knowledge and research priorities were identified.
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Affiliation(s)
- Marina Vivarelli
- Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Jonathan Barratt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Laurence H Beck
- Section of Nephrology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Fadi Fakhouri
- Department of Nephrology, Centre Hospitalier Universitaire, Nantes, France; INSERM UMR S1064, Nantes, France
| | - Daniel P Gale
- Centre for Kidney and Bladder Health, University College London, UK
| | - Elena Goicoechea de Jorge
- Department of Immunology, Ophthalmology and ORL, Complutense University, Madrid, Spain; Area of Chronic Diseases and Transplantation, Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
| | - Marta Mosca
- Department of Clinical and Experimental Medicine-Rheumatology Unit, University of Pisa, Pisa, Italy
| | - Marina Noris
- Clinical Research Center for Rare Diseases Aldo e Cele Daccò, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Ranica, Italy
| | - Matthew C Pickering
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College, Hammersmith Campus, London, UK
| | - Katalin Susztak
- Division of Nephrology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua M Thurman
- Division of Nephrology and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Michel Jadoul
- Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Richard J H Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Internal Medicine, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA; Department of Pediatrics, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
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4
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Nester C, Decker DA, Meier M, Aslam S, Bomback AS, Caravaca-Fontán F, Cook TH, Feldman DL, Fremeaux-Bacchi V, Gale DP, Gooch A, Johnson S, Licht C, Mathur M, Pickering MC, Praga M, Remuzzi G, Selvarajah V, Smith RJ, Tabriziani H, van de Kar N, Wang Y, Wong E, Mistry K, Lim M, Portillo C, Balogun S, Trachtman H, Thompson A. Developing Therapies for C3 Glomerulopathy: Report of the Kidney Health Initiative C3 Glomerulopathy Trial Endpoints Work Group. Clin J Am Soc Nephrol 2024:01277230-990000000-00395. [PMID: 38829708 DOI: 10.2215/cjn.0000000000000505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/28/2024] [Indexed: 06/05/2024]
Abstract
Randomized clinical trials are underway to evaluate the efficacy of novel agents targeting the alternative complement pathway in patients with C3 glomerulopathy (C3G), a rare glomerular disease. The Kidney Health Initiative convened a panel of experts in C3G to ( 1 ) assess the data supporting the use of the prespecified trial end points as measures of clinical benefit and ( 2 ) opine on efficacy findings they would consider compelling as treatment(s) of C3G in native kidneys. Two subpanels of the C3G Trial Endpoints Work Group reviewed the available evidence and uncertainties for the association between the three prespecified end points-( 1 ) proteinuria, ( 2 ) eGFR, and ( 3 ) histopathology-and anticipated outcomes. The full work group provided feedback on the summaries provided by the subpanels and on what potential treatment effects on the proposed end points they would consider compelling to support evidence of an investigational product's effectiveness for treating C3G. Members of the full work group agreed with the characterization of the data, evidence, and uncertainties, supporting the end points. Given the limitations of the available data, the work group was unable to define a minimum threshold for change in any of the end points that might be considered clinically meaningful. The work group concluded that a favorable treatment effect on all three end points would provide convincing evidence of efficacy in the setting of a therapy that targeted the complement pathway. A therapy might be considered effective in the absence of complete alignment in all three end points if there was meaningful lowering of proteinuria and stabilization or improvement in eGFR. The panel unanimously supported efforts to foster data sharing between academic and industry partners to address the gaps in the current knowledge identified by the review of the end points in the aforementioned trials.
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Affiliation(s)
- Carla Nester
- Department of Pediatrics, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | - Dima A Decker
- Apellis Pharmaceuticals Inc., Waltham, Massachusetts
| | | | - Shakil Aslam
- BioCryst Pharmaceuticals Inc., Durham, North Carolina
| | | | | | - Terence H Cook
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | | | | | - Daniel P Gale
- Department of Renal Medicine, University College of London, London, United Kingdom
- Rare Kidney Disease Registry (RaDaR), Bristol, United Kingdom
| | - Ann Gooch
- BioCryst Pharmaceuticals Inc., Durham, North Carolina
| | - Sally Johnson
- Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
| | | | | | - Matthew C Pickering
- Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
| | - Manuel Praga
- Department of Medicine, Nephrology Department, Complutense University, Madrid, Spain
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Viknesh Selvarajah
- Research and Early Development, Cardiovascular, Renal and Metabolism, Biopharmaceuticals R&D, AstraZeneca, Cambridge, United Kingdom
| | - Richard J Smith
- Molecular Otolaryngology and Renal Research Laboratories, Carver College of Medicine, University of Iowa, Iowa City, Iowa
| | | | - Nicole van de Kar
- Radboud Institute for Molecular Life Sciences, Amalia Children's Hospital, Radboud University, Nijmegen, The Netherlands
| | | | - Edwin Wong
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Kirtida Mistry
- Center for the Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
| | - Mark Lim
- Kidney Health Initiative, American Society of Nephrology, Washington, DC
| | - Cesia Portillo
- Kidney Health Initiative, American Society of Nephrology, Washington, DC
| | - Seyi Balogun
- Kidney Health Initiative, American Society of Nephrology, Washington, DC
| | - Howard Trachtman
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Aliza Thompson
- Center for the Drug Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland
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5
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Escudero-Saiz VJ, Gonzalez Á, García-Herrera A, Larque AB, Bomback AS, Morantes L, Martínez-Chillarón M, Ollé J, Guillén E, Xipell M, Molina-Andújar A, Rodríguez D, Cuadrado E, Cacho J, Arana C, Esforzado N, Bastida C, Poch E, Diekman F, Cucchiari D, Quintana LF, Blasco M. Factor B Inhibition with Iptacopan in Recurrent C3 Glomerulopathy Following Kidney Transplant: A Report of Two Cases. Kidney Med 2024; 6:100823. [PMID: 38741947 PMCID: PMC11089394 DOI: 10.1016/j.xkme.2024.100823] [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] [Indexed: 05/16/2024] Open
Abstract
C3 glomerulopathy is a rare disease caused by fluid phase dysregulation of the alternative complement pathway. Currently, treatment depends on clinical and histological severity and includes nephroprotection, unspecific immunosuppression, and terminal complement blockers (C5), without having an etiological treatment approved. C3 glomerulopathy has high recurrence rates after kidney transplantation with a high risk of graft loss. Fortunately, new molecules are being developed that specifically target the proximal alternative complement pathway, such as iptacopan, a factor B inhibitor that showed promising results in native kidneys and cases of transplant recurrence in a phase 2 clinical trial. We present 2 "real-world" cases of C3 glomerulopathy recurrence in kidney allografts treated with iptacopan, with initial excellent clinical response and safety profile, especially with early introduction. We also present follow-up biopsies that showed no C3 deposition during factor B inhibition. Our cases suggest that proximal blockade of the alternative complement pathway can be effective and safe in the treatment of C3 glomerulopathy recurrence in kidney transplantation, bringing other questions such as dual blockade (eg, in C3 and C5), the optimal patient profile to benefit from factor B inhibition or treatment duration and its potential use in other forms of membranoproliferative glomerulonephritis (eg, immune complex-mediated).
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Affiliation(s)
- Víctor J. Escudero-Saiz
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ángela Gonzalez
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | - Ana B. Larque
- Pathology Service, Hospital Clínic Barcelona, Barcelona, Spain
| | - Andrew S. Bomback
- Division of Nephrology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Laura Morantes
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Marta Martínez-Chillarón
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Júlia Ollé
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Elena Guillén
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Marc Xipell
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Alicia Molina-Andújar
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Diana Rodríguez
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Elena Cuadrado
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Judit Cacho
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Carolt Arana
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Núria Esforzado
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Carla Bastida
- Pharmacy Department, Division of Medicines, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Esteban Poch
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Fritz Diekman
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - David Cucchiari
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Luis F. Quintana
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Miquel Blasco
- Nephrology and Kidney Transplantation Department, National Reference Center on Complex Glomerular Disease (CSUR), IDIBAPS, Hospital Clínic, University of Barcelona, Barcelona, Spain
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6
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Antonucci L, Thurman JM, Vivarelli M. Complement inhibitors in pediatric kidney diseases: new therapeutic opportunities. Pediatr Nephrol 2024; 39:1387-1404. [PMID: 37733095 DOI: 10.1007/s00467-023-06120-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/31/2023] [Accepted: 08/01/2023] [Indexed: 09/22/2023]
Abstract
Historically, the complement system (classical, lectin, alternative, and terminal pathways) is known to play a crucial role in the etiopathogenesis of many kidney diseases. Direct or indirect activation in these settings is revealed by consumption of complement proteins at the serum level and kidney tissue deposition seen by immunofluorescence and electron microscopy. The advent of eculizumab has shown that complement inhibitors may improve the natural history of certain kidney diseases. Since then, the number of available therapeutic molecules and experimental studies on complement inhibition has increased exponentially. In our narrative review, we give a summary of the main complement inhibitors that have completed phase II and phase III studies or are currently used in adult and pediatric nephrology. The relevant full-text works, abstracts, and ongoing trials (clinicaltrials.gov site) are discussed. Data and key clinical features are reported for eculizumab, ravulizumab, crovalimab, avacopan, danicopan, iptacopan, pegcetacoplan, and narsoplimab. Many of these molecules have been shown to be effective in reducing proteinuria and stabilizing kidney function in different complement-mediated kidney diseases. Thanks to their efficacy and target specificity, these novel drugs may radically improve the outcome of complement-mediated kidney diseases, contributing to an improvement in our understanding of their underlying pathophysiology.
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Affiliation(s)
- Luca Antonucci
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
- Ph.D. Course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), University of Rome Tor Vergata, Rome, Italy
| | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Marina Vivarelli
- Division of Nephrology, Bambino Gesù Children's Hospital IRCCS, Rome, Italy.
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children's Hospital IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy.
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7
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Wooden B, Nester CM, Bomback AS. Update on C3 Glomerulopathy. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:223-233. [PMID: 39004462 DOI: 10.1053/j.akdh.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 07/16/2024]
Abstract
C3 glomerulopathy (C3G) is a rare disorder marked by deposition of C3 in the glomerulus, resulting in damage to the glomerular filtration unit and presenting with features of the nephritic and nephrotic syndromes. Fundamentally, C3G is caused by dysregulation of the alternative pathway of the complement cascade, either due to genetic variants or acquired humoral factors. Despite significant advances in recent years in the understanding of the underlying mechanisms and culprit lesions that result in the development of C3G, treatment options remain severely limited, and the prognosis is often poor. Fortunately, a number of anticomplement therapies are emerging from the drug development pipeline, with several in late-stage testing in patients with C3G, and there is hope that we will soon have more targeted options for managing patients with this devastating disease. In this review, we provide an overview of C3G, as well as summarizing the evidence for current treatments and detailing the clinical trials that are currently underway.
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Affiliation(s)
- Benjamin Wooden
- Division of Nephrology, Department of Medicine, Columbia University, New York, NY.
| | - Carla M Nester
- Division of Nephrology, Department of Medicine, University of Iowa, Iowa City, IA
| | - Andrew S Bomback
- Division of Nephrology, Department of Medicine, Columbia University, New York, NY
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8
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Watanabe-Kusunoki K, Anders HJ. Balancing efficacy and safety of complement inhibitors. J Autoimmun 2024; 145:103216. [PMID: 38552408 DOI: 10.1016/j.jaut.2024.103216] [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: 12/20/2023] [Revised: 03/17/2024] [Accepted: 03/26/2024] [Indexed: 05/15/2024]
Abstract
Complement inhibitors have been approved for several immune-mediated diseases and they are considered the next paradigm-shifting approach in the treatment of glomerulonephritis. The hierarchical organization of the complement system offers numerous molecular targets for therapeutic intervention. However, complement is an integral element of host defense and therefore complement inhibition can be associated with serious infectious complications. Here we give a closer look to the hierarchical complement system and how interfering with proximal versus distal or selective versus unselective molecular targets could determine efficacy and safety. Furthermore, we propose to consider the type of disease, immunological activity, and patient immunocompetence when stratifying patients, e.g., proximal/unselective targets for highly active and potentially fatal diseases while distal and selective targets may suit more chronic disease conditions with low or moderate disease activity requiring persistent complement blockade in patients with concomitant immunodeficiency. Certainly, there exists substantial promise for anti-complement therapeutics. However, balancing efficacy and safety will be key to establish powerful treatment effects with minimal adverse events, especially when complement blockade is continued over longer periods of time in chronic disorders.
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Affiliation(s)
- Kanako Watanabe-Kusunoki
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany; Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Hans-Joachim Anders
- Renal Division, Department of Medicine IV, Ludwig-Maximilians (LMU) University Hospital, LMU Munich, Germany.
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9
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Nayak A, Ettenger R, Wesseling-Perry K. Recurrent disease after pediatric renal transplantation. Pediatr Transplant 2024; 28:e14676. [PMID: 38650536 DOI: 10.1111/petr.14676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 11/15/2023] [Accepted: 11/30/2023] [Indexed: 04/25/2024]
Abstract
BACKGROUND Recurrent disease after kidney transplant remains an important cause of allograft failure, accounting for 7-8% of graft loss and ranking as the fifth most common cause of allograft loss in the pediatric population. Although the pathophysiology of many recurrent diseases is incompletely understood, recent advances in basic science and therapeutics are improving outcomes and changing the course of several of these conditions. METHODS Review of the literature. RESULTS We discuss the diagnosis and management of recurrent disease. CONCLUSION We highlight new insights into the pathophysiology and treatment of post-transplant primary hyperoxaluria, focal segmental glomerulosclerosis, immune complex glomerulonephritis, C3 glomerulopathy, lupus nephritis, atypical hemolytic uremic syndrome, and IgA nephropathy.
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Affiliation(s)
- Anjali Nayak
- Phoenix Children's Hospital and the University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Robert Ettenger
- Mattel Children's Hospital and the University of California at Los Angeles, Los Angeles, California, USA
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10
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Obata S, Vaz de Castro PAS, Riella LV, Cravedi P. Recurrent C3 glomerulopathy after kidney transplantation. Transplant Rev (Orlando) 2024; 38:100839. [PMID: 38412598 DOI: 10.1016/j.trre.2024.100839] [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: 01/25/2024] [Revised: 02/17/2024] [Accepted: 02/19/2024] [Indexed: 02/29/2024]
Abstract
The complement system is part of innate immunity and is pivotal in protecting the body against pathogens and maintaining host homeostasis. Activation of the complement system is triggered through multiple pathways, including antibody deposition, a mannan-binding lectin, or activated complement deposition. C3 glomerulopathy (C3G) is a rare glomerular disease driven by complement dysregulation with high post-transplantation recurrence rates. Its treatment is mainly based on immunosuppressive therapies, specifically mycophenolate mofetil and glucocorticoids. Recent years have seen significant progress in understanding complement biology and its role in C3G pathophysiology. New complement-tergeting treatments have been developed and initial trials have shown promising results. However, challenges persist in C3G, with recurrent post-transplantation cases leading to suboptimal outcomes. This review discusses the pathophysiology and management of C3G, with a focus on its recurrence after kidney transplantation.
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Affiliation(s)
- Shota Obata
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Pedro A S Vaz de Castro
- Interdisciplinary Laboratory of Medical Investigation, Unit of Pediatric Nephrology, Faculty of Medicine, Federal University of Minas Gerais (UFMG), Brazil
| | - Leonardo V Riella
- Division of Nephrology and Center for Transplantation Sciences, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Paolo Cravedi
- Precision Immunology Institute, Translational Transplant Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
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11
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Mastellos DC, Hajishengallis G, Lambris JD. A guide to complement biology, pathology and therapeutic opportunity. Nat Rev Immunol 2024; 24:118-141. [PMID: 37670180 DOI: 10.1038/s41577-023-00926-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2023] [Indexed: 09/07/2023]
Abstract
Complement has long been considered a key innate immune effector system that mediates host defence and tissue homeostasis. Yet, growing evidence has illuminated a broader involvement of complement in fundamental biological processes extending far beyond its traditional realm in innate immunity. Complement engages in intricate crosstalk with multiple pattern-recognition and signalling pathways both in the extracellular and intracellular space. Besides modulating host-pathogen interactions, this crosstalk guides early developmental processes and distinct cell trajectories, shaping tissue immunometabolic and regenerative programmes in different physiological systems. This Review provides a guide to the system-wide functions of complement. It highlights illustrative paradigm shifts that have reshaped our understanding of complement pathobiology, drawing examples from evolution, development of the central nervous system, tissue regeneration and cancer immunity. Despite its tight spatiotemporal regulation, complement activation can be derailed, fuelling inflammatory tissue pathology. The pervasive contribution of complement to disease pathophysiology has inspired a resurgence of complement therapeutics with major clinical developments, some of which have challenged long-held dogmas. We thus highlight major therapeutic concepts and milestones in clinical complement intervention.
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Affiliation(s)
| | - George Hajishengallis
- Department of Basic and Translational Sciences, Penn Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - John D Lambris
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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12
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Miwa T, Sato S, Golla M, Song WC. Expansion of Anticomplement Therapy Indications from Rare Genetic Disorders to Common Kidney Diseases. Annu Rev Med 2024; 75:189-204. [PMID: 37669567 DOI: 10.1146/annurev-med-042921-102405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Complement constitutes a major part of the innate immune system. The study of complement in human health has historically focused on infection risks associated with complement protein deficiencies; however, recent interest in the field has focused on overactivation of complement as a cause of immune injury and the development of anticomplement therapies to treat human diseases. The kidneys are particularly sensitive to complement injury, and anticomplement therapies for several kidney diseases have been investigated. Overactivation of complement can result from loss-of-function mutations in complement regulators; gain-of-function mutations in key complement proteins such as C3 and factor B; or autoantibody production, infection, or tissue stresses, such as ischemia and reperfusion, that perturb the balance of complement activation and regulation. Here, we provide a high-level review of the status of anticomplement therapies, with an emphasis on the transition from rare diseases to more common kidney diseases.
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Affiliation(s)
- Takashi Miwa
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; , , ,
| | - Sayaka Sato
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; , , ,
| | - Madhu Golla
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; , , ,
| | - Wen-Chao Song
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; , , ,
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13
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Leung N, Heybeli C. Kidney Transplantation in Multiple Myeloma and Monoclonal Gammopathy of Renal Significance. Semin Nephrol 2024; 44:151497. [PMID: 38485643 DOI: 10.1016/j.semnephrol.2024.151497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Recent advances in the treatment of plasma cell disorders (PCDs) have provided a wealth of therapy alternatives and improved overall survival tremendously. Various types of PCDs are associated with kidney injury and end-stage kidney disease in a considerable number of patients. Kidney transplantation (KTx) is the best option for renal replacement therapy in select patients in terms of both quality of life parameters and overall survival. Even with modern therapies, all PCDs carry the risk of hematologic progression, whereas histologic recurrence and graft loss are other prevailing concerns in these patients. The risk of mortality is also higher in some of these disorders compared with KTx recipients who suffer from other causes of kidney disease. Unlike solid cancers, there is no well-defined "waiting time" after hematologic remission before proceeding to KTx. Thus, clinicians are usually reluctant to recommend KTx to patients who develop end-stage kidney disease due to PCDs. This review aims to provide the current evidence on KTx outcomes in patients with monoclonal gammopathy of renal significance and multiple myeloma. Although immunoglobulin light chain amyloidosis is a monoclonal gammopathy of renal significance subtype, KTx outcomes in this group are mentioned in another chapter of this issue.
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Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN.
| | - Cihan Heybeli
- Division of Nephrology, Dokuz Eylül University Hospital, Balcova, Turkey
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14
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Wong E, Nester C, Cavero T, Karras A, Le Quintrec M, Lightstone L, Eisenberger U, Soler MJ, Kavanagh D, Daina E, Praga M, Medjeral-Thomas NR, Gäckler A, Garcia-Carro C, Biondani A, Chaperon F, Kulmatycki K, Milojevic J, Webb NJ, Nidamarthy PK, Junge G, Remuzzi G. Efficacy and Safety of Iptacopan in Patients With C3 Glomerulopathy. Kidney Int Rep 2023; 8:2754-2764. [PMID: 38106570 PMCID: PMC10719607 DOI: 10.1016/j.ekir.2023.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/21/2023] [Accepted: 09/11/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Complement 3 glomerulopathy (C3G) is a rare inflammatory kidney disease mediated by dysregulation of the alternative complement pathway. No targeted therapy exists for this aggressive glomerulonephritis. Efficacy, safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) (measured by complement biomarkers) of iptacopan were assessed in patients with C3G. Methods In this phase 2, multicenter, open-label, single-arm, nonrandomized study, adults with biopsy-proven, native kidney C3G (native cohort) and kidney transplant recipients with C3G recurrence (recurrent kidney transplant [KT] cohort) received iptacopan twice daily (bid) for 84 days (days 1-21: 10-100 mg; days 22-84: 200 mg). The primary end point was the urine protein-to-creatinine ratio (UPCR; native cohort) and the change in the C3 deposit score of kidney biopsy (recurrent KT cohort). The complement pathway measures included Wieslab assay, soluble C5b9, and serum C3 levels. Results A total of 27 patients (16 native cohort and 11 recurrent KT cohort) were enrolled and all completed the study. In the native cohort, UPCR levels decreased by 45% from baseline to week 12 (P = 0.0003). In the recurrent KT cohort, the median C3 deposit score decreased by 2.50 (scale: 0-12) on day 84 versus baseline (P = 0.03). Serum C3 levels were normalized in most patients; complement hyperactivity observed pretreatment was reduced. Severe adverse events (AEs) included post-biopsy hematuria and hyperkalemia. No deaths occurred during the study. Conclusion Iptacopan resulted in statistically significant and clinically important reductions in UPCR and normalization of serum C3 levels in the native cohort and reduced C3 deposit scores in the recurrent KT cohort with favorable safety and tolerability. (ClinicalTrials.gov identifier: NCT03832114).
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Affiliation(s)
- Edwin Wong
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Carla Nester
- The University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa, USA
| | - Teresa Cavero
- Nephrology Department, University Hospital Doce de Octubre, Madrid, Spain
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges-Pompidou, APHP, Paris, France
| | - Moglie Le Quintrec
- Service de Néphrologie et Transplantation Rénale, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Liz Lightstone
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Ute Eisenberger
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Maria Jose Soler
- Nephrology Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Manuel Praga
- Instituto de Investigación Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Nicholas R. Medjeral-Thomas
- Centre for Inflammatory Disease, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Anja Gäckler
- Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Clara Garcia-Carro
- Nephrology Department, Vall d’Hebron University Hospital, Vall d’Hebron Institute of Research, CSUR National Unit of Expertise for Complex Glomerular Diseases of Spain, Barcelona, Spain
| | - Andrea Biondani
- Novartis Institutes for BioMedical Research, Translational Medicine, Novartis AG, Basel, Switzerland
| | - Frederique Chaperon
- Novartis Institutes for BioMedical Research, Translational Medicine, Novartis AG, Basel, Switzerland
| | - Kenneth Kulmatycki
- Novartis Institutes for BioMedical Research, Cambridge, Massachusetts, USA
| | - Julie Milojevic
- Novartis Institutes for BioMedical Research, Translational Medicine, Novartis AG, Basel, Switzerland
| | - Nicholas J.A. Webb
- Novartis Institutes for BioMedical Research, Translational Medicine, Novartis AG, Basel, Switzerland
| | | | - Guido Junge
- Novartis Institutes for BioMedical Research, Translational Medicine, Novartis AG, Basel, Switzerland
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
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15
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Zotta F, Diomedi-Camassei F, Gargiulo A, Cappoli A, Emma F, Vivarelli M. Successful treatment with avacopan (CCX168) in a pediatric patient with C3 glomerulonephritis. Pediatr Nephrol 2023; 38:4197-4201. [PMID: 37306717 DOI: 10.1007/s00467-023-06035-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/14/2023] [Accepted: 05/23/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND C3 glomerulonephritis (C3GN) is a subtype of C3 glomerulopathy (C3G), characterized by dysregulation of the alternative pathway of complement and by dominant C3 by immunofluorescence on the kidney biopsy. There is no approved treatment for patients with C3G. Immunosuppressive drugs as well as biologics have been used with limited success. In recent decades, substantial advances in the understanding of the complement system have led to the development of new complement inhibitors. Avacopan (CCX168) is an orally administered small-molecule C5aR antagonist that blocks the effects of C5a, one of the most potent pro-inflammatory mediators of the complement system. CASE REPORT We describe a child with biopsy-proven C3GN treated with avacopan. She was enrolled in the ACCOLADE double-blind placebo-controlled Phase 2 study (NCT03301467), where during the first 26 weeks she was randomized to receive an avacopan-matching placebo orally twice daily, while in the following 26 weeks, the study was open-label and she received avacopan. After a wash-out period, she was restarted on avacopan through an expanded access program. CONCLUSIONS In this case, use of avacopan in a pediatric patient with C3GN was safe and well tolerated. On avacopan, the patient was able to discontinue mycophenolate mofetil (MMF) while maintaining remission.
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Affiliation(s)
- Federica Zotta
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | | | - Antonio Gargiulo
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Andrea Cappoli
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Francesco Emma
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - Marina Vivarelli
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S. Onofrio 4, 00165, Rome, Italy
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16
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Tang B, Yang X. Clinical advances in immunotherapy for immune-mediated glomerular diseases. Clin Exp Med 2023; 23:4091-4105. [PMID: 37889398 PMCID: PMC10725396 DOI: 10.1007/s10238-023-01218-7] [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: 08/25/2023] [Accepted: 10/09/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND AND OBJECTIVE Due to the suboptimal therapeutic efficacy and potential adverse effects associated with traditional immunosuppressive medications, there has been an increasing emphasis on the development and utilization of immunotherapies. This paper aims to provide clinicians with valuable insights for selecting appropriate therapeutic approaches and contribute to the development of novel immunotherapeutic drugs. MAIN BODY This paper categorizes the immunotherapeutic drugs that are used for the treatment of immune-mediated glomerular diseases into three groups: immunotherapies targeting antigen-presenting cells (anti-CD80), immunotherapies targeting T/B cells (anti-CD20, anti-CD22, BAFF and APRIL inhibitors, CD40-CD40L inhibitors, proteasome inhibitors, Syk inhibitors, and Btk inhibitors), and immunotherapies targeting the complement system (C5 inhibitors, C5a/C5aR inhibitors, C3 inhibitors, MASP2 inhibitors, factor B inhibitors, and factor D inhibitors). The article then provides a comprehensive overview of advances related to these immunotherapeutic drugs in clinical research. CONCLUSION Certain immunotherapeutic drugs, such as rituximab, belimumab, and eculizumab, have exhibited notable efficacy in treating specific immune-mediated glomerular diseases, thereby providing novel therapeutic approaches for patients. Nonetheless, the efficacy of numerous immunotherapeutic drugs remains to be substantiated.
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Affiliation(s)
- Bihui Tang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China
| | - Xiao Yang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, Hubei, China.
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17
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Wooden B, Tarragon B, Navarro-Torres M, Bomback AS. Complement inhibitors for kidney disease. Nephrol Dial Transplant 2023; 38:ii29-ii39. [PMID: 37218685 DOI: 10.1093/ndt/gfad079] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Indexed: 05/24/2023] Open
Abstract
A refined understanding of the role of complement in the pathogenesis of glomerular and other kidney diseases has, over the past two decades, been matched by the development of novel, complement-targeting therapies. As we increasingly recognize the important role that complement activation across all three pathways-classical, lectin and alternative-plays in glomerular lesions both rare (e.g. C3 glomerulopathy) and common (e.g. immunoglobulin A nephropathy), we can identify avenues for precise, targeted approaches to modifying the natural history of these kidney diseases. In this review, we survey the evidence on using complement inhibition from the earliest, small-scale studies focusing on C5-targeting agents to more recent, large, multicenter, randomized trials utilizing complement blockade higher up in the complement pathway at the level of C3. We conclude by examining where the field of complement targeting therapy may be headed in light of these studies.
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Affiliation(s)
- Benjamin Wooden
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Blanca Tarragon
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Mariela Navarro-Torres
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
| | - Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, NY, USA
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18
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Dixon BP, Greenbaum LA, Huang L, Rajan S, Ke C, Zhang Y, Li L. Clinical Safety and Efficacy of Pegcetacoplan in a Phase 2 Study of Patients with C3 Glomerulopathy and Other Complement-Mediated Glomerular Diseases. Kidney Int Rep 2023; 8:2284-2293. [PMID: 38025230 PMCID: PMC10658235 DOI: 10.1016/j.ekir.2023.08.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Dysregulated complement activation is likely the primary driver of disease in C3 glomerulopathy (C3G) and contributes to other complement-mediated diseases, including immunoglobulin A nephropathy (IgAN), lupus nephritis (LN), and primary membranous nephropathy (PMN). No complement inhibitors are proven to halt disease progression in these diseases. Pegcetacoplan, a targeted C3 and C3b inhibitor, may mitigate complement-mediated kidney damage in C3G and other glomerular diseases in which complement may have a pathogenic role. Methods This open-label, phase 2, 48-week study evaluated the preliminary efficacy and safety of subcutaneous pegcetacoplan for patients with complement-mediated glomerular diseases. The primary end point was proteinuria reduction, measured as 24-hour urine protein-to-creatinine ratio. Secondary end points included remission status, changes in estimated glomerular filtration rate (eGFR), and pharmacodynamic biomarkers. Treatment-emergent adverse events (TEAEs) were monitored. Results Efficacy results for the C3G cohort are reported herein, along with safety results for the study population. In the C3G cohort, mean proteinuria reduction from baseline to week 48 was 50.9% in the intent-to-treat (ITT) population (n = 7) and 65.4% in the per-protocol (PP) population (n = 4). Mean serum albumin normalized and mean eGFR was stable over 48 weeks. Mean serum C3 levels increased 6-fold and mean soluble C5b-9 levels decreased by 57.3% at week 48. The most common adverse events (AEs) were upper respiratory tract infection, injection site erythema, nausea, and headache. No meningitis or sepsis cases were reported, and no serious treatment-related AEs were observed. Conclusion Pegcetacoplan may provide therapeutic benefit for C3G and has a favorable safety profile across the 4 glomerular diseases studied.
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Affiliation(s)
- Bradley P. Dixon
- Renal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Larry A. Greenbaum
- Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Liwei Huang
- Tidewater Kidney Specialists, Inc, Chesapeake, Virginia, USA
| | - Sandeep Rajan
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Chunlei Ke
- Apellis Pharmaceuticals, Inc., Waltham, Massachusetts, USA
| | - Yiwei Zhang
- Apellis Pharmaceuticals, Inc., Waltham, Massachusetts, USA
| | - Li Li
- Apellis Pharmaceuticals, Inc., Waltham, Massachusetts, USA
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19
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Lim JH, Shin SW, Kim MS, Han MH, Kim YJ, Jung HY, Choi JY, Cho JH, Park SH, Kim YL, Hwang D, Yun WS, Kim HK, Huh S, Yoo ES, Won DI, Kim CD. Recurrent C3 Glomerulonephritis along with BK-Virus-Associated Nephropathy after Kidney Transplantation: A Case Report. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1308. [PMID: 37512118 PMCID: PMC10383463 DOI: 10.3390/medicina59071308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023]
Abstract
C3 glomerulonephritis (C3GN) is a rare cause of end-stage kidney disease and frequently recurrent in allografts following kidney transplantation (KT). Herein, we describe the case of a kidney transplant recipient who developed recurrent C3GN along with BK-virus-associated nephropathy (BKVAN) following KT. A 33-year-old man diagnosed with membranoproliferative glomerulonephritis 17 years ago underwent preemptive KT with a donor kidney from his aunt. Proteinuria gradually increased after 3 months following KT, and graft biopsy was performed 30 months after KT. Histopathological examination revealed recurrent C3GN. The dosages of triple immunosuppressive maintenance therapy agents were increased. Subsequently, serum C3 levels recovered to normal levels. However, at 33 months following KT, the BK viral load increased and graft function gradually deteriorated; a second graft biopsy was performed at 46 months following KT, which revealed BKVAN and decreased C3GN activity. The dosages of immunosuppressive agents were decreased; subsequently, BKVAN improved and graft function was maintained with normal serum C3 levels at 49 months following KT. This case indicates that C3GN is highly prone to recurrence following KT and that immunosuppressive therapy for C3GN increases the risk of BKVAN.
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Affiliation(s)
- Jeong-Hoon Lim
- Department of Internal Medicine, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Seong-Won Shin
- Department of Internal Medicine, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Mee-Seon Kim
- Department of Pathology, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Man-Hoon Han
- Department of Pathology, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Yong-Jin Kim
- Department of Pathology, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Hee-Yeon Jung
- Department of Internal Medicine, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Ji-Young Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Jang-Hee Cho
- Department of Internal Medicine, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Sun-Hee Park
- Department of Internal Medicine, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Yong-Lim Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Deokbi Hwang
- Department of Surgery, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Woo-Sung Yun
- Department of Surgery, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Hyung-Kee Kim
- Department of Surgery, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Seung Huh
- Department of Surgery, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Eun Sang Yoo
- Department of Urology, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Dong Il Won
- Department of Clinical Pathology, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
| | - Chan-Duck Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University Hospital, Kyungpook National University, Daegu 41944, Republic of Korea
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20
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Windpessl M, Odler B, Bajema IM, Geetha D, Säemann M, Lee JM, Vaglio A, Kronbichler A. Glomerular Diseases Across Lifespan: Key Differences in Diagnostic and Therapeutic Approaches. Semin Nephrol 2023; 43:151435. [PMID: 37945450 DOI: 10.1016/j.semnephrol.2023.151435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Glomerular diseases are common causes of chronic kidney disease in childhood, adolescence, and adulthood. The epidemiology of glomerular diseases differs between different age groups, with minimal change disease being the leading cause of nephrotic syndrome in childhood, while membranous nephropathy and focal segmental glomerulosclerosis are more common in adulthood. IgA vasculitis is also more common in childhood. Moreover, there is a difference in disease severity with more children presenting with a relapsing form of nephrotic syndrome and a more acute presentation of antineutrophil cytoplasmic antibody-associated vasculitis and concomitant glomerulonephritis, as highlighted by the higher percentage of cellular crescents on kidney biopsy specimens in comparison with older patients. There is also a female preponderance in antineutrophil cytoplasmic antibody-associated vasculitis and more children present with tracheobroncholaryngeal disease. This article aims to summarize differences in the presentation of different glomerular diseases that are encountered commonly by pediatric and adult nephrologists and potential differences in the management.
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Affiliation(s)
- Martin Windpessl
- Section of Nephrology, Department of Internal Medicine IV, Klinikum Wels-Grieskirchen, Wels, Austria; Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Balazs Odler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ingeborg M Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands; Department of Pathology and Medical Biology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Duvuru Geetha
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Marcus Säemann
- 6th Medical Department, Nephrology and Dialysis, Clinic Ottakring, Vienna, Austria; Sigmund Freud University, Medical School, Vienna, Austria
| | - Jiwon M Lee
- Division of Rare Disease Management, Korea Disease Control and Prevention Agency, Cheongju-si, Republic of Korea
| | - Augusto Vaglio
- Department of Biomedical Experimental and Clinical Sciences "Mario Serio", University of Firenze, Nephrology Unit, Meyer Children's Hospital, Firenze, Italy
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom; Vasculitis and Lupus Clinic, Addenbrooke's Hospital, Cambridge, United Kingdom; Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria.
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21
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Jandal A, Zhong W, Gopal D, Horner V, Frater-Rubsam L, Djamali A, Bhutani G. What lies in-between: C3 glomerulopathy with non-hemolytic renal microangiopathy and an ultra-rare C3 variant. Am J Med Sci 2023; 365:286-293. [PMID: 36473547 DOI: 10.1016/j.amjms.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 08/31/2022] [Accepted: 10/12/2022] [Indexed: 12/12/2022]
Abstract
We report a 36-year-old female with mixed nephritic-nephrotic syndrome and recurrent pancreatitis. Kidney biopsy showed a crescentic membranoproliferative glomerulonephritis with dominant C3 staining on immunofluorescence (IF) but only scant deposits on electron microscopy (EM) and instead, evidence of severe acute and chronic microangiopathy - endothelial swelling, sub-endothelial fluff, and segmental basement membrane remodeling. Her serum C3 was normal, Factor Ba, and serum Membrane attack complex (sMAC) levels were elevated, and Properdin was low. Genetic testing revealed a heterozygous ultra rare C3 variant of unknown significance (c.4838G>T, p.Gly1613Val) as well as a heterozygous deletion of CFHR3-CFHR1. She showed an initial response to terminal complement blockade with eculizumab, but her renal disease progressed in the next year. Notably, our patient never demonstrated microangiopathic hemolysis, yet pancreatitis of unclear etiology recurred periodically. Our case suggests the existence of a "C3G/aHUS overlap" clinicopathologic syndrome and highlights the challenges of treating complement-mediated kidney disease.
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Affiliation(s)
- Ali Jandal
- Divsion of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Weixiong Zhong
- Department of Pathology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Deepak Gopal
- Divsion of Gastroenterology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Vanessa Horner
- Wisconsin State Laboratory of Hygiene, University of Wisconsin, Madison, Wisconsin, United States; Department of Pediatrics, University of Wisconsin, Madison, United States
| | - Leah Frater-Rubsam
- Wisconsin State Laboratory of Hygiene, University of Wisconsin, Madison, Wisconsin, United States; Department of Pediatrics, University of Wisconsin, Madison, United States
| | - Arjang Djamali
- Divsion of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States
| | - Gauri Bhutani
- Divsion of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, United States.
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22
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Diagnostic and Prognostic Comparison of Immune-Complex-Mediated Membranoproliferative Glomerulonephritis and C3 Glomerulopathy. Cells 2023; 12:cells12050712. [PMID: 36899849 PMCID: PMC10000503 DOI: 10.3390/cells12050712] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023] Open
Abstract
Membranoproliferative glomerulonephritis (MPGN) is subdivided into immune-complex-mediated glomerulonephritis (IC-MPGN) and C3 glomerulopathy (C3G). Classically, MPGN has a membranoproliferative-type pattern, but other morphologies have also been described depending on the time course and phase of the disease. Our aim was to explore whether the two diseases are truly different, or merely represent the same disease process. All 60 eligible adult MPGN patients diagnosed between 2006 and 2017 in the Helsinki University Hospital district, Finland, were reviewed retrospectively and asked for a follow-up outpatient visit for extensive laboratory analyses. Thirty-seven (62%) had IC-MPGN and 23 (38%) C3G (including one patient with dense deposit disease, DDD). EGFR was below normal (≤60 mL/min/1.73 m2) in 67% of the entire study population, 58% had nephrotic range proteinuria, and a significant proportion had paraproteins in their serum or urine. A classical MPGN-type pattern was seen in only 34% of the whole study population and histological features were similarly distributed. Treatments at baseline or during follow-up did not differ between the groups, nor were there significant differences observed in complement activity or component levels at the follow-up visit. The risk of end-stage kidney disease and survival probability were similar in the groups. IC-MPGN and C3G have surprisingly similar characteristics, kidney and overall survival, which suggests that the current subdivision of MPGN does not add substantial clinical value to the assessment of renal prognosis. The high proportion of paraproteins in patient sera or in urine suggests their involvement in disease development.
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23
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Noris M, Daina E, Remuzzi G. Membranoproliferative glomerulonephritis: no longer the same disease and may need very different treatment. Nephrol Dial Transplant 2023; 38:283-290. [PMID: 34596686 DOI: 10.1093/ndt/gfab281] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Indexed: 12/17/2022] Open
Abstract
Membranoproliferative glomerulonephritis (MPGN) is a pattern of glomerular injury that may be primary or secondary to infections, autoimmune diseases and haematological disorders. Primary C3G and IC-MPGN are rare and the prognosis is unfavourable. Based on immunofluorescence findings, MPGN has been classified into complement-mediated C3 glomerulopathy (C3G) and immune complex-mediated MPGN (IC-MPGN). However, this classification leaves a number of issues unresolved. The finding of genetic and acquired complement abnormalities in both C3G and IC-MPGN indicates that they represent a heterogeneous spectrum rather than distinct diseases. An unsupervised hierarchical clustering in a cohort of patients with primary C3G and IC-MPGN identified four distinct pathogenetic patterns, characterized by specific histologic and clinical features, and genetic and acquired complement abnormalities. These results provide the groundwork for a more accurate diagnosis and the development of targeted therapies. The drugs that are currently used, such as corticosteroids and immunosuppressants, are frequently ineffective in primary C3G and IC-MPGN. Eculizumab, an anti-C5 monoclonal antibody, has been used occasionally in single cases or small series. However, only a few patients have achieved remission. This heterogeneous response could be related to the extent of terminal complement activation, which may vary substantially from patient to patient. Several drugs that target the complement system at different levels are under investigation for C3G and IC-MPGN. However, clinical trials to test new therapeutics will be challenging and heavily influenced by the heterogeneity of these diseases. This creates the need to characterize each patient to match the specific complement abnormality with the type of intervention.
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Affiliation(s)
- Marina Noris
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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24
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Welte T, Arnold F, Westermann L, Rottmann FA, Hug MJ, Neumann-Haefelin E, Ganner A. Eculizumab as a treatment for C3 glomerulopathy: a single-center retrospective study. BMC Nephrol 2023; 24:8. [PMID: 36631797 PMCID: PMC9832765 DOI: 10.1186/s12882-023-03058-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 01/03/2023] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND C3 Glomerulopathy (C3G) is a rare glomerular disease caused by dysregulation of the complement pathway. Based on its pathophysiology, treatment with the monoclonal antibody eculizumab targeting complement C5 may be a therapeutic option. Due to the rarity of the disease, observational data on the clinical response to eculizumab treatment is scarce. METHODS Fourteen patients (8 female, 57%) treated for C3 glomerulopathy at the medical center of the University of Freiburg between 2013 and 2022 were included. Subjects underwent biopsy before enrollment. Histopathology, clinical data, and response to eculizumab treatment were analyzed. Key parameters to determine the primary outcome were changes of estimated glomerular filtration rate (eGFR) over time. Positive outcome was defined as > 30% increase, stable outcome as ±30%, negative outcome as decrease > 30% of eGFR. RESULTS Eleven patients (78.8%) were treated with eculizumab, three received standard of care (SoC, 27.2%). Median follow-up time was 68 months (IQR: 45-98 months). Median eculizumab treatment duration was 10 months (IQR 5-46 months). After eculizumab treatment, five patients showed a stable outcome, six patients showed a negative outcome. Among patients receiving SoC, one patient showed a stable outcome, two patients showed a negative outcome. CONCLUSIONS The benefit of eculizumab in chronic progressive C3 glomerulopathy is limited.
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Affiliation(s)
- Thomas Welte
- Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Frederic Arnold
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany ,grid.5963.9Institute for Microbiology and Hygiene, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lukas Westermann
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Felix A. Rottmann
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Martin J. Hug
- grid.5963.9Pharmacy, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Elke Neumann-Haefelin
- grid.5963.9Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Athina Ganner
- Department of Nephrology, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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25
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Abstract
Uncontrolled alternative pathway activation is the primary driver of several diseases, and it contributes to the pathogenesis of many others. Consequently, diagnostic tests to monitor this arm of the complement system are increasingly important. Defects in alternative pathway regulation are strong risk factors for disease, and drugs that specifically block the alternative pathway are entering clinical use. A range of diagnostic tests have been developed to evaluate and monitor the alternative pathway, including assays to measure its function, expression of alternative pathway constituents, and activation fragments. Genetic studies have also revealed many disease-associated variants in alternative pathway genes that predict the risk of disease and prognosis. Newer imaging modalities offer the promise of non-invasively detecting and localizing pathologic complement activation. Together, these various tests help in the diagnosis of disease, provide important prognostic information, and can help guide therapy with complement inhibitory drugs.
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Affiliation(s)
- Joshua M. Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Veronique Fremeaux-Bacchi
- Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Department of Immunology Biology and INSERM UMRS1138, Centre de Recherche des Cordeliers, Team "Inflammation, Complement and Cancer", Paris, France
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26
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Abstract
Dysregulation and accelerated activation of the alternative pathway (AP) of complement is known to cause or accentuate several pathologic conditions in which kidney injury leads to the appearance of hematuria and proteinuria and ultimately to the development of chronic renal failure. Multiple genetic and acquired defects involving plasma- and membrane-associated proteins are probably necessary to impair the protection of host tissues and to confer a significant predisposition to AP-mediated kidney diseases. This review aims to explore how our current understanding will make it possible to identify the mechanisms that underlie AP-mediated kidney diseases and to discuss the available clinical evidence that supports complement-directed therapies. Although the value of limiting uncontrolled complement activation has long been recognized, incorporating complement-targeted treatments into clinical use has proved challenging. Availability of anti-complement therapy has dramatically transformed the outcome of atypical hemolytic uremic syndrome, one of the most severe kidney diseases. Innovative drugs that directly counteract AP dysregulation have also opened new perspectives for the management of other kidney diseases in which complement activation is involved. However, gained experience indicates that the choice of drug should be tailored to each patient's characteristics, including clinical, histologic, genetic, and biochemical parameters. Successfully treating patients requires further research in the field and close collaboration between clinicians and researchers who have special expertise in the complement system.
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Affiliation(s)
- Erica Daina
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Monica Cortinovis
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
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27
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Stenson EK, Kendrick J, Dixon B, Thurman JM. The complement system in pediatric acute kidney injury. Pediatr Nephrol 2022; 38:1411-1425. [PMID: 36203104 PMCID: PMC9540254 DOI: 10.1007/s00467-022-05755-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/08/2022] [Accepted: 09/09/2022] [Indexed: 10/24/2022]
Abstract
The complement cascade is an important part of the innate immune system. In addition to helping the body to eliminate pathogens, however, complement activation also contributes to the pathogenesis of a wide range of kidney diseases. Recent work has revealed that uncontrolled complement activation is the key driver of several rare kidney diseases in children, including atypical hemolytic uremic syndrome and C3 glomerulopathy. In addition, a growing body of literature has implicated complement in the pathogenesis of more common kidney diseases, including acute kidney injury (AKI). Complement-targeted therapeutics are in use for a variety of diseases, and an increasing number of therapeutic agents are under development. With the implication of complement in the pathogenesis of AKI, complement-targeted therapeutics could be trialed to prevent or treat this condition. In this review, we discuss the evidence that the complement system is activated in pediatric patients with AKI, and we review the role of complement proteins as biomarkers and therapeutic targets in patients with AKI.
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Affiliation(s)
- Erin K. Stenson
- grid.430503.10000 0001 0703 675XSection of Pediatric Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, 13121 E 17th Avenue, MS8414, Aurora, CO 80045 USA
| | - Jessica Kendrick
- grid.430503.10000 0001 0703 675XDivision of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Aurora, CO USA
| | - Bradley Dixon
- grid.430503.10000 0001 0703 675XRenal Section, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Joshua M. Thurman
- grid.430503.10000 0001 0703 675XDivision of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Aurora, CO USA
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28
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Gross hematuria, edema, and hypocomplementemia in a 9-year-old boy: Answers. Pediatr Nephrol 2022; 37:2349-2353. [PMID: 35352193 DOI: 10.1007/s00467-022-05539-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 03/03/2022] [Indexed: 10/18/2022]
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29
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Schmidt T, Afonso S, Perie L, Heidenreich K, Wulf S, Krebs CF, Zipfel PF, Wiech T. An Interdisciplinary Diagnostic Approach to Guide Therapy in C3 Glomerulopathy. Front Immunol 2022; 13:826513. [PMID: 35693785 PMCID: PMC9186056 DOI: 10.3389/fimmu.2022.826513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Since the re-classification of membranoproliferative glomerulonephritis the new disease entity C3 glomerulopathy is diagnosed if C3 deposition is clearly dominant over immunoglobulins in immunohistochemistry or immunofluorescence. Although this new definition is more orientated at the pathophysiology as mediated by activity of the alternative complement pathway C3 glomerulopathy remains a heterogenous group of disorders. Genetic or autoimmune causes are associated in several but not in all patients with this disease. However, prognosis is poorly predictable, and clinicians cannot directly identify patients that might benefit from therapy. Moreover, therapy may range from supportive care alone, unspecific immune suppression, plasma treatment, or plasma exchange to complement inhibition. The current biopsy based diagnostic approaches sometimes combined with complement profiling are not sufficient to guide clinicians neither (i) whether to treat an individual patient, nor (ii) to choose the best therapy. With this perspective, we propose an interdisciplinary diagnostic approach, including detailed analysis of the kidney biopsy for morphological alterations and immunohistochemical staining, for genetic analyses of complement genes, complement activation patterning in plasma, and furthermore for applying novel approaches for convertase typing and complement profiling directly in renal tissue. Such a combined diagnostic approach was used here for a 42-year-old female patient with a novel mutation in the Factor H gene, C3 glomerulopathy and signs of chronic endothelial damage. We present here an approach that might in future help to guide therapy of renal diseases with relevant complement activation, especially since diverse new anti-complement agents are under clinical investigation.
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Affiliation(s)
- Tilman Schmidt
- III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sara Afonso
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Jena, Germany
| | - Luce Perie
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Jena, Germany
| | | | - Sonia Wulf
- Nephropathology Section, Institute of Pathology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Christian F Krebs
- Division of Translational Immunology, III. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Hamburg Center for Translational Immunology (HCTI), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter F Zipfel
- Department of Infection Biology, Leibniz Institute for Natural Product Research and Infection Biology, Hans-Knöll-Institute, Jena, Germany.,Institute of Microbiology, Friedrich Schiller University, Jena, Germany
| | - Thorsten Wiech
- Nephropathology Section, Institute of Pathology, University Hospital Hamburg Eppendorf, Hamburg, Germany
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30
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Riedl Khursigara M, Matsuda-Abedini M, Radhakrishnan S, Hladunewich MA, Lemaire M, Teoh CW, Noone D, Licht C. A Guide for Adult Nephrologists and Hematologists to Managing Atypical Hemolytic Uremic Syndrome and C3 Glomerulopathy in Teens Transitioning to Young Adults. Adv Chronic Kidney Dis 2022; 29:231-242. [PMID: 36084970 DOI: 10.1053/j.ackd.2022.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 04/11/2022] [Indexed: 11/11/2022]
Abstract
Atypical hemolytic uremic syndrome and C3 glomerulopathy/immune complex membranoproliferative glomerulonephritis are ultra-rare chronic, complement-mediated diseases with childhood manifestation in a majority of cases. Transition of clinical care of patients from pediatric to adult nephrologists-typically with controlled disease in native or transplant kidneys in case of atypical hemolytic uremic syndrome and often with chronic progressive disease despite treatment efforts in case of C3 glomerulopathy/immune complex membranoproliferative glomerulonephritis-identifies a challenging juncture in the journey of these patients. Raising awareness for the vulnerability of this patient cohort; providing education on disease pathophysiology and management including the use of new, high-precision complement antagonists; and establishing an ongoing dialog of patients, families, and all members of the health care team involved on either side of the age divide will be inevitable to ensure optimal patient outcomes and a safe transition of these patients to adulthood.
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Affiliation(s)
| | - Mina Matsuda-Abedini
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Seetha Radhakrishnan
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Michelle A Hladunewich
- Division of Nephrology and Obstetric Medicine, Department of Medicine, Sunnybrook Health Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mathieu Lemaire
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Chia Wei Teoh
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Damien Noone
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, ON, Canada; Department of Paediatrics, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Cell Biology Program, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.
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31
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Sethi S, De Vriese AS, Fervenza FC. Acute glomerulonephritis. Lancet 2022; 399:1646-1663. [PMID: 35461559 DOI: 10.1016/s0140-6736(22)00461-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 02/10/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
Glomerulonephritis is a heterogeneous group of disorders that present with a combination of haematuria, proteinuria, hypertension, and reduction in kidney function to a variable degree. Acute presentation with full blown nephritic syndrome or rapidly progressive glomerulonephritis is uncommon and is mainly restricted to patients with post-infectious glomerulonephritis, anti-neutrophil cytoplasmic antibodies-associated vasculitis, and anti-glomerular basement membrane disease. Most frequently, patients present with asymptomatic haematuria and proteinuria with or without reduced kidney function. All glomerulonephritis disorders can show periods of exacerbation, but disease flairs characteristically occur in patients with IgA nephropathy or C3 glomerulopathy. The gold standard for the diagnosis of a glomerulonephritis is a kidney biopsy, with a hallmark glomerular inflammation that translates into various histopathological patterns depending on the location and severity of the glomerular injury. Traditionally, glomerulonephritis was classified on the basis of the different histopathological patterns of injury. In the last few years, substantial progress has been made in unravelling the underlying causes and pathogenetic mechanisms of glomerulonephritis and a causal approach to the classification of glomerulonephritis is now favoured over a pattern-based approach. As such, glomerulonephritis can be broadly classified as immune-complex glomerulonephritis (including infection-related glomerulonephritis, IgA nephropathy, lupus nephritis, and cryoglobulinaemic glomerulonephritis), anti-neutrophil cytoplasmic antibodies-associated (pauci-immune) glomerulonephritis, anti-glomerular basement membrane glomerulonephritis, C3 glomerulopathy, and monoclonal immunoglobulin-associated glomerulonephritis. We provide an overview of the clinical presentation, pathology, and the current therapeutic approach of the main representative disorders in the spectrum of glomerulonephritis.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
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32
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Werion A, Rondeau E. Application of C5 inhibitors in glomerular diseases in 2021. Kidney Res Clin Pract 2022; 41:412-421. [PMID: 35354244 PMCID: PMC9346396 DOI: 10.23876/j.krcp.21.248] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/17/2022] [Indexed: 11/04/2022] Open
Abstract
The complement pathway is an essential mechanism in innate immunity, but it is also involved in multiple pathologies. For kidney diseases, strong evidence of a dysregulation in the alternative pathway in atypical hemolytic uremic syndrome (aHUS) led to the use of eculizumab, the first anti-C5 inhibitor available in clinical practice. Intensive fundamental research resulted in the development of subsequent new drugs, such as long-acting C5 inhibitors, oral medications, or antagonists of C5aR, the receptor for C5a. New data in the domain of C5-inhibition in glomerular diseases are still limited and mainly focus on 1) the efficacy of ravulizumab, a long-acting C5 inhibitor in aHUS, and 2) the use of avacopan, a C5aR antagonist, in antineutrophil cytoplasmic antibody vasculitis. Several new studies ongoing or planned for the next few years will evaluate the efficacy of C5 inhibition in secondary thrombotic microangiopathy, C3 glomerulopathy, membranous nephropathy, or immunoglobulin A nephropathy.
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Affiliation(s)
- Alexis Werion
- Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Rondeau
- Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Assistance Publique-Hôpitaux de Paris, Paris, France
- Correspondence: Eric Rondeau Intensive Care and Acute Nephrology Department, SINRA, Hospital Tenon, Rue de la Chine 4, 75020 Paris, France. E-mail:
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33
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Vivarelli M, van de Kar N, Labbadia R, Diomedi-Camassei F, Thurman JM. A clinical approach to children with C3 glomerulopathy. Pediatr Nephrol 2022; 37:521-535. [PMID: 34002292 DOI: 10.1007/s00467-021-05088-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 03/28/2021] [Accepted: 04/20/2021] [Indexed: 11/28/2022]
Abstract
C3 glomerulopathy is a relatively new clinical entity that represents a challenge both to diagnose and to treat. As new therapeutic agents that act as complement inhibitors become available, many with an oral formulation, a better understanding of this disease and of the underlying complement dysregulation driving it has become increasingly useful to optimize patient care. Moreover, recent advances in research have clarified the role of complement in other glomerular diseases in which its role was less established, namely in immune-complex membranoproliferative glomerulonephritis (IC-MPGN), ANCA-vasculitis, IgA nephropathy, and idiopathic membranous nephropathy. Complement inhibitors are being studied in adult and adolescent clinical trials for these indications. This review summarizes current knowledge and future perspectives on every aspect of the diagnosis and management of C3 glomerulopathy and elucidates current understanding of the role of complement in this condition and in other glomerular diseases in children. An overview of ongoing trials involving therapeutic agents targeting complement in glomerular diseases is also provided.
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Affiliation(s)
- Marina Vivarelli
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy.
| | - Nicole van de Kar
- Department of Pediatric Nephrology, Amalia Children's Hospital, Radboud University Medical Center, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Raffaella Labbadia
- Division of Nephrology and Dialysis, Department of Pediatric Subspecialties, Bambino Gesù Pediatric Hospital IRCCS, Piazza S Onofrio 4, 00165, Rome, Italy
| | | | - Joshua M Thurman
- Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
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Complement C3-targeted therapy in C3 glomerulopathy, a prototype of complement-mediated kidney diseases. Semin Immunol 2022; 60:101634. [PMID: 35817659 DOI: 10.1016/j.smim.2022.101634] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/28/2022] [Accepted: 07/01/2022] [Indexed: 01/15/2023]
Abstract
C3 glomerulopathy (C3G) is a rare and complex kidney disease that primarily affects young adults. Renal outcomes remain poor in the absence of specific treatment. C3G is driven by uncontrolled overactivation of the alternative complement pathway, which is mainly of acquired origin. Functional characterization of complement abnormalities (i.e., autoantibodies targeting complement components and variants in complement genes) identified in patients and experimental models of the disease improved the understanding of the disease, making C3G a prototype of complement-mediated diseases. The contribution of C3 convertase, as well as C5 convertase, in disease occurrence, phenotype, and severity is now well established, offering various potential therapeutic interventions. However, the lack of sufficient efficiency in anti-C5 therapy highlights the extreme complexity of the disease and the need for new therapeutic approaches based on C3 and C3 convertase axis inhibition. Here, we provide an overview of the complement activation mechanism involved in C3G and discuss therapeutic options based on complement inhibitors, with a specific focus on C3 inhibition.
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Comparison of Complement Pathway Activation in Autoimmune Glomerulonephritis. Kidney Int Rep 2022; 7:1027-1036. [PMID: 35571000 PMCID: PMC9091805 DOI: 10.1016/j.ekir.2022.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 12/11/2022] Open
Abstract
Introduction Methods Results Conclusion
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Kamel MH, Jaberi A, Gordon CE, Beck LH, Francis J. The Complement System in the Modern Era of Kidney Transplantation: Mechanisms of Injury and Targeted Therapies. Semin Nephrol 2022; 42:14-28. [DOI: 10.1016/j.semnephrol.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Kamala O, Malik TH, Hallam TM, Cox TE, Yang Y, Vyas F, Luli S, Connelly C, Gibson B, Smith-Jackson K, Denton H, Pappworth IY, Huang L, Kavanagh D, Pickering MC, Marchbank KJ. Homodimeric Minimal Factor H: In Vivo Tracking and Extended Dosing Studies in Factor H Deficient Mice. Front Immunol 2021; 12:752916. [PMID: 34956184 PMCID: PMC8696033 DOI: 10.3389/fimmu.2021.752916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/23/2021] [Indexed: 12/12/2022] Open
Abstract
C3 glomerulopathy (C3G) is associated with dysregulation of the alternative pathway (AP) of complement and treatment options remain inadequate. Factor H (FH) is a potent regulator of the AP. An in-depth analysis of FH-related protein dimerised minimal (mini)-FH constructs has recently been published. This analysis showed that addition of a dimerisation module to mini-FH not only increased serum half-life but also improved complement regulatory function, thus providing a potential treatment option for C3G. Herein, we describe the production of a murine version of homodimeric mini-FH [mHDM-FH (mFH1-5^18-20^R1-2)], developed to reduce the risk of anti-drug antibody formation during long-term experiments in murine models of C3G and other complement-driven pathologies. Our analysis of mHDM-FH indicates that it binds with higher affinity and avidity to WT mC3b when compared to mouse (m)FH (mHDM-FH KD=505 nM; mFH KD=1370 nM) analogous to what we observed with the respective human proteins. The improved binding avidity resulted in enhanced complement regulatory function in haemolytic assays. Extended interval dosing studies in CFH-/- mice (5mg/kg every 72hrs) were partially effective and bio-distribution analysis in CFH-/- mice, through in vivo imaging technologies, demonstrates that mHDM-FH is preferentially deposited and remains fixed in the kidneys (and liver) for up to 4 days. Extended dosing using an AAV- human HDM-FH (hHDM-FH) construct achieved complete normalisation of C3 levels in CFH-/- mice for 3 months and was associated with a significant reduction in glomerular C3 staining. Our data demonstrate the ability of gene therapy delivery of mini-FH constructs to enhance complement regulation in vivo and support the application of this approach as a novel treatment strategy in diseases such as C3G.
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Affiliation(s)
- Ola Kamala
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Talat H. Malik
- Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Thomas M. Hallam
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Thomas E. Cox
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Yi Yang
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Falguni Vyas
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Saimir Luli
- Preclinical In Vivo Imaging, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Chloe Connelly
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Beth Gibson
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Kate Smith-Jackson
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Harriet Denton
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Isabel Y. Pappworth
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Lei Huang
- Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - David Kavanagh
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Matthew C. Pickering
- Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Kevin J. Marchbank
- Complement Therapeutics Research Group and National Renal Complement Therapeutics Centre, Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle-upon-Tyne, United Kingdom
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Mack HG, Colville DJ, Harraka P, Savige JA, Invernizzi A, Fraser-Bell S. Retinal findings in glomerulonephritis. Clin Exp Optom 2021; 105:474-486. [PMID: 34877922 DOI: 10.1080/08164622.2021.2003691] [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: 10/19/2022] Open
Abstract
The complement system is part of the innate immune system activated by three distinct pathways: classical, lectin and alternative. It is also involved in retinal development and homoeostasis. Dense deposit disease is a rare renal disease associated with mutations in Complement factor H and overactivity of the alternative complement pathway. As well as glomerulonephritis, many affected individuals have retinal drusen and may be at risk of vision loss due to macular atrophy or choroidal neovascularisation. We discuss the reclassification of dense deposit disease as a type of C3 glomerulonephropathy, and hypothesise on the mechanisms of retinal abnormalities. Drusen have also been described in individuals with other types of glomerulonephritis involving abnormalities of the classical (membranoproliferative glomerulonephritis type 1) or lectin (IgA nephropathy, lupus nephritis) complement pathways. Although drusen are found in abnormalities of all three complement pathways, the age at onset, aetiology, and the threat to vision differs. This review describes drusen and other retinal abnormalities associated with the glomerulonephritides due to abnormal activation in each of the three complement activation pathways, and provides the first report of drusen occurring in a patient with the recently reclassified C3 glomerulonephritis with homozygous variant V62I in complement factor H. Optometric management of young patients presenting with retinal drusen is discussed, and complement-based therapies for visual loss are reviewed.
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Affiliation(s)
- Heather G Mack
- Department of Surgery (Ophthalmology), University of Melbourne, Melbourne, Australia.,Department of Ophthalmology, Melbourne Health, Melbourne, Australia.,Centre for Eye Research, University of Melbourne, Melbourne, Australia
| | - Deborah J Colville
- Department of Surgery (Ophthalmology), University of Melbourne, Melbourne, Australia.,Department of Ophthalmology, Melbourne Health, Melbourne, Australia
| | - Phillip Harraka
- Department of Medicine (Northern), University of Melbourne, Melbourne, Australia
| | - Judith Anne Savige
- Department of Medicine (Northern), University of Melbourne, Melbourne, Australia
| | - Alessandro Invernizzi
- Department of Biomedical and Clinical Sciences 'Luigi Sacco', University of Milan, Milan, Italy
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Naseer MS, Singh A, Singh N. Repository Corticotropin in Treating de novo C3 Glomerulonephritis after Transplantation. GLOMERULAR DISEASES 2021; 2:100-105. [PMID: 36751532 PMCID: PMC9670034 DOI: 10.1159/000520387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/17/2021] [Indexed: 11/19/2022]
Abstract
Introduction De novo C3 glomerulonephritis (C3GN) after transplant is uncommon. Although eculizumab has been used successfully in several cases, the response is heterogeneous, and treatment strategies remain undefined. The use of repository corticotropin in C3GN has not been described in the literature. Case Report A 48-year-old African American male with kidney transplantation secondary to presumed diabetic nephropathy presented 6 years after transplant with lower extremity edema and nephrotic range proteinuria. His urine protein to creatinine ratio (UPCR) was 8.2 g/g. Renal allograft biopsy confirmed the diagnosis of C3GN. He was treated with eculizumab (Solaris®) 900 mg IV once weekly for 4 weeks and repository corticotropin (H.P. Acthar® gel) 80 units SQ twice weekly for 6 months with a near-complete resolution of proteinuria within 3 months of the treatment. The patient presented again 6 months after completing the therapy with a recurrence of proteinuria, which peaked at 11.6 g/g of UPCR. Repeat kidney allograft biopsy was consistent with C3GN. He was started on repository corticotropin 80 units SQ twice weekly, which resulted in a reduction of proteinuria to >50% within 2 months of therapy. When eculizumab 900 mg IV weekly for 4 weeks was added with repository corticotropin, the proteinuria resolved within 10 weeks of treatment. The patient was maintained on monotherapy of repository corticotropin and has been in complete remission of proteinuria for more than a year until his last follow-up. Conclusion This is the first case report describing the role of repository corticotropin as an effective therapy in reducing proteinuria and maintaining patients with C3GN in proteinuria remission.
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Fernandez-Ruiz R, Blank RB, Wu M, Belmont HM. C3 glomerulonephritis and systemic lupus erythematosus: A report of a patient treated with eculizumab and review of the literature. Lupus 2021; 30:1671-1678. [PMID: 34192954 DOI: 10.1177/09612033211027938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Activation of the complement pathway by immune complexes is a key feature of systemic lupus erythematosus (SLE) and SLE glomerulonephritis, which translates into low levels of C3 and C4 during active disease. C3 glomerulonephritis (C3GN) is part of a broader group of rare renal diseases, the C3 glomerulopathies, characterized by prominent C3 accumulation in the glomeruli with minimal to no immunoglobulin (Ig) deposition secondary to dysregulation of the alternative pathway of the complement system. Distinguishing lupus nephritis from other complement-mediated kidney disorders, including C3GN, represents a diagnostic challenge with potential therapeutic implications. METHODS We report an unusual case of a 55-year-old woman with SLE and previous biopsy-proven class IV lupus nephritis, subsequently diagnosed with C3GN. Furthermore, we review the available literature published from January 2010-March 2021 on the clinical features and management of C3GN in the setting of SLE. RESULTS In addition to our case, very few reports exist in the literature regarding C3GN in association with SLE. The underlying pathogenic mechanism of C3GN consists of dysregulation of the alternative pathway of the complement system, either due to genetic variation in complement-related genes or to acquired autoantibodies targeting C3 or C5 convertases; the latter mechanism could explain the occurrence of C3GN in the setting of autoimmune diseases, although it was not definitively identified in our patient or others with SLE. Similar to some of the previous reports, after suboptimal renal response on mycophenolate mofetil and rituximab, our patient has been successfully treated with eculizumab, thus far with >50% improvement in proteinuria. CONCLUSIONS C3GN represents an additional mechanism of renal injury in SLE mediated by alternative complement pathway dysregulation. Although rare, patients with SLE and persistent proteinuria with very low C3 would benefit from expedited renal biopsy to evaluate for C3GN as well as genetic testing, since this entity could require a different therapeutic approach.
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Affiliation(s)
- Ruth Fernandez-Ruiz
- Division of Rheumatology, New York University Grossman School of Medicine, New York, USA
| | - Rebecca B Blank
- Division of Rheumatology, New York University Grossman School of Medicine, New York, USA
| | - Ming Wu
- Department of Pathology, New York University Grossman School of Medicine, New York, USA
| | - H Michael Belmont
- Division of Rheumatology, New York University Grossman School of Medicine, New York, USA
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Muff-Luett M, Sanderson KR, Engen RM, Zahr RS, Wenderfer SE, Tran CL, Sharma S, Cai Y, Ingraham S, Winnicki E, Weaver DJ, Hunley TE, Kiessling SG, Seamon M, Woroniecki R, Miyashita Y, Xiao N, Omoloja AA, Kizilbash SJ, Mansuri A, Kallash M, Yu Y, Sherman AK, Srivastava T, Nester CM. Eculizumab exposure in children and young adults: indications, practice patterns, and outcomes-a Pediatric Nephrology Research Consortium study. Pediatr Nephrol 2021; 36:2349-2360. [PMID: 33693990 PMCID: PMC8263513 DOI: 10.1007/s00467-021-04965-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 01/07/2021] [Accepted: 01/21/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Eculizumab is approved for the treatment of atypical hemolytic uremic syndrome (aHUS). Its use off-label is frequently reported. The aim of this study was to describe the broader use and outcomes of a cohort of pediatric patients exposed to eculizumab. METHODS A retrospective, cohort analysis was performed on the clinical and biomarker characteristics of eculizumab-exposed patients < 25 years of age seen across 21 centers of the Pediatric Nephrology Research Consortium. Patients were included if they received at least one dose of eculizumab between 2008 and 2015. Traditional summary statistics were applied to demographic and clinical data. RESULTS A total of 152 patients were identified, mean age 9.1 (+/-6.8) years. Eculizumab was used "off-label" in 44% of cases. The most common diagnoses were aHUS (47.4%), Shiga toxin-producing Escherichia coli HUS (12%), unspecified thrombotic microangiopathies (9%), and glomerulonephritis (9%). Genetic testing was available for 60% of patients; 20% had gene variants. Dosing regimens were variable. Kidney outcomes tended to vary according to diagnosis. Infectious adverse events were the most common adverse event (33.5%). No cases of meningitis were reported. Nine patients died of noninfectious causes while on therapy. CONCLUSIONS This multi-center retrospective cohort analysis indicates that a significant number of children and young adults are being exposed to C5 blockade for off-label indications. Dosing schedules were highly variable, limiting outcome conclusions. Attributable adverse events appeared to be low. Cohort mortality (6.6%) was not insignificant. Prospective studies in homogenous disease cohorts are needed to support the role of C5 blockade in kidney outcomes.
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Affiliation(s)
- Melissa Muff-Luett
- Department of Pediatrics, Pediatric Nephrology, University of Nebraska Medical School, Children's Hospital and Medical Center, 8200 Dodge St., Omaha, NE, 68114-4113, USA.
| | - Keia R Sanderson
- Department of Medicine-Nephrology, University of North Carolina, Chapel Hill, NC, USA
| | - Rachel M Engen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rima S Zahr
- Division of Pediatric Nephrology and Hypertension, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Scott E Wenderfer
- Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Cheryl L Tran
- Division of Pediatric Nephrology, Mayo Clinic, Rochester, MN, USA
| | - Sheena Sharma
- Division of Nephrology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Yi Cai
- Division of Nephrology, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Susan Ingraham
- Kapi'olani Medical Center for Women and Children, Honolulu, HI, USA
| | - Erica Winnicki
- Department of Pediatrics, University of California Davis, Sacramento, CA, USA
| | - Donald J Weaver
- Division of Pediatric Nephrology and Hypertension, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Tracy E Hunley
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Stefan G Kiessling
- Division of Pediatric Nephrology, Department of Pediatrics, University of Kentucky, Lexington, KY, USA
| | | | - Robert Woroniecki
- Pediatric Nephrology and Hypertension, Stony Brook Children's Hospital, Stony Brook, NY, USA
| | - Yosuke Miyashita
- Department of Pediatrics, Division of Pediatric Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Abiodun A Omoloja
- Nephrology Department, The Children's Medical Center, Dayton, OH, USA
| | - Sarah J Kizilbash
- Department of Pediatric Nephrology, University of Minnesota, Minneapolis, MN, USA
| | - Asif Mansuri
- Children's Hospital of Georgia, Augusta University, Augusta, GA, USA
| | - Mahmoud Kallash
- Division of Nephrology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Yichun Yu
- Department of Medicine-Nephrology, University of North Carolina, Chapel Hill, NC, USA
| | - Ashley K Sherman
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Tarak Srivastava
- Division of Pediatric Nephrology, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Carla M Nester
- Departments of Internal Medicine and Pediatrics, Division of Nephrology, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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Pınarbaşı AS, Dursun I, Gokce I, Çomak E, Saygılı S, Bayram MT, Donmez O, Melek E, Tekcan D, Çiçek N, Yılmaz D, Tabel Y, Yıldırım ZY, Bahat E, Koyun M, Soylu A, Canpolat N, Aksu B, Çelakıl ME, Taşdemir M, Benzer M, Özçelik G, Bakkaloğlu SA, Düşünsel R. Predictors of poor kidney outcome in children with C3 glomerulopathy. Pediatr Nephrol 2021; 36:1195-1205. [PMID: 33130981 DOI: 10.1007/s00467-020-04799-7] [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: 05/07/2020] [Revised: 08/13/2020] [Accepted: 09/24/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND C3 glomerulopathy (C3G) is characterized by heterogeneous clinical presentation, outcome, and predominant C3 accumulation in glomeruli without significant IgG. There is scarce outcome data regarding childhood C3G. We describe clinical and pathological features, treatment and outcomes, and risk factors for progression to chronic kidney disease stage 5 (CKD5) in the largest pediatric series with biopsy-proven C3G. METHODS Sixty pediatric patients with C3G from 21 referral centers in Turkey were included in this retrospective study. Patients were categorized according to CKD stage at last visit as CKD5 or non-CKD5. Demographic data, clinicopathologic findings, treatment, and outcome data were compared and possible risk factors for CKD5 progression determined using Cox proportional hazards model. RESULTS Mean age at diagnosis was 10.6 ± 3.0 years and follow-up time 48.3 ± 36.3 months. Almost half the patients had gross hematuria and hypertension at diagnosis. Nephritic-nephrotic syndrome was the commonest presenting feature (41.6%) and 1/5 of patients presented with nephrotic syndrome. Membranoproliferative glomerulonephritis was the leading injury pattern, while 40 patients had only C3 staining. Patients with DDD had significantly lower baseline serum albumin compared with C3GN. Eighteen patients received eculizumab. Clinical remission was achieved in 68.3%. At last follow-up, 10 patients (16.6%) developed CKD5: they had lower baseline eGFR and albumin and higher frequency of nephrotic syndrome and dialysis requirement than non-CKD5 patients. Lower serum albumin and eGFR at diagnosis were independent predictors for CKD5 development. CONCLUSIONS Children with C3G who have impaired kidney function and hypoalbuminemia at diagnosis should be carefully monitored for risk of progression to CKD5. Graphical abstract.
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Affiliation(s)
- Ayşe Seda Pınarbaşı
- Department of Pediatric Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
| | - Ismail Dursun
- Department of Pediatric Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey.
| | - Ibrahim Gokce
- Department of Pediatric Nephrology, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Elif Çomak
- Department of Pediatric Nephrology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Seha Saygılı
- Department of Pediatric Nephrology, Cerrahpasa Faculty of Medicine, Istanbul University, İstanbul, Turkey
| | - Meral Torun Bayram
- Department of Pediatric Nephrology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Osman Donmez
- Department of Pediatric Nephrology, Faculty of Medicine, Uludağ University, Bursa, Turkey
| | - Engin Melek
- Department of Pediatric Nephrology, Faculty of Medicine, Cukurova University, Adana, Turkey
| | - Demet Tekcan
- Department of Pediatric Nephrology, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkey
| | - Neslihan Çiçek
- Department of Pediatric Nephrology, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Dilek Yılmaz
- Department of Pediatric Nephrology, Faculty of Medicine, Adnan Menderes University, Aydın, Turkey
| | - Yılmaz Tabel
- Department of Pediatric Nephrology, Faculty of Medicine, İnönü University, Malatya, Turkey
| | - Zeynep Y Yıldırım
- Department of Pediatric Nephrology, Istanbul Faculty of Medicine, Istanbul University, İstanbul, Turkey
| | - Elif Bahat
- Department of Pediatric Nephrology, Faculty of Medicine, Karadeniz Teknik University, Trabzon, Turkey
| | - Mustafa Koyun
- Department of Pediatric Nephrology, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Alper Soylu
- Department of Pediatric Nephrology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Nur Canpolat
- Department of Pediatric Nephrology, Cerrahpasa Faculty of Medicine, Istanbul University, İstanbul, Turkey
| | - Bağdagül Aksu
- Department of Pediatric Nephrology, University of Health Sciences, Haseki Education and Research Hospital, İstanbul, Turkey
| | - Mehtap Ezel Çelakıl
- Department of Pediatric Nephrology, Faculty of Medicine, Kocaeli University, İzmit, Kocaeli, Turkey
| | - Mehmet Taşdemir
- Department of Pediatric Nephrology, Faculty of Medicine, Koç University, İstanbul, Turkey
| | - Meryem Benzer
- Department of Pediatric Nephrology, Bakırköy Dr Sadi Konuk Training and Research Hospital, İstanbul, Turkey
| | - Gül Özçelik
- Department of Pediatric Nephrology, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, İstanbul, Turkey
| | - Sevcan A Bakkaloğlu
- Department of Pediatric Nephrology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ruhan Düşünsel
- Department of Pediatric Nephrology, Erciyes University, Faculty of Medicine, Kayseri, Turkey
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Li L, Liu LQ, Yang YY, Hu ZX. C3 glomerulonephritis associated with ANCA positivity: a case report. BMC Nephrol 2021; 22:143. [PMID: 33882866 PMCID: PMC8061169 DOI: 10.1186/s12882-021-02354-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 04/13/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND C3 glomerulopathy (C3G) is a recent disease classification that is characterized by the presence of glomerular deposits (composed of C3) in the absence of significant amounts of immunoglobulin and comprises dense deposit disease and C3 glomerulonephritis (C3GN). Most C3GN manifests as membranoproliferative, mesangial proliferative glomerulonephritis patterns via light microscopy. Pure membranous nephropathy (MN)-like glomerular lesions are rare manifestations of C3GN. Anti-neutrophil cytoplasmic antibodies (ANCAs) are also seldomly reported to be positive in C3GN. Herein, we report the case of a C3GN patient presenting with an MN-like glomerular pattern with ANCA positivity. CASE PRESENTATION A 68-year-old woman was admitted to a local hospital with elevated serum creatinine for two weeks. Laboratory tests showed a hemoglobin level of 85 g/L. Urinalysis was positive for 2 + protein and 360 RBCs/HPF. Blood biochemistry analysis revealed the following concentrations: albumin, 30.3 g/L; globulin, 46.2 g/L; blood urea nitrogen, 19.9 mmol/L; and serum creatinine, 234 µmol/L. The serum C3 level was 0.4950 g/L, and the serum C4 level was 0.1050 g/L. The direct Coombs test was positive. Serologic testing for ANCA revealed the presence of p-ANCA (1:10) by indirect immunofluorescence microscopy assay, as well as the presence of PR3 1.2 (normal range < 1) and MPO 3.5 (normal range < 1) by enzyme immunoassay. Renal biopsy sample pathology showed 2/6 cellular crescents and thickened glomerular basement membranes. Immunofluorescence testing revealed only diffuse, finely granular depositions of C3 along the glomerular capillary walls in frozen and paraffin-embedded tissue sections. Electron microscopy demonstrated the presence of subepithelial electron-dense deposits, similar to those that are observed in membranous nephropathy. Corticosteroid and cyclophosphamide were administered, with a subsequent improvement in renal function. CONCLUSIONS We present the rare case of a patient with MN-like C3GN with ANCA positivity. C3GN with ANCA positivity may be represented by more crescents, severe renal dysfunction and more extrarenal manifestations. More cases are needed to elucidate the clinicopathologic features and optimal treatments of these patients.
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Affiliation(s)
- Ling Li
- Renal Division, Department of Medicine, West China Hospital of Sichuan University, 610041, Chengdu, China
| | - Li-Qin Liu
- West China School of Medicine, Sichuan University, 610041, Chengdu, China
| | - Ying-Ying Yang
- Renal Division, Department of Medicine, West China Hospital of Sichuan University, 610041, Chengdu, China
| | - Zhang-Xue Hu
- Renal Division, Department of Medicine, West China Hospital of Sichuan University, 610041, Chengdu, China.
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Hossain MA, Ahmed N, Gupta V, Bajwa R, Alidoost M, Asif A, Vachharajani T. Post-traumatic thrombotic microangiopathy: What trauma surgeons need to know? Chin J Traumatol 2021; 24:69-74. [PMID: 33518399 PMCID: PMC8071723 DOI: 10.1016/j.cjtee.2021.01.004] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 12/10/2020] [Accepted: 12/29/2020] [Indexed: 02/04/2023] Open
Abstract
Thrombotic microangiopathy (TMA) is characterized by systemic microvascular thrombosis, target organ injury, anemia and thrombocytopenia. Thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome and Shiga toxin E-coli-related hemolytic uremic syndrome are the three common forms of TMAs. Traditionally, TMA is encountered during pregnancy/postpartum period, malignant hypertension, systemic infections, malignancies, autoimmune disorders, etc. Recently, the patients presenting with trauma have been reported to suffer from TMA. TMA carries a high morbidity and mortality, and demands a prompt recognition and early intervention to limit the target organ injury. Because trauma surgeons are the first line of defense for patients presenting with trauma, the prompt recognition of TMA for these experts is critically important. Early treatment of post-traumatic TMA can help improve the patient outcomes, if the diagnosis is made early. The treatment of TMA is also different from acute blood loss anemia namely in that plasmapheresis is recommended rather than platelet transfusion. This article familiarizes trauma surgeons with TMA encountered in the context of trauma. Besides, it provides a simplified approach to establishing the diagnosis of TMA. Because trauma patients can require multiple transfusions, the development of disseminated intravascular coagulation must be considered. Therefore, the article also provides different features of disseminated intravascular coagulation and TMA. Finally, the article suggests practical points that can be readily applied to the management of these patients.
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Affiliation(s)
- Mohammad A. Hossain
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Nasim Ahmed
- Department of Surgery, Division of Trauma Surgery, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA,Corresponding author.
| | - Varsha Gupta
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Ravneet Bajwa
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Marjan Alidoost
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Arif Asif
- Department of Medicine, Hackensack Meridian Health Jersey Shore University Medical Center, Neptune, NJ, 07753, USA
| | - Tushar Vachharajani
- Global Nephrology, Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH, 44103, USA
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Eculizumab use in a tertiary care nephrology center: data from the Vienna TMA cohort. J Nephrol 2021; 35:451-461. [PMID: 33599971 PMCID: PMC8927043 DOI: 10.1007/s40620-021-00981-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/22/2021] [Indexed: 11/09/2022]
Abstract
Background Practice patterns of eculizumab use are not well described. We examined indications for, and outcomes of, eculizumab therapy in a tertiary care nephrology center. Methods We used the “Vienna TMA cohort” and the hospital pharmacy database at the Medical University of Vienna to identify patients that received eculizumab treatment between 2012 and 2019. We describe clinical characteristics, details of eculizumab use, and outcomes of patients with complement gene-variant mediated TMA (cTMA), secondary TMA (sTMA) and C3 glomerulopathy (C3G). Results As of December 2019, 23 patients received complement blockade at the Division of Nephrology and Dialysis: 15 patients were diagnosed with cTMA, 6 patients with sTMA and 2 patients with C3G. Causes of sTMA were bone marrow transplantation (n = 2), malignant hypertension, malignant tumor, systemic lupus erythematosus, antiphospholipid syndrome and lung transplantation (each n = 1). Across all indications, patients had a median age of 31 and were predominantly female (78%) and the median duration of treatment was 227 days. Hematological recovery was seen in most patients, while renal response was best in patients with cTMA. Adverse events were recorded in 26%. Conclusions In summary, eculizumab is the treatment of choice for cTMA patients that do not respond to plasma therapy. In patients with sTMA and C3G, the response rates to therapy are much lower and therefore, the decision to start therapy needs to be considered carefully. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s40620-021-00981-8.
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Budge K, Dellepiane S, Yu SMW, Cravedi P. Complement, a Therapeutic Target in Diabetic Kidney Disease. Front Med (Lausanne) 2021; 7:599236. [PMID: 33553201 PMCID: PMC7858668 DOI: 10.3389/fmed.2020.599236] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/21/2020] [Indexed: 01/15/2023] Open
Abstract
Currently available treatments of diabetic kidney disease (DKD) remain limited despite improved understanding of DKD pathophysiology. The complement system is a central part of innate immunity, but its dysregulated activation is detrimental and results in systemic diseases with overt inflammation. Growing evidence suggests complement activation in DKD. With existent drugs and clinical success of treating other kidney diseases, complement inhibition has emerged as a potential novel therapy to halt the progression of DKD. This article will review DKD, the complement system's role in diabetic and non-diabetic disease, and the potential benefits of complement targeting therapies especially for DKD patients.
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Affiliation(s)
- Kelly Budge
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Sergio Dellepiane
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Samuel Mon-Wei Yu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Paolo Cravedi
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Pinarbasi AS, Dursun I, Poyrazoglu MH, Akgun H, Bozpolat A, Dusunsel R. Evaluation of the children with C3 glomerulopathy. SAUDI JOURNAL OF KIDNEY DISEASES AND TRANSPLANTATION 2021; 31:79-89. [PMID: 32129200 DOI: 10.4103/1319-2442.279964] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
C3 glomerulopathy (C3G) is a clinical spectrum that presents with a variety of symptoms, ranging from a mild disease with asymptomatic microhematuria and/or proteinuria to severe disease with nephritic or nephrotic syndrome and renal impairment. Herein, we aim to document the clinical and laboratory findings, response to immunosuppressive and supportive treatment and prognosis of the children with C3G. We retrospectively reviewed the medical records of patients diagnosed with membranoproliferative glomerulonephritis (MPGN). Kidney biopsy materials were reexamined for the diagnosis of C3G. The inclusion criteria for C3G are the dominant C3 staining with or without scanty immunoglobulins (Ig) deposition on immuno- fluorescence (IF) and MPGN patterns on light microscope. Twelve of 69 patients with MPGN were included in the study based on the definition criteria of C3G. Ten of them had only C3 staining and the rest of the patients had both C3 staining and a small amount of IgG/M staining on IF microscopy. One patient was on remission with only ACEI. The rest of the patients used immunosuppressive treatment and two of them needed eculizumab therapy. One of them did not respond to the treatment of eculizumab and progressed to end-stage renal failure. C3G is a disease characterized by a heterogeneous clinical presentation and outcome. Because of this broad spectrum of disease, treatment may vary widely. We think that complement-targeting therapy with eculizumab should be an alternative option for refractory cases, especially in the early stage of disease, if they did not respond to immunosuppressive treatment.
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Affiliation(s)
- Ayse Seda Pinarbasi
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Ismail Dursun
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Muammer Hakan Poyrazoglu
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Hulya Akgun
- Department of Pathology, Erciyes University Faculty of Medicine, Kayseri, Turkey
| | - Adil Bozpolat
- Department of Pediatrics, Nevsehir State Hospital, Nevsehir, Turkey
| | - Ruhan Dusunsel
- Department of Pediatrics, Division of Pediatric Nephrology, Erciyes University Faculty of Medicine, Kayseri, Turkey
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Turkmen K, Baloglu I, Ozer H. C3 glomerulopathy and atypical hemolytic uremic syndrome: an updated review of the literature on alternative complement pathway disorders. Int Urol Nephrol 2021; 53:2067-2080. [PMID: 33389509 DOI: 10.1007/s11255-020-02729-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022]
Abstract
The complement system plays a significant role within the pathological process of C3 glomerulopathy (C3GP) and atypical hemolytic uremic syndrome (aHUS). In daily practice, clinicians should differentiate the subgroups of C3GP because of they should apply different treatment modalities. In the past, C3GP was considered as a part of membranoproliferative glomerulonephritis (MPGN). MPGN is defined as glomerular capillary thickening secondary to the synthesis of the new glomerular basement membrane and mesangial cellular hyperplasia with mesangial matrix expansion. Atypical hemolytic uremic syndrome is an ultra-rare disease that can be outlined by the triad of Coombs negative microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury. Recent advances demonstrated that these diseases share common abnormalities of the control of the alternative complement system. Therefore, nowadays, most researchers advocate that there may be overlap in the pathogenesis of C3GP and aHUS. This review will provide recent novel mechanisms and treatment options in these diseases. For the purposes that we mentioned above and to help clinicians, we aimed to describe the etiology, pathophysiology, and treatment of C3GP and aHUS in this comprehensive review.
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Affiliation(s)
- Kultigin Turkmen
- Department of Nephrology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey.
| | - Ismail Baloglu
- Department of Nephrology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey
| | - Hakan Ozer
- Department of Nephrology, Necmettin Erbakan University Meram School of Medicine, Konya, Turkey
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Eculizumab for pediatric dense deposit disease: A case report and literature review. Clin Nephrol Case Stud 2020; 8:96-102. [PMID: 33329990 PMCID: PMC7737524 DOI: 10.5414/cncs110309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/29/2020] [Indexed: 01/04/2023] Open
Abstract
Dense deposit disease (DDD), a subtype of complement component 3 (C3) glomerulopathy (C3G), results from alternative complement pathway hyperactivity leading to membrane attack complex formation. DDD treatment strategies are limited. We report a case of a 13-year-old girl diagnosed with DDD at 9 years of age, with nephritic and nephrotic syndrome and C3 nephritic factor-negative alternative complement pathway activation. Initial treatment with prednisolone, methylprednisolone pulses (MPs), and mizoribines was effective for 3 years, after which she relapsed. Despite MP treatment followed by prednisolone and mycophenolate mofetil (MMF), her kidney function and proteinuria deteriorated with a high soluble (s)C5b-9 level; she also developed dyspnea and pleural effusion (PE). Three days after the first eculizumab (ECZ) infusion, urine volume increased, respiratory condition improved, PE resolved, and proteinuria decreased in 1 month. Serum creatinine level decreased, and kidney function completely normalized within 7 weeks. The sC5b-9 level normalized, and although proteinuria decreased, nephrotic range proteinuria persisted during ECZ treatment with MMF for 53 weeks, even with increased treatment interval. Thus, complement activation pathway-targeted therapy may be useful for rapidly progressing DDD. Our data support the role of complement pathway abnormalities in C3G with DDD.
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Ort M, Dingemanse J, van den Anker J, Kaufmann P. Treatment of Rare Inflammatory Kidney Diseases: Drugs Targeting the Terminal Complement Pathway. Front Immunol 2020; 11:599417. [PMID: 33362783 PMCID: PMC7758461 DOI: 10.3389/fimmu.2020.599417] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/09/2020] [Indexed: 12/15/2022] Open
Abstract
The complement system comprises the frontline of the innate immune system. Triggered by pathogenic surface patterns in different pathways, the cascade concludes with the formation of a membrane attack complex (MAC; complement components C5b to C9) and C5a, a potent anaphylatoxin that elicits various inflammatory signals through binding to C5a receptor 1 (C5aR1). Despite its important role in pathogen elimination, priming and recruitment of myeloid cells from the immune system, as well as crosstalk with other physiological systems, inadvertent activation of the complement system can result in self-attack and overreaction in autoinflammatory diseases. Consequently, it constitutes an interesting target for specialized therapies. The paradigm of safe and efficacious terminal complement pathway inhibition has been demonstrated by the approval of eculizumab in paroxysmal nocturnal hematuria. In addition, complement contribution in rare kidney diseases, such as lupus nephritis, IgA nephropathy, atypical hemolytic uremic syndrome, C3 glomerulopathy, or antineutrophil cytoplasmic antibody-associated vasculitis has been demonstrated. This review summarizes the involvement of the terminal effector agents of the complement system in these diseases and provides an overview of inhibitors for complement components C5, C5a, C5aR1, and MAC that are currently in clinical development. Furthermore, a link between increased complement activity and lung damage in severe COVID-19 patients is discussed and the potential for use of complement inhibitors in COVID-19 is presented.
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Affiliation(s)
- Marion Ort
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Jasper Dingemanse
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
| | - John van den Anker
- Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, United States
| | - Priska Kaufmann
- Department of Clinical Pharmacology, Idorsia Pharmaceuticals Ltd, Allschwil, Switzerland
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